July/August 2011 Physicians Bulletin

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thisissue

2011 Legislative Review

Health Care Reform . . . . . . . . . . . . . . . . . . . . . . 14 Rethinking Care Delivery

Legal Update. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 HIPAA Update and the Proposed Rule

Clinical Update . . . . . . . . . . . . . . . . . . . . . . . . . . 18 10 Ways to Avoid Litigation

Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Resident Report . . . . . . . . . . . . . . . . . . . . . . . . .

Campus Updates . . . . . . . . . . . . . . . . . . . . . . . . .

Member News. . . . . . . . . . . . . . . . . . . . . . . . . . . .

6 PHYSICIANS BULLETIN July/August 2011

30 31 33 36

E S R

NMA Message . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

The Death Certificate . . . . . . . . . . . . . . . . . . 21 Cover story: . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Jawbones vs. Sawbones

U

Taking Aim at “Operation Prairie Fire”

A T

Editor’s Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

F E

D E P A R T M E N T S

Table of Contents: July/August 2011

An extended look at Scope of Practice legislation. . . . . . . . . . . . . . . . . . 27 Meet new MOMS Director Diane Parsons . . . . . . . . . . . . . . . . . . . . . . . . 30

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editor’sdesk

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has targeted Nebraska. That’s what I heard at a MOMS Executive Board meeting.

Ophthalmologists explained it to us. They said that optometrists want to expand their scope of practice. Optometrists want to do surgery. Considering the extensive education and training that ophthalmologists undergo, as well as the extensive credentialing and re-credentialing processes to which they submit, I was surprised. Why would a state loosen the restrictions on medical practice, especially when it comes to the eye?

As I listened further to the ophthalmologists, I realized that I was not the only one who was skeptical about expanding the scope of practice for optometrists.

Nebraska has a formal process for reviewing proposals to expand the scope of practice of non-physicians. An optometry/ surgery proposal had been reviewed. The reviewers rejected the proposal. Yet, essentially the same proposal arrived in the legislature and got serious consideration. How could that happen?

That’s where “Operation Prairie Fire” comes in. This is said to be the name of a national project by optometrists to expand their scope of practice. The project sees Nebraska as a prairie state that is ripe for the picking. With our unicameral legislature, they need to convince only 25 senators to vote for their plan. They can focus a lot of resources on a few key legislators. The ophthalmologists explained what a $5,000 contribution to a key legislator, coupled with multi-district activism, can do.

This raised concern among several MOMS board members. After all, it’s not just the optometrists who seek to expand their scope of practice. The podiatrists, it is said, are headed toward the knee. In other states, psychologists are prescribing.

In other states, nurse practitioners practice

inmemoriam William Graham, MD 09/17/20 – 06/15/11

independently. Pharmacists see themselves as the experts in therapeutics, and they want to prescribe, too.

Interestingly, a colleague told me of a situation in a sparsely populated part of the state where it was proposed, in limited circumstances, that non-pharmacists dispense certain medications. My colleague added that the pharmacists were adamant about not giving an inch to allow others to encroach on this aspect of their own scope of practice!

So what can we do? Should we write op eds in the Omaha World-Herald, as some suggested at the meeting? Or would this merely invite the optometrists to trumpet their message in opposing op eds? How can physicians match the intensity of “Operation Prairie Fire”?

As I thought about this, I recalled the subject matter of the Nebraska Medical Association’s summer 2011 retreat workshop. Out-of-state anesthesiology activists — one of whom is a member of the Texas House of Representatives — were placed on the morning schedule. Their topic: “Strategizing an Effective Political Advocacy Plan and Planning for the 2012 Election.”

The remainder of the schedule includes these subjects: “Key State and Local Legislative Issues” and “Development of a Political Advocacy Strategic Plan for 2012.”

As I contemplate the question of who should perform an eye surgery on me—or on anyone else for whom I care — I’d want to turn to an individual with special expertise. The extensive system of medical education and training has provided us with ophthalmologists. As I contemplate the question of who should develop political action plans, I’d also want the benefit of expertise.

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NMAmessage

By Dale Mahlman, Executive Vice President, Nebraska Medical Association

2011 Legislative Review

Our 2011 Legislature adjourned

on May 26 following an 87-day session, which included the passage of a two-year budget during very trying financial times.

Our Commission on Legislation monitored approximately 85 of the 698 bills introduced this session along with numerous other legislative resolutions that we have an interest in.

While the budget discussions were significant and affected legislation that required funding from the state, we believe we had a successful 2011 session as the following legislative review demonstrates: LB 431, the Health Care Quality Act, revises and updates the laws governing medical peer review within hospitals and other health care facilities. It allows for a full array of self-critical analysis at the same time as the current confidentiality provisions that protect peer review participants and records from being subject to discovery in civil actions. This legislation is the result of discussions in 2010 with our Professional Liability Committee and the Defense Bar, and many thanks go to Senator Galen Hadley of Kearney for his sponsorship (and prioritizing of) this legislation.

LB 406 was a bill introduced by Senator Tanya Cook of Omaha at the request of the NMA. The bill changes the physician licensure law to facilitate re-entry of physicians to practice if they leave for personal reasons.

Based on a similar bill recently passed in Colorado, this legislation allows the Board of Medicine/Surgery to grant provisional licenses to physicians seeking to re-enter practice.

The board may impose conditions relating to retraining and practicing under supervision until a re-entering physician is able to hold a general license.

LB 197, legislation that eliminates legal barriers to breastfeed in public, was passed after several years of unsuccessful attempts.

This legislation was part of the NMA plan for 2011 attempting to improve the public health of all Nebraskans, and included other legislation focusing on childhood obesity issues along with nutrition issues for our Medicaid population.

We remain active with each Legislature opposed to the usual legislation, including attempts to repeal the state’s mandatory

motorcycle helmet law (LB 52), attempts to reduce reimbursement for Medicaid providers statewide, and the increasing presence of scope of practice expansion legislation by mid-level providers. Again this session, optometry introduced legislation to significantly expand their scope of practice similar to legislation in 2010 that was not advanced.

Once again, the latest attempt was met with vigorous opposition from the NMA along with eye physicians and surgeons across the state. They did an excellent job of activating their membership to get involved in the legislative process by making direct contacts with Senators. While this bill, along with others relating to scope of practice, remains in committee, we continue to encourage all of our members to become active and familiar with their Legislators before they have a similar critical issue.

There were no bills introduced in the 2011 session affecting the Hospital Medical Liability Act or directly addressing the cap.

Healthcare reform legislation was extensive but only one bill passed. It prevents insurance companies participating in exchanges mandated by federal law from covering abortion services. Health Insurance Exchanges were not addressed in the 2011 session but a study by the Department of Insurance is underway as we speak to review this important component of the Accountable Care Act. Additionally we are following the discussions on Accountable Care Organizations (ACOs) and have recently released our current issue of Nebraska Medicine on this topic.

2012 will provide opportunities for legislative involvement at both the state and federal level. Our 2011 NMA Annual Meeting on Sept. 30th in Lincoln will focus on advocacy this year, and I’d encourage all NMA members to attend. Understanding the legislative process will be a primary focus of our day-long session and we encourage all interested members to take part in this event. We intend to be much more involved in the 2012 legislative session at the state level and that begins with active members in each legislative district. We hope each of you will take the time to be involved in this important part of our democracy.

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health carereform

By Lee Handke Vice President of Health Care Services for Blue Cross and Blue Shield of Nebraska lee.handke@bcbsne.com

Rethinking Care Delivery In the year

I have been writing this column for Physicians Bulletin, much has been written and said about accountable care. Despite all of the buzz, there has been little substantive change to create a health care system that prioritizes patients, enhances quality and controls cost. While locally we have partnered with several physician and hospital organizations to test new models, we need to continue to think innovatively and implement new solutions that advance patient care.

This year we will go beyond our current medical home and pay-for-performance pilot projects by funding new delivery models conceived by Nebraska-based providers. We have established a Fund for Quality and Efficient Healthcare, which will support programs that have the potential to improve the quality, efficiency and satisfaction of healthcare received by patients. We realize that a lack of funding is often a barrier to innovation, and that change will occur when providers have the capacity to initiate and investigate opportunities for change.

We are especially interested in seeing approaches that put primary care physicians and their support teams at the forefront. Not in an HMO “gatekeeper” model, but under a design where primary care clinicians are incentivized to spend time with the chronically ill, manage specialty referrals, control the total cost of care and focus on the health and wellness of a patient population.

We need to be careful that we have the end in mind and make sure we are not embarking on the wrong path. Much of the thrust in designing accountable care models has been led by large health systems with hospitals at the center. We have to question if this is the best approach, when

14 PHYSICIANS BULLETIN July/August 2011

hospital services account for much of the opportunity to bend the cost curve. “Soft” admissions, preventable readmissions, lowseverity emergency room visits, and preventable ancillary services are driving health care costs ever higher.

Last year alone, at Blue Cross and Blue Shield of Nebraska, we spent more than $60 million on low-severity ER visits – things like strains, sprains and colds – a source of revenue that could be better utilized in a primary care setting. And though we have focused with all the major acute hospitals in Omaha on preventable readmissions, it is simply not enough.

A recent article by Dr. Atul Gawande in The New Yorker focused on physicians who prioritize patients who are high users of healthcare services. One of these physicians, Dr. Jeffrey Brenner of Camden, N.J., stated it this way, “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise.” While there is always going to be the need for emergency and hospital care, this certainly is a charge to prioritize prevention, wellness and ambulatory care. It also challenges us to consider how to make the most appropriate level of service the most convenient choice, and how to align that choice with a patient’s insurance benefit.

Beyond getting patients to the most appropriate and efficient level of service, it is time to start thinking about reinventing professional reimbursement. If PCPs continue to be paid using traditional resourcebased and relative-value scale payments, and specialists and hospitals are rewarded for volume, then real, sustainable change will prove to be elusive. Bundled payments are not the answer either – at least not yet.

They are operationally burdensome, hard to fairly distribute the dollars and are not clearly related to a reduction in costs or improvements in quality.

The current professional reimbursement system creates the wrong incentives on so many fronts, but inertia with the current methodologies will be hard to overcome.

Key items that need to be addressed include promoting financial parity between primary care physicians and specialists, creating payments that promote appropriate care over volume, providing funding to support investments that enhance performance, and providing actionable information at the point of care.

I am not naïve to think significant change will happen overnight. Though Dartmouth estimates that 20 to 30 percent of all medical services delivered are wasted, one man’s waste is another man’s income.

We have work to do in an evolutionary fashion to drive the change that will keep health care affordable.

As this marks my last column for the Bulletin, I would like to thank the Metro Omaha Medical Society for allowing me the privilege and opportunity to share my thoughts with the physician community over the last year. While we will never be short of challenges, we at Blue Cross and Blue Shield of Nebraska will stay engaged in working jointly with the physician communities in Omaha and throughout Nebraska to develop and test solutions that work locally to the benefit of our customers.

Please feel free to reach out directly to me in the future with your comments, thoughts or ideas at lee.handke@bcbsne.com.

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LEGALupdate

By Karen M. Shuler, Richard D. Vroman and Stephanie N. Mahlin, Members of Koley Jessen P.C., L.L.O.’s Health Law Practice Group

HIPAA Update and the Proposed Rule

Keeping up with the Health Insurance Portability and Accountability Act (“HIPAA”) and the amendments to HIPAA implemented by the 2009 Health Information Technology for Economic and Clinical Health Act (“HITECH”) seems to be a never-ending process.

It is time-consuming and expensive to continually revise policies and procedures and employee training programs.

Nevertheless, patients are becoming more proactive in filing complaints for alleged HIPAA violations, and as such, it is more important than ever to maintain up-todate HIPAA privacy and security policies and procedures. Our experience in dealing with the U.S. Department of Health and Human Services’ Office for Civil Rights (“OCR”) tells us that the first documents requested in an OCR investigation are usually the health care provider’s HIPAA policies and procedures and documentation of employee training. If the provider has proper documentation and employee training in place, DHHS is generally easier to deal with and less likely to impose civil monetary penalties.

A newly proposed rule to implement some of the HITECH amendments is again setting the stage requiring revisions to current HIPAA policies and procedures.

Providers need to understand the proposed rule and its ramifications, which are explained below.

Accounting of Disclosures As we know, HIPAA currently requires health care providers and other covered entities to make available to a patient, upon request, an accounting of certain disclosures of the patient’s protected health information (“PHI”) made during the six-year 16 PHYSICIANS BULLETIN July/August 2011

period immediately prior to the request (an “Accounting of Disclosures”). A disclosure is defined as any release, transfer, provision of access to, or divulging in any other manner of information outside the covered entity holding the information. HIPAA currently does not, however, require that disclosures of PHI related to treatment, payment, and health care operations be included in an Accounting of Disclosures.

On May 31, the U.S. Department of Health and Human Services published a proposed rule (the “Proposed Rule”) to implement HITECH’s clarifications and modifications to a patient’s right to an Accounting of Disclosures. Specifically, the Proposed Rule: • Clarifies that an Accounting of Disclosures is limited to PHI about the patient contained in a designated record set, defined by HIPAA as the medical and health care payment records maintained by or for a covered entity, and other records used by or for the covered entity to make decisions about patients.

• Clarifies that an Accounting of Disclosures must include all disclosures made by the covered entity’s business associates.

• Adds a requirement that disclosures to carry out treatment, payment, and health care operations made through an electronic health record (“EHR”) (as opposed to a paper record) must be included in an Accounting of Disclosures.

• Changes the time period for accounting for all disclosures (whether paper or electronic) from six years to three years.

• Changes the time period for disclosure requests (whether paper or electronic) from 60 days to 30 days.

Access Reports A more controversial provision in the Proposed Rule is the creation of a right for a patient to receive an “access report” from health care providers and other covered entities maintaining an EHR. This access report must identify who (regardless of whether such person is a member of the covered entity’s workforce or an outside third party) electronically accesses the patient’s medical and health care payment information contained in an EHR (including access related to treatment, payment, and health care operations). The access report must provide the date, time, and name of the person (or, if the person’s name is not available, the entity) who accessed the PHI as well as a description of the PHI accessed and the user’s action (i.e., what did they do to the information accessed), to the extent such information is available. Similar to responding to requests for EHR disclosures, responses to requests for an access report cover a three-year period and must be provided within 30 days of the request.

Also, access reports must include access information for any business associates of the covered entity if the business associate maintains electronic medical and health care payment information.

This new access report right has been criticized for being too burdensome because logging the required information for every access of someone’s PHI in an electronic system could exceed the capabilities of many of the current systems and it would be costly to update software systems to add this functionality. Furthermore, even if a software system records the necessary information, many believe it will be overly burdensome, in time and money, to comb

through such records to create the proposed access report. The mere thought of requiring systems to log each time a physician, nurse, billing personnel, scheduler or other employee access a patient’s information, and then to identify what information was accessed and what was done with the information is mind boggling. The purpose of this requirement is unclear, and the authority for the requirement in the Proposed Rule is questionable.

Contact us today at 402.399.4555 2120 South 72nd Street • Omaha, NE

Effective Dates It is important to note that the Proposed Rule is not law. If the Proposed Rule is finalized, however, covered entities and business associates will need to comply with the new EHR Accounting of Disclosures’ requirement beginning 180 days after the effective date of the final regulation.

Covered entities and business associates will need to provide access reports requested by patients beginning Jan. 1, 2013 for EHRs acquired after Jan. 1, 2009, and beginning Jan. 1, 2014, for EHRs acquired prior to Jan. 1, 2009.

Next Steps Assuming the Proposed Rule will become law, health care providers and other covered entities need to prepare to update their HIPAA policies and procedures to reflect the new changes. This will include updating the Notice of Privacy Practices. If health care providers or other covered entities want to express concerns about all, or part of the Proposed Rule, comments should be submitted to OCR before Aug. 1, 2011.

July/August 2011 PHYSICIANS BULLETIN 17

clinicalupdate

By Dr. Alan M. Lembitz, COPIC Vice President of Risk Management

10 Ways to Avoid Litigation

By modifying

the following 10 risky behaviors, you can reduce your chances of being involved in costly litigation: 1. Develop a good bedside manner.

People sue their doctors because they are angry. Whether they feel disrespected or “talked down to,” anger spurs most lawsuits. Building a relationship with your patient by actively listening and using good communication skills decreases your chances of being sued. Treat people the way you want your family to be treated—and encourage your office staff to do the same.

2. Always follow up. COPIC sees many claims that result from systems issues, including being unable to provide proof of follow up. Lab reports and X-rays need to be seen by the provider and results need to be communicated to the patient. Document any time you suggest a test. High-priority tests, such as referrals for a worrisome biopsy, need to be documented and a tracking system needs to be in place to ensure the patient’s follow-up.

3. Make medications a priority. Ten percent of medical litigation results from issues with medication. Do you review and document the medication list for every patient? Don’t forget that herbals, natural medications and even marijuana have a risk of interaction. Are you aware of all the medications the patient is prescribed from other providers? Don’t be afraid to look up interactions and medications you haven’t seen before. Finally, make sure that every patient with a medica-

18 PHYSICIANS BULLETIN July/August 2011

tion allergy has an allergy sticker or alert on their chart.

4. Avoid making negative comments about other providers. Criticizing other providers, a.k.a. jousting, can foster litigation. While you should always document the facts as you find them, beware: Do you really know what happened when the patient saw the other provider? As a physician, stick to rendering opinions based on objective findings—not on subjective claims or descriptions. Review the previous medical records and contact the previous provider before offering an opinion to the patient.

5. Do not—under any circumstances— alter your medical records. Altered notes look suspicious. Many of us have reviewed our notes after learning of an unanticipated outcome and wish we had documented more thoroughly and precisely. But altered records are indefensible. Remember, the timing of an electronic note can and will be determined. For notations that are incorrect, consider making a supplemental note with a clear date and time but do not delete your original notation. Call us if you’re not sure how to handle a situation, and always avoid the temptation to alter your original note.

6. Take depositions seriously.

Depositions are sworn testimony and can be used in future legal proceedings. Who is deposing you and why?

Are you at risk of being named in a lawsuit? Do you have a release signed

from the patient that allows you to discuss the care? If someone wants to take your deposition and you are COPIC-insured, call COPIC and obtain counsel. It is your right and is part of your COPIC benefits. Call us at 720-858-6395 or 1-800-421-1834 ext. 6395 for more information on depositions.

7. Carefully consider informed consent.

In brief summary, some of the important elements for informed consent include: 1) the nature of the illness, injury or medical condition; 2) the nature of the operation, procedure or treatment; 3) alternatives, if any; 4) substantial risks, if any, in undergoing the operation, procedure or treatment and the substantial risks, if any, of alternatives and of doing nothing.

The information given is measured by what a reasonably careful physician or provider would give under the circumstances in the applicable area of practice. Informed consent is always a process, and a consent or permit form as well as other records are documentation of that process. The physician or provider performing the operation, procedure or treatment should take an active role in the process. Portions of the process can be delegated; however, a discussion affirming the patient’s understanding and desire to proceed along with a signed consent or permit form is ultimately the physician’s responsibility.

8. Document the differential diagnosis.

Whether you’re in the office or in a hospital, legibly document what

Continued on page 20

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you’re thinking and why you did (or did not) recommend further testing.

Failure to diagnose is still the leading cause for claims in cognitive specialties. Document your test suggestions.

When you are on call, have a system for noting phone calls and what you did or didn’t say. A well-documented chart is your best defense in a lawsuit.

Opposing counsel will always say if it wasn’t documented, it wasn’t done.

9. Recognize problem patients. Certain patients are more risky than others.

You need to identify these patients early in your relationship. Who are the most risky? You might recognize them as those who have overly long visits with psychosomatic complaints.

Often they fail to pay their bills, are disruptive to your staff, and complain frequently about prior physicians.

Many fail to follow your medical advice and treatment plan. You need to decide whether you want to continue to care for such patients. Either continue their care and document well or consider discharging them from your practice.

10. If you are insured with us, always call COPIC. When an unexpected event occurs, you must call COPIC to report the incident. You get access to COPIC’s incident specialists and physician risk managers, who can counsel you on dealing with the situation, answer your questions, and provide guidance about communicating with the patient. When you notify COPIC promptly after an incident—before anger sets in and attorney contact is made—it enhances COPIC’s ability to facilitate (with your consent) a resolution that meets the patient’s immediate needs, allows open disclosure, and hopefully salvages the physician/patient relationship. If you’re already a member of COPIC’s 3Rs early intervention program, we’ll assess whether the situation can be resolved through the program. Not a 3Rs member? Learn more at callcopic.com/3rs-program.

feature

Story by J.R. Newland, MD and J.W. Jones, MD

The Death Certificate Filling in

the cause of death on a death certificate commonly falls upon the shoulders of the attending physician who knows the patient best. An accurate, meaningful cause of death is important for both medicolegal and incidence and mortality rates in vital statistics. In the rare circumstance of the physician having to testify in court on a patient’s cause of death, one wants to be sure that the cause of death is correct! As well, accurate and meaningful causes of death are most useful in public health and preventive medicine including the private sector. For example, some diseases are common in different parts of the country.

The cause of death can be divided into two categories: the underlying (proximate) cause of death and the immediate cause of death. The underlying cause of death can be defined as: the disease or injury which initiated the train of morbid events leading directly to death. The underlying (proximate) cause of death is responsible for the death. Without this underlying cause, the death would not have occurred. Conversely, the immediate cause of death is the disease, injury, or complication that directly precedes death. The immediate cause of death is complications and sequelae of the underlying cause of death. There may be one or more immediate cause of death, and they may occur over a period of time.

Some Thoughts on the Cause of Death Let’s take some examples. An elderly man has widely metastatic prostatic carcinoma.

He is admitted to the hospital but dies of bronchopneumonia. His underlying cause of death is prostatic carcinoma; the bronchopneumonia occurred in the patient’s setting of metastatic carcinoma and is therefore an immediate cause of death.

Another example would be a young girl under treatment for acute leukemia who develops systemic aspergillosis related to neutropenia while under treatment: underlying cause of death–acute leukemia and immediate cause of death–systemic aspergillosis. How about an unfortunate person who is killed instantly in an automobile crash? He has a skull fracture with a disrupted brain, liver lacerations, and broken ribs. Here, the underlying and immediate cause of death is simply multiple injuries.

Similarly, in the victim of a gunshot wound who dies immediately, the underlying and immediate cause of death is a gunshot wound. Had this person survived initially and later died of a pulmonary embolus while in the hospital, the underlying cause of death would be a gunshot wound, while the immediate cause of death would be a pulmonary embolus.

Imprecise or meaningless terms should not be placed as a cause of death on the death certificate. “Cardiopulmonary arrest”

really says nothing. In fact most of us die this way. This begs the question, “Why did the patient’s heart and breathing stop?”

Mechanisms of death, although useful for the physician to consider in the care of the patient, are likewise more or less useless on a death certificate. Mechanisms of death are biochemical and physiologic consequences by which the cause of death causes death.

A common mistaken cause of death for death certificate purposes is ‘congestive heart failure.’ One can then ask, “What caused the heart failure?” In most instances the heart fails as a pump related to coronary atherosclerosis. But there are multiple other less common reasons for the heart to fail such as valvular abnormalities, fluid overload, and even amyloidosis. Similar arguments could be used in other mechanisms of disease.

In summary, when filling out the cause of death on a death certificate, bring to mind the most likely underlying (proximate) cause of death, and then consider the immediate circumstances. Never use meaningless terms and similar terms such as, “cardiopulmonary arrest,” and don’t put down a mechanism such as ‘congestive heart failure.’ Instead, consider the patient’s pathology when filling out the cause of death on a death certificate.

July/August 2011 PHYSICIANS BULLETIN 21

feature

By Dr. Stanley S. Cooper, MS, PhD, Nebraska Vital Records Office

Nebraska’s Birth and Death Registration System Overview:

Statewide registration of deaths and births occurring in Nebraska was approved Feb. 16, 1905. Birth and death certificates are used to establish age, and citizenship, to qualify for health and retirement benefits and as proof of death. In addition they are essential in helping to document health status of populations, identify disparities in health status, identify health problems and provide information for making changes in public policies and programs.

A number of local and county governments, notably Douglas and Lancaster counties have had registration systems in place prior to 1905.

Nebraska birth certificates are customized from the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) U.S. Standard Birth Certificate form. Nebraska’s statutes, rules and regulations and policies govern its content. Approximately every 10 years revisions to the form are made.

The vast majority of birth and death data is centralized in the Nebraska Department of Health and Human Services(DHHS) Division of Public Health’s Vital Records Electronic Registration System.

Death Registration: Past and Present: The funeral director initiates the death record. A physician completes the cause of death with the exception of suspicious or unattended deaths, which are handled by the county attorney.

22 PHYSICIANS BULLETIN July/August 2011

Past, Present and Future

The decedent’s name, date, place of death, and parents names of the deceased have been a standard legal part of the death certificate. Cause of death, if it was work related, and manner of death have also been a part of the medical portion of the death certificate and the responsibility of the physician. Data fields, such as if the individual served in the military, did tobacco use contribute to death, and if organ donation was considered, have been added over time.

In 2005, Nebraska’s introduced a confidential portion of the death record which includes education, race, Hispanic origin and occupation and industry.

Electronic death registration was initiated in 2006 for death records permitting funeral directors, physicians, county attorneys and later physician assistants to complete and sign their portion of the death record electronically. By the end of 2010, over 70 percent of death records were initiated electronically by funeral homes and 27 percent were filed fully electronically.

Death certificates are being used as proof of death for insurance and social security.

In addition, they are the source for statistical information such as determining the leading and primary causes of death and infant mortality.

Besides the issuance of certified copies, some DHHS-specific uses of death records data have been: Birth Defect Registry- utilizes death and

fetal death certificates for information to update the birth defect database.

Child Death Review- Allows Child Death Review Team to create a complete picture of child deaths in the state.

Flu Surveillance Program- Funeral establishments are able to notify DHHS Epidemiology section of flu-related deaths using the Electronic Death Registration System (EDRS).

Nebraska Crash Outcome Data Evaluation System (CODES) – Death data is linked to motor vehicle crash data and hospital discharge data to verify and supplement information for motor vehicle crash fatalities Later this year an alternative medical certifier registration procedure (FAX Attestation) will be introduced. This procedure is expected to further reduce the time it takes to register deaths. * Birth and Death Registration: Future: In the future, death and birth registration will increasingly rely on enhanced electronics which will allow for more frequent revisions and updates in response to changing public health demands. Linkages between the birth and death registration system, medical records system and health related systems will improve overall quality of the data and allow a greater wealth of health-related statistics from birth to death. *http://www.dhhs.ne.gov/vitalrecords/partners/Fax%20Attestation%Project.pdf.

Story by Corey Ross. Photos by www.minorwhitestudios.com

cover story

A Home Run for Health Care The annual Jawbones vs. Sawbones charity softball game brings together doctors and attorneys for charity and familiarity

Above: Softball game organizers Mike and Kathy Gross, Joe Daly and Kellie Harry.

Local physician Mike Gross says the relationship between the medical and legal communities in Omaha can often be as combustible “flint and steel.” Well, for one day a year, that relationship becomes aluminum and cowhide.

The Jawbones vs. Sawbones charity softball game was started in 2006 by Mike’s wife, Kathy, to help build relationships between the two sides and raise a little money for charity.

OneWorld Community Health Centers receives the proceeds from the game, which this year will take place on Sept. 11 at 4 p.m. at Gross High School, 7700 South 43rd Street.

Kathy Gross says developing a fundraiser to support OneWorld in its mission of serving the underserved in the health care community was the original goal, but then a secondary need and purpose was discovered.

“The real goal was to bring visibility to OneWorld and what it does for the community, but the other goal was to develop some sort of camaraderie between the medical and legal

continued on page 24

July/August 2011 PHYSICIANS BULLETIN 23

cover story

professions in Omaha,” she says.

“And this has done that.”

Mike Gross says the softball field has proven to be comfortable common ground for two professions that more often see each other in courtrooms or other legal settings over such matters as workman’s compensation cases. And the networking that takes place between the two sides is critical to the professional success of each, he says.

“It’s two communities that need to get to know each other better.

The lawyers need the doctors – and vice versa,” he says, referring to such matters as when attorneys need doctors to testify as expert witnesses.

Gross is as an orthopedic surgeon, with an expertise in shoulder injuries, for GIKK Ortho Specialists. He and his wife assemble the medical team (the Sawbones) each year, while Joe Daly of Sodoro, Daly & Sodoro and Kellie Harry of Mutual of Omaha, assemble the legal team (the Jawbones). The players are recruited from medical service providers in hospitals, medical clinics and private practice as well as area law firms and law schools.

So far, the attorneys have won every game, except for one tie.

“We can’t quite beat them,” Kathy says. “I don’t know why that is.”

Support for the game has grown each year and last year netted $17,000 for OneWorld, making it a significant source of support, says OneWorld CEO Andrea Skolkin.

“It started as a small fundraiser, but it’s really growing,” Skolkin says, noting the proceeds come from sponsorships and players paying to play.

The proceeds support the Every Baby Matters Program at OneWorld, which provides prenatal care to women who might not otherwise have access to high-quality, affordable health care.

That program is part of OneWorld’s overarching mission to serve the underserved. In 2010, 21,341 patients utilized those services, more than double what OneWorld served when Skolkin arrived. In her 6 ½ years as CEO, Skolkin has relocated OneWorld from an 11,000 square foot store front to a 40,000 square foot state-of-the24 PHYSICIANS BULLETIN July/August 2011

art facility with a comprehensive array of primary care services and grown her annual budget from $4 million to $19 million.

For her leadership efforts and OneWorld’s growth, Skolkin was among the 10 women honored by the WCA at its annual Tribute to Women banquet on June 7. She was also a finalist for the Greater Omaha Chamber of Commerce’s Women in Business Award.

Skolkin says those accolades are a reflection of the support OneWorld has received from the community.

“We’ve enjoyed a lot of community support, philanthropic support and federal and state support, and we’ve worked hard for that,” she said. “We have been able to recruit and retain the best staff, and it’s all about bringing more health care to people who typically wouldn’t have access to health care.”

OneWorld has its main location and five others to serve what Skolkin says is an expanding need.

“The surprising thing about this community is that we have patients from every zip code and have seen increasing numbers from the suburbs,” she says.

Yet for all the capacity it has built, the demand still outstrips OneWorld’s ability to serve.

“What breaks my heart, and those of our physicians and providers, is that we have to turn away patients,” she says. “We have not been able to build fast enough to keep up with demand.”

That’s why a construction initiative is under way to add to the South Omaha location by 2016, making it a health care campus able to serve twice as many patients, and adding affordable housing to the campus for seniors.

By then, national health care reform will have been enacted and more Americans may be being served by the model OneWorld has worked under successfully for so long now.

“We know that the model works, especially for people who are struggling,” Skolkin says. “We are the wave of the future. We’re providing pro-active preventive health care services, keeping people

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Having the support of people such as the Gross’ makes that brighter future possible for OneWorld, Skolkin says.

“Kathy is the envy of every organization,” Skolkin says, noting that Kathy Gross serves several local non-profits. “She’s a gogetter. It’s really the spring in her step that has driven this event, and Mike has done an extremely good job in getting sponsorship.

Gross founded the game when she was president of the MOMS Alliance six years ago. Since then, she’s done everything from helping organize the teams to cooking the food.

Skolkin says the benefits of the game are far more than monetary. It has helped, she says, truly bridge the gap between the medical and legal communities.

“This cuts the tension between medical and legal,” she says. “Both sides leave the game with better relationships for the long haul.”

There’s plenty of time for networking after, Kathy Gross, notes seeing as while the player may be all-stars at their professions, they aren’t quite so much at their sport.

“Nobody can play,” she jokes, “so the games go pretty quickly.”

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LB417 and LB316, a Case Study in Surgical Scope of Practice Legislation

What started in Nebraska in 2009 regarding optometric scope of practice, and is still happening in 2011, presents an ongoing case example of how scope of practice legislation is processed in the Nebraska state legislature. It also raises several ethical and philosophical questions that should be pondered and addressed by organized medicine.

On Jan. 20, 2009, Senator Friend of Omaha introduced LB417 to the Nebraska Legislature. LB417 was a very broad scope of practice bill written by representatives from the Nebraska Optometric Association (NOA) and inspired by a law currently in place in Oklahoma. In a national push by optometry, similar bills are being introduced in several other states across the country.

LB417 would have granted surgical privileges to over 300 optometrists in Nebraska, none of whom have formal surgical training. Specifically, this bill would have allowed optometrists in Nebraska to do the following: 1) Perform laser surgery on the anterior segment of the human eye and eyelids. 2) Prescribe any pharmaceutical agent rational to diagnosing or treating conditions of the eye, eyelids, or visual system and remove restrictions on the use of prednisone or other immunosuppressants. 3) Injection of pharmaceutical agents to perform injections in and around the ocular adnexa, IV injections for angiography or other diagnostic testing. 4) Allow optometrists to prescribe and dispense and new type of medicated therapeutic contact lens. 5) Establish a new level of certification for optometrists that would authorize eye surgery to be performed by optometrists in Nebraska so long as they had been certified by the Board of Optometry.

This last provision would mean that the Board of Optometry would have sole discretion to decide the future training and certification requirements for optometrists who wish to perform eye surgery, or prescribe virtually any medication deemed ratio-

nal to treat a condition that involves the “visual system.� No oversight would be provided by Board of Medicine and Surgery or any independent body such as or similar to the Accreditation Council for Graduate Medical Education (ACGME).

After being alerted to the introduction of LB417, the Nebraska Academy of Eye Physicians and Surgeons (NAEPS) worked quickly to assimilate the contents of the bill. Along with key representatives from the Nebraska Medical Association (NMA) and the American Academy of Ophthalmology (AAO), the NAEPS Executive Committee critically examined every detail of the bill. LB417 was scoured for any merit the bill might have as well as what dangers such a bill might pose to patient safety in Nebraska. The Nebraska Academy of Eye Physicians and Surgeons opposed LB417 on the basis that optometrists are not routinely trained in eye surgical procedures, and that they do not receive extensive training in the use of IV medications or the use of potentially dangerous immunosuppressant medications. In addition, the broad language used in the bill would allow for unprecedented and unforeseen future expansion. The Nebraska Academy of Eye Physicians and Surgeons also felt strongly that allowing the Board of Optometry, and not the Board of Medicine and Surgery, to have sole authority and oversight over future certification of optometric scope of practice in Nebraska was not in the best interest of patients in our state.

This proposal would usurp the current training and certifications regulations currently in place on a national and state level. From a purely practical perspective, Nebraska has over 300 licensed optometrists who have not experienced any prior surgical training. To assume that this number of practitioners could retroactively become proficient in surgical procedures, the same procedures that it takes an ophthalmologist four years of medical school and four years of residency to perfect, was not realistic. As one could imagine, not only NAEPS, but the NMA and the AAO

continued on page 28

July/August 2011 PHYSICIANS BULLETIN 27

feature were also concerned. In addition, the Metro Omaha Medical Society, the American Medical Association and approximately twenty other medical groups, special interest groups and individuals expressed their concern in the form of opposition letters which outlined the patient safety implications of LB417 were it to ever become law. Once the inherent dangers of LB417 became evident, these groups clearly expressed their formal opposition to LB417.

We all know that as Nebraskans, we have a lot to be proud of. Our Nebraska Legislature should be near the top of the list. The citizens of our state have been graced with a very effective, ethical and thoughtful legislative body. This may stem from the fact that our Legislature is unique in a variety of ways.

For example, Nebraska has the only unicameral legislature in the country. Also, in a comparison by the Chronicle of Higher Education the Nebraska Legislature ranked No. 3 in the country with regard to the education level of our State Senators.

Nebraska has also set an exemplary example for other states by putting in place a rigorous Credentialing Review Program, which was first implemented in 1985.

Also known as the “407 Process,” this process consists of a 407 Technical Review Committee, which is comprised of seven individuals. The duty of the 407 Committee is to critically and objectively review scope of practice bills and present a formal recommendation based on four specified criteria.

In the case of LB417, the 407 Committee spent approximately 20 hours in five separate sessions over six months reviewing every word and every detail of LB417 prior to making a recommendation. The committee spent these hours listening to extensive testimony and data presented by both optometry and ophthalmology. After this indepth review, the final recommendation by the 407 committee was to reject LB417 on all 4 criteria assessed. After reviewing the 407 committee recommendations and hearing additional testimony from both ophthalmologists and optometrists, the Board of Health also voted to reject LB417 as written. The Chief Medical Officer, Joann Schaefer, MD, also critically assessed the 407 committee findings and gave a final report

Have you been supporting the

in which she upheld the 407 Committee’s recommendation to reject the bill on all four criteria. In other words, the final outcome of the 407 Process was to reject LB417. This outcome was a victory for patient safety in Nebraska. However, this was not the end, but rather the beginning of a push for surgical scope advancement by optometry.

At the conclusion of the LB417 proceedings, leaders from NAEPS and the NOA met to discuss whether there could be any possible common ground. The NOA and NAEPS leaders actually came to an agreement that the prescribing of a new type of medicated therapeutic contact lens would be within the scope of optometric training.

This provision was removed from LB417 and put into another bill, which would go on to pass.

During this meeting, representatives from the NOA also made it clear that despite the outcome of the 407 process in regard to LB417 they would continue to introduce surgical scope of practice legislation every session until it passes. In response, leaders from the NAEPS executive committee and the ophthalmology community at large made it very clear that the NAEPS leadership has full respect for the skills and training that optometrists do have. Furthermore, the services optometrists currently provide for Nebraskans are extremely valuable. However, when it comes to surgery, the bottom line is simple: surgery should be performed by those who have been trained to perform surgery.

As expected, on Jan. 12, 2011 optometric scope of practice legislation was reintroduced. This time it was in the form of LB316, a bill introduced by Senator Lavon Heidemann of Elk Creek and co-sponsored by Senator Norman Wallman of Cortland, NE. Very similar to LB 417 and even more broad in some respects, LB316 would allow optometrists to: 1) Perform laser eye surgery. 2) Perform scalpel surgery and injections to the eyelids and ocular adnexa, including surgery for removal of skin cancers. 3) Prescribe of any oral pharmaceutical agent rational to diagnosing or treating conditions of the eye or visual system. 4) Treat infantile glaucoma (a surgical disease that is currently specifically prohibited). 5) Create a certification status that

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feature would be regulated solely by the Board of Optometry (not the Board of Medicine and Surgery) 6) Allow training programs to take place in Nebraska to train optometrists from out of state to perform surgical procedures in Nebraska without regard to the current scope of practice law.

In short, LB316 was a reintroduction of a bill that was strikingly similar to LB417, a bill that had been categorically rejected by an extensive and thoughtful 407 review process over the prior 2 years. Again NAEPS and the NMA felt strongly that LB316 proposed a scope expansion that was in no way commensurate with optometric training. Furthermore, LB316 was not required to go through the 407 process because it was seen as a reintroduction of a recent scope of practice bill, LB417.

On March 3, 2011 a formal public hearing took place before the Nebraska Legislature’s Health and Human Services Committee in regards to LB316. Two optometrists from the NOA testified in support of LB316. Also, one optometrist representative, who serves on the Board of Optometry, testified on behalf of the Nebraska State Board of Optometry in support of LB316.

In opposition to LB316 was a unified group of testifiers including physician representatives from the ophthalmology community, the American Academy of Ophthalmology and the Nebraska Academy of Eye Physicians and Surgeons. In addition, representatives from dermatology and rheumatology presented compelling testimony with regard to skin cancers and the use of powerful immunosuppressant medications . The president of the Nebraska Medical Association also gave testimony in clear opposition to LB316. The opposition testimony seemed to be well received by the committee. While the committee did not vote to “kill” the bill, they did not vote to advance the bill to the floor. This was another small victory for patient safety in Nebraska.

On March 14, in a somewhat surprising turn of events, LB316 was named as one of the 25 Priority Bills for the Speaker of the Legislature, Senator Mike Flood of Norfolk.

This meant that Senator Flood felt the bill was of sufficient importance to be discussed further. However, as the legislative session came to an end on May 26, LB316 remained

in committee. It will remain there at least until the 2012 session.

As 2012 draws near and the fate of LB316 hangs in the balance, the Nebraska Academy of Eye Physicians and Surgeons, the Nebraska Medical Association, and the Metro Omaha Medical Society must remain active and united in an effort to promote patient safety in Nebraska. This will involve individual meetings with our senators to educate them regarding the contents of LB316 and other bills that will affect patient care in the 2012 session.

The above case study is ongoing. To date, it presents an example of how our system in Nebraska is equipped to handle scope of practice bills and requests. During the last 3 years LB417 and LB316 have, if nothing else, raised a multitude of ethical questions surrounding how quality care should be delivered and by whom in our state. To that end, we should all ask ourselves, In an ideal system, what is the best way to handle scope of practice enhancement requests? Is the current system adequate, or should it be changed?

Should surgical privileges be “legislated”(That is, should scope-of-practice decisions rely heavily on the legislative lobbying efforts by a special interest group? Or, is critical evaluation of the problem or need with a subsequent rational solution from an independent body a better approach)? Should our society demand and require that every caregiver at every level receive adequate training and education prior to being granted the privilege to practice within a given scope in medicine? Or should legislation of scope of practice be allowed to take place with the assumption that practitioners would be trained retroactively? Who would provide that education, and who would be educated?

These are just a few questions that come to mind. Some are laden with rhetoric no doubt, but others deserve to be answered after thoughtful deliberation. We owe that to our profession and to our patients. Going forward, organized medicine will be faced, perhaps inundated, with continued requests and demands for enhanced scope of practice, not only by optometry, but by many other interested groups. If nothing else, organized medicine must live up to our obligation to “organize” and promote that which is in the best interest, not of ourselves or our individual specialties, but of our patients.

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MOMSevents

Story and photo By Corey Ross.

MOMS “Dashing Docs” Relay for Life Team

Meet Diane In May, Diane Parsons succeeded Cindy Hamilton as the executive director of the Metro Omaha Medical Society.

Parsons has more than 35 years experience working with physicians both in the clinic and hospital environment and had served for the past five years as the director of NCVO. The Nebraska Credentials Verification Organization, (NCVO) is an affiliate of the Metro Omaha Medical Society.

MOMS President, Dr. Pierre Lavedan, M.D., says that experience will serve Parsons and the society well in her new role.

“She has demonstrated a commitment to physicians and providers in the area, as well as understanding of the healthcare climate in Omaha,” Lavedan says. “We feel that Diane brings a level of knowledge and experience that will complement the mission of our organization while continuing to meet the needs of our members, the healthcare community and the community at large.”

Parsons says the move was a natural progression and is confident it will be a smooth transition since MOMS and NCVO worked closely together.

“The wonderful thing about working with Cindy Hamilton the past three years, is she really made it a priority to combine the two businesses together,” Parsons says. “It makes (the transition) easier on the whole team.”

Parsons is originally from Fremont, Neb., and is married with three sons.

Dr. Lavedan, too, expressed his appreciation for Cindy Hamilton’s three years as executive director.

“Cindy has fervently molded a structure of stability and growth that will guide our organization in the future,” Lavedan says.

Hamilton accepted a position at Methodist Hospital.

Parsons can be reached at dparsons@omahamedical.com or 402.393.1415.

30 PHYSICIANS BULLETIN July/August 2011

The Metro Omaha Medical Society “Dashing Docs” were at it again – raising money for the American Cancer Society at the Relay for Life held June 11th and 12th at Millard South High School. The Society also hosted a tent complete with refreshments for the walkers and games for everyone.

MOMS Represented at Resident Orientation meetings

The Metro Omaha Medical Society welcomed incoming residents at both the UNMC and Creighton Resident Orientation meetings held the last week of June. Rowen Zetterman, MD -- MOMS member, MOMS Past-President, former NMA President and current Dean at the Creighton School of Medicine, addressed Creighton residents while Harris Frankel, MD, MOMS member and MOMS Past-President, addressed UNMC residents.

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MOMS Members Receive Special Savings on AAA Membership

The Metro Omaha Medical Society (MOMS), through an exclusive partnership with AAA, has added even more value to your MOMS membership. MOMS member physicians, their staff and immediate family members can take advantage of no enrollment fee and a 15% special savings on AAA membership dues whether you are new to AAA or simply renewing your membership. AAA membership serves as a passport to dozens of helpful benefits, services and discounts including roadside assistance, travel, auto touring, insurance and more.

To find out more about MOMS Member AAA benefits, contact Linda Grohs at AAA’s Clocktower office @ (402) 390-1000 ext. 256, lgrohs@aaane.com or stop by the office located at 815 No. 96th St. Not a MOMS member? Contact Laura Polak at laura@omahamedical.com or 3931415 for more information or complete an application located either at the back of this publication or online at www.omahamedical.com under “Join Us Today.”

MOMS/NMA member physicians who utilize COPIC Insurance are eligible for up to a

10% premium reduction

(5% for membership; 5% for participation in risk management education) Contact Laura Polak at the Metro Omaha Medical Society - 402-393-1415 or laura@ omahamedical.com if you are interested in membership. Or contact Ms. Pat Zimmer, Director of Sales at COPIC, at (800) 4211834, ext. 6186 or pzimmer@COPIC. com for more information on the premium credit or a premium indication.

Another great benefit of membership!

The Importance

of Being Idle

I can finally exhale, as I sit here at my uncle’s dining table eating breakfast. My flight landed safely an hour or so ago at Comodoro Arturo Merino Benítez International Airport in Santiago, Chile, and I’m currently in a small town outside the city named Chicureo.

Two weeks ago I took the USMLE Step 1 and a month before that I began studying for it. Yet my story doesn’t really begin there. My story begins about a week before the first day of M1 year began.

I was a bit restless and admittedly nervous about what to expect from medical school. The MCAT, applications, and interviews don’t really prepare you for actually getting in. I decided to take my mind off of things by making a bucket list. I had just seen the movie with Jack Nicholson and thought it’d be a fun idea. This list had a twist however. The items had time-lines.

The things I wanted to do weren’t open until I died or I got to it. Rather, I thought of short fun things to do, made a list, ranked it (OCD medical student style) and placed a time span I’d accomplish it in. I decided to also try to place the trips in time slots when I knew I’d have free time.

That’s around the time I sat pondering what I wanted to do after Step 1. Thinking too far ahead, you say? I disagree. I believe in the importance of being idle, the value of a long deserved, and earned, break.

The purpose of this short essay is to try to remind my fellow medical professionals

that along with planning study time, work time, and the coveted sleep time, it’s important to plan for down time as well. I’ll then quickly give some tips for getting started.

Post-Step 1–Chile trip. Check. Postgraduation-Europe backpacking- can’t wait!

There are many other things I’m looking forward to accomplishing–the World Cup in Brazil, etc.–but that isn’t the point.

It really is quite simple. Just take a moment of spare time to make yourself a quick list of things you’d like to do and set a time span to accomplish it. I chose Chile because most of my family lives there, Europe because of my roots, and the World Cup because I’m certain the Chilean national team will go to the next World Cup as well! It’s very personal, but it can be fun to sit with a colleague or friend and plan trips together!

Now plan it. Where will you get the money? How long will you go? Where will you go? Chile was easy, I know where my family lives, but Europe will be a beast. I’ll have to plan what countries, what family, what cities and sites! I can’t say I’m not looking forward to it, however, because I’ll have finished the last two years of medical school and I’ll be hungry for an adventure.

Who knows, maybe I’ll see you there!

Kevin Gysling is third-year medical school student at Creighton University School of Medicine.

July/August 2011 PHYSICIANS BULLETIN 31

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campusupdates School of Medicine Faculty, Students Recognized Creighton University School of Medicine hosted its annual Golden Apple Banquet and Awards Ceremony on April 30 in the Grand Central Ballroom at Hilton Omaha.

More than 500 attended, including School of Medicine faculty and staff as well as medical students and their guests.

Aesculapian Awards, which go to one student from each class for guidance, compassion, and selfless service to the class, community and university, were also awarded.

Mark Goodman, M.D., Department of Family Medicine, was honored as a national finalist for the Humanism in Medicine Award, sponsored by the Arnold P. Gold Foundation.

First-, second-, third- and fourth-year medical students gave faculty Golden Apple awards to Drs. Robert Mackin, Margaret

CUMC Campus Update Scofield, Eric Peters and John Hurley, respectively. Resident Golden Apples went to Drs. Andrew DeNazareth and Wilson Gonsalves.

Peters Named Director of Medical Simulation Education Eric Peters, M.D., assistant professor of medicine, has been named director of medical simulation education for the Creighton University School of Medicine’s Department of Medicine’s Clinical Assessment Center.

Peters has been a member of the Medical Simulation Education Training Committee since 2008. He has completed specialized training on medical simulation education, including a course at Mayo Clinic in 2009.

“His knowledge and experience in this area will greatly enhance the overall educational experience provided by the Department of Medicine, said Syed

Mohiuddin, M.D., department chair, in announcing the appointment.

Faculty Recognized at Spring Meeting Caron Gray, M.D., associate professor of OB/GYN, has earned Creighton University School of Medicine’s Distinguished Service Award. Dr. Gray received that award and the Women in Medicine and Science Award at the School’s 2011 Spring Faculty Meeting in May. Other awards announced at the meeting include: Devendra Agrawal, Ph.D., professor, Department of Biomedical Sciences, and associate dean for Clinical and Translational Research, Distinguished Professor Award Frank Dowd, D.D.S., professor of pharmacology, Dedicated Teaching Award Daniel R. Wilson, M.D., chair of psychiatry, Outstanding Mentor Award.

UNMC Campus Update UNMC researchers developing test to detect warning signs of joint replacement failure More than 1.5 million total joint replacement operations are performed worldwide each year. While the success rate is 90 percent, almost 10 percent of implants fail and require additional surgery.

Now, University of Nebraska Medical Center researchers have discovered a promising test to detect the early stages of a major cause of failure in joint replacement implants, so patients can be treated and possibly avoid additional surgery.

The research, published online in the American Chemical Society’s Molecular Pharmaceutics, highlights the work of Dong Wang, Ph.D., associate professor of pharmaceutical sciences in the College of Pharmacy.

Researchers know that wear and tear in a joint replacement can create tiny bits of debris — micrometers in size — that cause local inflammation and lead to bone loss. When this happens, the implant can become loose and set the stage for failure. Treatment usually comes too late because it’s difficult to detect the problem in its early stages.

“Unfortunately,” Dr. Wang said, “when pain or clear X-ray evidence is noted, usually considerable bone loss already has occurred that often cannot be easily restored.”

Ed Fehringer, M.D., associate professor of orthopaedic surgery at UNMC, agrees. “If we

can identify bone destruction earlier, it could be beneficial,” he said. “Ultimately, we hope to reduce the number of revision surgeries as they are incredibly expensive and less successful than primary or first-time replacements.”

To provide an early diagnostic tool for implant failure, Dr. Wang developed a polymer-based system for imaging the inflammation associated with the wear debris. Tests of the imaging agent in mouse bone suggest that it can help detect the early stages of bone loss that might cause a joint implant to become loose and/or painful.

Researchers also found that they could tether a powerful anti-inflammatory drug to the polymeric system, offering a way to locally treat inflammation and bone loss in these early stages of wear.

The next step for the team is to test the polymeric system in an animal model with a prosthetic joint and then in humans.

Fortunately, the nanocarrier system already has been approved in Europe and the United States for human phase I or phase II trials to improve anticancer chemotherapies.

In the end, the research team hopes to prolong the life of the implant with improved patient outcomes.

UNMC one of eight sites selected for suicide prevention study The University of Nebraska Medical Center is one of eight participating sites in a national

research study designed to identify ways to improve the detection and prevention of suicide among patients who present to hospital emergency departments (EDs).

The project is being funded through a five-year award from the National Institutes of Mental Health, a division of the National Institutes of Health. The University of Massachusetts Medical School is the lead institution.

The project – called the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) trial – is expected to enroll 1,440 participants from eight hospitals over five years. At UNMC, up to 180 patients will be enrolled.

The three key objectives are to: 1. Develop and test a standardized approach to screening ED patients for suicide risk; 2. Refine and test an ED-initiated intervention to reduce suicidal behavior among people who self-identify or screen positive for contemplating suicide; and 3. Conduct a cost analysis to compare costs and benefits associated with ED suicide screening and intervention.

“Suicide is something that flies under the radar screen, but it’s a problem that needs to be addressed,” said Wesley Zeger, D.O., who is heading the research project at UNMC. Zeger said three people per day with a primary psychiatric diagnosis are seen in the emergency room of The Nebraska Medical Center, UNMC’s hospital partner.

July/August 2011 PHYSICIANS BULLETIN 33

Application for Membership This application serves as my request for membership in the Metro Omaha Medical Society (MOMS) and the Nebraska Medical Association (NMA). I hereby consent and authorize MOMS to use my application information that has been provided to the MOMS credentialing program, referred to as the Nebraska Credentials Verification Organization (NCVO), in order to complete the MOMS membership process.

Personal Information Last Name: _____________________________ First Name: _______________________ Middle Initial: ______ Birthdate: _________________________________________________ Gender: Male or Female Clinic/Group: __________________________________________________________________________________ Office Address: ________________________________________________________________ Zip: __________ Office Phone: ____________________ Office Fax: ___________________ Email: _________________________ Office Manager: _______________________________________ Office Mgr. Email: ________________________ Home Address: ____________________________________________________ Zip: ________________________ Home Phone: __________________________________________ Name of Spouse: ________________________ Preferred Mailing Address: Annual Dues Invoice: Event Notices & Bulletin Magazine:

Office

Home Other: __________________________________

Office

Home Other: __________________________________

Educational and Professional Information Medical School Graduated From: __________________________________________________________________ Medical School Graduation Date: ____________________ Official Medical Degree: (MD, DO, MBBS, etc.) _______ Residency Location: _____________________________________________ Inclusive Dates: _________________ Fellowship Location: _____________________________________________ Inclusive Dates: _________________ Primary Specialty: ______________________________________________________________________________

Membership Eligibility Questions YES

NO

(If you answer “Yes” to any of these questions, please attach a letter giving full details for each.)

Have you ever been convicted of a fraud or felony?

Have you ever been the subject of any disciplinary action by any medical society, hospital medical staff or a State Board of Medical Examiners?

Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine?

(Including revocation, suspension, limitation, probation or any other imposed sanctions or conditions.)

Have judgments been made or settlements required in professional liability cases against you?

I certify that the information provided in this application is accurate and complete to the best of my knowledge.

_____________________________________

Signature

___________ Date

B

Fax Application to: 402-393-3216

Mail Application to: Metro Omaha Medical Society 7906 Davenport Street Omaha, NE 68114

Apply Online: www.omahamedical.com

membersupdate New Members In Focus

Ryan Arnold, MD

Medical School: UNMC Specialty: Orthopaedic Surgery Location: OrthoWest Dr. Arnold and his wife are expecting their second daughter. He enjoys spending free time with his wife and family. He also likes to find time for an often frustrating round of golf.

As an avid sports fan, Dr. Arnold spends his time cheering for both the Vanderbilt Commodores and the Nebraska Cornhuskers.

Thomas Frederickson, MD

Medical School: University of Minnesota, Minneapolis Specialty: Hospitalist Location: Alegent Health Hospital Medicine Service

Liane Donovan, MD

Medical School: University of Kansas School of Medicine Specialty: Pain Medicine Location: Spine & Pain Center of Nebraska, PC – Lincoln & Omaha Clinics Dr. Donovan’s true passion is art – whether admiring the works of others or participating. Her favorite mediums are pencil, watercolor and pastel. She also enjoys designing and making jewelry.

He enjoys spending time with his family (four children), hiking and backpacking, and attending sporting events (especially KU basketball and KC Royals).

Interested in becoming a MOMS Member?

Medical School: UNMC Specialty: Pain Medicine Location: Spine & Pain Center of Nebraska, PC – Lincoln & Omaha Clinics Dr. Essay is a high school basketball official of the NSAA and officiated 65 varsity contests last year in the Lincoln and Omaha areas. He also enjoys cycling and is going to attempt to complete the Triple Bypass Ride in Colorado in July.

Tess Karre, MD

Medical School: Creighton University Specialty: Pathology (Subspecialty in Medical Microbiology) Location: Methodist Hospital and Children’s Hospital & Medical Center Dr. Karre recently relocated from Denver, CO.

Dr. Frederickson’s family just moved to Omaha from the Kansas City area after living there for 16 years. He, his wife and youngest daughter look forward to becoming part of the Omaha community.

Phillip Essay, MD

She is an amateur jazz musician and has played saxophone for over 20 years. While living in Denver she played in a small jazz combo, performing a few times at a local jazz club. She is on the hunt for a band to join here in Omaha.

John Massey, MD

Medical School: UNMC Specialty: Pain Medicine Location: Spine & Pain Center of Nebraska, PC – Lincoln & Omaha Clinics Dr. Massey spends many hours attending his children’s sporting events across the state and elsewhere. He particularly enjoys his outdoor pizza oven and continually developing many variations on authentic Italian pies.

Call 402-393-1415, apply online at www.OmahaMedical.com or complete the application on page 34.

July/August 2011 PHYSICIANS BULLETIN 35

membernews

Dr. Luke Nordquist Opens Urology Cancer Center In July, Dr. Luke Nordquist opened the Midwest region’s only Urology Cancer Center and GU Research Network dedicated exclusively to prostate and urologic cancers. These cancers account for nearly one in four cancers in the United States and one in 10 cancer deaths.

The Urology Cancer Center opened at 17607 Gold Plaza (176th & West Center Road). This innovative care center is part of a national network of research partners including major cancer centers, universities and pharmaceutical companies. Through this network, these experts actively pursue and participate in the most advanced treatments, drug trials and research studies for prostate and urologic cancers.

The center also serves as the headquarters for CancerOpinions. com, a unique service which provides patients with worldwide second opinions for any type of cancer. The YourTeam Cancer Foundation also is housed at the center. It is a nonprofit organization that pairs cancer patients with community companies and volunteers that can provide a wide range of support for patients and families.

Dr. Armitage

Dr. James Armitage Honored The UNMC Physicians Midtown Clinic at 139 S. 40th St. held a dedication ceremony for a conference room named for legendary UNMC professor James Armitage, M.D. The honor recognizes Dr. Armitage, who, during a 10-year stint as chairman of the department of internal medicine, worked to provide the department’s residents a place to practice in an ambulatory clinic without an abundance of full-time tenured physicians.

Dr. Armitage’s vision helped lead to the birth of the UNMC Physicians Turner Park Clinic, which recently moved and became the new midtown clinic.

“Dr. Armitage has always taken the time to support our residents,” said Rebecca Runge, M.D., former ambulatory care chief resident for internal medicine. “The room dedication is our way of thanking him for everything that he has done for us.”

The new clinic opened in February and is approximately 10,000 square feet. It has houses 17 exam rooms and has a work room that accommodates eight residents and two staff.

Dr. Weeks

William Weeks, M.D. One of the First to Achieve Meaningful Use William Weeks, M.D. and Southwest Family Physicians, P.C. were recently honored by Wide River Technology Extension Center as one of the first healthcare providers to achieve Meaningful Use of the Electronic Health Record system. During a celebration on July 19, 36 PHYSICIANS BULLETIN July/August 2011

2011, Dr. Weeks and the clinic were recognized for demonstrating their commitment to significantly improving the quality of patient care through the use of certified health information technology.

Latacha

Follett

Dr. Latcha Makes Cardiac History Cardiologist Matthew Latacha, MD made history on May 24th when he performed Methodist Hospital’s first cardiac CryoAblation procedure on a patient suffering from atrial fibrillation, an abnormal heart rhythm.

Methodist Hospital became the fourth hospital in the Midwest, to offer the Arctic Front Catheter used to conduct the procedure.

According to the American Heart Association and Medtronic (the Arctic Front manufacturer), atrial fibrillation is the most common and one of the most under-treated heart rhythm disorders in America.

Approximately 3 million Americans have the disease, and about 40 percent don’t exhibit symptoms and may be under-diagnosed.

The CryoAblation technique is a significant improvement over more recent methods of treatment. The balloon-based technology is novel because it ablates or blocks the conduction of atrial fibrillation in cardiac tissues through the use of coolant rather than heat, which is delivered through a catheter. The freezing technology allows the catheter to adhere to the tissue during ablation, allowing

for greater catheter stability and more complete ablation.

“Earlier technology, which required us to burn the area around the veins, was very tedious and you were always at risk of causing damage to the patient’s esophagus. Plus, it was a very time consuming procedure,” Dr. Latacha said. “This new technology allows us to insert the catheter directly into the base of the vein and freeze each of the four veins. There is very little chance of causing damage to the esophagus, the procedure is much safer and technically it is much easier.”

Dr. Latacha received training for the procedure and equipment at Medtronic, Inc., in Minneapolis. The Arctic Front Cardiac CryoAblation Catheter system was approved by the U.S. Food and Drug Administration in December.

Dr. Latacha cardiologist said he has a large number of patients that suffer from atrial fibrillation, and this landmark technology and procedure will bring great relief to those battling the condition.

Neurosurgeon Dr. Follett Part of National Committee on Chronic Pain

A University of Nebraska Medical Center neurosurgeon, Ken Follett, M.D., Ph.D., was part of an Institute of Medicine committee that developed a report on chronic pain, a condition that annually impacts at least 116 million adult Americans and costs the nation between $560 billion and $635 billion.

The report found that much of this pain is preventable or could be better managed. The committee called for coordinated, national efforts of public and private organizations to create a cultural transformation in how the nation understands and approaches pain management and prevention.

Some of the recommended changes can be implemented by the end of 2012 while others should be in place by 2015 and maintained as ongoing efforts.

Dr. Follett, who is professor and chief of neurosurgery at UNMC, was one of 19 members on the committee that developed the report. He was the only neurosurgeon on the committee.

The report was mandated by Congress as part of health care reform legislation. Sponsored by the National Institutes of Health (NIH), it was conducted over a nine-month period.

“Chronic pain is a huge problem,” Dr. Follett said. “It affects more people than heart disease, cancer and diabetes combined and costs more to manage than any of these diseases. It has truly become a public health issue for our country.”

July/August 2011 PHYSICIANS BULLETIN 37

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Your wants, your needs, your style, your preferences – everything we do at Curt Hofer & Associates is advanced with the thought of you in mind. That means spending time with you, from the very beginning and at every step along the way.

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Treating patients like never before.

As part of the Alegent Health Heart and Vascular Institute, the Valve Clinic provides specialized care for patients with complex diseases of cardiac valves. Our unique, streamlined process offers your patients access to the region’s most advanced technologies, leading cardiologists and new treatments for previously untreatable conditions — all in a single location. The Alegent Health Valve Clinic is one of a few centers across the U.S. that is equipped to perform minimally invasive surgeries due to the combination of Dr. Ruby Satpathy’s expertise and Nebraska’s only state-of-the-art HYBRID surgical suite. It’s treatment options like these that result in shorter hospital stays, faster recoveries and better outcomes for your patients.

To learn more about the Valve Clinic and to meet Dr. Satpathy, visit Alegent.com/Valve or call 402-398-5880 to schedule an appointment.

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Metropolitan Omaha Medical Society 7906 Davenport Street Omaha, NE 68114

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Intensive Care for Newborns

In whose hands will you place her?

Physicians’ Priority Line

1.888.592.7955

When a newborn is critically ill, a single call gives you instant access to our neonatal intensive care specialists and a full range of pediatric and surgical subspecialists, all supported by state-of-the-art technology and equipment.

It can also link you to our neonatal transport service team, who will arrange for transport to Children’s Hospital & Medical Center based on the child’s needs. Twenty-four hours a day, seven days a week, one call links you to physician-to-physician consults, referrals and admissions. There’s no problem too large, no child too small. www.ChildrensOmaha.org

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