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Volume XXlV, No. 12

March 2011

The Independent Medical Business Newspaper

Clinic managers face challenges in world of flux

Success hinges upon teamwork by physicians and administrators By Shari Ohland, MHA, CMPE


n any given day, a medical practice administrator juggles a myriad of critical projects, all of nearly equal importance. More than likely, the administrator maintains a constantly updated priority list—with the understanding that, above all else, change is certain. Health care reform and market forces are changing medical practice, and our greatest strength is the ability to adapt to those changes and not fall victim to them. This article looks at the current state of medical practice administration and the challenges administrators face in today’s health care environment.


Profits vs. care?

Cutting-edge medicine—a driver octors are faced with of the “medical arms race” challenging imperaWhether to achieve a real or a tives: The need to perceived advantage, doctors provide the best care possible increasingly compete for “busiand the need to keep our business” (i.e., patients) by staying on ness in the black so that we the cutting edge of medical techcan provide that care. Yet, Sometimes nology. The so-called “arms race” are these imperatives mutually in health care refers the expento less is more exclusive? What ethical, operasive (and often tional, and financial issues unproven) treatBy Nicholas J. does the current health care ments, gadgets, and Meyer, MD reform and reimbursement gizmos we feel we environment raise? And most must offer patients important: Can physicians find a satisfactory in the name of progress. All too balance between profit and care? often, over time we find that I would argue that we can and must find these newer, nearly always a balance. Focusing on profit alone compromore expensive options serve mises patient care and trust while also nothing more than to line the straining our health care system; and focuspocket of the manufacturer, ing on care alone will unwittingly cause our sales representative, or, perpractices, as businesses, to fail.

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PROFITS VS. CARE? to page 10

What do administrators do?

Administrators are recruited to lead a medical practice. We are trained to CHALLENGES to page 12

IN THIS ISSUE: Chronic illness Page 26

One Heart, One Mind, One Universe May 8, 2011 at Mariucci Arena, University of Minnesota Medicine Buddha Empowerment: A Tibetan Cultural and Spiritual Ceremony Promoting Personal and Societal Healing featuring His Holiness the 14th Dalai Lama 9:30 - 11:30 a.m. Peace Through Inner Peace: A Public Address featuring His Holiness the 14th Dalai Lama 2:00 - 3:30 p.m. May 9, 2011 at University Radisson Hotel Second International Tibetan Medicine Conference: Healing Mind & Body 9:00 a.m. - 7:30 p.m. (* His Holiness is not expected to be in attendance.)

2 Days Only, 3 Events

The Minnesota Visit 2011 His Holiness the 14th Dalai Lama 

A special invitation to health professionals: The Second International Tibetan Medicine Conference May 9, 2011 This event will bring to the Twin Cities the foremost practitioners of Tibetan medicine from the Men-Tsee-Khang, the Tibetan Medical Institute of His Holiness the Dalai Lama, in Dharamsala, India. By the end of the conference, participants will be able to meet the following objectives involving Tibetan Medicine: Examine the relationship between ethics, spirituality, and healing. Investigate participants' own unique constitution. Determine what lifestyle choices to make, based on participants' own constitution. Explain how to heal from the source and develop health through balance. Describe research about Tibetan medicine, as well as propose additional research needed. Apply teachings of Tibetan medicine personally and professionally.

etan Ame Tib r

Minnesota of

For tickets and more information, visit or call 612-624-2345

un n Fo dation ica


MARCH 2011 Volume XXIV, No. 12

FEATURES Profits vs. care? Sometimes less is more



By Nicholas J. Meyer, MD

Clinic managers face challenges in world of flux 1 Success hinges upon teamwork by physicians and administrators By Shari Ohland, MHA, CMPE

2011 Community Caregivers Making a difference in Minnesota and the world


By Scott Wooldridge



INTERNATIONAL MEDICINE Global health training 14



By William Stauffer, MD, MSPH, CTropMed


8 Patricia J. Lindholm, MD

DERMATOLOGY Faces of rosacea


By Jennifer Ray, MD

Minnesota Medical Association

PROFESSIONAL UPDATE: RADIOLOGY Systems collaborate 18 for a win-win-win By Cally Vinz, RN



By Robert Rizza, MD

A health care home for complex patients


By Terry Dunklee, MD

A cultural approach to improving health

T H I R T Y- F I F T H


Background and focus: Until recently, when the word wellness came up in organized medicine it was regularly dismissed as pseudo-science. Our health care delivery system, or as many call it “sick care delivery system,” evolved in a way that doctors were not paid to keep patients well and thus wellness strangely fell outside the purview of medicine. Obviously it is better to stay healthy than try to fix complex and sometimes avoidable medical conditions. Selling servA changing focus in health care ices supporting this approach was often criticized for lack of randomized clinical trial April 28, 2011 research; inadequate licensing, 1:00 – 4:00 PM • Duluth Room credentialing, and oversight for practit-ioners; and many other Downtown Mpls. Hilton and Towers concerns. Wellness as an industry, with its wide diversity of methods and approaches, was kept at arm’s length by the medical establishment. Economics have forced this to change.

The Wellness Revolution

Objectives: We will explore the definition of wellness, why today there is a wellness revolution, and why doctors now embrace the concept. Examining multiple collection methodologies and sets of data, we will discuss how and why employers are driving this new approach to health care. We will consider privacy issues and many other challenges to an already overburdened administrative process posed by collecting and storing individual health care data in places such as work sites and health clubs. We will discuss the breadth of wellness initiatives, their pros and cons, and how they can lower the cost of health care while improving individual health status. Panelists include: N Elizabeth Klodas, MD, President, Preventive Cardiology Consultants


By Diana DuBois, MPH, MIA

N Karen L. Lawson, MD, Director Health Coaching, U of M Center for Spirituality and Healing N William Litchy, MD, Chief Medical Officer MMSI, Mayo Clinic The Independent Medical Business Newspaper PUBLISHER Mike Starnes EDITOR Donna Ahrens ASSOCIATE EDITOR Martha Malan ASSISTANT EDITOR Scott Wooldridge

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MDH Urges Hospital Leaders to Focus Intently on Safety The annual report on adverse events in hospitals in Minnesota found that the number of such events overall held steady between 2009 and 2010, with a jump in medication errors. Officials with the Minnesota Department of Health (MDH) say the stagnant numbers are a concern, and add that a new focus on patient safety from hospital leadership is needed. Overall, the number of adverse events in Minnesota hospitals went from 301 in 2009 to 305 in 2010. In 2009, there were four deaths; in 2010, 10, including two deaths from medication errors, an area that increased from four events in 2009 to 13 in 2010. Other areas such as the numbers of falls, serious bedsores, and adverse events related to surgery remained roughly the same, the report finds. “The system has helped us to learn so much about why these events have happened and

continue to happen,” says Diane Rydrych, assistant director of MDH’s health policy division. “As a result, we have dedicated staff all around the state working on implementing new solutions. But when we see that we’re holding steady from where we were last year, that’s not where we want to be. We think that the numbers can and should be lower than they are.” Rydrych says MDH is putting a new emphasis on leadership from hospital boards and CEOs. “Leaders at that level really need to send a strong message that safety is the primary focus of the organization and that everybody is going to be held accountable for compliance with best practices,” she says. “It’s all part of developing a culture of safety. No matter how many dedicated frontline staff you have, if you don’t have a culture that is focused 100 percent on safety, you’re not going to be able to make progress.” Some of the strategies being recommended by MDH include telling patient stories of pre-

ventable harm at every board meeting, training hospital board members on patient safety, and requiring board members to participate in “leadership rounds” that put them in contact with frontline staff and patients.

Mayo Executive Says Health Reform Efforts Should Be Continued Health reform efforts in Minnesota have made progress but have not gone far enough, a Mayo Clinic executive told state legislators recently. Doug Wood, MD, vice president of Mayo’s Division of Health Care Policy and Research, spoke before the House Health and Human Services Reform Committee on Feb. 2. Although court challenges to the federal health care reform legislation have made headlines in recent weeks, Wood said Minnesota must press on with its own reforms. “In Minnesota, we’ve been ahead of the federal govern-

ment the whole time, and there’s no reason for us to step back and wait,” he said. Wood told the legislators the problem with the federal Affordable Care Act (ACA) is that it tried to copy the health care reform model of Massachusetts. “In Minnesota, we decided that our effort had to be on controlling costs first, and then work on access later. Massachusetts decided to do access first and not work on cost,” he said, adding that because of rising costs the Massachusetts model is not faring well. “They have coverage but they don’t truly have access.” However, Wood said Minnesota has more work to do in controlling cost as well. “The fundamental problem for us is that health care spending is still rising at a rate that outpaces economic growth,” he said. “If we don’t solve this problem, we’ll really going to threaten the economic vitality of every community in the state.” Wood urged lawmakers to think carefully about budget

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cuts to health programs as they try to address the state’s $6 billion budget deficit. “This is a complicated circumstance, and we have to think carefully and try not to go for simple solutions that may be attractive but then have adverse effects elsewhere.�

research may include collecting samples such as blood and hair, and researchers also will conduct cognitive, developmental, and physical health assessments. In addition, soil, water, and other samples from the physical environment may also be gathered to understand the role they play in children’s health.

U.S. Children’s Study Will Include Families U of M Ranks in Top From Ramsey County Quartile of Schools Officials with the University of Getting NIH Funding Minnesota announced recently that residents of Ramsey County will play a role in the largest and longest study of children’s health ever conducted in the United States. The National Children’s Study (NCS) was originally launched in 2000, with funding provided by Congress and directed by the National Institutes of Health. The latest phase will include 105 counties across the U.S., which were chosen because of the diversity of their residents. The study will look at environmental health factors that affect children, such as air pollution, nutrition, schools, neighborhoods, and family history. The researchers will contact eligible households in 16 neighborhoods across St. Paul and suburban Ramsey County, and will invite pregnant women, women considering becoming pregnant, and, eventually, fathers in those neighborhoods to join the study. The study will follow hundreds of children and their families from before birth until age 21. “By joining this study, women and their families can contribute to improving the health of children not only here in Ramsey County, but across the United States,� says Pat McGovern, PhD, MPH, principal investigator for the NCS in Ramsey County and a professor at the University of Minnesota. She adds that the information gathered will be confidential and private. Researchers will collect information during pregnancy, at birth, and throughout the child’s life. Officials say the

The University of Minnesota Medical School ranks in the top 25 percent of universities for receiving funds from the National Institutes of Health (NIH), according to a yearly analysis of NIH funding. The Blue Ridge Institute for Medical Research, based in Horse Shoe, N.C., is an independent firm that compiles and releases NIH rankings each year. The institute says the U of M Medical School secured more than $141 million from NIH in 2010, ranking it 29th of the 134 schools reviewed. Despite the relatively high level of national funding, officials emphasize that the university will still be looking to state support for its research efforts. “NIH funding is one of the most critical ways for our researchers to complete specific, targeted work within their fields,� say Aaron L. Friedman, MD, vice president for health sciences and dean of the university’s medical school. “But our state funding is also critical because it allows us to put into place the facilities, faculty, and systems that help us leverage that grant funding to make landmark discoveries and develop new advances. In fact, researchers often have to demonstrate a level of support from the state before a grant will even be awarded. The partnership with the state is critical for us, and it’s a partnership we’re proud of.� CAPSULES to page 6

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Pertussis Vaccination Campaign Get Your Shots Minnesota is combating a high rate of pertussis. It’s imperative that physicians and their staff be immunized. Physicians and their clinics can join the Pertussis Vaccination Campaign to immunize staff, and limit exposure and the potential to spread pertussis to patients. Help the Minnesota Academy of Family Physicians Foundation in its campaign to protect patients, physicians and health care workers against pertussis. To sign up for a free campaign kit for your clinic, contact Lynn at 952-224-3873 or To learn more, visit

MARCH 2011




Capsules from page 5

Sanne Magnan, MD, PhD. “It builds and expands the highly effective DIAMOND program which targets depression, and it addresses one of the leading preventable causes of illness and death—alcohol.” Bloomington-based ICSI will receive $900,000 for the three-year program. As part of the AHRQ collaborative project, ICSI will incorporate substance abuse screening methods used by a Wisconsin initiative, and some Wisconsin clinics will start using the DIAMOND program for depression treatment.

ICSI Included in Multi-State Project The Institute for Clinical Systems Improvement (ICSI) will receive part of a $3.5 million grant for a multi-state project that implements screening and early intervention in the areas of behavioral health and substance abuse. The program is sponsored by the Rockville, MD-based Agency for Healthcare Research and Quality (AHRQ), and will work with up to 90 primary care practices in Minnesota, Wisconsin, and Pennsylvania to screen patients for both depression and substance abuse, rather than one or the other. ICSI officials say the program will complement the successful DIAMOND program, which has been adopted by many clinics in Minnesota as a more comprehensive approach to treating depression. “This grant is exciting in two ways,” says ICSI President and CEO

Dayton Budget Gets Mixed Reviews from Health Care Interests Gov. Mark Dayton’s budget proposal drew a mixed response from the health care community last week, as the new governor put forth a plan to eliminate the state’s $6 billion deficit. Health and human services took big hits, with reduced reimbursements to providers, cuts to health services, and 7,200

enrollees of MinnesotaCare slated to lose coverage, but health groups seemed resigned to painful cuts. In a statement, Dayton’s office painted the budget as a balanced approach to making tough choices. In the area of health care, the budget calls for raising $877 million in revenues through Medical Assistance surcharges to providers. It would then give back some of the MA surcharges by providing $265 million in provider reimbursement increases. It would reduce overall spending for health care programs by $775 million. Analysis and commentary from different health groups quickly followed the Feb. 15 announcement. The Minnesota Medical Association (MMA) noted that the budget retains coverage for children on state plans. However, the physician association questioned the MinnesotaCare cuts, which would affect adult enrollees. “We appreciate Governor Dayton’s effort to protect Minnesota’s health care safety net, but we are concerned about

the loss of MinnesotaCare coverage for 7,200 working Minnesotans,” says MMA President Patricia Lindholm, MD. Lindholm says MMA supports Dayton’s decision to continue to fund health reform efforts such as the Statewide Health Improvement Program. “The governor’s proposal seeks to balance the state budget by using a combination of new revenues and cuts—an approach that the MMA believes is preferable to a cuts-only budget fix,” Lindholm says. Lawrence Massa, president and CEO of the Minnesota Hospital Association (MHA), says his group supports Dayton’s approach of generating new revenues—raising taxes— as part of the solution to the state’s budget woes. However, he says MHA has concerns about the new provider surcharges, which he says will hit hospitals hard.

Upcoming CME Courses Office of Continuing Medical Education U 612-626-7600 or 1-800-776-8636 U email:

2011 CME SPRING COURSES 12th Annual Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners April 18 – 19, 2011 “Bridging the Transition to Life after Cancer Treatment” Cancer Survivorship Conference April 29 – 30, 2011 North Central Chapter Infectious Disease Society of America (NCC-IDSA) Annual Meeting April 30, 2011 Bariatric Education Day May 25 – 26, 2011 Workshops in Clinical Hypnosis “Introductory and Advanced Sections” June 2 – 4, 2011 Topics and Advances in Pediatrics June 9 – 10, 2011 Advances in Breast, Endocrine, and Cancer Surgery June 16 – 18, 2011



2011 AHRQ National PBRN Research Conference June 22 – 24, 2011 Global Health Training August 1 – 26, 2011

UPCOMING FALL 2011 COURSES Psychiatry Review September, 2011 Pediatric Clinical Hypnosis September 15 – 17, 2011 Pediatric Trauma Summit September 22 – 23, 2011 Obstetrics, Gynecology, & Women’s Health Autumn Seminar September 23, 2011 Pain Management for Primary Care September 28, 2011 Practical Dermatology September 30 – October 1, 2011 Twin Cities Sports Medicine September 30 – October 1, 2011

MARCH 2011

Urology for Primary Care October 6, 2011 Transplant Immunosuppression “The Difficult Issues” October 12 – 15, 2011 Internal Medicine Review and Update November 2 – 4, 2011 Emerging Infections November 18, 2011

ON-LINE COURSES Courses available for AMA PRA category 1 credit. s Reducing Recurrent Preterm Birth s Travel Medicine s Healthcare for Immigrant & Refugee Populations s ECG of the Week s Adult Congenital Heart Disease All courses are held in the Twin Cities unless noted


Minnesota Oncology has added several physicians to its staff. Tim G. Larson, MD, is practicing at the group’s Minneapolis clinic. He previously practiced with the Hubert H. Humphrey Cancer Center, part of North Memorial Health Care, from 1995 through 2010. Larson received his medical degree from the University of California, San Francisco, and completed a residency in internal medicine and Tim G. Larson, MD a postdoctoral fellowship at UC Davis Medical Center. He is board-certified in internal medicine and medical oncology. Larson has participated as principal and co-investigator on numerous medical oncology clinical trials, reflecting his interest in the development of cutting-edge cancer treatments. Khalid Kambal, MD, is seeing patients at the group’s outreach clinic at Hutchinson Area Health Care. He completed his medical degree at Kasr Al Ainy School of Medicine in Cairo, Egypt, and completed a residency in internal Khalid Kambal, MD medicine and a fellowship in oncology and hematology at Howard University Hospital in Washington. Kambal is boardcertified in medical oncology and hematology. In January, Rod Christensen, MD, was named chief medical officer of the Allina Medical Clinic (AMC), after having served since April 2010 as AMC’s interim chief medical officer. In this role, Christensen will be responsible for the Rod Christensen, MD development and implementation of AMC clinical and quality enhancement initiatives. Prior to being named interim AMC chief medical officer, Christensen was the district medical director for the AMC South Central District. He has been a family practice physician at AMC’s Northfield clinic since 1987. In January, Fairview Health Services appointed two new executives. Mark Werner, MD, has been named chief clinical integration officer, and Brent Asplin, MD, has been named presiMark Werner, MD dent of Fairview Medical Group. Werner, a pediatrician, was president of Carilion Clinic Physicians and executive vice president and chief medical officer for the Carilion Clinic in Roanoke, Va. He will be in charge of Fairview’s quality, patient safety, and patient experience initiatives; medical staff manageBrent Asplin, MD ment; and clinical research and education. He will work with Fairview Medical Group and Fairview Health Network, a group of employed and independent physicians, as well as the academic side of the organization, which includes University of Minnesota Physicians and Fairview Physician Associates. Asplin was chairman of the Department of Emergency Medicine at Mayo Clinic in Rochester, and formerly was department head of emergency medicine at Regions Hospital in St. Paul. He will provide physician administrative leadership for the organization’s group practice and will work to achieve the system’s goals in the areas of clinical quality, patient experience, effective and efficient use of resources, and strategic growth. Stefan Friedrichsdorf, MD, director of Children’s Hospitals and Clinics of Minnesota’s Department of Pain Medicine, Palliative Care, and Integrative Medicine, is one of five American physicians honored by the Cunniff-Dixon Foundation for improving the care of patients near the end of life. He received the Hastings Center Cunniff-Dixon Physician Award for “innovative symptom management of pediatric patients, compassion, and family-centered care.”

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Physicians, just like patients, need well-being ■ How would you define the term “physician Photo credit: Minnesota Medical Association/Steve Wewerka

well-being?” It encompasses a lot of things. Primarily what we are looking at is the ability for physicians to not only survive, but to thrive in their profession personally and professionally. We encompass mental health, physical health, and collegiality. It is a holistic point of view that we take.

Patricia J. Lindholm, MD Minnesota Medical Association Patricia J. Lindholm, MD, is president of the Minnesota Medical Association (MMA) and a family medicine physician with Lake Region Healthcare in Fergus Falls. As president of MMA, Lindholm has been a champion of physician well-being, and has led a task force that recently came up with recommendations for addressing physician burnout. In January, the MMA adopted the plan put forth by Lindholm’s task force, which will allow the physician association to develop educational materials and other resources to address physician well-being issues.


■ What do you find to be the most significant

problems facing physicians when it comes to maintaining their well-being?

We are trained that you are to be perfect, never make a mistake because—God forbid—you could kill somebody or have some tragic thing happen. We are set up with these unrealistic expectations. There is no one who never made a mistake out there in the human race that I am aware of. ■ What led to this becoming an issue for you We all have to have this mask of invulnerabiland for the MMA? ity. Then reality hits us on the head and we find out that we are not always perfect, we don’t always Several years ago I was working through some make the right decisions, or a bad outcome hapissues and realized that this is a common theme pens in spite of doing all the right things. We have among my colleagues. A lot of people are burned a tendency to turn in on ourselves, blame ourout, unhappy, have struggled to balance their famselves, become depressed and demoralized. ily life with their professional life, and so forth. The other issue is that most physicians today, Physicians tend to work in their own little particularly in primary care and in general surgery, silos, even if they share an office. We tend to not are frankly overworked. They are overwhelmed want to display anything that would suggest weakwith the workload. Burnout ness or possible impairment can happen very quickly to each other. That causes The bottom line is that when we are sleep-deprived more isolation, more burnwe are as human as and more and more demands out, and more difficulties in placed upon us, even really enjoying a medical everybody else, and yet we are though we are not at our best career. are held to superhuman physically and mentally. A lot of research on this Many physicians move topic has been done in standards sometimes. from practice to practice, Minnesota. Some data from hoping to find that place researchers at Mayo Clinic where life is more comfortable, the workload is indicated that about 60 percent of medical stumore manageable. Some physicians have left medidents, at some point during their career, were cine completely, because they just do not see themshowing signs of burnout. At any point in time, selves ever getting out of that rat race. A lot of 11 percent of students had suicidal thoughts in physicians are going into consulting work, other the previous year. The more I read about that, the physicians are retiring or leaving the profession. more I realized that there is a lot of pain out there, The bottom line is that we are as human as and we should be able to help each other. everybody else, and yet we are held to superhuman Several years ago, at a Minnesota Academy of standards sometimes. Physicians get sick just like Family Physicians meeting, I shared the statistics, everybody else. Physicians have mental illness as as well as my own personal journey, with about often as everybody else. Physician suicide is dis400 physicians. After that, I started to get a lot of turbingly prevalent. personal contacts, questions, and discussions with I think we need to be more proactive in our many other physicians all over the state. Much to approach to physician well-being. We have seen my surprise, about a year after that, I was asked if that by sharing with colleagues who are underI would consider being president-elect of MMA. standing and keep the confidences, people have At that time, I explained that if I were to do started to build relationships with each other that this, my emphasis would be on physician wellness. we did not have before. We have more of a feeling I was given a great deal of encouragement to move of community. forward with that. Many physician leaders as well as physicians in the community were rooting for ■ Health care reform has been a big topic nationme and wanted to see something happen. ally and in Minnesota. What are some good Preceding my presidential year, I put together and bad points of the national health law? a task force that worked on studying the issues and thinking about ways in which the medical associaThe good points for sure include the fact that tion could be of some help to our members and to young people can stay on their parents’ insurance the profession as a whole. until age 26 even if they are not full-time students. In January, we presented our report to the The insurance reform issues that have to do with MMA Board of Trustees. It was accepted, and we not excluding people with preexisting conditions—I are now going to move forward with integrating think that is good. Also that health plans cannot physician well-being into the work of the medical drop your insurance when you become ill. I think association. that is very good.


There is some promise here. Quite a bit of work has been going on in the medical homes arena, for example. This is a principle that we have been in favor of for a while, and yet we need to have some pilot projects and see how it works. Of course, trying to get everybody on electronic health records is very important, although very expensive and painful in the transition. The peer grouping is still being worked out as I understand it. Some of our ideas will probably get picked up by other states and by the feds as well.

when the governor signed the early Medicaid Expansion Act, because that infuses $1.2 billion into our state to help care for these people. These are people who probably have higher medical needs than the average Minnesotan. And they cost the average Minnesotan a tremendous amount in tax dollars and in health premium dollars. To not be able to care for them at the preventive level makes it much more expensive for the rest of us when they show up in the emergency room. I think we also want to be closely involved with continuing the quality improvement, community measurementtype movement. We would like to see increased transparency among the health plans that are administering the Medicare Advantage Program, for example, and the PMAP programs where they get paid extra dollars to coordinate care of some of these patients. We don’t know where that money is necessarily going—that is an issue. The budget is a challenge, both at the state and federal levels. We are very aware of that, but we think that investing in prevention and public health will save us money in the long run.

■ What are the top legislative priorities for

■ Why did the MMA oppose Medica’s

The MMA and I personally agree with the individual mandate, that all people should have insurance and be responsible for that, whether it is subsidized or whether we pay for it ourselves. In our plan, the Physicians Plan for a Healthy Minnesota, that was one key part of health insurance reform. Because if people do not all pay into the system, then when an uninsured patient, as often happens, has a serious illness and goes to the hospital and cannot pay for their care, then the rest of us pay for their care. ■ What about state reforms such as med-

ical homes and peer grouping—how do you see those?

recent online physician ratings program?

MMA this year in Minnesota? Our top legislative priority is to keep safety net programs intact. We were very pleased

We opposed it because it is very different from the ongoing work that has been hap-

pening in the rest of Minnesota. The MMA is a founding member of Minnesota Community Measurement. We sit on the board, as does Medica. [For that program], we use agreed-upon standards of care that aggregate data from the entire clinic. The Medica program is trying to rank individual physicians. We feel that methodology is flawed. If we are all aggregated together in our clinic groups, then if we see outliers of quality in one area, our clinic can work on that. We can do a quality improvement program. But if you have individual doctors all over the board—especially when it is on limited data, limited to one insurance company—who knows what to do with that information? ■ What message do you have for

physicians in Minnesota? The MMA is all about physicians and our patients. We need to remember that supporting each other and maintaining the professionalism of medicine is not going to happen from business people and a business model. It is going to happen for those of us who are idealistic and care about the standards of our profession and who frankly understand the burdens of our profession. For me, adding an emphasis on physician wellness will make MMA more relevant and move valuable to physicians in Minnesota.

Supporting Our Patients. Supporting Our Partners. SupportingYou. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

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Profits vs. care? from cover haps, the practitioner. This has been shown, time and again, in the use of certain orthopedic and cardiac devices (among other culprits) that drive up cost with no proven benefit to patient quality of life, quantity of life, or satisfaction. Yet without new developments that

push the envelope, where would we be today? Without pioneers inoculating common people with smallpox, perhaps against the wishes of the medical establishment, who would drive the innovation? The answers, simply put, are nowhere and no one. We need innovation and medical

,,!79%23 !79%23 7 4(!4 4(! !4 $/#4/23 $/ /#4/23 42534 4 534 42 -EDICINE IS CCOMPLICATED -EDICINE OMPLICATED 33O O AR ARE E THE LA LAWS WS THAT THAT DOCTORS






anesthesia fees, facility fees, surgeon fees, and therapy, is likely to cost $5,000–$15,000. Another option is a technique called needle aponeurotA case in point: Dupuytren’s, omy, which involves the use of the Viking disease small needles to cut the conTo illustrate the intersection of tracted cords beneath the skin. profit vs. efficient treatment, let’s This technique was championed take the example of Dupuytren’s in France by a group of rheumatologists and is now used by some surgeons in the United States. The beauty of the technique is its simAll too often, over time we find that these newer, plicity: straight local anesthesia and a handful of nearly always more expensive options serve 25-gauge needles. That’s nothing more than to line the pocket of it. The bevel of the needle is used to sever the conthe manufacturer, sales representative, tracted cords in several or, perhaps, the practitioner. locations, to allow the finger to straighten. It is similar to cutting a rope into multiple sections to remove the itage (it has been called the disease. Dupuytren’s is a genetic tension, whereas open surgery “Viking disease�) and thus is disease process that afflicts the involves removing the rope. very prevalent in the Midwest, hands, causing contracture of Along with the quick recovery and Minnesota in particular. the fingers over the course of and immediate use of the hand, Dupuytren’s causes contracmany years and often leading to the other wonderful thing for ture of the palmar fascia, which the inability to straighten the is the thick fascia underlying the patients is the inexpensive finger(s). In approximately 10 nature of the procedure: It typipalmar skin. As this fascia conpercent of patients, it can also cally costs less than $1,000 tracts into tight cords and nodaffect the plantar surface of the (often only about $500). ules, it causes an inflexible flexAnother technique, recently ion contracture of the digit that released to the health care marprogresses over time. While ket, is an enzymatic treatment trauma (including surgery) may (brand name Xiaflex) in which instigate the formation of this collagenase is injected into the contracture, more often it develcontracted cord to enzymatically ops spontaneously. The diagnosis of this disease break down the tissue and rupture the contracted cord, thereby is fairly straightforward and straightening a previously clinical: You see cords promicrooked finger. This treatment is nently in the palm of the hand similar in theory to the needle that look like errant tendons; technique, but it only treats one nodules in the palm or fingers part of the cord. The real conthat resemble mats of deep scar trast, however, is in the cost: The tissue; or perhaps pits in the injection alone costs $3,200. palm due to the “puckering� of This does not cover the cost of the skin as the contracted fascia administration, manipulation, or pulls the skin inward, while the other professional fees. Thus, fingers are pulled to varying the total cost of treatment for a degrees into flexion. single injection is likely to be at To treat this condition, surleast $4,000. As well, only one gery traditionally has been used injection can be given at a time. for many years. While there are While one treatment is usually many types of surgery persufficient for both needle formed for Dupuytren’s contracaponeurotomy and collagenase ture, in general surgery involves injection, additional treatments removing as much of the diswill come with a similar price eased and contracted tissue as tag. possible, in an effort to straighten the finger(s). The surgery is In today’s health care cliusually successful, but it inmate and in the spirit of saving volves a fair amount of therapy, money while simultaneously recovery, pain, and suffering. offering effective treatment, Such a procedure, including the treatment of choice is obvi-

progress. However, when profits and money enter the equation, their delineation becomes much less clear.


feet (Ledderhose’s disease), and in about 1 percent of those males affected, it can cause contracture in the penis (Peyronie’s disease). Named after Baron Guillaume Dupuytren, the surgeon who described an operation to correct the affliction, Dupuytren’s primarily affects those of northern European her-

ous: needle aponeurotomy. This is a truly minimally invasive technique that requires little downtime for the patient, and yet costs thousands of dollars less than the alternatives. However, there is no driver in the medical/surgical community to use this technique: It pays much less than surgery, and no drug company profits from its use. The driver, in this case, is the patient seeking an inexpensive alternative to surgery or collagenase injections. Too often we associate minimally invasive techniques with high-tech, computer-assisted surgery. In contrast, needle aponeurotomy is low-tech and simple: hence the savings. The emphasis here is not just on patient care, but on medically effective and cost-effective patient care. While not all patients with Dupuytren’s contracture are candidates for this technique, and recurrence rates are slightly higher or faster with the needle technique than with open surgery, needle aponeurotomy should remain a treatment of choice for this common dis-

ease in the appropriate patient. It melds the important factors of low cost, high effectiveness, and high patient satisfaction. As the saying goes, sometimes less is more. That is the case when it comes to needle aponeurotomy and Dupuytren’s disease. So, what happens to the profit? The individuals that garner less profit are the surgeons, the surgery center, the anesthesiologists, and the makers of Xiaflex. The winners are the patients and the insurance carriers for those patients. Do the aforementioned individuals stay in the black? Absolutely. However, they do have to sacrifice some profit for the benefit of the patient and, ultimately, the health care system. Can we rescue the system?

Beyond the example of Dupuytren’s disease and needle aponeurotomy lies a crisis that doctors (and other health care providers) must address—before it gets addressed for us to the

Too often we associate minimally invasive techniques with high-tech, computer-assisted surgery. detriment of our practice autonomy and medical expertise. We cannot continue to up the ante in the medical arms race, touting the use of unproven hightech treatments—many of which involve computer navigation, expensive equipment and devices, and added cost—and letting the profit motive drive our treatment recommendations. Rather, we need to look carefully at less expensive, less invasive treatments that are proven to serve patients just as well. Ultimately, we will serve our patients, reduce the costs of health care, and rescue our health care system from the brink of disaster. Who is going to lead the charge? We physicians, as members of the health care industry, must dedicate ourselves to determining our most effective treatments, caring for our patients

respectfully and compassionately, and reining in costs. In the current climate of rising overhead, decreasing reimbursement, and more money going toward less or equally effective care, we need to work together to find solutions for effective, value-centered patient care. If we do not, the future of health care (and health care providers) is bleak: The medical arms race will continue—and neither patients nor practitioners will be the winners. Nicholas J. Meyer, MD, practices at St. Croix Orthopaedics in Stillwater, Minn.

MARCH 2011



Challenges from cover multi-task at the highest level, managing day-to-day business operations, leading personnel, addressing patient inquiries, and monitoring clinical care guidelines and changes in legislative regulations, to name a few of our responsibilities. Successful medical practice administrators demonstrate a high level of professionalism; provide an environment of open communication; possess detailed organizational and analytical skills; are talented managers of human resources; and employ a breadth of business knowledge, from operations to risk management, information systems, financial management, clinical care, and quality improvement processes. Some of the most important responsibilities of a medical practice administrator are described below. Facilities management. Whether your practice owns or leases a medical office, there are always tasks associated with maintaining the office. Purchasing new land and building an office building or surgery center

is a full-time job in itself. Administrators must be savvy about finding the right space, negotiating a fair price, and determining the best designers, architects, and contractors for the practice’s needs. When renting an office, administrators need to negotiate a lease, manage housekeeping staff, and remodel and repurpose the space according to the practice’s clinical and administrative needs. It is essential to keep space needs in mind in planning for growth and expansion of the practice. Human resources management. Medical practice administrators oversee the recruitment, orientation, ongoing training, and retention of clinical and non-clinical staff. They administer performance management programs, benefits, and compensation to enhance efficiency and productivity and comply with employment regulations. A high level of employee satisfaction is a key component in any successful organization. Information management. Administrators need to develop

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and maintain a technology infrastructure that provides for seamless and secure operation of practice management systems and the electronic health record, which supports internal and external connectivity with multiple applications (clinical equipment, imaging systems, outside providers, institutions, payers, reporting agencies). Risk management. Administrators oversee the development and implementation of a risk management plan to ensure a safe environment for patients, staff, and visitors; policies to manage the impact of adverse legal events; and a compliance program for federal and state laws and regulations. Financial management. Administrators develop and implement internal controls to achieve organizational objectives, as well as a process for external review for fiscal accountability. A revenue cycle management process and an accounts receivable management program evaluate the patient experience, from how we schedule appointments and obtain the necessary information for billing, to the analysis of coding and reimbursement, negotiation of payer contracts, and review of federal RVU and policy changes. Administrators have to stay current on these matters to identify the greatest opportunities for prompt and effective payment as well as to be in alignment with provider compensation contracts. Consistent and timely analysis and monitoring of the financial performance of the organization, and reporting financial results to stakeholders, are essential for effective group decision-making. Administrators must establish and maintain the organization’s banking, investment, and other financial relationships in collaboration with the physician management team. They also must develop open and collegial relationships with individual insurance carriers in order to optimize contract negotiations and maintain existing contracts. Clinical patient care. Working with providers and staff members, administrators formu-

late appropriate resources to enhance patients’ knowledge and understanding so they may fully participate in the decisionmaking for their medical care. An understanding of the demographics of the patient population is essential to provide appropriate literacy and language education materials. Online decision-making tools are beginning to be used in a variety of practices to help patients better understand their treatment options. Quality management. Working with the physicians and staff members, administrators plan for and oversee internal processes to enhance clinical quality, which will improve the patient experience. Quality improvements committees have been common among practices for a long time, but some are now including patients as participants in order to better understand the consumer view. Governance. The strength and consistency of the foundational structure of the physician group are essential to its overall success. The administrator facilitates the development, implementation, and monitoring of the corporate legal structure, including strategic planning that integrates the mission statement into action plans. The administrator must demonstrate a leadership model that fosters growth and development of physician leaders, management, and staff, and that encourages their participation in clinical, financial, and legislative endeavors. Working as a team

The health care landscape has experienced monumental changes over the past several years. The trend toward integrated delivery systems has moved numerous physicians away from independent practice. The economic crisis of the past few years has resulted in higher deductibles for health coverage, which places a higher financial burden on the consumer and ultimately increases debt for the medical practice. It is getting more and more difficult for a practice to remain solvent. Confronting change successfully requires that administra-

tors and physicians work as a team to solve problems and make decisions effectively. The strength of the physician/administrator team is key to an organization’s success. Medical practice administrators typically focus on the large picture, constantly engaging with various groups of people to solve problems by working together. Physicians, on the other hand, are trained in medical school to treat patients, make decisions, and deal with people on a one-on-one basis. These differences in approach can help create a comprehensive physician/administrator team. If the two approaches are not aligned, however, frustration and unresolved conflict may result. It is imperative that physicians and administrators recognize these differences in professional styles and work collaboratively to develop a strong foundation of trust and integrity in order to lead the practice to success. The administrator’s role is to foster team development among physicians and staff through open communication,

thoughtful leadership, and supportive motivation. Effective administrators use their own strengths to help others grow and develop. Health care reform expands the administrator’s role

As of this writing, a chief challenge of health reform is that administrators must constantly brainstorm how to implement state and federal policy requirements—while monitoring legislative efforts to repeal them. As an example, it’s difficult at present to know whether the weeks, months, and years of planning and training staff to support “meaningful use” recommendations regarding electronic health records (EHRs) will have been worth it or not (i.e., if the recommendations are ultimately changed or repealed). Given the complexities of managing a medical practice in an era of health care reform, mergers, and acquisitions, what are some of the imminent challenges for medical practice administrators? • We must be involved at the


Colloquium Thriving in an Era of Health Care Reform

legislative level and do our part to participate in meaningful payment reform, assist in developing a structure for the provider tax that our practices currently fund, and work collaboratively with one another to promote fair contracting relationships. • We need to participate in the evolution of accountable care organizations or other quality health networks aimed at measuring outcomes in order to deliver better care and reward those who do so. I encourage all administrators and physicians to start developing your own opportunity to demonstrate the high quality you provide. Our financial future rests on outcomes reporting for improved payment. • We need to recognize the important role of mid-level providers, advance practice nurses, and other medical staff. All practices will need to embrace the value of various providers and encourage all professionals to work up to the top level of their skill set. In an era of cost restraints, fiscal

Attend the 14th Annual ICSI/IHI Colloquium on Health Care Transformation, May 16–18, 2011, Saint Paul RiverCentre Last year’s ICSI/IHI Colloquium achieved record attendance and received rave reviews. This year’s program will equally help you successfully navigate the new health care landscape. The program and pre-conference workshops will focus on “Advancing Accountability, Affordability and the Patient Experience” along three tracks: 1. Leadership and Accountability 2. Quality and Safety 3. Patient Engagement/Consumer Experience

responsibility demands that we use the most appropriate resource for a given task. • We must work to match the service to the appropriate location. Where a medical service is performed is a driver of the overall level of cost. We need to be good stewards of health care dollars by recommending the most cost-effective site of service for a particular clinical event, whether that is an office setting, a surgery center, or a hospital. Given the current state of flux in health care delivery and management, it’s impossible to predict what challenges clinic administrators will face in the future. What I know for sure is that change is certain. We must have confidence in our ability to consistently adapt to the changes and challenges to our practices in a way that results in a better health care delivery. Shari Ohland, MHA, CMPE, is the current president of the Minnesota Medical Group Management Association and is the clinic administrator for Midwest Spine Institute, LLC.

Our Keynoters are: Susan Dentzer, Editor-in-Chief, Health Affairs: Implications and Opportunities in the New Era of Health Care Jane Sarasohn-Kahn, THINK-Health: Participatory Health — The New Patient Engagement Early Registration Ends April 18 Don’t miss the Upper Midwest’s most important event to help you thrive today and position your organization for future success. Register and view the final program at:

MARCH 2011




Global health training


ith more than 1 billion people crossing international boundaries and the United States receiving more than 2 million international travelers and migrants every day, all clinicians in the U.S. need some understanding of global health issues, regardless of whether they travel or work internationally. Over the past five years, the University of Minnesota Department of Medicine’s Global Health Pathway has developed a global health curriculum, called the Global Health Course, that offers comprehensive training while allowing physicians and other health care providers to tailor course offerings to the specific needs of their practice. Since January, Minnesota practitioners have been able to take the Global Health Course either in person or online. The Global Health Pathway curriculum

The overall theme of the Global Health Course is decreasing dis-

Promoting best practices to reduce disparities in health care outcomes By William Stauffer, MD, MSPH, CTropMed parities of care experienced by immigrant and refugee populations in the U.S., as well as by people living in resource-poor areas of the world. The 300-hour

an disasters (e.g., the 2010 Haiti earthquake). The course also teaches hands-on clinical skills such as laboratory methods and ultrasound procedures.

The Global Health Course and the individual modules are CME-accredited for both physicians and nurses. course curriculum traditionally has been presented in eight modules, each one week long, that cover tropical medicine, traveler’s health, and medical work in resource-poor overseas settings and during humanitari-

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The key objectives of the Global Health Course are to: • Provide the most current and relevant training and support for providers to promote best practices to reduce health care disparities and improve health care systems • Inspire providers to assist underserved communities • Train providers to care for culturally diverse patients The course has been created for health care providers whose practice requires them to recognize, diagnose, and treat a patient base that may include American travelers; refugees; immigrants; people traveling back and forth to their home land; and/or those who are seen internationally as a result of natural disaster, crisis, trauma, or infectious or chronic disease. Co-sponsored by the U.S. Centers for Disease Control and Prevention, the U of M’s Global Health Course represents a broad and unique collaborative effort, with more than 150 speakers from multiple local, national, and international partners, including Mayo Clinic, the Minnesota Department of Health, HealthPartners/Regions Hospital, Hennepin County Medical Center, Children’s Hospitals and Clinics, Allina Hospitals and Clinics, Center for Victims of Torture, American

Refugee Committee, Beth Israel/ Harvard Medical School, United Nations High Commission for Refugees, and Colorado Center for AIDS Research, as well as a variety of community groups and international institutions. Along with their extensive experience and deep knowledge, these volunteer speakers from around the world share a passion for reducing health disparities in vulnerable and disadvantaged populations. More than 30 hours of lectures are available within each course module. Clinicians may take the entire course or just the portions or modules that are most applicable to their practice. In recognition that the needs of clinicians differ, the course is designed to provide tailored curriculum to those who may desire only certain knowledge and skill sets. Each module is designed as a stand-alone curriculum, so whether clinicians desire training in immigrant/ refugee health, traveler’s health, or parasitic diseases, or want to obtain a comprehensive training and certification, they may accomplish their goals. Accreditation and certification

The Global Health Course and the individual modules are CME-accredited for both physicians and nurses. The American Society of Tropical Medicine and Hygiene (ASTMH) has deemed the Global Health Course one of only 17 certification courses in the world and one that qualifies participants to sit for the Certification of Knowledge in Clinical Tropical Medicine and Travelers’ Health (CTropMed) offered by ASTMH ( The complete curriculum can now be achieved through a combination of online and in-person participation. Detailed information about the Global Health Course is available at www. globalhealth. home.html. See the sidebar for additional information about the Global Health Course online offerings. The Global Health Course offers the most current and rele-

Online training in global health at the University of Minnesota The University of Minnesota’s Global Health Course is one of just 17 accredited global health courses in the world, and is the only course co-sponsored by the Centers for Disease Control and Prevention. The Global Health Course, in its entirety, includes more than 300 hours of training. It consists of contributions from more than 170 regional, national, and international faculty experts, and offers the most current and relevant information for health care providers to deliver the highest quality of care to their patients and reduce disparities in health care outcomes for globally mobile populations such as immigrants, refugees, and travelers. In an effort to make the course more accessible for busy clinicians, trainees, public health professionals, and administrators, it is now offered in an online format. As of March, enrollment is open for five of the seven online course modules: 1. Introduction to Health Care for Immigrant and Refugee Populations 2. Disaster response and clinical medicine in resource-limited settings (available April 2011) 3. Public health and non-infectious disease in developing countries (available April 2011) 4. Parasitic infections 5. Bacterial, mycobacterial (TB), and fungal infections 6. Viral infections 7. Travel medicine

Each module has been designed as a standalone curriculum and may be taken independently of the other modules. Health care providers may register for any number of the course modules, register specifically for individual course modules of interest, and take the course modules in any order. Detailed information about the online training in global health is available on the University of Minnesota Global Health website: www. home.html. For more information about the online course modules, go to onlinetrainingglobalhealth/onlinemoduletitles/home .html. CME credits, as well as Minnesota and national nursing credits, are available. For more information about CME credits, go to www. cmecredits/home.html. If Global Health Course participants plan to sit for the ASTMH examination, they must complete all seven of the online course modules, with a minimum of two of the in-person course modules, to acquire the ASTMH-required comprehensive didactic information and hands-on experience.

vant information for health care providers serving immigrants, refugees, and international travelers. The skills and knowledge that physicians and other health care providers gain from the course will help prepare them to manage an increasingly diverse and globally mobile patient population. William Stauffer MD, MSPH, CTropMed, is director of the Global Health Course at the University of Minnesota. He is an associate professor in the Department of Medicine and the Department of Pediatrics, Division of Infectious Diseases and International Medicine, and an adjunct professor in the School of Public Health at the University of Minnesota. He is on the faculty of the HealthPartners Center for International Health and International Travel Clinic, and is a technical adviser to the Centers for Disease Control and Prevention, Division of Global Migration and Quarantine.

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lushing, persistent facial redness, dilated blood vessels, red bumps, pustules, swelling, acne-like lesions, bulbous changes in the nose— these are some of the clinical manifestations of rosacea. Rosacea, a skin disease that primarily involves the face, affects approximately 5 percent of the U.S. population—about 15 million people—and can be psychologically distressing. Fair-skinned Caucasians are most susceptible to rosacea, especially Europeans of Celtic descent, with up to 10 percent reported to be affected. Rosacea is primarily a disease of adulthood and is commonly diagnosed in individuals between 30 and 50 years of age, even though symptoms may have started years earlier. Women are slightly more likely to develop rosacea, but men are often more severely affected. It is men who almost exclusively develop the most severe form of the disorder, called phymatosis. W.C. Fields and Bill Clinton are two famous examples of individuals with phymatous


Faces of rosacea Inflammatory skin condition has four main subtypes By Jennifer Ray, MD rosacea, characterized by facial redness and, often, a bulbous nose. Types of rosacea

Physicians often diagnose rosacea simply by physical examination. Although patients may have a range of symptoms covering several subtypes, there are four main subtypes based on symptoms and appearance: • Vascular (erythematotelangiectatic) rosacea is exemplified by persistent facial flushing and redness, which can evolve into enlargement of superficial blood vessels. This most commonly affects the central facial region but can also involve the chin, forehead, and ears. • Inflammatory (papulopustular) rosacea can look very


similar to acne, with red papules, pustules, and nodules. The main difference between acne and rosacea is that the inflammation in acne involves the follicle, whereas in rosacea it does not. Also, acne is partially a disorder of skin cell turnover, which is not the case with rosacea. • Phymatous rosacea involves enlargement of the sebaceous glands and usually affects the nose. However, it also can involve the forehead, chin, cheeks, and ears. As the disease progresses, thickening of the skin and scar-like changes occur. • Ocular rosacea is an underappreciated form of rosacea. Common symptoms are a gritty, scratchy, dry sensation; foreign body sensation;

blurred vision; and the development of styes or chalazions, a type of small lump or cyst of the eyelid. Up to 50 percent of patients with other types of rosacea also have ocular symptoms, but in some people ocular symptoms may occur alone. This type of rosacea may involve impaction of the oil gland near the eyelashes, causing inflammation and dysfunction in the formation of tears. It also can pose a threat to vision, if it gets big enough. Some patients have multiple forms of rosacea, but one type does not turn into another. Each type of rosacea tends to get worse if untreated, though all types except for phymatous can wax and wane. Once phymatous rosacea starts, the only way to make it better is physical removal of the affected tissue. Cause and triggers

Physicians and patients have long known the numerous triggers that can exacerbate rosacea, including alcohol, sunlight, emotional stress, heat,

and certain medications and food. Until recently, however, relatively little was known about rosacea’s underlying mechanism of disease. It was long felt that infectious agents, such as the microscopic mite Demodex folliculorum, could be a cause. These organisms can be much higher in concentration in the skin of patients with rosacea than in individuals without the disease. Recently, though, patients with inflammatory rosacea were found to have a bacterium called Bacillus oleronius living inside the Demodex mites. Studies showed that the bacteria had certain proteins in it that caused inflammation in susceptible individuals with the mite. Thus, rosacea is not an infectious disease and cannot be transmitted; it is an inflammatory disease. Other recent investigations have isolated gene defects in proteins that ultimately lead to damage to the skin with the formation of new blood vessels, dermal destruction, inflammation, and angiogenesis associated with the disease. The antimicrobial substances produced by the body, called cathelicidins, normally function as the first line of defense against infectious agents. These “natural antibiotics” normally increase the local skin inflammatory response and are secreted by immune and skin cells. The cathelicidins in patients with rosacea have been shown to be 10 times higher than in individuals without rosacea. Cathelicidins increase vascular permeability, thereby leading to facial redness. People with rosacea also possess 1,000 times higher concentration of enzymes called proteases that can cause inflammation in the skin. It is now felt that the body’s over-exuberant inflammation is the cornerstone for the development of rosacea. Treating rosacea

There is no cure for rosacea, but advances in understanding the causes have led to new treatments focused on decreasing disease symptoms and slowing disease progression. For example, the recent discovery

Rosacea is not an infectious disease and cannot be transmitted; it is an inflammatory disease. of the dysfunctional inflammatory pathway has helped to explain why protease inhibitors and anti-inflammatory antimicrobial agents, such as the tetracyclines, have been so effective. These medications inhibit proteases that activate cathelicidin. The secondgeneration tetracyclines include doxycycline and minocycline, which are commonly prescribed for more severe forms of rosacea. A new slow-release, low-dose form of doxycycline, Oracea, has recently become available. Because Oracea is very low-dose, it does not affect a person’s normal bacteria, which decreases the chance of bacterial resistance. Another antimicrobial agent, metronidazole, has been a standard treatment agent in the papulopustular form of rosacea, having anti-inflammatory and antioxidant properties as well. Azelaic acid, with antioxidant and anti-inflammatory properties, has been used topically and decreases the expression of cathelicidin (the most important protein in rosacea). Topical sodium sulfacetamide in combination with sulfur is also effective. Sulfacetamide is antibacterial as well as antifungal and antidemodectic, so it acts against the Demodex mite. Topical clindamycin antibiotic has also been used with success, alone or in combination with benzoyl peroxide. Topical or oral vitamin A-related medications (retinoids) are occasionally used, but these are considered controversial by some because of the potential for irritation and aggravation of the underlying vascular disease. They do, however, minimize the acnelike lesions of papulopustular rosacea and can improve severe rosacea. Additional agents are being investigated but have not been approved. They include antiparasitic medications and newer

immune-system modulating agents. Some have helped with the vascular component of rosacea by constricting blood vessels. Anyone with symptoms of rosacea should be evaluated by a dermatologist for proper diagnosis and treatment. Rarely, other skin diseases such as acne can mimic rosacea yet require entirely different management

strategies. It is important that all patients with rosacea avoid triggers that induce inflammation of the skin, especially ultraviolet light, and engage in good, gentle daily skin care. More information for physicians and educational materials for patients are available at the website of the National Rosacea Society, Jennifer Ray, MD, is a dermatologist with Skin Care Doctors. She practices in St. Cloud, Burnsville, and at the Apple Valley Medical Center.

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he use of high-technology diagnostic imaging (HTDI) has increased significantly in the past decade. While much of this increase has resulted in better diagnoses and care, part of the increase has been attributed to non-clinical needs such as patient expectations, defensive medicine, and the complexity of HTDI indications. This usage has contributed to unsustainable increases in imaging costs and patient exposure to unnecessary radiation. In an effort to improve diagnostic imaging around the country, many health plans instituted prior notification processes through radiology benefits management (RBM) firms to help ensure appropriate use of HTDI scans. However, this created delays for patients and added inefficiencies and expense for providers, health plans, and patients. The Institute for Clinical Systems Improvement (ICSI) was asked to develop an efficient way to improve the accuracy of diagnostic imaging

Lessons learned using decision support to order HTDI scans By Cally Vinz, RN ordering and use. Providers, radiologists, health plans, and the Minnesota Department of Human Services collaborated through ICSI to develop a decision-support approach that enables providers and patients to find an appropriate diagnostic approach supported by the right study. Five Minnesota medical groups have used this approach for three years to order more than a million HTDI scans. Based on their results, ICSI is now leading a statewide initiative to make the option available to clinics across Minnesota. This article shares some of the early adopters’ lessons learned in implementing a deci-






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sion-support approach to ordering HTDI scans. ICSI approach vs. current practice

Today, many providers around the country or their staff call an RBM firm to determine whether a proposed scan will be covered by insurance. With the EMR (electronic medical records) and Web-based decision-support solutions in the ICSI option, the provider selects the test and enters the patient’s indications into the electronic tool. The system provides an appropriateness score for the provider’s selection, based on American College of Radiology and other national standards. “Although we’ve been on our EMR for years, most of our doctors used support staff to order scans, often after a patient had left the exam room,” said Ross Chambers, MD, Fairview Medical Group, Milaca, Minn. “Decision support requires that doctors do the ordering with the patient present. This creates a little more work for the doctor, but the approach delivers appropriateness criteria immediately so the tool educates both doctor and patient. What differs for the patient is a reduced waiting time for the imaging and increased confidence that an ordered scan won’t be denied and rescheduled.” Fairview Health Services found that using decision support increased the productivity of its ordering staff. Under callin prior notification, staff spent about 10 minutes for each approval of an HTDI scan. Now, it takes 10 seconds, according to Barry Bershow, MD, Fairview’s vice president of quality. “In one month, we spent 308 hours to get RBM

approval on 1,850 HTDI scans,” he said. “Using decision support, the time was reduced to five hours. The savings in administrative time has been the equivalent of nearly six FTEs over the past three years.” Similar results were seen at Essentia Health (formerly SMDC Health System), which has the decision-support criteria embedded in its Epic EMR. Here, the authorizations for four hospitals and 14 clinics funnel through one location. Case manager Theresa Stumbris, RN, said the automatic EMR option has replaced the typical 15-minute phone calls for prior notification/prior authorization. “Without the decision-support tool, we would be doing dozens of prior notifications/prior authorization calls each day,” she said. “Now we do perhaps 10 to 15 to payers who do not accept the decisionsupport method. One person is currently dedicated to the process. With-out the decision support tool in the EMR, we would need about three FTEs to submit these requests.” Another motivation for ensuring appropriate HTDI scans are ordered is to reduce patient exposure to unnecessary radiation. “A report in the New England Journal of Medicine says 1.5 to 2 percent of cancers may be caused by medical imaging,” said Brian Rank, MD, medical director of HealthPartners Medical Group. “Using decision support is better for patients if we can decrease the risk of radiation exposure and improve diagnostic accuracy of our orders.” Culture change

Using decision support brings a philosophical change to ordering scans, according to Phil Hoversten, MD, district director of Allina Medical Clinic. “The amount of information from professional guidelines embedded into the computer and available at the point of ordering makes using decision support a far superior option to calling an RBM. Plus, with the tool’s simple drop-down box and immediate response, it’s convenient.” Chambers said that doctors typically order what they be-

lieve is the right HTDI scan for whatever indication they feel a patient needs. Prior notification put in parameters, which pushed doctors to get on board. He said they are finding decision support more acceptable than call-in prior notification. Physicians note that one of the benefits of decision support while in the exam room is the ability to share the appropriateness recommendations with the patient. This provides a joint decision-making opportunity. Because health plans accept using the appropriateness criteria in the EMR as an electronic prior notification, patients leave the office knowing the right imaging test has been ordered. Patients, too, have had to make a cultural shift. Some push hard to get an MRI when one may not be needed, said Hoversten. “With this system, the provider can turn the computer screen to the patient who wants an MRI and show that decision support says an MRI isn’t indicated. It’s not just the provider telling the patient, but it’s expert panels and the best thinkers in imaging bringing answers right to the situation in real time.” Bershow noted that decision support can just as easily indicate a more expensive procedure is required to achieve higher diagnostic utility. “This is reassuring to those who think this is all about the money and not about improving care,” he said. “It’s about delivering the right scan to the right patient the first time.” Chambers said his patients recognize the shared decisionmaking process and get more information about appropriate care. “More and more patients are engaged, especially when they are responsible for payments,” he said. “A patient might say, ‘I know this procedure indicated by decision support is an expensive test, but it’s an appropriate test for my condition.’” Training

“With any computer change, training in the reasons for the change and the technical aspects of the change is needed,” said Hoversten. “At Allina, we

are including pre-work tip sheets and short video learnings, as well as putting someone at the physician’s elbow to demonstrate the new system.” Allina initiated decision support in more than 50 of its clinics, overcoming resistance by explaining how it was more cost-effective and efficient than call-in prior notification. “This made it easier to implement the rollout,” said Hoversten. “With the new version, there is increased technical rigor in the software, which will be even better.” Providers in the pilot medical groups also got on board because of improvement in scans ordered. HealthPartners Research Foundation audited 300 charts, which showed a 10 percent improvement in diagnostic utility in scans ordered with decision support versus those ordered after calling an RBM.

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IT integration

Integrating decision-support criteria into an EMR must be addressed. Most of the medical groups in the ICSI HTDI pilot started with decision-support criteria developed and shared by HealthPartners. “I can’t give HealthPartners enough credit for the work they did and their willingness to share their decision-support criteria with competitors in the collaborative mindset of ‘let’s improve care,’” said Bershow. While that approach worked for the pilot, the ICSI HTDI steering committee determined that developing a common set of appropriateness criteria would be more costeffective and less labor-intensive than having an individual medical group develop and maintain its own appropriateness criteria in its EMR. ICSI has facilitated the licensing of the Radport electronic decision-support tool with a common set of criteria from Nuance Communications. It can be embedded into an EMR or accessed via a secure website. Due to work done in the pilot, the decision-support tool will be added to Epic EMRs first.

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SYSTEMS to page 36 MARCH 2011




Making a difference in Responding to disaster

Recognizing Minnesota’s volunteer physicians Each year, Minnesota Physician Publishing honors physicians who have volunteered medical services in recent years. In volunteer medical activities that span the globe, Minnesota’s volunteer physicians have provided medical care and medical education and expanded crosscultural skills and understanding. Their compassion, commitment, and generosity reflect

In the days following the devastating earthquake in Haiti on Jan. 12, 2010, medical groups from all over the world scrambled to offer assistance in different forms. One of these groups, an orthopedic practice from St. Paul, managed to get a team on the ground in Haiti just days after the earthquake, and for weeks they worked tirelessly to save lives and mend broken bodies in the Haitian capital of Port au Prince. Summit Orthopedics had a previous relationship with Nuestros Pequenos Hermanos (NPH), a charity group that runs nine orphanages in South and Central America. NPH has a children’s hospital in Port au Prince called St. Damien. When the 2010 earthquake struck, the hospital’s founder, Father Richard Frechette, called Summit orthopedic physician Peter Daly, MD, and asked him to come immediately and help with the injured people who were flooding into the hospital. Daly organized a team that flew first to the Dominican Republic, because it was impossible to fly directly into Haiti’s capital at the time, then drove overland more than 8 hours to Port au Prince. Jerome Perra, MD, a Summit Orthopedic physician who had worked with NPH before, arrived with a second group of health care workers from Summit about three weeks after the earthquake. According to Perra, that first team faced chaos when they arrived.

“At first we had no census, we had no numbers or names, it was just ‘the kid in the fourth bed of that room.’” Jerome Perra, MD

deeply held values of Minnesota’s medical community. Story by Scott Wooldridge



“This is a children’s hospital, built to hold about 120 patients, and they had 500 patients on the grounds surrounding the hospital who had been dragged in there by families, including 80 with femur fractures,” he says. Perra recalls that the first team worked around the clock, collaborating with a team of Italian physicians there. “The Italian team would run the operating room during the day from about 8 a.m. to 5 p.m., and the American team would take over from 5 p.m. until 2 or 3 in the morning,” he says. “They slogged day and night for the first couple of weeks. Shortly after I got there, the deci-

sion was made that we needed to slow down to some kind of controllable pace. We relied on local staff, and these people had to have a break. They had to have a chance to go home and to take care themselves, too.” By the time Perra arrived, teams of physicians were working 12 hours a day to treat earthquake casualties. “There was kind of a rotating staff of physicians and nurses coming from different aid groups in the States, and most people would just stay for five to seven days and have to leave. Every week, we had new people coming in,” he says. “At first we had no census, we had no numbers or names, it was just ‘the kid in the fourth bed of that room.’ At first we had 75 patients; by the time we left, we had it down to 25 postoperative patients because we were getting some people discharged, getting them home. But home was a tough question. How do you send somebody home when home is a tent on the side of the road? It was very difficult to find a safe place for people to go after they left the hospital.” The physician team that went to Haiti from Summit, in addition to Daly and Perra, included Paul Donahue, MD; Mike Forseth, MD; Mark Holm, MD; and Daren Wickum, MD. The team brought their own equipment and even their own food, since basic supplies were so short and the demand for incoming relief supplies was so great. The Summit physicians did amputations and after-care for amputations, applied fixators and casts to broken bones, and provided other types of surgical and medical care. Perra says the trip was difficult in some ways but he is proud of the way the team responded to the disaster. And, he says, there were some bright spots. “The children, once they got through the worst of things and weren’t in bad pain anymore, were still children,” he says. “They may have one leg amputated; they may have a big fixator sticking out of their thigh; but they still could smile and laugh and play some games. So seeing the bright faces on the children was uplifting. And the Haitian people themselves are very tough, very stoic people who put up with a lot of adversity and did amazingly well.”

Minnesota and the world A different view Practicing medicine in a country that is hot, crowded, and desperately poor comes with many challenges. But Steven Rousey, MD, a physician with Minnesota Oncology, says his two medical missions to Bangladesh not only have made him grateful for the resources we have here but also have given him a new appreciation for the basics of medical practice. “It was exhausting and it puts you out of your comfort zone, but that’s OK,” he says. “It is quite rewarding to get rid of all the other stuff around you and just focus on what is the right thing to do for people in very difficult circumstances.” Rousey’s trips were sponsored by Lutheran Health Care Bangladesh (LHCB). He has traveled twice to Dumki, a small, rural community in southern Bangladesh. The LHCB missions bring American physicians to the Dumki hospital, a 15-bed facility that was originally built to provide care for women and children, although in recent years that has changed to include men. With only basic health services being provided by the hospital, there is not much work for an oncologist, so Rousey assisted with primary care and providing support to the Bangladeshi physicians. “The physicians in

Bangladesh are trained by two years of studying books, some of which are out of date, and then they are asked to go out and practice medicine,” Rousey says. “The professional isolation for many physicians is profound. One of the things that was most helpful was to be in

“The professional isolation for many physicians is profound.” Steven Rousey, MD outpatient settings with them and be someone of whom they could ask questions—[someone] who would have a different perspective.” Rousey is quick to say he respected the cultural differences that exist between Bangladeshi and American providers. “Like anywhere else, there is professional pride,” he notes. “You want to respect their way of doing things and then respond in a way that says, ‘Well, this would be another way you could do it.’ There was a lot of learning about how you communicate to other people. There are solutions we might think of in the United States

that simply do not work there.” The typical day at the Dumki hospital would find American physicians, teamed with Bangladeshi staff, seeing more than 30 patients. The medical mission physicians saw a wide range of conditions, with Rousey noting an alarming rate of diabetes. “It appears to be type 2 diabetes, which in the U.S. would ordinarily be associated with someone who is overweight,” he says. “These are rail-skinny people with type 2 diabetes, which does not fit the stereotypes.” Rousey says it’s unclear why so many have the condition, though he thinks changes in diet may be playing a role. One challenging part of this particular mission is the long hours in the air and further traveling by road to get to Dumki, Rousey notes, but he adds that the welcome the American providers received from the local staff made the travel worthwhile. “It must have been 11 or 12 o’clock at night when we got there, and the entire hospital has shown up, all of the staff, the employees, and the children of the employees—all singing songs and with flowers to greet us—talk about getting blown away! They had been there all day waiting for us. We were received in a very wonderful fashion.” Caregivers to page 22

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COMMUNITY CAREGIVERS 2011 would be graduated and put in hospitals and told, ‘You are a pediatrician’ or, ‘You are an obstetrician.’“ Quirk adds that the Health Frontiers Hospitalists Rosemary Quirk, MD, and Jon White, MD, are a husband programs have now advanced to the point where Laotian physicians and wife team who have trained hundreds of residents, both in the are taking over the training and beginning research projects, something Twin Cities and in Vientiane, the capital of Laos. Since 2005, the two they lacked the capability to do until recently. have played an important role in helping to rebuild a medical educaWhite notes that for 12 years, Laos was bombed by American tion system that was destroyed during the Vietnam War and is only forces and its allies to the point where it was the most-bombed counnow getting back on its feet. try, per capita, in history. However, he says there is no remaining Quirk and White joined Karen Olness, MD, a Minneapolis native animosity toward Americans. “There should be,” he says. “[Laotians] who has been running the Health Frontiers program in Laos since 1991. are moving on. In the Lao culture, the role of teacher is really one of Health Frontiers has worked with the Laos University of Health Science the most highly respected roles in society. It was a to create medical residency programs in pediatrics low-paying job, but the emotional feedback from and internal medicine. The programs have greatly all the people we worked with was always extremely expanded the rudimentary medical training that positive.” Laotian physicians had previously received. Since returning to the U.S., Quirk and White “Education is the main problem in a country have worked as hospitalists at Regions Hospital in like Laos. The communist revolution in 1975 meant St. Paul. They continue to make yearly visits and supthat most of the educated class left the country,” port the Health Frontiers program out of their own White says. “It has taken 30-some years to even try pockets. The two contribute $15,000 to $20,000 a to replace those educated levels of society.” year to the program, not including their travel Quirk and White arrived in Laos in 2005, after expenses. “When you realize what physicians here in a stint providing health care in Indonesia in the the States make, and that a physician in Laos makes aftermath of the 2004 tsunami. They worked for 16 probably $40 to $50 a month, … you feel so grossly months in Laos and have continued to support the overpaid that it seems like absolutely nothing to Health Frontiers program by returning for one commit some of your wealth to really changing the “It has taken 30-some month every year, as well as contributing financially. educational infrastructure of a capital city, and hope“The medical school in Vientiane was in a build- years to even try to replace fully someday it will filter down to the more rural ing that, a few years ago, before it was renovated by those educated levels of places,” White says. the World Bank, was a crumbling building with Quirk and White also teach here in the Twin society.” Jon White, MD chalkboards, no computers, and no medical books Cities by training medical students at Regions and by written in the Laotian language,” says Quirk. volunteering at the Phillips Neighborhood Clinic, “People would go to school, [sometimes taught] in where they oversee medical students who care for languages the students could not understand. They underserved patients.

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tant step was completing an 18-month program with the Stratis Health Cultural Care Connection, which gives providers around the state tools For Deborah McCarl, MD, the benefits of medical missions don’t end for communicating effectively with patients from different cultures. She with the friendships and good memories that come from working in a has also taken Spanish language classes and has studied immigration foreign country. McCarl has taken several trips to Guatemala and medicine at the University of Minnesota. worked on the Navajo-Hopi Reservation in the southwest United States. The extra training is helpful in a community that is seeing an She says that working in other cultures has given her skills that she uses increase of immigrants, McCarl says. Among the key things she has on a daily basis in her practice, especially when dealing with patients learned in working with patients from different cultures is the imporfrom other cultures. tance of listening and keeping an open mind, she adds. “It’s being able “I’ve always been interested in cross-cultural experiences,� says to listen and be open to other ways to approach problems that is helpMcCarl, an ob/gyn physician at CentraCare Clinic in St. Cloud, noting ful, and it takes some learning to do that,� she says. “The models of that she has spent time in Japan and India over the years. She has been practice that we have now in the U.S., with the constriction in time, do on several medical missions to Guatemala with HELPS make it a little bit difficult.� International, which has its northern U.S. office in St. Cloud. The need for cultural competency in health care has On her most recent trip to Guatemala, in 2009, McCarl grown, not only in the Twin Cities but in greater Minnesota was part of team that set up a temporary clinic and hospital communities such as McCarl’s hometown of St. Cloud. in Tejutla. She says the medical staff, which included a “During the last 15 to 20 years or so, we’ve had a real range of specialties, focused on basic procedures that could influx of immigrants in our community,� McCarl says. “First be done on a short-stay basis. Her work covered a range of we had Southeast Asian immigrants, and then more recentobstetric and gynecological issues such as ovarian cysts, ly we’ve had Somali and some other African immigrants uterine fibroids, and some cesarean deliveries. arriving, and I found working with [the different groups] to Guatemala’s history of civil war is fading into the past, be very similar.� McCarl says, with little danger to medical mission staff, but McCarl says she has enjoyed watching generations of psychological scars remain among the people who lived immigrants become part of the St. Cloud community. “I’ve always through it. She notes that the repercussions of war are “They’re just great people, and very dedicated to this been interested something she has seen not only in her mission work in place, to making our community a good community,� Guatemala but also in caring for Somali immigrants in her in cross-cultural she says. “I had always envisioned that I was going to go practice in St. Cloud. The patients from both Somalia and out somewhere and do cross-cultural medicine in some experiences,� Guatemala may have been through traumatic experiences other country. What’s actually happened is that enriching in war and can have issues that arise from that, she says. Deborah McCarl, MD experiences have come here to my community, and that’s In addition to what she’s learned from medical mismade me very happy. I think really we all are benefiting sions, McCarl has taken steps over the years to increase from this.� her communication skills and cultural literacy. One impor-

The medical mission at home

Caregivers to page 24




MARCH 2011



COMMUNITY CAREGIVERS 2011 these kids and they undergo full evaluation, including chest x-ray, EKG, echocardiogram. Then we contact the hospitals to see if we can get the If providing medical charity work for groups on four continents is surgery done,” she says. stressful, you couldn’t tell by talking to Shanthi Sivanandam, MD. The trust was formed because Sivanandam saw a tremendous need Sivanandam chats pleasantly over the phone, discussing her work in for this kind of medical treatment in India. “There are hardly 10 conBrazil, India, Minnesota, and—via e-mail—for patients in Africa. The genital heart surgeons in India—for a billion people, there are 10 CHD electrocardiographer and pediatric cardiology expert has done medical surgeons,” she says. With the CHD screening program, she hopes for missions, participated in cross-cultural clinics, and started her own foun- the first time to start recording the numbers of children who have the dation, but she seems at ease juggling the various tasks, saying the disease, something that is not being monitored now. work makes her feel “peaceful.” “We are trying to establish a database in south India that we can Sivanandam is a native of India who received her medshow to the government,” Sivanandam says. “There are ical degree there and then did a residency in pediatric carvery few pediatric cardiologists available. If I showed the diology at the University of Minnesota. She currently is the incidence, the prevalence, … the government will start director of fetal cardiology at the University of Minnesota thinking about more training programs and working with Amplatz Children’s Hospital Heart Center. international organizations.” Since 2009, Sivanandam has been a volunteer physiThe trust also hopes to bring children from Africa to cian with Children’s Heartlink, traveling to Brazil that year India for treatment at some point. Sivanandam has volunas part of a team that treated children with congenital teered to read echocardiograms of African children over the heart disease (CHD). In January, on a second trip to Brazil, past two years, and some of those children may end up she taught physicians in that country about using imaging being candidates for surgery. scans during heart surgery. The effort also requires fund raising, and Sivanandam Sivanandam has also participated as a volunteer at “This is why I says she is fortunate to have people willing to contribute to health clinics at the Maple Grove Hindu Temple. The wanted to be a the cause. Poverty in south India is widespread, and there clinics have a preventive care and educational format, are few options for poor children who may have heart physician, to go defects. “It’s fee-for-service in India; there is no insurance and Sivanandam says a lot of the work is simply talking with families about good lifestyle choices and preventive back and help company that is paying for anybody,” Sivanandam says. health topics. out-of-pocket is not imaginable.” She adds that some people.” “Paying Sivanandam has also started her own group in India, the trust is a result of “a lot of people helping me out,” called the Narasimhan Family Trust. The group’s goal is to Shanthi primarily family and friends in India. screen for CHD and provide financial support for diagnosis, Sivanandam, MD “They said, ‘We will support you,’” Sivanandam says. treatment, and surgery. The organization paid for two suc“And I really wanted to do it, because the health care is not cessful heart surgeries last year and will screen 700 children there. I thought, ‘This is why I wanted to be a physician, to in south India this year for CHD. “This is free—we pick up go back and help some people.’”

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Fairview facility in the former St. John’s Hospital in Red Wing. As medical director, Heilman oversees 23 volunteer providers. In addition, more than Dann Heilman, MD, needed some convincing about the necessity of a 200 volunteers from the community help with registration, resource free clinic in his community. Heilman, a pediatric physician with Fairview coordination, and other jobs. The clinic, open one night a week, sees Red Wing Health Services, also serves as the medical director for the free approximately 20 patients a night. CARE Clinic in Red Wing. But at first he wasn’t sure there was a need for Heilman says the CARE clinic treats a range of uninsured patients, a clinic serving the uninsured. with an income requirement of 250 percent of poverty level or less. The “I knew from working at the [Fairview] clinic and hospital that any- clinic has worked with some General Assistance Medical Care (GAMC) one who needed health care could come in and be seen,” he says. “We patients, as that program has struggled under cutbacks, but Heilman didn’t turn people away because they couldn’t pay.” notes those patients tend to be complicated and present a challenge to However, as he learned more about the issue, he found that there a free clinic. were an estimated 3,000 people in Goodhue County without health Being open one day a week also means that the clinic is limited in insurance. “I knew we weren’t seeing 3,000 patients in our taking acute-care cases, but Heilman notes that they see Fairview Red Wing clinic who weren’t insured,” he says, “So cases of strep, sinus infections, skin conditions, and other that woke me up a little bit.” ailments that primary care clinics see on a regular basis. And As he began talking to people about the CARE clinic, since the clinic represents the first care that some patients which opened in February of last year, Heilman says he have seen in a long time, the clinicians diagnose a number revised his earlier opinion. “I realized from talking to people of chronic illnesses. “Our three most common diagnoses are that many who couldn’t afford health care didn’t come in hypertension, diabetes, and depression,” Heilman says. The because they were proud,” he says. “I began to realize that clinic can refer patients not only to medical specialists but people were staying home with some serious problems to psychiatric providers as well, and has a program for promore out of pride than total inaccess to care.” viding low-cost prescription medications. The free clinic, he came to realize, was a way for people With changes to state programs such as GAMC and the “We provide to access the health care system in a low-pressure setting, ongoing rollout of health reform legislation, Heilman says an easier entry the long-term future of the clinic is uncertain. “We feel quite and possibly find that they needed more specialized care.”I think we provide an easier entry point into the system for point into comfortable that we’re funded well enough through 2012, people,”he says. For people without insurance, dealing with but after that we just don’t know,” he says. “I think we all the system the health care system can be intimidating, and a free clinic went into this not knowing what the future would be.” for people.” seems less daunting, Heilman says. “A lot of these patients In the meantime, Heilman says there is an enthusiastic end up going to Fairview Red Wing Clinic, but it is a way for Dann Heilman, MD volunteer base and strong support in the community for the them to be seen and for someone to tell them, ‘It’s OK for project. “I run into people every week that go out of their you to go in and get this checked out by a specialist.’” way to say how glad they were to see Red Wing doing someThe CARE clinic was developed by a coalition of comthing like this,” he says. munity and health care groups. The clinic is housed at a

A gateway to care







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Subject to availability. All artists and programs subject to change.

MARCH 2011







Control and Prevention

Conquering diabetes

has reported that seven

Minnesota’s next medical breakthrough

The Centers for Disease

out of 10 deaths among

By Robert Rizza, MD

Americans each year are from chronic diseases. This month’s special focus looks at a Minnesota partnership dedicated to optimally treat and ultimately cure diabetes; a Twin Cities-based organization working to reduce chronic disease in the state’s large Somali community; and a health care home aimed at improving care of patients with multiple chronic conditions or disability through care coordination.


eform, cost and quality of care, access for all patients, reimbursement structures, and ballooning costs—for many Americans, these are buzz words, media sound bites, or political hot topics. For physicians, this is the context of our daily work. Underlying this context is the reality, for physicians in nearly every specialty and/or practice, of the pervasive and dramatic toll a small number of chronic diseases are taking on American patients, families, and our health care system. Chief among them is diabetes. Today, more than 270,000 Minnesotans and nearly 24 million Americans and their families suffer the emotional, physical, and financial impacts of diabetes. The physical toll: seventh leading cause of death,


leading cause of blindness, and a key contributor to kidney and coronary disease. The economic toll: one in three Medicare dollars spent on diabetes-related treatment each year. The current price tag of $170 billion nationally and nearly $3 billion in Minnesota will be a drop in the bucket if nothing intervenes to slow the rise to 75 million American diabetes sufferers that the Centers for Disease Control and Prevention is projecting by 2050. This alarming trend adds even greater urgency to the historic initiative recently launched by the Minnesota Partnership for Biotechnology and Medical Genomics, the globally recognized research collaboration between Mayo Clinic and the University of Minnesota. For care providers,

the announcement that Minnesota is in a position to defeat diabetes offers not only a visionary goal but a health imperative for our state and country. Our mission is clear. Decade of Discovery: A Minnesota Partnership to Conquer Diabetes is a statewide effort to optimally treat and ultimately cure type 1 and type 2 diabetes. If we are successful, this initiative will lead to better health outcomes, reduced health care costs, and increased economic opportunity for Minnesota in the form of jobs and commercialization. The demographic, health, and economic dynamics of today and future decades demand bold approaches to health care. A critical assessment of how we perform and apply research, as well as how individual patients and communities are engaged in making responsible, effective health care decisions, is in order. Application of this new thinking is the essence of Decade of Discovery; it goes beyond basic

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research to a broader engagement of Minnesota’s care providers, public health community, and citizens in combating a disease that’s spinning out of control. During this time of dramatic change, the Decade of Discovery initiative has the potential to be Minnesota’s “moon shot�—our chance not only to improve the lives of millions of Americans with diabetes, but also to prove that an innovative model of statewide collaboration can deliver the kind of game-changing medical results we need in the face of 21st-century challenges. The Minnesota model

The Decade of Discovery initiative is the result of an intensive two-year process led by the Minnesota Partnership to fully evaluate its capabilities, with a focus on identifying a bold, but achievable, medical goal. Based on the past advances and collective research strengths of Mayo and the University of Minnesota, as well as other Minnesota attributes, the partnership iden-

The announcement that Minnesota is in a position to defeat diabetes offers not only a visionary goal but a health imperative for our state and country. tified diabetes research as the optimal focus for a major medical breakthrough. It launched Decade of Discovery: A Minnesota Partnership to Conquer Diabetes in October 2010. No other state or region comes close to the strength Minnesota offers in diabetes research. We have a solid foundation on which to build an ambitious campaign. Scientists at Mayo Clinic and the University of Minnesota are among the most renowned leaders in the basic science of diabetes. Mayo is considered one of the leading centers in the world for care of people with diabetes, and the University of Minnesota has made groundbreaking strides in the science of regeneration. The fact that these homegrown institutions

Come home. Where organizational strength lies in the diversity of people who call SANFORD HEALTH – home. Sanford Health – Fargo Region is redefining health care. Serving northwestern Minnesota and eastern North Dakota, we offer innovative technology, support of a multi-specialty organization, and dependable colleagues. Excellent practice opportunities exist in family-oriented communities that offer year-round outdoor activities, cultural events, and superior education districts that will allow you to balance your work & life. Our employment model features competitive salaries, a comprehensive benefits package, paid malpractice insurance, and a generous relocation allowance. Contact: Kathryn Norby, MHA Physician Recruiter Phone: (701) 280-4851

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already are united in a partnership that, in its six years of existence, has become a model for innovative approaches to advancing life-saving medical discoveries enhances this opportunity. Charting the path to success

In many ways, the approach to this work is as important as the outcome. By developing a strategic, focused method of research, the Minnesota Partnership hopes to emerge not only with the medical breakthroughs we are seeking in diabetes, but also with a proven structure that can be applied to research and treatment of other diseases. The science behind the Decade of Discovery initiative will be laser-focused on discov-

ery, translation, and delivery within three core areas. Physicians and health care providers will play a critical role in advancing three strategies: prevention, broad adoption of best practices, and treatment/cure. Prevention. By learning more about the underlying biology of diabetes and understanding the entire population that can be affected, we can prevent and reduce the severity of the disease. This will include: • New methods for screening and surveillance • Basic research into disease process • Community-based programs Broad adoption of best practices. We will apply proven strategies and explore the science of broader implementation. This will include: • Statewide surveying based on clinical and public health methodologies • Patient and provider incentives DIABETES to page 38

Allina Hospitals & Clinics in Minnesota/Western Wisconsin Allina Hospitals & Clinics is known for its clinical quality, and an award-winning EMR. At Allina, physician leadership and involvement drive our success. The Clinic and Community Division features the Allina Medical Clinic, Aspen Medical Group, and Quello Clinics, as well as Home and Community Services. Our clinics, as well as our 11 hospitals, are located in the Twin Cities metro area, throughout Minnesota, and in western Wisconsin.

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MARCH 2011





ince the 1980s, our nation has made substantial progress in improving residents’ health and reducing health disparities, but ongoing racial/ethnic, economic, and other social disparities in health are both unacceptable and correctable.” — Thomas R. Frieden, MD, MPH, director of the Centers for Disease Control and Prevention, from the foreword to the CDC Morbidity and Mortality Supplement, Weekly Report, Jan. 14, 2011

In Minnesota and the United States, the cost of treating chronic diseases is skyrocketing. While Minnesota historically ranks high nationally on provision of quality health care, huge health disparities remain, especially for African Americans, Native Americans, and newly arrived refugees and immigrants. For the past 10 years, WellShare International (formerly called Minnesota International Health Volunteers) has been pioneering a new approach to addressing chronic disease prevention and care in underserved communities in



A cultural approach to improving health Reducing chronic disease in Minnesota’s Somali community By Diana DuBois, MPH, MIA Minnesota, specifically with the Somali community. The approach involves creating culturally sensitive programming that includes the active participation of the Somali community in planning, research, implementation, and evaluation of all programs. A decade of work with the Somali community

Minnesota is home to the largest Somali population in the United States, with estimates ranging from 25,000 (Minnesota State Demographic Center) to over 60,000 (community estimates). According to the Minnesota Department of Health’s Refugee Health Program, Somalis

Occupational Medicine Immediate full time opportunity to join our growing occupational health practice. Seeking BC/BE physician with occupational health background, but open to primary care physician with interest in an exciting sub-specialty. As a NorthWorks provider, enjoy a wide variety of Occupational Medicine challenges. From acute injury care to health and safety in the workplace, your days will be filled with interesting cases. NorthWorks provides clinical and on-site services to our clients. Join an experienced team of occupational medicine Specialists practicing unfettered by HMO or Medicare restrictions. For more information, please contact John Capouch, CEO 4080 W. Broadway, Suite 200 Robbinsdale, MN 55422





accounted for 45 percent of primary arrivals from all countries from 2006 to 2010, and the largest group of refugees from Africa. Many more Somalis relocate to Minnesota via secondary migration from other states. The large influx of Somali refugees to Minnesota is due to the ongoing civil war and the collapse of the government of Mogadishu, the capital of Somalia. Since refugees have been arriving in Minnesota for over a decade, the population includes a cross-section of the population. Some early arrivals had more financial resources and education, while later groups included more farmers and nomads. The majority of Somali refugees have resettled in the Twin Cities, but growing numbers of Somalis have moved to the suburbs as well as to large and small towns in Greater Minnesota. WellShare International began its work with Minnesota’s Somali community in 2000. Wellshare had worked on community health outreach, education, and disease management for more than 20 years in East Africa, and the staff was knowledgeable about the history and culture in the horn of Africa. As for any new refugee group, there were numerous health barriers, including difficulty understanding and navigating our complex health care system and a lack of awareness of disease prevention (versus treatment). In addition, when WellShare began its work with Somalis 10 years ago, there was almost no existing health data on Somalis in Minnesota. Surveillance data at the state level often did not disaggregate by ethnicity or country of origin. Even today, many health statistics list Somalis under the category of “Black” or “African

American” on health forms. These categories often mask important cultural differences among distinct populations. WellShare began its work by partnering with two Somali organizations and started gathering critical baseline health data in 2003–2004. More than a dozen focus groups were held, and WellShare and its partners also created and conducted a large quantitative Somali health survey (87 questions) with approximately 300 adults. This generated a large dataset that yielded important information about Somalis’ health knowledge of various infectious and chronic diseases, barriers to accessing care, and current health-seeking behaviors, and also showed where many of the refugees went for care. WellShare also learned that the concept of prevention was new to Somalis. In their home country, Somalis would generally go to see a physician only if they were sick (a curative model), and they could just wait in line to see the physician. This is in sharp contrast to the U.S. health system, with its numerous health insurance programs to decipher, a strong prevention component, more variation in the levels of health workers, and a focus on keeping scheduled appointments. Somalis have to learn new concepts of health care when they arrive in the U.S., including the importance of getting preventive care such as regular prenatal care and screening for chronic diseases. WellShare works on numerous health areas, but two examples of our work on a chronic disease that started as a result of the baseline health survey work were in the areas of breast and cervical cancer and cardiovascular disease. Breast and cervical cancer

In Minnesota, breast cancer is the most common cancer diagnosed in women with the exception of skin cancer. Women of color, and particularly African American women, are less likely to be screened for these cancers and therefore are more likely to be diagnosed with cancer at a later stage, reducing their chances of survival.

Results from WellShare’s Somali health survey showed that 68 percent of Somali women surveyed had had a mammogram at some time in their lives. This is lower than previous and current overall mammography rates for the state of Minnesota. It is difficult to get exact breast cancer statistics broken down by race and ethnicity. Currently, approximately 80 percent of women in Minnesota aged 40 and older receive a mammogram, but the rates vary by education and location (with higher screening rates in urban areas and in women with more education, and lower screening rates in rural areas and with women who only finished high school). Rates of cervical cancer screening in the Somali community (55 percent of the Somali women WellShare surveyed) were far below the previous and current general population rates. Currently, approximately 87 percent of women in Minnesota received a Pap test in the last two years, with higher percentages in urban and more edu-

cated women (91 percent) and lower rates in rural areas and in women with a high school education (72 percent), according to the Sage Screening Program at the Minnesota Department of Health. Because of the many barriers to screening that persist, it is essential to continue outreach to this community. During early focus group sessions, WellShare also uncovered some common myths about cancer. These included comments such as “Somali women don’t get cancer,” “I don’t feel sick so I don’t need the test,” and “Mammograms cause cancer.” Based on the results of the data, WellShare began a fiveyear Somali breast cancer program. Somali community health workers from WellShare visited small groups of women in their homes to provide them with health education about cancer, in order to dispel myths and reduce stigma. WellShare also produced a high-quality DVD in the Somali language in partnership with Twin Cities Public Television and funded by the

Susan G. Komen Foundation. The DVD built on the oral storytelling tradition in the Somali community, and was widely distributed and shown on public television and Somali cable TV channels. The small-group education visits, combined with community education efforts, greatly reduced stigma and fear around the topic of cancer and resulted in an increase in the number of Somali women who received mammograms. Our pre-/postand follow-up test demonstrated a proven increase in breast cancer awareness, and the rate of women age 40 and older obtaining mammograms in 2007/2008 was on par with the statewide rate for all women, a remarkable success given the many barriers Somali women face (Reference: Report to the Susan G. Komen Foundation, Jan. 6, 2009). WellShare’s Somali community health workers also accompanied women to their first mammogram appointment (if desired), ensured they were aware of other existing resources, and encouraged

Minneapolis VA Medical Center

Urgent Care

Internal Medicine or Family Practice Physician

Minneapolis/St. Paul

The Minneapolis Veterans Affairs Health Care System (MVAMC) is seeking BE/BC Family Practice or Internal Medicine primary care providers at several community-based outpatient clinics to provide primary care services during daytime hours Monday through Friday (no weekend duties or night call). Locations include Superior,Wisconsin; Rice Lake,Wisconsin; Rochester, Minnesota; and two Twin Cities metro area clinics, Maplewood and a new clinic in the Northwest Metro area. Competitive salary, recruitment incentive possible, and performance pay.

women to get regular breast and cancer screenings. Cardiovascular disease

Heart disease and stroke are the second and third causes of death in Minnesota after cancer. Our 2003–2004 WellShare Somali health survey found that very few Somali adults were moderately physically active on a daily basis. This was in sharp contrast to their lives in Somalia or in the refugee camps of Kenya or Ethiopia, where Somalis were constantly moving as they herded animals or walked to school or the market. In Somalia, exercise was built into their daily life. As Somalis have become acculturated to life in the U.S., many of the negative nutrition and exercise habits of the general population have become ingrained. Indeed, the negative effects are exacerbated in the Somali population, since many new arrivals have to work several jobs to meet expenses and some Somalis are isolated in high-rise buildings that do not CULTURAL to page 34

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

Send CV and application to: Veterans Affairs Medical Center Human Resources Management Service Attention: Brittany Buck One Veterans Drive, Minneapolis, MN 55417 or, e-mail

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

For additional information, please call 612-725-2060. Equal Opportunity Employer ©

MARCH 2011





t wasn’t until age 33, after a lifetime of health complications, that Chris Anderson was diagnosed with DiGeorge syndrome (22q11.2 deletion syndrome), a rare and complex chromosomal disorder that can affect several body systems. Even then, it would take several more years before his cardiac and immune system and mental health needs would be coordinated in a way that made him feel treated as a whole individual instead of as an amalgam of many separate parts. Like many individuals with complex or chronic conditions that require multiple specialists to improve and maintain overall health, Anderson had experienced his care as fractured, confusing, and not always helpful. He longed for care that put all the pieces together in a way that linked his medical issues and multiple appointments. He found it by joining the health care home at Courage Center, in Golden Valley. “I’m so pleased to have all my mental and physical health care under one roof,” Anderson




A health care home for complex patients Lower cost, fewer hospitalizations, better health By Terry Dunklee, MD said. “It’s far less confusing and way more convenient for me. And it cuts down on my anxiety of coordinating appointments and driving, which for some people with mental illness issues is significant. Coordinated appointments are a blessing.” What is a health care home?

A health care home is a not a place, but a philosophy of care that puts the patient at the center of an integrated planning team. While definitions vary, the state of Minnesota defines a health care home (sometimes called a medical home) as an approach to primary care in which primary care providers,


Remember graduating from college and passing your MCATs, then spending the next four years of your life getting through classes like clinical epidemiology, neurology and radiology so you could practice medicine? Today’s financially driven managed care environments make having a practice difficult. Hurrying patients in and out of the office to make a quota and going into negotiations to prescribe treatments that don’t coincide with a patient’s policy aren’t practicing medicine. We’d like to prescribe a solution: Move your profession to the United States Air Force. Get back to what’s important — practicing medicine.


families, and patients work in partnership to improve health outcomes and quality of life for people with chronic health conditions and disabilities. In introducing the health care home concept in 1967, the American Academy of Pediatrics wrote, “For children with chronic diseases or disabling conditions, the lack of a complete record and a medical home is a major deterrent to adequate health supervision.” Over time, health care homes evolved to serve adults as well, with a focus on care planning and coordination of services for those with complex health needs. The goal is to maximize health and independence, while eliminating unnecessary costs due to a lack of planning and coordination. In some cases, this includes linking to non-medical services to meet the ongoing support needs of chronically ill patients (e.g., by facilitating transportation to and from a clinic or nutrition counseling for patients and their families). National organizations such as the National Committee for Quality Assurance (NCQA) have developed rigorous certification standards defining what constitutes a health care home. Minnesota’s approach, developed jointly by the Minnesota departments of Health and Human Services, used these NCQA benchmarks as the baseline for its standards. [More about the Minnesota approach to health care homes is available at healthreform/homes/about/ index.html.] Who needs a health care home?

©2009 Paid for by the U.S. Air Force. All rights reserved.



While many people could benefit from a re-invigorated and patient-centered approach to

primary care, individuals with multiple chronic conditions or disabilities are at the heart of the current policy discussion. As overall health care costs escalate and the state’s Medicaid budget balloons (it now consumes 30 percent of the total state budget), there is increasing pressure to reduce the costs of those who use health services more often. Chronically ill and complex patients like Chris Anderson are not well served in today’s health system. They often present at the clinic or emergency room after a triggering event has occurred. Medical interventions often follow, too often at great expense to the patients and the providers who treat them; this is particularly true for those who rely on the publicly funded Medicare and Medicaid programs. These patients are prime candidates for a more preventive, multidisciplinary approach to care planning and treatment. The work of Thomas Bodenheimer, MD, a leading national voice on improving primary care, has outlined the escalating costs—particularly to Medicare—as the number of co-occurring chronic conditions increases. This segment of the population experiences multiple hospitalizations, requires treatment from multiple specialists, and often needs several medications to ensure health stability. Of course, there are human as well as financial consequences for these hospitalizations, and the odds of re-hospitalization are high. For many, a hospitalization may be a medical, perhaps life-saving necessity, but the result is a permanent, lower state of “good” health. Preventing this downward spiral and encouraging patients to take charge of their health and circumstances are key components of the health care home approach. What does it look like?

How a clinic or practice chooses to implement the health care home approach will vary, but several important elements must be present: • Information systems. A patient registry to assist in identifying and monitoring

potential candidates for active care planning and increased communication must be in use. Increasingly, electronic medical records are used. • Care management. Bodenheimer defines this as “activities that assist patients and their support systems to manage medical and psychosocial problems with the aim of improving health and reducing the need for expensive medical services.” The amount and intensity of this service, often performed by a nurse or nurse practitioner, will vary based on patient needs. • Care planning. Discovering the multiple needs of an individual who may be touching multiple parts of the health system is critical. It’s essential that the patient be actively engaged in this process. • Simplicity of access. Multiple surveys reflect the dissatisfaction of patients who feel lost and stymied by voice mail, delayed response times, and long waits for specialty care. A single point of contact, even

after regular business hours, as well as multiple communication options, is an important part of a health care home. • Quality assurance. Meeting patient needs in a patient-centered way requires that those who use the service be asked about their experience. In Minnesota, clinicians are encouraged to have health care home enrollees participate in their ongoing quality improvement efforts. Courage Center’s health care home has incorporated all of these elements, with a strong focus on patient assessment and data-driven decisions. A majority of the nearly 100 patients now enrolled in our health care home have complex neurological conditions as their primary diagnosis. They also average about eight co-existing conditions, with chronic pain and mental health conditions occurring most often. All new enrollees receive a number of surveys to track overall health outcomes. A “readiness to change” survey is critical in

determining strategies for effective care planning and patient compliance with treatments. Enrollees have a single point of contact via dedicated care coordination staff. Naming a staff team member to oversee the quality of the clinic’s operation has also helped ensure that Courage Center’s health care home is meeting the needs of its multiple stakeholders. To that end, client Chris Anderson has been added to the board of advisers. “Holding ourselves accountable for the patient experience is what this is all about,” says Dianne Miron, director of physician services. A health care home takes effort

In many cases, establishing a health care home requires a fundamental redesign of care processes and administrative tasks within the clinic to support the optimal coordination of patient care. Additional staff (often an advance practice nurse or social worker) may be needed. An electronic record system must be implemented or

modified to accurately identify patients within a panel who need more time, attention, and ongoing monitoring to ensure sustained positive health outcomes. But the rewards can be great. At the individual level, many clients of Courage Center’s health care home have seen noticeable and statistically significant gains in health. The clinic goal for these highly complex and often hard-to-serve patients is to maximize and sustain their active participation in their home communities. Thoughtful care planning and execution by an interdisciplinary team of clinicians and ancillary professionals are essential. Care may include mental health professionals, rehabilitation therapists, and even family members. Often, nonmedical social supports (transportation, recreation, employment, family life) may be key to maximizing health. These services, and the professionals who provide them or can link to them, must be inteHOME to page 32

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multi-specialty 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: • Family Medicine • General Surgery • Geriatrician/ Outpatient Internal Medicine • Hospitalist

• Infectious Disease • Internal Medicine • Oncology • Orthopedic Surgery • Pain Management

• Psychiatry • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology

For additional information, please contact: Kari Bredberg, Physician Recruitment, 320-231-6366 Julayne Mayer, Physician Recruitment, 320-231-5052 MARCH 2011



Home from page 31 grated into the care plan and acknowledged and supported in ongoing care team discussions. At the clinic level, the rewards are also financial. While payments for primary care visits in Minnesota remain among the lowest in the nation, especially for Medicaid and other public program recipients, there are new funding streams to pay for the care coordination provided within a health care home. In Minnesota, the 2008 Health Reform Act included a number of initiatives to improve the overall health system. A key element of this effort was defining and encouraging the development of health care homes for those with complex and chronic conditions. These care coordination payments (averaging just over $30 per member per month) don’t resolve the issue of undervaluing primary care, but they can help underwrite the addition of a care coordinator to the clinic staff. At the systems level, “the goal is to transform primary

Chronically ill and complex patients ... are prime candidates for a more preventive, multidisciplinary approach to care planning and treatment. care,” says Minnesota Department of Human Services Medical Director Jeff Schiff, MD. As a practicing pediatrician, Schiff was intimately involved with the Minnesota medical home learning collaborative that began in 2004. “It isn’t just a strong, patientcentered approach that is needed, but a re-structuring of processes as well,” he notes. This includes a focus on continuous improvement and improved office systems to track and monitor progress as well as measure outcomes. Does it work?

Minnesota’s health care delivery system and how it’s paid for are rapidly changing. In an age of fiscal austerity, practitioners and administrators alike are

struggling to maintain current business models and achieve positive outcomes on behalf of their patients. It’s a daunting task. But as we evolve from a system that pays largely according to units of service provided toward one that rewards the results those interventions may achieve, the health care home model has emerged as a part of the solution. Many see it as a building block and critical component of further payment reform efforts, such as performance payments and gainsharing. The state is now finalizing the selection of outcome measures that all state-certified clinics must use to measure success. At Courage Center, preliminary data show that a focus on targeted clinical pathways for urinary tract infections, pres-

sure sores, and other conditions affecting patients with severe neurological conditions have resulted in reduced hospitalizations and more frequent selfreported healthy days. Client Chris Anderson is no statistical expert, but he believes that the quality of his care has improved through Courage Center’s health care home. “Everyone here is very knowledgeable, not to mention personable. They are professional and excellent resources for finding answers to difficult health questions. And because they are all working as a team to help me, I feel I’m getting the best care possible. I feel welcome, connected, and useful.” Terry Dunklee, MD, is a family practitioner with Courage Center Physicians’ Associates (health care home).

Family Medicine w/ OB Opportunities in 2 Wonderful Rural Locations Altru Health System is seeking Family Practitioners to join our existing and thriving practices in Crookston, MN and Roseau, MN. Crookston, MN, a strong community of 8,000, is located along the Red Lake River in the heart of the fertile Red River Valley. Altru Clinic—Crookston is a well-established, collegial medical group with 5 Family Practice Physicians, 4 Internists and 3 Mid-Level Providers. We have an ongoing partnership with RiverView Hospital in Crookston that is a 25-bed, critical-access hospital connected to our clinic. Call is 1:7.

Altru is a physician-led, not-for-profit integrated health system that serves a referral population of more than 225,000. More than 180 physicians representing 44 specialties serve this population base. Altru Health System provides competitive compensation, reviewed annually with specialty-specific industry data, along with an extensive benefits package including generous pension and profit-sharing plans.

Roseau, MN, which is just 20 minutes from beautiful Lake of the Woods, is a Family Practice clinic consisting of 6 Family Practice Physicians, 3 Mid-Level Providers and 1 Internist. The town of Roseau has over 2,500 residents. LifeCare Medical Center is a 25bed, critical-access hospital just adjacent to our clinic. Our friendly community is safe and welcoming. Call is 1:7.

Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003 1-800-437-5373 Fax: 701-780-6641 32


Physician-owned, multi-specialty group practice with 100+ providers, has an exceptional opportunity for a BC/BE Neurologist to join two others. You will see patients with a full spectrum of disease states and have an opportunity to participate in clinical trials. We provide staff and support for EMG, Lumbar Punctures, Polysomnograpy, Botox, Occipital Block and a full-time, plus a registered EEG technologist. We offer a first year income guarantee with a production incentive income thereafter; service area 300,000; great payer mix; $6,600 annual CME business allowance; potential shareholder status after one year; 401(k); profit sharing. Our picturesque community, population 50,000+ provides a great setting to practice medicine and raise a family plus year-round indoor/outdoor recreational at nearby lakes and resorts; excellent public and private schools with award winning academics and sports teams; state university, two colleges, community college, business school with combined enrollment of over 18,000; shopping mall with four anchor stores and new retail construction. Just over an hour from Minneapolis/St. Paul southern metro; easy access to international airport. No J-1 openings. Contact Dennis Davito, Director of Physician Placement, Mankato Clinic, 1230 East Main Street, P.O. Box 8674, Mankato, MN, 56002-8674; phone: 507-389-8654; fax: 507-625-4353; email:

Sioux Falls VA Medical Center “A Hospital for Heroes” 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. They all come together at the Sioux Falls VA Medical Center. • Physician – CBOC (Community-Based Outpatient Clinic), Sioux City, IA

• Orthopedic Surgeon

• Pulmonologist

• Medical Director – CBOC (Community-Based Outpatient Clinic), Wagner, SD

• Radiologist

• Oncologist

• Pathologist

To be a part of our proud tradition, contact:

Human Resources Mgmt. Service P O Box 5046 Sioux Falls SD 57117 605-333-6852

With more than 200 providers, Prevea Health offers expertise in nearly every specialty, with advanced specialties that are not found anywhere else in Northeast Wisconsin. Our patients have their choice of care at 18 locations, as well as their choice of three hospitals: St. Mary's and St. Vincent Hospitals in Green Bay and St. Nicholas Hospital in Sheboygan. At Prevea Health we believe that we're all part of one family, and that the best health care starts with a trusted relationship—someone who is there for the patient, whatever their health care needs. If that sounds right for you, we invite you to join our family. Prevea offers a very competitive salary and benefit program including: • 4 weeks vacation/CME • Malpractice, health, life, (6 weeks as shareholder) dental and disability insurance • And much more! • Relocation assistance • 401(k) and retirement plan Opportunities are currently available in: *note if no site listed – opportunity is for Green Bay (J-1 Visa Waiver not available) Cardiology (Sheboygan) Geriatrics Pediatrics Family Medicine Gyn Oncology Pediatric (Green Bay, Sheboygan) Ophthalmology Hospitalist Dermatology Psychiatry Internal Medicine Emergency Medicine Pulmonology/ Neurology Sleep Medicine Endocrinology Orthopedic Hand Rheumatology Gastroenterology Orthopedic Spine Contact Information

Dolly Willems, Physician Recruitment Green Bay, WI

(888) 277-3832 ext 1182 (920) 272-1182

MARCH 2011



Cultural from page 29 have walking paths or access to stores that carry fresh fruit and vegetables within walking distance. WellShare built on the strengths of the Somali community in creating cardiovascular programming. For example, it is not traditionally acceptable for Somali women to smoke. Our project encourages Somali women to continue this positive preventive behavior. We also created nutrition and exercise classes for youth, adults, and elders in order to promote a healthy lifestyle. In order to work on some of the social determinants of health such as access to healthier foods, WellShare and its Somali partners conducted a mapping exercise of stores in the Cedar Riverside area and other locations that have a high concentration of Somalis. The project looked at the proximity and types of stores and the availability of fresh fruits and vegetables, as well as basic food prices. Based on the results, the project

worked to bring a local farmers market to one of the populated community centers in the summer. Future plans include WellShare partnering with a county program to co-create a Somali cookbook that will include traditional but lower-fat recipes. In addition to working directly with the Somali community, WellShare has conducted dozens of community forums and a conference series for physicians, nurses, and other allied health professionals to provide education on the Somali culture as it relates to health. WellShare has also created numerous Somali-specific health materials such as an anatomy flipchart for use by nurses, a child spacing (family planning) booklet that lists the pros and cons of contraceptive methods, and a recent DVD entitled Healthy Moms, Healthy Babies II. The DVD discusses the importance of healthy eating and attending prenatal visits, and explains why cesarean deliveries are sometimes necessary to save the life of the mother or

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baby (this was a topic of much concern to Somali women). Partnering with the health care community

WellShare staff can work with health care teams in a number of ways to decrease chronic disease health disparities and improve outcomes: • Work with communities to reduce no-shows • Divert clients from high-cost emergency room visits • Better communicate with patients to decrease medication errors, increase patient compliance and satisfaction, and provide support to families • Help identify individuals at risk in the community • Provide outreach, home visits, and follow-up contact • Teach individuals to use the health care system • Assist clients in finding a primary care physician • Help clients complete insurance forms • Help clients understand the benefits of prevention, early

intervention, and treatment • Assist patients in gathering family medical history • Assist clients in identifying and resolving barriers to care (child care, transportation, money, insurance) • Reinforce compliance behaviors • Provide opportunities for community-based health education • Remind and educate clients about the need to keep appointments Over the past 10 years, WellShare has built a national reputation for its Center for Somali Health. Future plans include working more closely with Minnesota health plans, expanding work to other underserved populations, and more closely linking the organization’s domestic and international programming. For more information about WellShare International, visit the organization’s website at Diana DuBois, MPH, MIA, is executive director of Wellshare International.

Practice Well. Live Well.

Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner. Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Internal Medicine • Internal Medicine • Pediatrics • Pediatrics

• Family Medicine • Urology • Family Medicine • General Surgery • Psychiatrist • General Surgery

For more information contact

Barb Miller, Physician Recruiter • (218) 736-8227

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

Lake Region Healthcare is an Equal Opportunity Employer. EOE

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Minneapolis VA Medical Center Medical Director of Community-Based Outpatient Clinics The Minneapolis VA Medical Center (MVAMC), affiliated with the University of Minnesota, is seeking a dynamic leader for the position of Medical Director of the Community-Based Outpatient Clinics (CBOCs).The Director supervises the clinical operations and providers of 10 clinics throughout Minnesota and Wisconsin, and oversees the development of several new clinics in both metropolitan and rural settings.We seek a physician with experience in ambulatory medicine and administration who will provide leadership and clinical duties for the CBOCs.The CBOCs provide primary care, and mental health care onsite and through telemedicine to more than 20,000 veterans.This position would include an academic appointment at the University of Minnesota. Applicants must be board-certified in Internal Medicine and experience working in VA facilities is preferred. Competitive salary, recruitment incentive, and benefits with performance pay.

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Send CV and application to: Human Resources Management Service Attention: Brittany Buck MVAMC One Veterans Drive Minneapolis, MN 55417 or, e-mail For additional information, please call 612-725-2060.

MPP, Inc. • 2812 East 26th Street • Minneapolis, MN 55406 •

Equal Opportunity Employer

MARCH 2011



One of the benefits of decision support while in the exam room is the ability to share the appropriateness recommendations with the patient.

Systems from page 19 “There’s a lot of IT firepower in the decision-support software,” said Chambers. “This type of tool will be the wave of the future. Medicine is a science and an art. We have more science now than we can remember, so the more we can embed the science of medicine in a decision-support tool, the better we can practice the art of medicine.” Data analysis

The new ICSI-Nuance solution also includes a data warehouse element to provide feedback to participating organizations, including the appropriateness of scans ordered by modality, body part, and specialty. Individual provider and location data can also be made available. Analysis of these data over time can ensure that Minnesota providers have access to evidence-based criteria for improving clinical outcomes. “I believe the greatest value is in identifying opportunities for process improvement rather than benchmarking physicians

and institutions,” said David Homans, MD, chief of specialty services for Park Nicollet Health Services. “A potential major benefit of a wide-scale rollout will be to collect data on how often specific imaging studies contribute to improved patient outcomes across different health care systems. Those larger data sets will enable us to improve the decision-support criteria so that specialty guidelines can be supplemented by empirical evidence of efficacy.” “We know there is a lot of variation, not just between medical groups, but also clinic to clinic and even hallway to hallway within a clinic,” said Bershow. “Having the capability to mine that data and notice the variation has helped us with local education to providers.” Fairview looked at the number of scans before and

after decision support. “Even though we increased the number of physicians and saw a growing number of indications for imaging studies, we saw a net decrease in the number of scans,” said Bershow. “We even saw a 15 percent decrease in scans ordered on our Medicare population over two years.” “The average length of time for a new technique or business practice to become established as a common task among doctors is about seven years,” said Chambers. “For years, a doctor may have ordered an MRI for headache, but if something were to change in neurology, it might take seven years for that doctor to change. We now can educate many providers at the time they order a test. This can impact practices very quickly.”

- Hospitalist (IM) - Psychiatry - Urology - Chief Medical Informatics Officer - Family Medicine Faculty - Emergency Medicine

- Rheumatology - Hematology/ Oncology - Bariatric Surgery - Vascular Surgery - Palliative Medicine Fellowship Director - Hospice Director

Contact Denise Siemers, Physican Recruitment Mercy Medical Center – North Iowa Phone: (888) 877-5551 or (641) 428-5551 CV to:



“I see decision support as a win-win-win,” said Chambers. “It curbs the cost of medical care by making sure we’re not doing inappropriate scans, patients get appropriate care without exposure to unnecessary radiation, we’re more efficient, and the approach builds stronger relationships between doctors and patients.” “In Minnesota, a number of organizations put aside their competitiveness for the greater good,” added Rank. “This is what health care reform should be about. There is no other state where health plans and medical groups can come together to determine how to do things better. We want to bolster even more effective collaboration between payers and care systems to make care more affordable, of higher quality, and more satisfying for patients. This HTDI initiative is a massive step in that direction.” Cally Vinz, RN, is vice president for clinical products and strategic initiatives at ICSI, and leads ICSI’s HTDI initiative.

Look for the friendly doctor in a MN based physician staffing service ...

Mercy Medical Center-North Iowa is at the center of a 9 hospital/ 44 clinic premier rural health care delivery network. Enhance your personal and professional life with low cost of living, competitive compensation and benefits, and a financially stable and growing health system. Practice where your skills are appreciated. Live where you and yours will flourish as you become rooted in a lifestyle second to none!

- Family Medicine (OB) - Pediatrics - Neurology - Occupational Medicine - Family Medicine - Ophthalmology - Neurosurgery

Clear benefits for all

Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff

Clients: • Prevent loss of revenue • BC/BE physicians • Competitive rates • Quality coverage • Malpractice coverage paid by us



St. Cloud VA Medical Center

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

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

Please contact or fax CV to: Joel Sagedahl, M.D. 1495 Highway 101 North, Plymouth, MN 55447 763-504-6600 • Fax 763-504-6622

is accepting applications for the following full or part-time positions:

• Internal Medicine

• Geriatrician

(Nursing Home— St. Cloud, Brainerd)

(Nursing Home—St. Cloud)

• Hematology/Oncology

• Family Practice

(St. Cloud)

(St. Cloud)

• Neurology (St. Cloud)

• Psychiatrist (St. Cloud) • ENT

(St. Cloud)

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

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

Excellent benefit package including: Favorable lifestyle 26 days vacation CME days

Competitive salary 13 days sick leave Liability insurance

Interested applicants can mail or email your CV to VAMC

Visit our website at

Growing multi-specialty group practice in Northern Minnesota is looking for a BC/BE Family Practice Physician, Internal Medicine Physician, Emergency Room Physician, OB/GYN Physician, Urologist as well as an Orthopaedic Surgeon. Join an existing group practice and take over existing practices from departing physicians. Grand Itasca Clinic & Hospital in Grand Rapids, Minnesota has recently opened a new state of the art clinic & hospital. Excellent salary guarantee with outstanding income potential, full benefits and sign-on bonus. Community located in the beautiful northern Minnesota lakes area.

Sharon Schmitz ( 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-255-6436 or Telephone: 320-252-1670, extension 6618

Opportunities available in the following specialty: Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.

Family Medicine Rochester Northwest Clinic

Family Medicine St. Charles Clinic

Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities.

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 1650 4th Street SE Rochester, MN 55904

Contact: Gail Anderson (218) 999-1447

Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

email: Phone: 507.529.6610 Fax: 507.529.6622 EOE

MARCH 2011



Diabetes from page 27 • Statewide system of reporting best practices adoption Treatment/cure. We will focus the science on replacing what does not work in the body, protecting the body against known complications, and delivering better treatments. This will include: • Basic research—into genomics, proteomics, islet cells, stem cells—that leads to clinical trials • Better research methodologies to understand complications • New scientific infrastructure for generating new approaches to treatment A true statewide collaboration

The Decade of Discovery initiative can succeed only with support, coordination, and collaboration among the research, medical, business, civic, and philanthropic organizations and institutions interested in advancing diabetes research, treatment, and cure in Minnesota and elsewhere.

Fortunately, Minnesota is perfectly positioned to lead this effort. Our expertise and advances in the areas of prevention, health care delivery, and biobusiness development make our state a logical leader in the effort to conquer diabetes. A strong culture of public health and nation-leading corporate and private philanthropic organizations strengthen Minnesota’s ability to maximize the health, quality-of-life, and economic benefits of achieving a groundbreaking medical advancement. Curing diabetes will require a sustained investment from a variety of sources, including public funding. Private and philanthropic interests also will be asked to bring their resources and advocacy to the table. A 10-year investment of $250 million to $350 million will build more robust research capabilities within the partnership, advance IT infrastructure, implement population-wide changes, and fully integrate recognized best practices into clinical practice.


Conferences 2011

Transparency, accountability build public confidence

As those who work with patients know all too well, medical promises have been made and broken. To ensure success in our drive to conquer diabetes, Decade of Discovery will be transparent and accountable for achieving specific milestones along the way. An external oversight committee composed of respected leaders, including scientists, will guide the initiative. The oversight committee will ensure that the initiative progresses in a way that is measurable, focused, and accountable for key milestones and results. How can physicians get involved?

The Minnesota Partnership will drive the science and research behind Decade of Discovery— but one of the most critical elements of the initiative is physicians who can provide valuable first-hand insight into the challenges and opportunities associated with new care-delivery approaches. Whether it’s screen-

ing and prevention, promoting best practices, implementing new methods and treatments, or assisting with tracking and reporting, physicians will have an important role to play. As we enter a new year, partnership leaders are working on the detailed plans that will drive the multi-sector, comprehensive, statewide campaign to conquer diabetes. While the research potential of this initiative is always a motivating part of our work, it’s the opportunity to work with a statewide network of physician colleagues and health experts to positively affect patients that truly energizes us to make sure that Decade of Discovery succeeds. Robert Rizza, MD, is an endocrinologist and diabetes researcher. As executive dean for research at Mayo Clinic, he leads Mayo’s research operations across its national enterprise. He is the Earl and Annette R. McDonough Professor of Medicine and principal investigator for Mayo’s Center for Translational Science Activities.

29th Annual OB/GYN Update April 7- 8, 2011

11th Annual Psychiatry Update: Selected Topics for the Non-Psychiatrist April 29, 2011

Pediatric Fundamental Critical Care Support May 19- 20, 2011

Fundamental Critical Care Support July 14 - 15 and October 13 - 14, 2011

29th Annual Strategies in Primary Care Medicine September 22- 23, 2011

12th Annual Women’s Health Conference November 4, 2011

Otolaryngology Conference November 18, 2011

33rd Annual Cardiovascular Conference December 1- 2, 2011

Emergency Medicine and Trauma Update Education that measurably improves patient care. 952-883-6225



Fall 2011

Pediatric Conference Fall 2011




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You wouldn’t give a 2-year-old a drink, so why would you give one to an unborn child? As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.

Minnesota Physician March 2011