Minnesota Physician June 2014

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Vo l u m e x x v i i I , N o . 3 J u n e 2 014

Improving communication Working with patients who are blind or visually impaired By Maurita Christensen, MS, PhD, CRC


lmost every physician has had a patient who is blind or vision impaired. As the psychologist for Minnesota State Services for the Blind (SSB), I work exclusively with people who experience vision loss. This article provides some practical tips on working with patients with vision loss, and an overview of resources available through SSB. Legal blindness is defined as central visual acuity of 20/200 or worse with best correction, or a visual field of less than 20 degrees. Typically, visual impairment is visual acuity of 20/60 or worse in the better eye with best correction. However, people with vision loss use a variety of terms to describe themselves—blind, visually impaired, or having low vision. You may want to ask your patients for their personal preference.

Electronic media and children Health implications and the physician’s role By Nusheen Ameenuddin, MD, MPH


ad, we’re supposed to ask our doctor about Levitra.”

As a newly minted pediatrician, I never expected to deal with a question about a drug for erectile dysfunction, much less one posed by a 4-year-old patient who was simply following instructions put forth in a television ad.

But this experience drove home to me, in a way no statistic could, the power the media had on even the youngest members of society. Years later, I realize how much the media landscape has changed and expanded since that encounter. I think of how we, as physicians, need to understand Electronic media and children to page 10

According to 2010 census data, about 75,000 Minnesotans are legally blind. The National Center for Health Statistics indicates that the number of individuals who are legally blind will double in the next seven years, due in large part to our aging population. It is estimated that rates of vision loss increase nearly 400 percent as one moves from the 18 to 44-year-old bracket to the 70- to 84-year-old bracket. Roughly 17 percent of Minnesotans Improving communication to page 12

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June 2014 • Volume XXVIII, No. 3

Features Electronic media and children Health implications and the physician’s role


By Nusheen Ameenuddin, MD, MPH

Improving communication Working with patients who are blind or visually impaired


By Maurita Christensen, MS, PhD, CRC





Mental health in transition By James J. Jordan, MD


Intranasal insulin By William H. Frey II, PhD


Catherine M. Rydell, CAE American Academy of Neurology

Women’s Health


Hormone therapy and the WHI By Jon Nielsen, MD

2014 health care architecture honor roll Recognizes 10 outstanding building projects By MPP Staff


Special Focus: Medical Facility Design Phased building projects 30 By Richard Engan and Mitra Milani Engan

Beyond walls and built spaces By Allison Matthews


Background and focus: As tools and techniques for treating chronic illness have expanded, so have methods and mechanisms of provider reimbursement. More people now have access to care, and with this comes a heightened awareness of the impact of social determinants on health. The transition to rewarding physicians for maintaining a healthier population is slow but the promise is clear. Treating chronic illness remains an area of high-volume use and, improperly managed, quickly becomes an area of high cost. Objectives: We will evaluate changes that health care reform is bringing to chronic illness care. We will examine new community-based partnerships that are forming to address prevention, compliance, and better identification of risk. We will look at specific diseases and how workplace solutions, insurance companies, clinics, hospitals, long-term care facilities, and home care providers are working together to lower costs and improve outcomes. Please send me ____ tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, Inc., 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone 612.728.8600 or fax 612.728.8601.

Publisher Mike Starnes | mstarnes@mppub.com Senior Editor Janet Cass | jcass@mppub.com Editor Lisa McGowan | lmcgowan@mppub.com

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Account Executive Stacey Bush | sbush@mppub.com Account Executive Iain Kane | ikane@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email mpp@ mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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New Law Allows APRNs to Practice Independently Gov. Mark Dayton has signed a bill that allows advanced practice registered nurses (APRNs) in Minnesota to practice independently from physicians. The bill passed the Senate 64 to 0, and the House 119 to 13 earlier this month. The licensing change applies to nurse-midwives, nurse practitioners, clinical nurse specialists, and registered nurse anesthetists. It will go into effect Jan. 1, 2015. “We really believe that this is an important step for keeping our newly educated APRNs interested in staying in Minnesota and providing care to our citizens,” said Mary Chesney, PhD, RN, CNP, president of the Minnesota Advanced Practice Registered Nurse Coalition. Chesney says the legislation will help address a growing physician shortage in some areas of the state. “It’s going to increase access to care because it removes barriers that were keeping some


advanced practice registered nurses from being able to practice,” she said. New advanced practice nursing graduates must work 2,080 hours in a hospital or collaborative setting in order to qualify to gain full authority to practice independently.

Prenatal Nicotine Exposure Higher than Reported, Study Finds The Masonic Cancer Center at the University of Minnesota has released research showing that more women smoke tobacco products while pregnant than is reported on their babies’ birth certificates. Researchers used newly developed assay methods and newborn dried blood spots from four states that store and release samples anonymously for public health advancement: California, Michigan, New York, and Washington. “Prenatal exposure to tobacco smoke has been connected to both short- and long-term effects

Minnesota Physician June 2014

on babies, including lower birth weights, birth defects, asthma, and neurobehavioral problems,” said lead author Logan Spector, PhD, associate professor at the University of Minnesota. “These effects also don’t consider other potential [lifetime] risks, such as cancer.” Currently, maternal smoking rates are tracked mostly through information recorded on birth certificates. To determine smoking rates among pregnant women objectively, researchers tested the dried blood spots for cotinine, a marker created by the body after nicotine exposure. They found that 12 percent of the tested samples showed levels indicating the mother had smoked within the last several days before birth. However, 41 percent of those mothers were not noted to be smokers. “The numbers we found were similar to other studies of socially disapproved behaviors during pregnancy, showing many women underreported their tobacco use to physicians or nurses,” said Spector. “Still, this number may underestimate the number of women who smoke late in

pregnancy; our tests only show those babies exposed to tobacco products between three and five days prior to birth.” The new assay was developed by Sharon Murphy, PhD, at the University of Minnesota to collect quantitative data from small dried blood samples. “This collection method may be particularly useful in low-resource nations or in data collection points where many participants will be sharing their samples,” said Spector. “Dried blood spots are hygienic, lightweight, and do not require refrigeration, as well as being non-invasive for participants. It’s a very efficient model for research.”

Allina and Children’s Begin $30 Million Expansion On May 14, Allina Health and Children’s Hospitals and Clinics of Minnesota broke ground on a $30 million, 62,000-square-foot expansion at Mercy Hospital in Coon Rapids.

Mercy will move its current birth center into the two-story addition, called the Mother Baby Center. A skyway will connect the expansion to the hospital’s main operating room to better serve high-risk patients. The new facility will include 10 labor and delivery rooms, 22 postpartum rooms, two large operating rooms, an infant resuscitation room, a 10-room Level II special care nursery, and private patient rooms with full bathrooms and foldout sofas. “Adding more specialized services at Mercy, especially for high-risk mothers and babies, will mean fewer will need to go farther from home for care,” said Penny Wheeler, MD, president and chief clinical officer at Allina Health. Hospital officials expect the center to open by mid-2015. It initially will have the capacity for 2,700 births each year, with shelled space for growth and the potential to accommodate 3,500 births annually.

Researchers Study Strategies to Reduce Early Readmissions Mayo Clinic researchers reviewed 47 randomized studies that assessed several methods to reduce readmissions, and found that the rate of 30-day readmissions can be reduced by nearly 20 percent when specific preventive measures are taken. “Reducing early hospital readmissions is a policy priority aimed at improving quality of care and lowering costs,” said Aaron Leppin, MD, research associate at Mayo Clinic. “Most importantly, we need to address this issue because hospital readmissions have a big impact on our patients’ lives.” Currently, studies estimate that one in five Medicare beneficiaries is readmitted within 30 days of hospitalization, costing $26 billion annually. “Patients are sent home from hospitals because we have addressed their acute issues,” said Leppin. “They go home with a list of tasks that include what they were doing prior to the hospitalization and new self-care tasks prescribed on discharge. Some patients cannot handle all these requests, and it is not uncommon

for them to be readmitted soon after they get home. Sometimes these readmissions can be prevented.” Researchers found that the most effective interventions, those that reduced readmission rates by almost 40 percent, are more complex and help patients do the work that is needed on their part. In addition, researchers found that the trend toward simpler, high-tech strategies during the last two decades generally has been less effective in reducing readmissions.

Minnesota Ranks First on Health Performance Minnesota has ranked first among 50 states and the District of Columbia on the 2014 Commonwealth Fund’s Scorecard on State Health Performance. The scorecard measured 42 health indicators of health care access, quality, costs, and outcomes from 2007 through 2012. The majority of states in the bottom quartile rankings are located in the south, with the exception of Indiana and Nevada. Most states in the top quartile rankings are in the upper Midwest, along with Colorado and Hawaii. Despite the overall high ranking, Minnesota did not score well on several specific health indicators. It ranked 37th in “children ages 19 to 35 months who received all recommended seven doses of vaccines,” 48th in “home health patients whose wounds improved or healed after operation,” and 34th in “adults with a usual source of care.” In addition, some scores worsened from the last scorecard, including those in the categories “adults who went without care because of cost in the past year,” “children ages 10 to 17 who are overweight or obese,” “adults who smoke,” and “adults without a dental visit in the past year.” According to the overall results, most states did worse, or didn’t improve on the 34 indicators for which long-term data is available. “No state is making widespread progress toward the achievable outcomes that all individuals should expect considering Capsules to page 6

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Capsules from page 5

the substantial and increasing resources devoted to health care in the United States,” noted Douglas McCarthy, Commonwealth Fund senior research director, and his colleagues in a commentary on the report. “Spending increased in all states on both a per-capita basis and as a share of total state income. And still, the scorecard points to deteriorating access to care for adults, stagnant or worsening performance on other key measures such as preventative care for adults, and widespread disparities in peoples’ health care experiences across and within states. These findings together suggest that the return on our nation’s health care investment is falling woefully short.”

UCare Releases P4P Details UCare has announced specifics of its 2014 Pay for Performance (P4P) program, including the health-care quality measures that will be used to determine rewards for providers and health care

systems serving the 400,000-plus Medicaid, Medicare, and Special Needs Plan members in Minnesota and western Wisconsin. Criteria were chosen to improve preventive care, identify health issues through screenings, and achieve improved outcomes for chronic conditions such as diabetes and cardiovascular disease. Quality measures are based on specifications from the Minnesota Department of Human Services, Minnesota Department of Health, the Healthcare Effectiveness Data and Information Set, the Institute for Clinical Systems Improvement, and MN Community Measurement. All measures will be rated equally in determining rewards. “We are pleased to offer a Pay for Performance program that encourages and supports providers in their work to help UCare members improve and maintain optimal health,” said Russel Kuzel, MD, MMM, senior vice president and chief medical officer at UCare. The program rewards improvement in the preventive care areas of breast cancer screenings,

cardiovascular LDL cholesterol screenings, diabetes LDL cholesterol screenings, diabetes-monitoring nephropathy, well-child visits within the first 15 months of life, adolescent well-care visits for 12- to 21-year-olds, antidepressant medication management, and postpartum care. Providers were required to opt in by Feb. 28 to participate in the program. UCare will prepare quarterly “action lists” for providers that contain the names and contact information for members who may be due for services related to the 2014 measures. UCare will examine patient care claims processed in 2014 for each provider, and compare them to the P4P criteria and provider’s goals to determine financial rewards in 2015. UCare has had a P4P program in place since 2002.

Park Nicollet Announces Maple Grove Expansion Park Nicollet has announced

plans to develop a $48 million, 115,000-square-foot outpatient regional center in Maple Grove. “Patients want access to primary and specialty care services in one convenient location where care teams are working together to make it easy for them,” said David Abelson, MD, Park Nicollet president. “This model is an opportunity to improve health, experience, and affordability for patients.” The regional center will consist of a newly constructed three-story medical building that will connect to the health care system’s existing clinic in Maple Grove. It will house specialty clinics, and offer primary care and outpatient services. The existing structure will be converted to an ambulatory surgery and endoscopy center, services that Park Nicollet currently does not offer in Maple Grove. Park Nicollet plans to begin construction on the new facility this summer and finish by late 2015. The ambulatory and endoscopy center conversion is expected to open in 2016.

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Minnesota Physician June 2014

Medicus Sheldon Burns, MD, Edina Family Physicians, has been named 2014 Family Physician of the year by the Minnesota Academy of Family Physicians. The award is presented annually to a family physician that represents the highest ideals of family medicine, including caring, comprehensive medical services; community involvement; and service as a role model. In addition to his clinical practice, Burns serves Sheldon Burns, as medical director for the Minnesota TimMD berwolves, Lynx, and Wild, and has been the team physician for the Minnesota Vikings since 1985. He has volunteered at 11 Olympic games and is the on-call physician for the Target Center and Xcel Center to treat performers and touring staff. Burns is board-certified in family medicine, emergency medicine, and sports medicine. Patients, community members, and colleagues nominated physicians across the state for the award.

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Krisa Christian, MD, board-certified in internal medicine, has joined the hospitalist department at Essentia Health–St. Mary’s Medical Center, Duluth. She graduated from the University of Minnesota Medical School and completed a residency in internal medicine at Hennepin County Medical Center (HCMC), Minneapolis. William Allen, MD, board-certified in internal medicine, has joined HCMC’s internal medicine department. He graduated from the University of Minnesota Medical School and completed an internal medicine residency at HCMC. Sandra Lewis, MD, board-certified in family medicine, has joined the HCMC family medicine departWilliam Allen, MD ment. She graduated from the University of Minnesota Medical School and served a family medicine residency at HCMC, as did new HCMC family medicine staff member Bryan Nelson, MD, board-certified in family medicine. Krisa Christian, MD

William Lee, MD, board-certified in surgery, has joined Bryan Nelson, Glacial Ridge Hospital, MD Glenwood. Lee earned his medical degree from the University of Iowa Carver College of Medicine, Iowa City, and completed his internship and residency in general surgery at Michigan State University, Kalamazoo.

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Timothy J. Wilt, MD, MPH, board-certified in internal medicine, has received the 2014 VA Undersecretary’s Award for Outstanding Achievement in Health Services Research. A staff physician in general medicine at the Minneapolis VA Medical Center and a professor of medicine at the University of Minnesota Medical School, Wilt’s research has led to the development of national pracTimothy J. Wilt, tice guidelines for implementing high-value, MD, MPH cost-conscious health care, especially in the area of screening. He earned a medical degree from the University of Illinois School of Medicine–Chicago, and completed an internal medicine residency at the University of Minnesota, where he also earned a master’s degree in public health.

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June 2014 Minnesota Physician



The American Academy of Neurology A s executive director and CEO of the American Academy of Neurology (AAN), what are your duties?

Catherine M. Rydell, CAE American Academy of Neurology Catherine M. Rydell, CAE, has been the executive director and chief executive officer (CEO) of the American Academy of Neurology (AAN) since 1999 and is the executive director of the American Brain Foundation. Currently based in Minneapolis, Minn., with offices in Washington, D.C., and Rochester, N.Y., the AAN is a worldwide professional association of neurologists and neuroscience professionals dedicated to promoting the highest quality patientcentered neurologic care. Under Rydell’s leadership, membership in the AAN has grown from 16,000 to more than 27,000 members.

The textbooks will tell you an association CEO has ultimate management responsibility for the organization and primary responsibility for execution of strategic plans and policies as established by the Membership is a smart investment. By becoming board of directors. While all that is true, the poa member of the AAN, members join a group of sition is much more. I am committed to help staff neurologists committed to advancing the field of reach their potential, to develop a culture of trust, to neurology and improving the care of patients with assure the financial stability of the organization, and neurologic diseases. The AAN is the only neuroto keep our vision and mission the focus of all that logy organization of its kind that offers the array we do. We actively support continuing education of opportunities, products, programs, services, and for staff. Memberresources designed ship in professional to help all members organizations related These are exciting times for succeed at all stages of to their duties is their career⎯whether neurologists, and the options for encouraged. We they are a budding patients are expanding. also support their medical student conhigher education templating a career in goals through our neurology, a neurolotuition reimbursement program. For example, we gist in community practice, an academic educator, have supported two employees in pursuit of their law or a researcher. degrees. One of my greatest joys as CEO is seeing an employee, who has demonstrated a passion for the  How has operating a medical specialty AAN mission, advance to a position with additional professional association changed during responsibility. your tenure? While the core remains the same, the scope and  Why did you choose Minneapolis as your depth of the academy’s programs and services has headquarters? evolved dramatically in the last 15 years. When I beWe have a rich history that began in Minneapolis came the executive director/CEO, we had 68 people in 1948, when the AAN was founded by A.B. Baker, on staff, 15,000 members, and a budget of $14 milMD, the chair of the neurology department at the lion. We now have 160 people on staff, nearly 28,000 University of Minnesota. We have remained in the members, and a budget of $40 million. Our memTwin Cities for our 66 years, and until recently our bers, whether in private or academic practice, have office was in St Paul. In 2012, we were thrilled to seen dramatic changes in health care delivery and return to our roots in Minneapolis, establishing a we focus on getting them the resources they need to permanent global headquarters. With its proximity provide high-value, patient-centered care. to light rail transit, the Twin Cities airport, and numerous hotels, restaurants, and theaters, the historic  As technology moves forward, more Mill District is an ideal destination for academy staff neurologists are partnering with other and the more than 800 neurologists who travel to kinds of physicians. What can you tell us Minneapolis each year to attend academy meetings. about this? And like many national professional associations, Neurologists have always partnered with other we also have an office in Washington, D.C., focused providers to optimize patient care. Telemedicine has on federal advocacy for our members and their brought neurologic expertise to areas of the country patients. where very little was available.

W hat services do you provide for your members? We are the world’s largest association of neurologists, with more than 27,000 members. AAN members have access to exclusive member benefits such


Minnesota Physician June 2014

as top-quality education, science, practice management tools, clinical guidelines, and much more. The AAN is indispensable to its members by upholding its mission to promote the highest quality patient-centered neurologic care and enhance member career satisfaction.

We were one of the first specialties to recognize and support the primary care “medical home.” Primary care physicians look to their neurology colleagues to provide care for patients with complex and chronic neurologic conditions. We partner with

nearly every other specialty in the development of evidence-based practice guidelines that are critical in providing high-value care. For example, we worked with the American College of Emergency Physicians (ACEP) to develop a guideline for use of tPA in stroke care, we partnered with the American Headache Society to update AAN’s 2012 migraine prevention guideline, and we often collaborate with the Child Neurology Society on our guidelines regarding a pediatric focus.

W hat do you have to say about all the research linking sports-related concussions to neurologic disorders later in life? Due to the emphasis and increased awareness surrounding concussion, the AAN, which is the world’s leading authority on sports concussion, is holding its first-ever “The Sports Concussion Conference” for health care professionals, including neurologists, athletic trainers, primary care physicians, neuropsychologists, and sports medicine professionals. The conference will focus on the chance for attendees to learn about the very latest scientific advances, the science behind concussion, applying the latest advancements in the diagnosis and treatment of sports concussion, and information about post-concussion syndrome

in professional, collegiate, or high school arenas.

W here do you see the future of neurology heading? As our population ages, we will see a greater need for neurologists. Baby boomers are at an age where their chance of having neurologic illness is increasing. We currently have a shortage of neurologists and that shortage is expected to grow. We need to attract young people to the neurosciences to assure that the pipeline of qualified professionals is large enough to meet the need.

W hat are the most important things that you believe other doctors don’t know about neurologists—but should? When I interviewed for this position nearly 16 years ago, I was the executive director of the North Dakota Medical Association (NDMA) and one of my references was my former NDMA president. He was a primary care physician in rural North Dakota. He said, “Are you sure you want to go work for neurologists? They’re a little weird.” I assured him the ones I had met were not “weird” but very bright and passionate people who cared deeply about their professional organization and the patients they treated. During my interview, I

admitted that I knew little about neurologic disease and was shocked to find out that a neurologic disease affects one in six Americans. In 1999, there were very few treatments, no preventions, and no cures, and, as a result, neurologists had the reputation of “diagnose and adios.” Whether that phrase was earned or merely perceived I’m pleased to say that things have changed dramatically. Research has developed and identified preventions; drugs and devices have been developed to slow progression and improve quality of life; and cures for some major neurologic diseases may be on the horizon. These are exciting times for neurologists, and the options for patients are expanding. Other physicians may or may not be as familiar with these changes. To assure the best possible care for their patients, they should consult and refer to the expertise of neurologists and child neurologists. Diagnosis of a serious neurologic disease is a complicated process. Misdiagnosis can be devastating to patients and their families. In my time working side by side with neurologists and child neurologists, I have come to know them as the brightest, most caring, and dedicated people I know. They follow their patients for years and even decades and help them and their families cope with devastating and debilitating diseases. They are my heroes.


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Memory loss that disrupts daily life


New problems with words in speaking or writing


Challenges in planning or solving problems


Misplacing things and losing the ability to retrace steps


Difficulty completing familiar tasks


Decreased or poor judgment


Confusion with time or place


Withdrawal from work or social activities


Trouble understanding visual images and spatial relationships


Difficulty completing familiar tasks

Recognizing the symptoms is the first step toward doing something about it. Early detection matters. The Alzheimer’s Association can help your patients develop a plan for the future.

June 2014 Minnesota Physician


Electronic media and children from cover

not only how this affects the health of our patients, but also how we can help guide them to make rational media choices for themselves and their families as we navigate the health-related and social implications of this new digital world together. Not long ago, pediatricians recommended two simple media rules: keep television

world, where the proliferation of smartphones and other mobile devices have put movies, television shows, video games, and Internet access literally in the palm of our hand? What does it mean for children to be connected 24/7 and how does that affect their health and well-being? Media saturation It’s important to understand why media use is even consid-

Homes with even a few rules for media use had markedly less media usage than those without rules.

sets out of children’s bedrooms and limit screen time to no more than two hours a day. But how does that play out in today’s technology-drenched

ered a health problem, especially for children and teens. To do that, we first need to look at the scope of youth media use.

Are Your Patients Ready? Minnesota’s New Immunization Law Goes into Effect 9/1/14 There are important changes that apply to children entering school, child care, and early childhood programs. This means you likely have patients Are Your Kids Ready? who will need to get caught up on some of their immunizations between now AreMinnesota’s Your Kids Ready? Immunization Law Minnesota’s Immunization Law and the end of summer. vaccines that are required recommended, Usethe this chart as a guideFor to determine which vaccines are required to enrollor in child care, early childImmunization chart asand a guide to determine which vaccines are required to enroll in child care, early childhoodthis programs, school (public or private). Immunization Requirements Use please use thishood chart (legal exemptions are available). programs, and school (public private). Requirements Find the child’s age/grade level andorlook to see if your child had the number of shots shown by the Find the child’s age/grade level and look tobirth see iftoyour number of shots shownLook by the checkmarks under each vaccine. Children age child 2 mayhad notthe have received all doses. at the checkmarks under iteach vaccine. Children birth to age 2 may not have received all doses. Look at the table on the back, shows the age when doses are due. table on the back, it shows the age when doses are due. Age: 5 through 6 years Age: 7 through 11 years Birth through 4 years Age: 12 years and older Age: 5 through 6 years Age: 7 through 11 years Birth through 4 years Age: 12thyears and older Early childhood programs For 1st through 6th For 7 through 12th For Kindergarten th Early childhood programs & Child care For 1stgrade through 6 For 7th grade through 12th For Kindergarten & Child care grade grade

 Check marks represent number of doses

Hepatitis A (Hep A) Hepatitis A (Hep A)  Hepatitis B (Hep B)  Hepatitis B (Hep B) 

DTaP/DT  DTaP/DT 

Polio  Polio  MMR  MMR  Hib  Hib  Pneumococcal  Pneumococcal  Varicella  Varicella

Hepatitis B  B Hepatitis 


  DTaP   


Hepatitis B

 B Hepatitis  tetanus and anddoses tetanus diphtheria containing

diphtheria containing doses

 Polio  MMR  MMR 

Polio  Polio  MMR  MMR 



atTdap 7th grade at 7th grade

Polio  Polio  MMR  MMR  Meningococcal   atMeningococcal 7th grade & at  age 16

  at 7th grade & at  age 16


 Varicella   Immunizations recommended but not required: Immunizations recommended but not required: Influenza

Varicella  Varicella 

Immunizations recommended but not required: Rotavirus For infants Rotavirus

Hepatitis B  B Hepatitis

Annually for all children age 6 months and older Influenza Annually for all children age 6 months and older

For infants

Varicella  Varicella 

Human papillomavirus At age 11 -12 years Human papillomavirus At age 11 -12 years

Call in patients who need vaccines. Use the Minnesota Immunization Information Connection (MIIC) to identify and call in children who still need to get their shots. For more information or technical assistance, contact your MIIC regional coordinator:


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To enroll in child care, early childhood programs, and school in Minnesota, children must show To enrollhad in child early childhood and school in Minnesota, children must show they’ve thesecare, immunizations or fileprograms, a legal exemption. they’ve or file a legal Parentshad maythese file a immunizations medical exemption signed byexemption. a health care provider or a conscientious objection Parents may file a medical exemption signed by a health care provider or a conscientious objection signed by a parent/guardian and notarized. signed by a parent/guardian and notarized. For copies of your child’s vaccination records, talk to your doctor or call the Minnesota Immunization Information Connectionrecords, (MIIC) attalk 651-201-5503 or or 1-800-657-3970. For copies of your child’s vaccination to your doctor call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 1-800-657-3970.

Minnesota Department of Health, Immunization Program Minnesota Department of Health, Immunization Program

Minnesota Physician June 2014

IC# 141-3830 (3/2014) IC# 141-3830 (3/2014)

In 2010, the Kaiser Family Foundation published a comprehensive report on media habits of children ages 8 to 18. The report found that children engaged in some type of media use (television, music, video games) for approximately 7.5 hours/day. In other words, media impacts nearly one-third of the child’s day, a duration that exceeds time spent in the classroom and, by some estimates, even sleep. This takes time away from the 60 minutes of moderate to vigorous physical activity on most days of the week for children and adolescents recommended by the American Academy of Pediatrics (AAP).

nology that facilitates social interaction that allows users to create, exchange, and discuss content online.

The Kaiser report noted that about one-third of the children’s total media time was spent watching television, while one-quarter was on a computer. Twenty percent of children used a mobile device to access media. The report also accounted for media multitasking, or using more than one type of media simultaneously, which increased total media impact to 10.75 hours/day. Of note, even though television remained the most-used media platform at nearly 4.5 hours/day, television watching began to shift to alternate platforms, such as mobile devices.

It has been suggested that the anonymity offered by the Internet may allow for identity exploration in teenagers, free from possible judgment by family and real-life peers.

Teens online The Pew Internet and American Life Project released data in 2013 showing that 95 percent of teenagers age 12 to 17 had access to the Internet, with 74 percent of them having access through a mobile device such as a smartphone or tablet. About 80 percent of teens who went online used a social network such as Facebook, MySpace, or Twitter. Almost half went online to shop and 62 percent looked up news or current events. Pew also noted that texting had become the communication style of choice for teens; more than half (54 percent) reported texting on a daily basis. Teenage girls led the pack with an average of 100 texts per day. Social media and teens Social media is an online arena that teens have gravitated toward in recent years. “Social media” refers broadly to tech-

For teenagers, social media allows access to a seemingly limitless source of information on issues of interest, along with the opportunity to interact with others who share those interests, regardless of geographic and other barriers. According to a 2010 Pew report, 31 percent of online teens sought health information from the Internet, including diet and fitness tips. Some 17 percent reported using the Internet to get information on sensitive topics like sexual health and drug use.

Online pitfalls Concerns have been raised about the safety, privacy, and health of young users of social networks. According to a 2007 Pew report, almost one-third of teens reported being the target of online bullying. Cyberbullying is a form of online harassment that may take the form of hostile messages, sharing of private information, spreading rumors, manipulating photographs, or other negative online communication. Unlike face-to-face bullying, cyberbullying is not confined by geography or time. Embarrassing or hurtful content can be shared with a larger audience for an indefinite time. There is no protected area to which bullied teens can escape. Studies have shown that victims of cyberbullying may have lower self-esteem, suffer more health problems, and have poor academic performance. Moreover, because of the virtual immortality of Internet content, cyberbullying may have more lasting consequences for teens. A 1998 study in American Psychologist suggested that time spent online may increase feelings of loneliness and depression. However, “Facebook depression” is still somewhat controversial due to conflicting evidence. A 2012 study from

the University of Wisconsin did not find a connection between Internet activity and a clinically validated measure of depression. A 2009 study published in the Archives of Pediatric and Adolescent Medicine focused on online candor regarding highrisk behavior in 18-year-olds, noting that 54 percent publicly posted about sexual behavior, alcohol, or drug use. Additional studies reported a correlation between increased media use and obesity, sleep disturbance, poor body image, early sexual activity, violence, and eating disorders. Good news But the news isn’t all bad. Media that contains educational content and promotes positive social values has shown promise, when used judiciously. Pediatricians still recommend no screen time for children under age 2, since there is no evidence to show any developmental benefit from infant-directed “educational programs.” In fact, researchers at the Seattle Children’s Research Institute noted expressive speech delays among infants exposed to purported educational videos, compared with those who were not exposed. But for preschool age children, ad-free educational programming has shown gains in school readiness and diversity awareness. Although results are mixed, some studies have shown that “exergames” (video

Adolescents and the Media” to better address children’s widespread exposure to electronic media. Physicians can share these recommendations with families as part of their anticipatory guidance: • Create a family media use plan with reasonable, but firm, rules that limit total screen time to less than 2 hours per day (none for children under age 2) and a curfew for electronic devices. • Keep all screens and devices with an Internet connection out of children’s bedrooms. • Monitor what media children are using, including social media sites. • Co-view and discuss media with children. • Encourage use of pro-social media and responsible digital citizenship. The physician’s role There has also been growing interest among physicians to use social media to reach out to patients. The Mayo Clinic Center for Social Media even offers a “Social Media Residency,” geared toward physicians who would like to leverage the power of social media to educate and communicate with patients and the larger public, while understanding the unique issues related to patient confidentiality and professionalism that arise with an online presence.

Physician media education resources • AAP Pedialink Online CME course: http://pedialink.aap.org/visitor/ cme/cme_finder/cme-detail?guid=e7b42dfa-a9a6-4c36-b3e51845295b82cd&pageId=18c39bb1-3268-4c87-9652-396d22e4c473 (Disclosure: I served as editor and lead author for this course, which was just launched in April 2014. There is a fee associated with it, but I receive no financial compensation whatsoever from it)

• AAP COCM Education and Resources page: www.aap.org/en-us/ about-the-aap/Committees-Councils-Sections/Council-on-Communications-Media/Pages/Education-and-Resources.aspx • Mayo Social Media Residency: http://network.socialmedia.mayoclinic. org/learning/social-media-residency

and possibly more relatable— way, to educate the public about immunizations, child development, preventive care, and other important health issues, including breaking medical news. The task of counseling families on rational media use may seem daunting, but the Kaiser study showed that homes with even a few rules for media use had markedly less media usage than those without rules. While elimination of media is unrealistic and potentially crippling in an increasingly tech-driven world, it’s important to strike

a balance with media use, in terms of quantity and quality. Moreover, the ubiquity of media may present physicians with a novel opportunity to reach a wider audience than the exam room alone would allow. This may be the best possible time to take advantage of a very powerful tool to promote health and well-being. Nusheen Ameenuddin, MD, MPH, is a board-certified pediatrician and an assistant professor of pediatrics at Mayo Clinic. She also serves on the executive board of the AAP’s Council on Communications and the Media.

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Improving communication from cover

45 years or older self-report a vision problem. All these numbers indicate that it will become more common for physicians to have patients with vision loss. They should be treated like any other patient, of course, but a medical professional should be sensitive to a few issues. For example, it is all right to use the terms “see,” “look,” or “vision,” such as “It’s good to see you today.”

individual who is legally blind, who was seen at the emergency department for stomach pain and vomiting. The physician was more concerned about the vision loss experienced for years, however, rather than the reported pain. Adjusting to vision loss Although your patient with vision loss may have psychologically adjusted and is quite independent, occasionally, you may see a patient who is beginning the process, or you may

Patients with vision loss should be treated like any other patient, of course, but a medical professional should be sensitive to a few issues. When scheduling a patient with vision loss, it is important to ascertain if the vision loss will affect the appointment or treatment. At times, vision loss may be germane to the appointment, and at other times, it may not. For instance, I know of an

provide the initial diagnosis. It is important to let the patient know that even if nothing can be medically provided to save or repair his or her vision, it does not mean a future of dependence and isolation. This tends to be a tough time for patients,

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Minnesota Physician June 2014

but with time, education, and support, they can lead full and productive lives. As people adjust to vision loss, they need to incorporate vision loss into their self-concept. When first being told their vision loss is permanent or progressive, many people are shocked or saddened by the confirmation. They may appear depressed, but it usually does not indicate clinical depression and rarely is it chronic. I would encourage you to refer such patients to SSB, where they can learn about a variety of options available to them. Nonvisual skills can be learned. Aids, devices, and assistive technology are available to access print and other visual media. Hope can be provided when things seem hopeless. Tips for working with patients with a vision loss Overall, physicians are more aware of the breadth of human experience and the varieties of impairments than the general population. Nonetheless, it may be helpful to review some practical tips for interacting with patients who are blind, visually impaired, or deafblind. Always ask. The most straightforward and simplest guideline to remember is just to ask first, even questions to which you may already have a good idea of the answers. Ask your patient how much he or she can see or not see. Legal blindness does not necessarily mean total blindness or no vision. Interestingly, more than 90 percent of people with legal blindness have some vision. Conditions and diseases of the eye result in different kinds of vision loss, but even in instances where the eye condition is the same, the amount that one person can see—and the way they use what sight they have—may vary widely from another person with the same condition. Lighting conditions, glare, fatigue level, etc., all play a role in what a person is able to see. Ask if they would like assistance, and how they would like to be assisted. In general, it’s the prerogative of each individual to ask for assistance, and in the form they need it. But if you

are unsure, or believe a patient needs assistance, always ask first (e.g., “Would you like guidance to the chair?” or, “Would you like someone to guide you to the lab?”). These kinds of questions give the patient choices. When going from one area to another, some people who are blind or visually impaired prefer to use a sighted guide. This involves taking someone’s arm just above the elbow; others place a hand on the guide’s shoulder. In both cases, the guide is slightly in front of the individual, allowing for sensory cues on what is ahead. Many people with vision loss use white canes, which helps with locating doors, obstacles, curbs, people, or whatever is in the environment. White canes are long enough to be roughly two steps ahead of the person’s feet when walking, so the cane will find an object before the person. Canes come in all sizes; some fold for convenience. Some people use guide dogs. The dogs are trained to move the individual around things, locate doorways, and stop at curbs or steps. The person using the guide dog is in charge and must tell the dog what to do. Guide dogs are highly trained and should not be petted or distracted. Other people may prefer to navigate on their own and may ask for voice guidance. In such circumstances, remember to keep talking so that the individual has an extra audio cue for where you are headed—with or without the use of a white cane, they will be able to navigate from the sound of your voice. Patients who are deafblind will probably have some vision, some hearing, or both. They should have provided their preferred method of communication prior to the appointment, but if not, ask. There are a number of ways to communicate, including using an FM system; writing with a bold, black pen; tactile American Sign Language; or using a deafblind communicator. Be specific. We’re used to giving shorthand directions accompanied by gestures, such as “Sit here,” “The pharmacy is

that way,” or, “The papers are right there.” It’s important to remember to use specific language that doesn’t rely on a visual cue, or indicate a general direction such as “Sit over there.” When talking with a patient with a visual impairment, it can sometimes be helpful to use clock coordinates when identifying direction, such as “The table is at 1 o’clock from where you are standing.” In other cases, the more specific you can be, including adding references to tactile landmarks, the more helpful your directions will be, such as “Go down this hall and take a left when you reach the carpeted section,” or, “Follow the right-hand wall until you reach an opening.” Provide written materials in accessible formats. Many people who are blind or visually impaired use computers and can access documents in electronic formats. Some people use screen magnification programs, which enlarge the text,

provide options for color contrast settings, and offer other modifications. Others use screen-reading software, which translates text to speech. Making documents available in a digital format allows patients who are blind and visually impaired direct access. Fewer than 10 percent of people who are legally blind read Braille; most use enlargement or electronic formats. Resources available from State Services for the Blind The mission of SSB is to facilitate the achievement of vocational and personal independence by Minnesotans who are blind, visually impaired, or deafblind. All services are individualized according to a person’s unique needs. SSB serves individuals of all ages. SSB has several units to serve customers, including: • The Communication Center, which provides print

Do you have patients who are experiencing vision loss? If they are concerned with maintaining their independence, accessing print, remaining in their homes, or having difficulty with their employment due to vision loss, encourage them to contact State Services for the Blind. Its offices are located throughout the state of Minnesota. SSB’s main office is located at 2200 University Avenue West, Suite 240, St. Paul. The phone number is (651) 539-2300 or (800) 652-9000. Additional information can be found at www.mnssb.org

obtain, retain, and maintain employment

information in accessible formats including Braille and audio

When seeing patients with vision loss, just remember we are more alike than different. Treat these patients as you would anyone else, but be sensitive to accommodations they may need. If in doubt, just ask. Unless they have hearing loss, speak with a regular tone and volume to a person who is blind. There is no need to talk through their companions at the appointment. Just relax and focus on the common goal of your patients’ health.

• Senior Services, which serves individuals with vision loss who are not seeking employment and want to remain in their homes, but need the tools and knowledge to function with limited vision or non-visually • Workforce Development, which is part of the state-federal Vocational Rehabilitation Services assisting individuals with independence, and which works with customers to

Maurita Christensen, MS, PhD, CRC, is the psychologist at State Services for the Blind.

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anaged care payment mechanisms for mental health services have placed primary care physicians in an uncomfortable position. Often, during the typically brief patient visit, a primary care doctor encounters somatic complaints without a structured illness. These can include headaches, indigestion, insomnia, tiredness, lethargy, and backaches. Perhaps the primary care physician will prescribe medications to treat an underlying mental health issue, or maybe the underlying issue isn’t recognized at all. Most primary care doctors are unprepared by both time constraints and training to deal with patients whose primary concerns relate to mental health. Two recent developments suggest there may be hope for solving this problem. First, mental health parity became law in 2008. The late Minnesota Sen. Paul Wellstone, who spearheaded the legislation, wanted to address the stigma, isolation, and payment inequities that

Mental health in transition Integrating patient care into the medical home By James J. Jordan, MD

made the delivery of mental health services inadequate. Second, and occurring at approximately the same time, the concept of the “medical home”

When we embed a mental health professional directly into a group practice, a partnership is created between the patient and physician. gained momentum. The medical home provides an opportunity for holistic delivery of patient care, with an emphasis on

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Minnesota Physician June 2014

endorsed the incorporation of mental and behavioral health into the patient-centered medical home. This concept has great merit. Expanding on the idea, I believe that when we embed a mental health professional (MHP) directly into a group practice, a partnership is created between the patient and physician. The partnership involves looking at both the mental and physical condition of the patient. Some, but not all, family doctors are already well suited and sufficiently trained to treat most mental health disorders. Regardless of their training and suitability for the task, however, many doctors find they do not have adequate time to properly evaluate the mental health complexity and severity of a patient’s condition, and resort to drug therapy by default. But drug therapy often misses the mark and can cause additional side effects that complicate the picture. Luckily, Minnesota has an adequate supply of well-trained psychologists, social workers, and nurses prepared—or willing to be prepared—to work as MHPs along with family physicians. When MHPs are close at hand, family doctors can easily and more efficiently stratify risk, separating out the patients whose presenting concerns may

respond better to mental health treatment. MHPs can manage most routine mental health delivery. They can make recommendations as to when patients require medications and when a psychiatric consultation is needed. Creating a partnership The medical home model offers the opportunity to build a more robust partnership between the patient and primary care physician. Ideally, it would include a mental health evaluation with the physical examination. Patients in Minnesota benefit from access to a mental-health screening device, the PHQ9. This tool has been recommended as a screening measure for depression since 2008. It was initially promoted by the Depression Improvement Across Minnesota (DIAMOND) project. In 2013, the Minnesota Department of Health (MDH) issued final rules mandating the use of the PHQ9 for primary care patients. However, the MDH is not vigorously enforcing non-reporting because compliance has been so good. As of October 2013, 80 percent of family practice, internal medicine, psychiatry, and geriatric practices throughout Minnesota have been reporting PHQ9 data to MN Community Measurement. Access to the PHQ9 score gives the primary care physician some information regarding a patient’s mental health status. He or she can make better-informed decisions about whether the patient will benefit from referral to an MHP. It is important to remember that the PHQ9 is a measure for depression, and doesn’t address many other important elements of mental health. The mental health conversation The norm for a psychiatric first visit is one hour, but in my experience, a brief conversation can yield a gold mine of information. A method of investigation that I have found particularly helpful is something I call the “10-minute hour.” This is a term for a consultation liaison visit, and a skill I learned as psychiatry resident at the Mayo Clinic.

It can be adapted by primary care physicians assessing patients for functional determinants of illness. Taking approximately 10 minutes, a physician can elicit enough information from a patient to determine whether or not more tests are needed to uncover the cause of physical complaints, or if the complaints indicate the presence of somatic manifestations of mental illness. The doctor frames the discussion by telling the patient that “We have up to 10 minutes to talk about your concerns about stress, relationships, work problems, sleep and eating issues, etc.” Patients are surprised, but happy to be given permission to voice and give definition to their emotional lives. If the doctor detects one or more red-flag symptoms, rather than write a prescription for an anti-anxiety or an antidepressant medication, he or she explains that more needs to be done and that someone trained in further assessment is available to help address the patient’s

concerns. The doctor identifies the MHP at hand and writes a referral for the patient, then finishes the physical examination and necessary treatment. Only in a psychiatric emergency would the doctor prescribe drug medication at this point. The doctor informs the patient that he or she will be collaborating with the MHP. The doctor will undoubtedly want to see the patient again as soon as the mental health testing and consultation are completed; this is especially true if medication is required. The patient may continue working with the MHP, and this will be coordinated with the patient’s overall medical care. Furthering the partnership Patients who repeatedly raise concerns that need to be addressed by an MHP should be reassured that they are taken seriously and given an opportunity to talk with a mental health professional. Some primary care physicians are overwhelmed when

Learn more about the topic: • University of Minnesota Department of Family Medicine and Community Health (www.fm.umn.edu). CME credit available. • Collaborative Family Healthcare Association (www.cfha.net). Conference “From Fragmentation to Integration” will be held in Washington, D.C., October 2014. CME credit available. • Continuing mental health education for social workers, psychologists, psychiatrists, and family doctors sponsored by Hamm Clinic (www.hammclinic.org).

dealing with the chronically mentally ill patient. When the PHQ9 or the doctor’s impression of the patient raises concerns that the patient may have serious mental illness, the physician should waste no time in setting up a patient meeting with an MHP. Then, the doctor could work closely with the MHP in a long-term collaboration. The doctor may or may not be the first prescriber of psychoactive medication for the patient. An MHP could provide treatment plan monitoring and case management by contacting the patient to inquire whether medications are helping and/ or if the patient is suffering serious side effects. In addition,

an MHP could call patients to remind them of upcoming appointments, and provide treatment at home, much like a visiting nurse. Most primary care physicians have encountered patients like those discussed in this article. We have yet to establish or adopt best practices for how to approach the issues they pose. An expanded use of the medical home model, as I have proposed, holds significant promise. James J. Jordan, MD, is a board-certified psychiatrist. For 25 years, he was the director of Hamm Memorial Psychiatric Clinic, St. Paul. He now works as a consultant at Blue Cross and Blue Shield of Minnesota.


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June 2014 Minnesota Physician




Intranasal insulin

he severe anxiety condition called post-traumatic stress disorder (PTSD) can develop after a person is exposed to one or more traumatic events, such as sexual assault, serious injury, or the threat of death. It is characterized by symptoms that may include high levels of anxiety; disturbing, recurring flashbacks; and avoidance or numbing of memories of the event, which continue for more than a month after the traumatic event.

Onset of PTSD symptoms doesn’t necessarily start immediately after the precipitating event. They can occur years later, and the duration of these symptoms can last a lifetime. The intrusive memories—occurring as flashbacks or nightmares—have been reported to contribute more to the biological and psychological dimensions of PTSD than the precipitating event itself. The delayed onset may offer a significant window of opportunity to treat

A potential therapeutic for post-traumatic stress disorder and Alzheimer’s By William H. Frey II, PhD

individuals with PTSD, or even to intervene to prevent the onset of the devastating symptoms.

Approximately 7.7 million American adults and many more millions worldwide have PTSD. Not an uncommon disorder Approximately 7.7 million American adults and many more millions worldwide have PTSD. Adults aren’t the only

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ones who are affected, either. Children and adolescents exposed to war, physical or sexual assault, abuse, accidents, disas-

Minnesota Physician June 2014

ters or other life-threatening or frightening events, are also at risk for PTSD. Some individuals may experience PTSD after a friend or family member is exposed to danger or is severely harmed. The sudden, unexpected death of a loved one can also precipitate PTSD. But not everyone is equally susceptible. Many people who are exposed to a traumatic event don’t develop the disorder. Additionally, there is some evidence that it may run in families. Women are more likely to develop PTSD than men, because they are likely to experience more high-impact trauma. Glucocorticoids are the key In the 1980s, research showed that glucocorticoids—released in response to stress—could damage nerve cells in the hippocampus, an area that is key to both memory and emotional response. Multiple mechanisms are likely involved in this action, one of which is the inhibition by glucocorticoids of glucose uptake and use in the hippocampus. This is critical, since glucose is the only source of energy used by brain cells under normal conditions. Glucocorticoids also decrease the capacity of the hippocampus to survive neurological damage, because

they inhibit glucose transport by 15 percent to 30 percent, as demonstrated in both primary and secondary hippocampal astrocytic cultures. This could impair the ability of astrocytes to help neurons by removing damaging glutamate from the synapse during times of neurological damage. Additionally, glucocorticoids released in response to major stress inhibit local cerebral glucose use throughout the brain, and inhibit glucose transport in both neurons and glia in vitro. Studies using mice demonstrated that glucocorticoids induce PTSD-like memory impairments. Cortisol, a major glucocorticoid, has been reported to reduce hippocampal glucose use in healthy elderly adults on the basis of imaging brain glucose use in response to hydrocortisone. It has also been found that mean cerebrospinal fluid cortisol concentrations are significantly higher in combat veterans with PTSD than in healthy subjects. In one study, patients with PTSD had 61 percent higher group mean cortisol levels in the time leading up to a cognitive stress challenge, and 46 percent higher cortisol levels during the period of the cognitive challenge. Treating PTSD Additional studies found that intranasal insulin (40 IU) treatment of 26 healthy adult men— minutes before they were exposed to the Trier Social Stress Test—significantly diminished both the saliva and plasma cortisol response, in a placebo-controlled, double-blind, between-subject design. Since intranasal insulin attenuates the hormonal response to stress in adult men and generally facilitates the uptake of glucose into cells, this could be helpful as a way to treat and even protect against PTSD. For example, insulin nasal sprays targeted to the upper third of the nasal cavity could be used to treat individuals exposed to a traumatic stressful event shortly after it occurred—or even to treat military personnel or first

The noninvasive intranasal method for bypassing the blood-brain barrier to target therapeutics (including insulin) to the brain to treat brain disorders was first discovered in 1989. Intranasal therapeutics bypass the blood-brain barrier and rapidly reach the brain by traveling extracellularly along the olfactory and trigeminal neural pathways. This increases efficacy while reducing systemic exposure and unwanted side effects. Intranasal insulin has already been shown in multiple phase 2 clinical trials to improve memory in normal healthy adults and in patients with mild cognitive impairment or in the early stage of Alzheimer’s disease, with no change in the blood levels of insulin or glucose.

PTSD and Alzheimer’s Why should a treatment that improves memory, cognition, and functioning in patients with Alzheimer’s disease be expected to also benefit those with PTSD? These two disorders have several key things in common. Both are characterized by elevations in blood levels of cortisol, which can increase beta amyloid and tau pathology in

utilization of glucose in both patients with Alzheimer’s and those with PTSD (although results with PTSD appear to be more variable). Finally, deficits in verbal declarative memory have been reported in patients with PTSD, and short-term memory deficits are characteristic of patients with Alzheimer’s disease.

Intranasal therapeutics rapidly reach the brain by traveling extracellularly along the olfactory and trigeminal neural pathways. rodent models of Alzheimer’s disease. In patients with Alzheimer’s, increased plasma cortisol levels are associated with more rapid disease progression. Next, hippocampal degeneration is common in Alzheimer’s disease and has been reported in patients with PTSD. Additionally, FDG-PET imaging reveals decreased uptake and

Since intranasal insulin has already been shown to improve short-term memory in both normal healthy adults and in patients in the early stages of Alzheimer’s disease, it would not be surprising if it also improved short-term memory in patients with PTSD. (It’s fortunate that it’s short-term memory, since one wouldn’t necessarily want

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responders, who are at immediate high risk for traumatic stress, by helping protect their brains against the damaging effects of such stress.

to improve long-term memory in patients with PTSD.) Timing of intranasal insulin treatment relative to the traumatic event and development of PTSD needs to be carefully examined, so that it would attenuate the cortisol response and improve short-term memory. New clinical trials are needed to determine if intranasal insulin can also be of benefit to individuals with PTSD or who are at high risk for PTSD. The first such clinical trial is scheduled for later this year.

William H. Frey II, PhD, is director of the HealthPartners Alzheimer’s Research Center at Regions Hospital, St. Paul. He invented and patented intranasal delivery of therapeutic proteins to the brain in 1989 and intranasal delivery of insulin to the brain in 1999. He thanks Drs. Amy Herstein Gervasio and Gihun Yoon for helpful discussions.

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June 2014 Minnesota Physician


Women’s health


Hormone therapy and the WHI

e are now more than 11 years beyond the initial release of the results of the Women’s Health Initiative (WHI) landmark study (see sidebar). This study of hormone therapy (HT) has had a profound effect on women’s health, and information about and interpretations of the data continue to emerge.

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With 10-plus years of hindsight, we can begin to put the lessons learned from the WHI hormone trials into perspective. And, to paraphrase Mark Twain, reports of the death of hormone therapy have been greatly exaggerated. The mass fear that led to a 71 percent decrease in hormone usage from 2002 through 2009 has softened, and the perceived risk of hormone usage has decreased. In the aftermath of all this reanalysis, my impression is that understanding and managing hormone therapy

An update of the update By Jon Nielsen, MD

are now easier than they have been for a long time.

• 65 percent less coronary heart disease • 40 percent less total MI

The key is to individualize therapy. WHI results and the timing hypothesis The key take-away from further study of the data is that the age of the patient and the length of time since the menopause began are very important variables. The WHI studied

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women with an average age of 63 who had documented cardiac disease and were without

disease. They found statistically significant differences between the estrogen-alone (E-alone) group vs. the estrogen/progesterone (E+P) group and between the older vs. younger groupings: 28 percent more breast cancer was seen in the E+P study vs. placebo, and 21 percent less breast cancer was seen in the E-alone study. Women in the age 50 to 59 group who used estrogen alone had:

Minnesota Physician June 2014

symptoms. The study was done to determine whether or not HT decreased further cardiac events. In the older women in the study, HT clearly had no benefit and actually caused some harm. In the women in the age range 50 to 59 years, HT generally caused no harm and had significant benefit. This “timing hypothesis”—that there is a window of opportunity where HT may be beneficial in younger women, but does not appear to have the same benefits for older women—has been tested from many angles and most experts agree it is valid. An excellent summary of the findings from the studies of the postintervention phase of the WHI, written by JoAnn Manson, MD, and many other original authors of the WHI, was presented in the Oct. 2, 2013, edition of the Journal of the American Medical Association (JAMA). They analyzed data from the nearly 81 percent of women in the WHI study who made themselves available for continued follow-up for up to 13 years. The authors’ objective was to try to provide insight into the value of HT for prevention of chronic disease, just as the original study was designed to do in relation to cardiovascular

• 20 percent less cancer (all types) • 18 percent fewer global index events (the global index is a very meaningful conglomerate of several endpoints, including coronary heart disease, invasive breast cancer, stroke, pulmonary embolism, colorectal cancer, endometrial cancer, hip fracture, and all-cause mortality) These data clearly offer reassurance that the risk of hormone therapy is not what was originally thought for the newly menopausal women who had had previous hysterectomy and were on E-alone therapy. In the younger women on E+P therapy, the overall trend was positive but not statistically significant. The older women in both groups had greater risk vs. placebo, and the data confirmed the concept that HT should not be used for prevention of chronic disease in this population. Reasonable conclusions from the subgroup analyses and the longer-term evaluations are twofold. First, the older women in the study had no disease prevention benefits in either trial group. Second, the 50 to 59 age group had an entirely different profile, with positive effects in many cases. Grouping all the study participants together in the original analysis

WHI postmenopausal hormone therapy trials • T he Women’s Health Initiative (WHI) was a major 15-year research program to address the most common causes of death, disability, and poor quality of life in postmenopausal women—cardiovascular disease, cancer, and osteoporosis. • T he WHI consisted of a set of clinical trials and an observational study, which together involved 161,808 generally healthy postmenopausal women. • T he clinical trials were designed to test the effects of postmenopausal hormone therapy, diet modification, and calcium and vitamin D supplements on heart disease, fractures, and breast and colorectal cancer. • T he hormone trial had two studies: the estrogen-plus-progestin study of women with a uterus and the estrogen-alone study of women without a uterus. (Women with a uterus were given progestin in combination with estrogen, a practice known to prevent endometrial cancer.) In both hormone therapy studies, women were randomly assigned to either the hormone medication being studied or to placebo. Source: www.nhlbi.nih.gov/whi/

of the WHI study led to negative conclusions that, in retrospect, probably disadvantaged many women. Ongoing disagreements— and further study Ongoing disagreement persists among experts about the overall value of and knowledge gained from these studies. JoAnn Manson, MD, a professor at Harvard Medical School and chief of preventive medicine at Brigham and Women’s Hospital, Boston, has stated that the original study information led to millions of women stopping their hormone therapy and thus “undoubtedly saved countless lives and have been linked to a reduced risk of breast cancer in the population.” This statement is based on the theory that the progressive decrease in breast cancer deaths in the last decade is based on less hormone usage. In an interesting article published in the September 2013 issue of American Journal of Public Health, Philip Sarrel, MD, an emeritus professor of obstetrics, gynecology, and reproductive sciences at Yale University School of Medicine, reached an entirely different conclusion. His analysis (entitled “The mortality toll of estrogen avoidance: an analysis of excess deaths among hysterectomized women aged 50 to 59 years”) compared the mortal-

ity data for the women 50 to 59 years of age in WHI vs. the entire population of women in the U.S., found that a minimum of 18,601 and maximum of 91,610 women died prematurely by not having the advantage of hormone therapy. Even though this study had inherently messy assumptions, it has a very valuable message. His concluding recommendation is that we need to “apply rational distinction” between the population subgroups in an informed discussion with patients about the risks/benefits of hormone therapy. This may allay the excessive fear of hormone therapy still present in so many women. During the past decade, other information about hormone therapy has emerged. The safety and efficacy of transdermal as opposed to oral hormone therapy continues to be evaluated. Two recently published studies—the British Million Women’s Study and a study from the Netherlands—show no increased venous thrombosis risk at all in transdermal users. There are now six well-done observational studies showing that transdermal estrogen is safer than oral estrogen with respect to venous thromboembolism risk. Add in the benefits of steady-state dose delivery of the transdermals, and the ability to use blood levels at any time to help manage dosage

efficacy, and there is a fairly compelling argument for transdermal preference. Due to cost and logistical challenges, it is probably inappropriate to wait and hope for definitive randomized trials to compare oral vs. transdermal HT.

Talking with patients about hormone therapy Despite our better understanding of the limitations of the WHI study and the effects of HT, it is common for informed, educated patients to present with this stated dilemma: “I feel miserable, but with all the

Hormone therapy and the WHI to page 38

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2014 health care architecture honor roll


innesota Physician’s 2014 Health Care Architecture Honor Roll recognizes 10 outstanding projects completed recently. This year’s Honor Roll projects include new clinics, hospital renovations, remodeled spaces, and facility expansions in urban, suburban, Greater Minnesota, and the borders with neighboring states. The medical services range from routine clinic visits to specialized care. Populations served include the standard roster of patients seen at outpatient clinics, as well as specialized groups—such as women, seniors seeking assisted-living housing, and patients of all ages seeking psychiatric services. Alhough the facilities differ in intended use and population served, they share a focus on providing a welcoming environment, cutting-edge technology, and waiting areas designed to engage children. Several projects incorporated sustainability and energysaving elements into their design, such as a green roof. Recovery and therapy rooms have been designed to be bright, airy, and to offer patients comfort and privacy. Minnesota Physician Publishing thanks all those who participated in the 2014 Honor Roll. Top: The Legacy Building Middle: A lower-level lobby Bottom: Main lobby


Minnesota Physician June 2014

Park Nicollet Women’s Center Type of facility: Clinic Location: St. Louis Park Client: Park Nicollet/HealthPartners Architect/Interior design: AECOM Contractor: Mortenson Construction Completion Date: April 2014 Total Cost: $4,900,000 Square feet: 27,000 Park Nicollet’s new outpatient Women’s Center consolidates more than 15 preventive and specialty services into one location on the top floor of Methodist Hospital’s existing Heart and Vascular Center. The center was designed to support comprehensive health services for women of all ages in a convenient, comfortable environment. Upon entering the floor, patients are greeted by a relaxing, spa-like atmosphere. Services such as aromatherapy, massage, and plush robes are offered to enhance wellness and reduce stress. Access to daylight is maximized and the use of natural materials, artwork, and decorative lighting presents a contemporary image of wellness. Flexible space for group visits and education classes have been integrated into the design. The new space employs multiple innovative features, such as iPads, to anticipate the needs and perspectives of patients of various generations. Care-team neighborhoods facilitate self-rooming and reduce travel distances for staff. Onstage and off-stage circulation enhance the patient experience and maximize privacy. Flexibility of the space is increased through the use of hoteling exam rooms, demountable partitions, and systems furniture. Integrated, state-of-the-art technologies support wireless staff communication as well as patient engagement.

Top: Main lobby and reception Bottom: Waiting lounge

Gundersen Lutheran, Legacy Building Type of facility: Hospital Location: La Crosse, Wis. Client: Gundersen Health System Architect/Interior design: AECOM Contractor: Kraus-Anderson Completion Date: January 2014 Total Cost: Confidential Square feet: 420,000 sq. feet of new construction; 35,000 sq. feet of renovated space To meet future facility needs, Gundersen Lutheran has adopted an aggressive, eco-friendly, sustainability plan. A major part of this plan was the development of the new Legacy Building in La Crosse. This project supported the hospital’s energy goals and addressed key needs for a more prominent campus front door, more surgical space, and additional private inpatient rooms. As part of the Legacy Building project, which physically links to the existing hospital, the overall circulation pattern was reoriented to add clarity to wayfinding throughout the facility. A new northwest entry courtyard and lobby join the addition to a central passage that crosses through the existing hospital building. The new tower houses imaging and the surgery department, which were relocated to improve their proximity to the emergency department and to the new critical care inpatient beds. In addition, the Legacy Building meets Gundersen Lutheran’s sustainable design and overall energy reduction goals, with the goal of pursuing LEED Certification. June 2014 Minnesota Physician


Honor roll 2014

Left: Main entrance Right: Coffee shop

Murray County Medical Center Type of facility: C ritical access hospital and rural health clinic Location: Slayton Client: Murray County Architect/Interior design: TSP, Inc. Contractor: Parsons Completion Date: September 2013 Total Cost: $12,632,371 Square feet: 3 2,000 sq. feet of new construction; 10,000 sq. feet of renovated space With an eye toward readying for coming health care reforms, Murray County Medical Center engaged TSP to design a medical facility that supported its mission. The county wanted to provide a comprehensive range of health services and educa-

tion, and to serve local and regional needs with superior quality and value. TSP started by updating an out-of-date master plan. Needs were identified in several primary areas: clinic, inpatient, dietary, and business services. A larger staff and an expanded surgical center required additional space. Patient rooms were overhauled to achieve patient satisfaction goals related to inpatient services. Existing semi-private patient rooms with shared bathrooms were transformed into private rooms to better serve a mixed patient population. Murray County leadership decided to consolidate previously eliminated services and relocate the kitchen and several offices back to the main campus. The original building limited departmental growth and couldn’t keep up with the changing needs of patient services. The new facility meets Murray County’s vision within the limits of the existing site to create a facility that will address the needs of the hospital and the community of Slayton for many years to come.

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Minnesota Physician June 2014

Summit Orthopedics Type of facility: Medical office building Location: Vadnais Heights Client: Summit Orthopedics Architect/Interior design: Pope Architects Contractor: RJM Construction Completion Date: February 2014 Total Cost: $8,877,316 Square feet: 66,346 Summit Orthopedics consolidated three locations— Maplewood, Maplewood Therapy, and Vadnais Heights—into a single-specialty advanced center for orthopedics in Vadnais Heights. Located on the corner of 35E and County Road E, the new location offers north metro residents the full continuum of orthopedic care and treatment.

Top: Waiting area Bottom: Patient room

The 66,346-sq.-foot build-out includes recovery areas, a surgery suite, physical therapy space, and clinic space. Pope Architects was the programmer, interior designer, and interior architect. Pope worked collaboratively with the developer, MSP Commercial, and the core and shell architect, Genesis Architects. RJM Construction completed the interiors within an expedited schedule and collaborated with the shell building contractor, Welsh Construction, to start tenant finishes early, meeting the owner’s needs. The completed medical office building features contemporary finishes, an inviting reception space, and recovery areas reminiscent of a hotel room.

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June 2014 Minnesota Physician


Honor roll 2014

Left: Waiting area Right: Reception

PrairieCare Chaska Type of facility: Outpatient clinic and partial hospital program Location: Chaska Client: PrairieCare, LLC Architect/Interior design: Pope Architects Contractor: RJ Ryan Construction Completion Date: March 2014 Total Cost: $1,100,000 Square feet: 18,000 PrairieCare Chaska provides outpatient psychiatric services to all ages. PrairieCare began discussions with Ridgeview Medical Center in early 2013 about bringing specialty psychiatric services

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Minnesota Physician June 2014

to Two Twelve Medical Center. The new clinic has an art therapy room, where kids can use art to express their feelings. A state-ofthe-art patient care station allows close patient monitoring and streamlines staff communication. A break room accommodates gross motor skill activities and also acts as a cafeteria. PrairieCare incorporates multidisciplinary evidenced-based treatment including: psychiatry, psychology, psychotherapy, and complementary alternative medicine. The Partial Hospital Program (PHP) is a state-of-the-art therapeutic environment optimally conducive for psychiatric assessment and crisis stabilization. PHP is designed to assess and stabilize psychiatric crisis through intensive psychiatric intervention, therapy, and educational services. This is the fourth site within the PrairieCare psychiatric health system. It will provide intensive psychiatric care to 600 youth each year, as well as thousands more patients in the clinic.

Left: Reception Right: Waiting area

Fairview Orthopedic Sports Medicine/ St. Croix Orthopaedics Type of facility: Outpatient orthopedic specialty center Location: Wyoming Client: Partnership between Fairview Health Services and St. Croix Orthopaedics, PA Architect/Interior design: Mohagen/Hansen Architectural Group Contractor: Mortenson Construction, Inc. Completion Date: May 2013 Total Cost: $3,659,407 Square feet: 20,930 The new Fairview Orthopedic Sports Medicine/St. Croix Orthopaedics center is located on the Fairview Lakes Wyoming Hospital campus. Mohagen/Hansen Architectural Group was selected by

Fairview Health Services and Mortenson Construction to provide planning, architecture, and interior design services. Development of this new orthopedic center allows Fairview to address the continued growth of expanded outpatient services on the hospital campus. It also provides a new integrated model of care delivery that places emphasis on the consolidation and clustering of outpatient orthopedic services. The center was designed as an addition to the hospital building, and can be accessed from the hospital, or from its own entrance, which has an associated parking lot. The building was designed to include three individual orthopedic clinics. In order to achieve maximum efficiency and provide quality care within a healing environment, this new delivery of care model offers orthopedic patients a “one-stop shop.” The specialty center includes a large shared waiting area that serves as a comfortable starting point for patients who may receive one or more services that can include a visit to an orthopedic clinic, the rehabilitation gym, radiology, or the home health-care retail store.

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Honor roll 2014

Good Samaritan Specialty Care Center

Left: Main entrance Right: Chapel

Type of facility: Skilled care/assisted-living facility Location: Robbinsdale Client: Good Samaritan Society Architect/Interior design: Insite Architects Contractor: Benson-Orth General Contractors Completion Date: December 2013 Total Cost: $17,400,000 Square feet: 123,000 The Good Samaritan Specialty Care Center is a 96-bed, stateof-the-art facility that offers three levels of skilled nursing care,

along with a fitness center and therapy rooms. The center provides outpatient care and short-term rehabilitation, in addition to specialty care, home, and community services. This specialty care center is the latest in a series of community-benefitting projects undertaken by the Good Samaritan Society, based in Sioux Falls, SD. Insite Architects worked in close partnership with Good Samaritan and Benson-Orth to design this project. To increase energy savings, the design included a green roof and 100+ geothermal wells. Underground parking accommodates the tight footprint of the site.

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Minnesota Physician June 2014

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Mille Lacs Health System Type of facility: Rural critical access hospital Location: Onamia Client: Mille Lacs Health System

Left: Waiting area and reception Right: Children’s play area

Architect/Interior design: Leo A. Daly Contractor: Anderson Companies Completion Date: January 2013 Total Cost: $3,000,000 Square feet: 25,000 sq. feet of renovated space The Mille Lacs Health System (MLHS), originally built in 1955, underwent some renovations in 2012 and 2013. The outpatient therapy unit, and the lobby and play area for children were redone. Other renovation work included clinics, the pharmacy, the boardroom, meeting rooms, and some administrative areas. Additional phases of the project are ongoing. The lobby needed a facelift, a much-needed place for children to wait in, and a plan that made a better use of space. The children’s

area was dedicated to an MLHS physician couple’s daughter, who died of cancer. Because the girl wanted to be a large-animal vet, the design for the area was based on a barn theme. The area is filled with activities for children, keeps noise away from patients, and was a good fit for this rural facility. The renovated outpatient therapy unit, which used to be the pharmacy and boardroom, has been transformed into a space with private bays, as well as an enclosed room. Patients receive their chemo or infusion therapy in a bright, airy, warm, and secluded environment. This initiative meets the needs of patients, as well as visitors to the vacation area of Lake Mille Lacs. With a skylight, kitchenette, and chairside monitors, comfort was No. 1 in the design process.


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Honor roll 2014

Left: Operating room Right: Rehab room

Altru Specialty Center Type of facility: I-2 hospital, specializing in orthopedic surgery and inpatient rehab Location: Grand Forks, ND Client: Altru Health System

Architect/Interior design: EAPC Architects Engineers Contractor: Construction Engineers Completion Date: April 2014 Total Cost: $5,900,831 Square feet: 81,954

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Minnesota Physician June 2014

The Altru Specialty Center is a 5.9 million dollar renovation with 81,954 sq. feet of space. It contains a surgery suite with four operating rooms, 12 prep and recovery bays, and a sixbed, post-anesthesia care unit (PACU) for orthopedic surgery. The inpatient rehab unit houses 23 private patient rooms, a dining room and recreation/day space, and areas for a full complement of physical, occupational, and speech therapy. The facility is attached to the Altru Imaging Center and the Altru Professional Center, where clinical needs are served. In 2012, Altru Health Systems purchased the Doctors Hospital on the south end of Grand Forks. The facility had never been operational, but had been outfitted with medical equipment. Once Altru owned the building, EAPC Architects Engineers assisted with the review of existing conditions, which revealed that the building had many mechanical, electrical, life safety, and building code violations. EAPC designed the renovation that met the needs of the various departments involved, and corrected all of the existing code violations.

Left: X-ray room Right: Children’s play area and reception

Highland Park Clinic Type of facility: Outpatient clinic Location: St. Paul Client: HealthPartners Architect/Interior design: HGA Architects Contractor: Greiner Construction Completion Date: June 2013 Total Cost: $846,843 Square feet: 9,600 The Highland Park project renovated an existing two-story space that connects to a strip mall. The 9,600-sq.-foot renovation took three months to complete. The main floor of this high-end clinic

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houses a reception area, adult waiting room, pediatric play area with a “liquid” floor, procedure rooms, and multiple care team stations equipped with computers. The lower level of the facility houses X-ray equipment, the X-ray control room, and a blood draw area. Greiner Construction coordinated a third-party inspection to ensure that the structure could support the X-ray equipment. Also on the lower level are dressing rooms, an employee break room, multiple offices, restrooms, storage, and an area for IT, mechanical equipment, and the boiler.

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Special Focus: Medical Facility Design


Phased building projects

f you lead a rural health care facility, you need to read this. And if you have ever led or are going to lead a building project, you definitely need to read this. As health professionals know, critical access hospitals (CAH) are unique. CAH facilities are not simply smaller versions of their urban counterparts. They are unique in two fundamental ways—their economics and their culture. It’s an understanding of both economics and culture that determines the success of critical access health care building projects. This article discusses the economic and cultural realities of CAH facilities, specifically as they relate to successful building projects. The considerations of phased building projects—projects that are done in multiple stages and sometimes over multiple years—are detailed as an effective response to these realities. Finally, the article also describes some of the characteristics of the right project team that helps ensure a successful building project.

Making them work in rural hospital environments By Richard Engan and Mitra Milani Engan

Economics The economics of critical access hospitals are distinctive. Sixty percent of CAH revenue typically comes from government payers like Medicare and Medicaid, according to the American Hospital Association. Patient volume is a fraction of what it is in urban facilities. And while urban hospitals may have several hundred people on staff at any given time, a rural hospital may only have a handful of people on the clock between sunset and sunrise. In rural Minnesota, many of our 79 critical access hospitals

Olmsted Medical Center, a 160-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.

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Minnesota Physician June 2014

In these cases, a well-planned, phased building project can be an excellent approach. However, phased addition and remodel projects are significantly more complicated—both in planning and execution—than new building projects. In these cases, it’s essential that CAH leaders

Culture Just like economics, the culture of rural health care is unique. From inter-departmental relationships to decision-making dynamics, the culture of critical access health care is characterized by several key attributes. • CAH departments tend to collaborate and back each other up more intensively than in their urban counterparts. For example, when four people are on staff at midnight and a multi-vehicle car accident happens on a rural highway, all four of those people help care for accident victims, regardless of their daytime departmental assignments. • Decision-making in rural health care facilities happens differently. Consensus is built over informal table

Family Medicine

Stevens Community Medical Center’s Starbuck Clinic is looking for a family medicine physician. Enjoy the beautiful area lakes, quiet atmosphere and all that West Central Minnesota has to offer. Starbuck Clinic is home to Staff Care’s 2013 Country Doctor of the Year. Dr. Bösl and Greg Rapp, PA provide full clinic services in the picturesque town of Starbuck, MN on Lake Minnewaska. Dr. Bösl would like to transition into retirement. If you would enjoy the serenity of a rural lake community plus the comfort of an independent practice, this is your opportunity!

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do not have the option to simply replace their facilities when improvements are needed. This reality has been exacerbated by the recent recession. In response, rural health care leaders often opt for large additions and remodels of existing facilities, to upgrade and expand services.

understand the characteristics of successful phasing and, even more importantly, hire a project team who does, too. It’s here that CAH culture plays a role.

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talk, just as much as in the boardroom. Where communities are small and tightly knit, effective health care leaders understand that community support is vital for hospital building projects. This support is often built through conversations in coffee shops and church fellowship halls as much as in more formal settings. • CAH leaders are held accountable to stringent financial stewardship responsibilities. Community stakeholders expect that leaders will provide for the medical needs of the community with minimal waste, bells or whistles. While people appreciate comfort, they are unlikely to support facility improvements that appear ostentatious or flashy.

Choices Because of CAH economics and culture, a phased facility improvement project can provide an excellent solution for a hospital’s

needs. At the beginning of the process, rural health care leaders are faced with initial decisions, such as choosing which professionals are needed to deliver the project required. A skilled architect will help hospital leadership hire the proper team to do the right project for a community. The right design professional will demonstrate three key skills:

cility. To help you make decisions about how to phase your project, your architect may ask these questions: • Is there a time of year when it’s easier to get by without a given service or physical environment? For example, heating or cooling needs are more flexible in Minnesota’s

A phased facility improvement project can provide an excellent solution for a hospital’s needs. spring and fall, and less flexible in the winter and summer seasons.

1. Understanding the community’s economics and culture 2. Possessing expertise and experience in phased critical access health care project management

• Based on typical hospital usage, is there a time of year more favorable for construction?

3. Having excellent communication skills

• How does the order or sequencing of spaces relate to your use of them? Can this information be used to determine the scheduling/ sequencing of construction projects?

Communication is at the heart of the architectural process, and it begins with listening. Your architect will need to learn about the departmental organization and physical systems of your fa-

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• Can a specified department be closed or temporarily moved? For example, off-site laboratory services may need to be used temporarily. Based on the answers generated by this analysis, important choices can be made about whether any portions of a facility can be vacated during construction. Typically, these choices are made through considering such questions as: • Which portions can be vacated for the duration of a phase of construction (typically several months)? • Which portions can be vacated on a limited basis, such as while a specialist goes on vacation? • Which portions can be vacated after hours or on weekends? • Which portions can allow limited work to be done during operation, e.g., Boynton Health Service pulling tech wire through a functioning space? Phased building projects to page 36

Boynton Health Service


Located in the heart of the Twin Cities East Bank campus, Boynton Health Service is a vital part of the University of Minnesota community, providing ambulatory care, health education, and public health services to the University for nearly 100 years. It’s our mission to create a healthy community by working with students, staff, and faculty to achieve physical, emotional, and social well-being.

Boynton Health Service has an immediate opening for a full-time physician to provide services in the Primary Care and Urgent Care Clinics. Candidates should enjoy working in a college health environment with a large and diverse population of students and staff.

Boynton’s outstanding staff of 400 includes board certified physicians, nurse practitioners, registered nurses, CMAs/LPNs, physician assistants, dentists, dental hygienists, optometrists, physical and massage therapists, registered dietitians, pharmacists, psychiatrists, psychologists, and social workers. Our multidisciplinary health service has been continuously accredited by AAAHC since 1979, and was the first college health service to have earned this distinction.

The qualified applicant must be ABMS board certified/eligible and have training and/or experience in an outpatient practice and urgent care. Knowledge of electronic health records would be beneficial. This position offers a competitive salary, CME opportunities, and a generous academic status retirement plan. Professional liability coverage is provided.

Attending to over 100,000 patient visits each year, Boynton Health Service takes pride in meeting the health care needs of U of M students, staff, and faculty with compassion and professionalism.

To learn more, please contact Hosea Ojwang, Human Resources Director, at 612-626-1184, hojwang@bhs.umn.edu Apply online at https://employment.umn.edu and reference requisition number 191646. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer.

410 Church Street SE • Minneapolis, MN 55455 • 612-625-8400 • www.bhs.umn.edu

June 2014 Minnesota Physician


Special Focus: Medical Facility Design


n 2012, the Mayo Clinic Center for Innovation (CFI), an embedded service design group within the Mayo Clinic that is focused on transforming the delivery and experience of health and health care, was asked to begin a project with the Kasson Clinic, a small family medicine satellite clinic in rural Dodge County. We would research how a clinic could be designed to keep the community healthy, rather than the typical care delivery model of providing only sick care, when needed, to patients who visit the clinic. This goal was in response not only to new reimbursement models on the horizon, but also to a request from the local population seeking more engagement in their health care, to create a healthier community.

The project began much like any other building project within a large institution—a search for a site and funding, and deciding on the project’s parameters. From the beginning, the

Beyond walls and built spaces Designing the future in partnership with the community By Allison Matthews CFI design team added another, less typical, component to the work through detailed community engagement. Before the planning process began, community meetings were held in a variety of locations, to attempt to determine what people really wanted from their clinic. Engaging community The design team knew that the community needed to be part of the design process, but initial attempts were not as fruitful as hoped. The first error was asking people outright what they wanted from a clinic. They were

asked to imagine something completely new and different, but initially all the participants could do was reflect back on their experiences with the current services provided by the clinic. The community members excelled at listing what they expected from their current clinic, what it could do better, and what it already did well, but they had a harder time imagining the clinic providing services or spaces that aren’t traditionally related to a clinic. For example, patients were able to provide valuable insights about how they would

like the waiting spaces in a new clinic to be designed, how the hours could be improved to be more convenient for their work schedules, and better ways for the clinic to interface with the local high schools, but they weren’t able to move beyond the current health care paradigm. When the designers asked about new modes of interacting with the clinic, such as via a video connection, participants had a difficult time reconciling that with their current understanding of a clinic. Changing methodology Community meetings weren’t accomplishing the level of engagement the team was seeking. So we decided to change our methodology to better leverage the capabilities of the Center for Innovation as a service design group, through new ways of approaching the design problem that allowed for a deeper understanding of the unspoken needs and desires of the community. The team began having conver-

Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership. Currently we are seeking to add the following specialists:

• General Surgery

• Pediatrics

• Radiation Oncology

• Obstetrics/Gynecology

• Internal Medicine

• Family Practice

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • Dave.Dertien@avera.org Avera Marshall Regional • Medical Center 300 S. Bruce St. • Marshall, MN 56258

www.averamarshall.org 32

Minnesota Physician June 2014

sations with community members not about a new clinic, but about how they defined and perceived health. The conversations happened both in the clinic and all over the community. By purposely avoiding questions about solutions with patients during these sessions, and instead asking them about what they believed affected their ability to be healthy in their daily lives— and what stood in the way of achieving health—designers were provided insight and some answers that began to surprise and guide designs a bit more. It was revealed that the clinic was operating as if people only made decisions about health care at the clinic or under the clinic’s influence. The reality was that the community members defined health and health care much more holistically. People made decisions not based necessarily on the recommendations they received in the clinic, but on the information they got from other sources: the Internet, their families, their

workplaces, or their own beliefs and value systems.

Family Medicine

For example, instead of using his A1c level as the reason for wanting to get his diabetes under control, a patient shared how important it would be for him to see his granddaughter walk down the aisle in a few months. The clinic was set up to support diabetes care using A1c as the driver. How could we design a clinic that supported the patient as he or she used clinical markers not as the drivers, but as supportive metrics?

St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.

The design team realized quickly that building a new clinic in the current model wasn’t going to get anyone what they really wanted: essentially, better engagement with patients to promote health. Instead, building a new clinic in the old model would only help continue to do what already was being done (sick care and secondary prevention) in a brighter, shinier new setting.

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefit package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

Beyond walls and built spaces to page 34

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BC/BE Family Practice Physician

Sleep Medicine/Tele-medicine

Immediate opening at dynamic urban clinic serving the Native American community. We are passionate about our work and about providing exceptional care. We are looking for a physician who will be a good fit for our clinic and for the community we serve. This is a full-time position (80 hours per pay period), with health and dental benefits. We are a NHSC and IHS loan repayment site.

The Minneapolis VA Health Care System is recruiting a physician for a combined Sleep Medicine (50%) and Tele-ICU position (50%) within the Section of Pulmonary, Critical Care and Sleep. Board certified in: Internal Medicine, Pulmonary, Critical Care, and Sleep Medicine. A demonstrated track record in research as evidenced by peer review publications and academic status at an Assistant Professor level or higher is required. Experience in ICU Telemedicine, in addition prior experience in directing both Intensive Care Units and Sleep Laboratories. Substantial experience in supervising trainees including fellows, residents and medical students.

Must be licensed to practice in Minnesota and have current board certification or eligibility. Clinic hours are Monday thru Friday 9am-5pm and Saturdays 10am-2pm.

No phone calls please. Submit Cover Letter and Resume to hr@nacc-healthcare.org. CLOSING DATE: Open until filled. 1213 E. Franklin Avenue, Minneapolis, MN 55404

Be a part of this dynamic and rapidly growing clinic in a great location. Must have a valid medical license anywhere in the US. VA physicians enjoy an excellent benefits package, paid malpractice insurance, and a state-of-the-art electronic medical record. Competitive salary and benefits with recruitment/relocation incentive and performance pay.

For more information: Visit www.usajobs.gov or email Alisha.Crane@va.gov EEO employer June 2014 Minnesota Physician


Beyond walls and built spaces from page 33

Evolving design Our conceptual designs began to evolve from health care being based in a place to being based on capitalizing on relationships within the community, creating strategic partnerships and a network that supported health. This approach moved the focus out of the built space, and instead found that the clinic was able to have influence in unexpected areas within the community. Certainly, the traditional questions of where the building was sited were addressed (Should it be close to the high school? Near the major employer?), but so were requests for new types of spaces like demonstration kitchens, community gardens, and areas for community organizations to meet. A thoughtful analysis of spaces available but not serving patient and community needs was also completed, bringing ideas about patient-facing areas looking more like the local gym

than a hospital, and questioning if there were ways that could better welcome patients than a check-in desk. Breaking the clinic’s services up into components that could be spread throughout the community— both physically and operationally—started to emerge as a potential design option. The traditional thought behind designing and building a new primary care center typically centered around factors that combine maximizing the bottom line of a fee-for-service-based environment with solutions that support increasing patient throughput, such as adding more exam room space, and adding traditionally ancillary services such as laboratory and radiology. Often a gesture is made to create attractive physical spaces, because of the misperception that patient experience can be improved by more appealing waiting rooms. Our findings demonstrated that to really improve patient experience and outcomes, primary

care clinics needed to imagine new spaces, both within and outside of the traditional clinic, reaching people where they make daily health decisions. As we move from a fee-for-service to a fee-for-value model, this will be the true measure of success. In the end, despite our diligent work with the community and the Kasson Clinic, the project was put on hold. Interestingly, this did not stop the relationship that had been developed between the clinic and the community. The responsive and caring staff at the Kasson Clinic still wanted to meet the needs of the community, even if a new clinic was not on the immediate horizon. They created a community garden in front of the facility where patients could pick healthy food, and dietitian appointments could move outside for a hands-on experience when possible. A program was developed, called Dodge Refreshed, that sought to connect daily life with healthy

living through community engagement. Once the value of this connection was recognized by clinic leadership, policy changes were instituted to allow the clinic staff to work in the community more frequently. The Mayo Clinic and the Center for Innovation learned a lot in this community engagement process. We realized that health happens everywhere, and that creating a clinic that can be accessed where patients want it, when they want it, and how they want it—whether in person or through another avenue— is what is most important to keeping a community healthy. Service design is a useful tool that complements the traditional building design process, helps challenge current built space paradigms, and allows health care to expand beyond what people usually think of as a clinical space. Allison Matthews is a design researcher at the Mayo Clinic’s Center for Innovation in Rochester.

Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

BC/BE Family Medicine Physician Renville County Hospital & Clinics is looking for a BC/BE Family Medicine Physician. RCHC is 25-bed Critical Access Hospital with three clinics committed to quality, evidence-based care and exceptional patient satisfaction. Current call is 1:4.

• Family Practice

Excellent compensation. Enhanced physician benefits with PERA retirement benefit included with this position.

• Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

Please contact or fax CV to:

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

Minnesota Physician June 2014

Plus! We’re building a new medical center (projected completion 2015)! Contact: Lynette Bernardy 611 East Fairview Avenue, Renville, MN 56277



We’re located in a beautiful, family-oriented community just 90 miles west of Minneapolis/St. Paul. Recreational facilities include five golf courses, hunting, fishing, several relaxing lakes and Minnesota River within minutes.

bernardyl@rchospital.com Phone: (320) 523-1261 • Toll-free: (800) 916-1836

Psychiatrist Unique Practice – Unique Psychiatrist Needed! HealthPartners Medical Group is a top Upper Midwest multispecialty group practice based in Minneapolis/St. Paul, Minnesota. We have a unique metropolitan-based outpatient position available for a talented, bilingual BC/BE psychiatrist interested in a non-conventional practice. This full-time position combines cross-cultural psychiatric medicine with community mental health. Receiving practice support from both HealthPartners Center for International Health and from the Ramsey County Mental Health Center, 0.5 FTE of the position will provide psychiatric care to an international refugee patient population utilizing an integrated holistic/ primary care model. The other 0.5 FTE of the position will work as part of a multidisciplinary team to provide care to individuals with serious mental illness, chemical health difficulties and/or co-occurring medical problems. This exciting practice is full-time, but qualified candidates interested in part-time outpatient opportunities in Cross-Cultural Psychiatric Medicine or Community Mental Health are encouraged to apply. In addition to a competitive salary and benefits package, there are opportunities for an academic faculty appointment at the University of Minnesota, teaching involvement in the Global Health Pathway (globalhealth.umn.edu) and further development of best practice programming at Ramsey County Mental Health Center. For consideration, please forward your CV and cover letter to lori.m.fake@healthpartners.com, apply online at healthpartners.com/careers, or call Lori at (800) 472-4695 x1. EOE

Opportunities for full-time and part-time staff are available in the following positions:

• Geriatrician/ Hospice/ Palliative Care • Internal Medicine/ Family Practice

• Medical DirectorExtended Care & Rehab (Geriatrics) • Psychiatrist Applicants must be BE/BC.

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US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 June 2014 Minnesota Physician


volved all the key players: the hospital’s leadership team, the project design team, and the construction team. Facility staff should have been included in the communications loop, with multiple opportunities for dialogue during the project.

Phased building projects from page 31

Once a thorough facility analysis is completed, a building project’s phases and sub-phases can be defined. Written descriptions are developed for the requirements of each major- and sub-phase, including a statement of what is required for substantial completion of each part of the process. Also included is an outline of any construction activities that must extend beyond any defined phase; for example, fire alarm or electrical systems work may continue if the entire route of a system cannot be vacated during a specific project phase. The phasing plan is then illustrated in preliminary architectural drawings.

Construction Successful completion of a phased building project depends on several factors, including whether: • The phasing process was part of the discussion since the beginning of the project’s planning process. • Phasing discussions in-

• Project phasing was part of the agenda for all project review meetings. Refinements to the project schedule are often made during the construction process. These changes are sometimes driven by management needs, sometimes by design or construction team players. When all team members are involved in the planning from the beginning of the process, these changes are typically easy to accommodate.

Challenges Challenges are inherent in any building project. This is especially true during a phased construction project in a functioning critical access hospital. There’s an enormous contradiction between a health care environment and

a construction environment. It’s critical to maintain infection control and adhere to life safety codes throughout a construction project.

was able to continue without interruption and there were no staff complaints about the process.

The right architect will guide a health care facility through a phased project with honesty and frequent communication. It’s important that he or she avoids underselling the disruption that will be involved in a phased project. When hospital staff are fully engaged in a project’s planning process, they know what to expect and are typically able to be flexible as the work is completed.

Minnesota’s critical access hospitals play an essential role in caring for rural communities. Continuous maintenance and improvement of these facilities is vital. Critical access hospital leaders are better able to move forward with these improvements through phased building projects that are based on an understanding of rural Minnesotan economies and culture. Project phasing is a tool CAH leaders can use to accomplish large goals in bite-sized pieces, fulfilling their mission to provide both excellent health care and wise fiscal stewardship.

An example of this is illustrated by the case of a critical access hospital that needed to replace sewer pipes underneath the entire hospital because they had been eroded by acids used in the lab. The hospital needed to continue working during the project—services could not be moved off-site. All hospital staff were included in conversations about the impact of jack-hammering. Staff helped formulate a plan to schedule construction during times when disruptions would be most manageable. As a result, hospital work

Moving forward

Richard Engan is principal architect and founder of Engan Associates Architects and Interior Designers. Founded in 1979, Engan Associates specializes in critical access health care design. Mitra Milani Engan is the firm’s communications director.

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

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June 2014

BC/BE Family Practice Mankato Clinic is seeking a Family Practice provider to work at Madelia Hospital & Clinic in an inpatient/ outpatient/ Emergency Department practice. Madelia Hospital is a 25-bed, acute care, Critical Access Hospital that has received the JCAHO Gold Seal of Approval. Primary health services available include medical/surgical, Level 4 Trauma, 24/7 Emergency Room, 24-hour Lab, Physical Therapy, diagnostic imaging with a 16 slice CT, digital mammography and more. Madelia Hospital & Clinic offers a sign-on bonus of $75,000 and an additional $50,000 bonus to live in the community. Mankato Clinic employment features: • Excellent first year guarantee and production bonus opportunity • Competitive Benefit Package with 401(k) and profit sharing • Shareholder opportunity in your second year • Generous CME allowance

Contact Dennis Davito for more information at (507) 389-8654 or by email at dennisd@mankato-clinic.com Apply online at www.mankatoclinic.com

Fairview Health Services Opportunities to fit your life Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team. We currently have opportunities in the following areas: • Dermatology

• Hospitalist

• Pediatrics

• Emergency

• Hospice

• Psychiatry

• Internal Medicine

• Rheumatology

• Med/Peds

• Sports Medicine

• Ob/Gyn

• Urgent Care

• Orthopedic

• Vascular Surgery


• Endocrinology • Family Medicine • General Surgery • Geriatric



Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail recruit1@fairview.org

Sorry, no J1 opportunities.

fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer

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

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Rheumatology

F o r m o r e i n F o r m aT i o n :

Kari Lenz, Physician Recruitment | karib@acmc.com | (320) 231-6366 www.acmc.com |

Family or Internal Medicine Physician An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites. For more information Call Kirk Stensrud, CEO 320.634.4521 Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334 Email CV to: kirk.stensrud@glacialridge.org

www.glacialridge.org June 2014 Minnesota Physician


Hormone therapy and the WHI from page 19

conflicting information out there about hormone therapy, what should I do?” Appropriate answers may be: • Use hormone therapy predominantly for symptom relief.

tional Menopause Society) evaluated changes in evidence over the past 10 years. The authors support a return to “rational use of HT initiated near the menopause,” the “classic use of HT” concept.

Ongoing disagreement persists among experts.

• Use the lowest dose and for the shortest time possible. • Understand that the risks in general are less than previously represented. • Be aware that the route and type of hormones may be important. • Have a frank conversation with your provider about risks/benefits for you, specifically. A recently published reappraisal by international experts published in Climacteric (the official journal of the Interna-

Looking back over the past decade, we have gained perspective on the issue of hormone therapy; indeed, we have almost come full circle on it. The WHI was done to assess the possible cardiovascular benefit of HT in older women. The study therefore served its purpose; the answer was a definitive “no.” Unfortunately, generalizations about the results alarmed many younger women (and their physicians)—women

Here to care At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 12 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel.

Madalyn Dosch, Physician Recruitment Services Toll-free: 1-800-248-4921 Fax: 612-262-4163 Madalyn.Dosch@allina.com

allinahealth.org/careers 13273 0414 ©2014 ALLINA HEALTH SYSTEM ® A TRADEMARK OF ALLINA HEALTH SYSTEM

Minnesota Physician June 2014

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from the WHI was that large population studies are valuable but grouping studies does not always work; in this case, the subanalysis studies were necessary to expose the invaluable “timing hypothesis.” So how do clinicians move forward with this information? The key is to individualize therapy. Advice for the newly menopausal patient will be different from advice for the 65-year-old woman who continues to have

symptoms after stopping HT. The symptomatic patient “sitting on the fence” with regard to treatment needs to know that in most cases, the risks may be lower than she thinks. And the 70-year-old woman who still has fairly severe hot flashes needs to know that her risks with hormone therapy may be higher than she thinks, so alternative therapies may be indicated for her. We now have enough data and expert opinion to truly give informed individualized advice. The challenge is to get all of us up to speed with these concepts. And, of course, this is not the end of the story.

Jon Nielsen, MD, practices at Oakdale Ob-Gyn, a division of Premier Ob-Gyn of Minnesota.

Sioux Falls VA Health Care System

Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Primary Care (Family Practice or Internal Medicine) Psychiatrist

Pulmonologist Oncologist Cardiologist (part time)


Make a difference. Join our award-winning team.


who, we now know, could have benefitted from HT with relief of hot flashes, night sweats, and vaginal atrophy symptoms, as well as reduced risk of heart disease and fractures. One of the important lessons learned


Sioux Falls VA HCS (605) 333-6852 www.siouxfalls.va.gov

Applicants can apply online at www.USAJOBS.gov

Alcohol is more harmful to an unborn baby than cocaine, marijuana or heroin. Drinking during pregnancy can cause Fetal Alcohol Spectrum Disorders (FASD) which permanently harm the way your baby learns and behaves.




STAY ON THE ROAD TO 10 STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

Train Your Staff—Find options and resources to help your staff get ready for the transition

Update Your Processes—Review your policies, procedures, forms, and templates

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition


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