2003julyaugust

July/August 2003

a c i r e m A n i Safest or Safety f e g a t S he Setting t

e u s s i s i h In tnization Controversy Act Immu y r r a C l and a e c n o C

DERMATOLOGY CONSULTANTS, P.A. David W. Anderson, M.D. Lori R. Arnesen, M.D. Daryl A. Brockberg, M.D. Humberto Gallego, M.D.

Pierre M. George, M.D. Noel A. Hauge, M.D. Dennis M. Leahy, M.D. Jane B. Moore, M.D.

Harold G. Ravits, M.D. Malinee Saxena, M.D. Joseph J. Shaffer, M.D. Jerry W. Stanke, M.D.

are pleased to announce the association of INSLEY D. PUMA, M.D. and KRISTINA K. SHAFFER, M.D. in the practice of Dermatology Administrative Office St. Paul-Downtown Suite 2106 101 E. 5th St. St. Paul, MN 55101 (651) 291-9166 Fax: (651) 291-9169

Midway Office Central Medical Bldg.

Suite 720 393 N. Dunlap St. N. St. Paul, MN 55104 (651) 645-3628 Fax: (651) 645-3620

Maplewood Office 1560 Beam Ave. Maplewood, MN 55109 (651) 770-0110 Fax: (651) 770-0134

Eagan Office Town Centre Plaza Suite 220 1185 Town Centre Dr. Eagan, MN 55123 (651) 251-3300 Fax: (651) 255-3450

Woodbury Office 7616 Currell Blvd., #115 Woodbury, MN 55125 (651) 578-2700 Fax: (651) 578-7077

Visit our web site at: www.dermatologyconsultants.com DR. INSLEY PUMA was born in Charlottesville, Virginia, and moved shortly after birth to Caracas, Venezuela where she spent most of her childhood. She went to the Jose Maria Vargas Medical School at the Central University of Venezuela, and graduated in 1997. She then came to the Twin Cities, interned at Hennepin County Medical Center (HCMC), and later pursued her residency in Dermatology at the University of Minnesota, which she completed in June of 2003.

Within the field of dermatology, she has developed a strong interest in patients with psoriasis and cutaneous T-cell lymphomas (CTCL) and has spent time training in the use of phototherapy. In addition to practicing general medical and surgical dermatology with Dermatology Consultants, she will be seeing patients with CTCL and other lymphoproliferative disorders of the skin in the CTCL Clinic at the University of Minnesota, as well as teaching residents at Hennepin County Medical Center.

Dr. Puma is fluent in both English and Spanish, and has a strong background in Italian as well. She currently lives in St. Paul and her hobbies include gardening and running, as well as Yoga.

DR. KRISTINA SHAFFER was born in Lake Elmo, Minnesota. She attended Wellesley College in Boston for her undergraduate studies. Her medical degree was obtained from the College of Physicians and Surgeons of Columbia University in New York City. She completed her internship in internal medicine at St. Vincent’s Hospital and Medical Center in New York City. Dr. Shaffer completed her dermatology training at the University of Minnesota where she also served as Chief Resident in her final year.

Her clinical interests include general dermatology, allergic contact dermatitis, laser surgery, surgical removal of skin cancers and benign lesions sclerotherapy, and Botox injections.

She lives in St. Paul with her husband, Joe, who is also a dermatologist.

Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761.

To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. E-mail: bauerfamily@earthlink.net.

For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com.

MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy.

Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Doreen Hines at (612) 362-3705.

MetroDoctors

CONTENTS VOLUME 5, NO. 4

2

J U LY / A U G U S T 2 0 0 3

LETTERS

Classified Ad

3

Minnesota Health Plan Contracting Act Unexpectedly Defeated 29 to 25

4

COLLEAGUE INTERVIEW

Deborah E. Powell, M.D.

8

FEATURE

Transforming Quality: New Priorities for Action from the IOM

12

Safest in America Creates Community Focus on Patient Safety

15

Canadian Prescription Importation— an Answer for High Drug Prices?

18

Minnesota Legislature’s Health and Human Services Appropriations Decisions HMS/RMS Exhibit at PriMed CME Conference

19

Advocates and Adversaries Childhood Immunization in the 21st Century

21

PHYSICIAN’S SOAP BOX

Physician Leadership and Tobacco Reduction

23

Minnesota’s New Conceal-Carry Act RAMSEY MEDICAL SOCIETY

25 26 27

President’s Message

28

RMS Alliance

New Members/In Memoriam

July/August 2003

Physician Co-editor Y. Ralph Chu, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Pete Fabian, Risdall Advertising Agency

erica Safest in Am Safe ty Stag e for Sett ing the

RMS Leadership Meets with Betty McCollum/ Dr. Asplin Addresses RMS Board issue In thzatision Controversy Act Immuni and Carry Conceal

HENNEPIN MEDICAL SOCIETY

29 30 31 32

Chair’s Report Hoban Scholarship Educational Event New Members/In Memoriam HMS Alliance

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: Wrong side surgery, medication errors, drug importation risks all contribute to the challenge of providing quality health care to patients. Articles begin on page 8.

July/August 2003

1

LETTERS

July/August Index to Advertisers Clary Document Destruction .......................

Inside Back Cover Classified Ad ............................................... 2 Crutchfield Dermatology .......................... 26 Dermatology Consultants .............................

Inside Front Cover Hazelden .................................................... 5 Medical Billing Professionals ....................... 3 Methodist Hospital .................................. 22 Minnesota Healthcare Network ................ 17 MMIC ...................................................... 11 Multicare Associates .................................... 3 RCMS, Inc. .............................................. 22 Southdale Internal Medicine ..................... 20 U of M CME ................. Outside Back Cover Valley Hospital at Hidden Lakes ............... 24 Weber Law Office ..................................... 23 Xcelerate Sales (Phone Tree) ...................... 16

Mark Your Calendar...

HMS/RMS Winter Medical Conference February 14-21, 2004 Puerto Vallarta, Mexico For more information, call Doreen Hines, 612/362-2705.

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2

July/August 2003

To the Editor, After reading Lee Kurisko’s diatribe on Canadian Universal Health care in the May/ June edition of MetroDoctors, I thought such a biased and reactionary piece surely would be recognized as such by all readers and would not merit a response. However, with the risk of seriously oversimplifying an evolving and tremendously complex subject with a very brief discourse, I would like to address a few specific issues.

First of all, every country’s way of delivering and financing health care probably has its own horror stories, so anecdotal accounts of bad outcomes isn’t very helpful in this debate. Even Canada, with all its health system shortcomings, does better than the U.S. in some important outcomes such as life expectancy and infant mortality. There is no perfect system.

Kurisko railing against socialism as “immoral….based upon coercion,” is not only unhelpful in any real debate on health care systems, but is frankly insulting to many, I’m sure. And comparing government health systems with socialized food production in the Soviet Union? This blind emotional response to “socialism” as being something inherently evil stifles debate regarding any centralized governmental involvement in health care delivery and financing, and is unfortunate.

On this point, many in this country use the argument that federal government involvement with health care will be “socialized medicine” analogous to the Canadian system.

This is not only a tired, worn out argument, but also fear mongering at its most insidious.

Any system developed in the U.S. on a national scale would bear little resemblance to the Canadian system given our history of supporting individual rights and the tremendous wealth and resources in this country.

Kurisko includes a paragraph addressing medical liability in the U.S. Criticism, however, isn’t directed at the trial lawyers or a MetroDoctors

litigious society, it’s aimed at “government in the form of the courts.” This is not rational discussion and appears to be thrown in even though it’s not germane to the topic at hand.

Lastly, and then I’ll get off my own soapbox, Kurisko supports “return to a free market.” The support given is that there is a free market for food, tennis rackets, and CD players, and there are plenty of these things in Canada and the U.S. It has been painfully obvious that medical care cannot be governed by the rules of a “free market.” One really has to look no further than the U.S. over the last 30 years. The fundamental reason for the failure of a market based approach to health care is that it produces a health care delivery system that seeks to avoid and limit health care for the very people that need it most in order to make a profit.

Eventually, there will be national coordination of health care delivery and financing for all Americans. The hope of many is that it will be more efficient, less costly, and lead to better outcomes than our current non-system, which leaves millions of Americans without access to care or insurance coverage. Many difficult questions remain.

One important one is “Who is going to be at the forefront in helping design and bring to fruition the health care system of the future?”

If we, as physicians, only scream about what we don’t want, try to protect our own economic well-being, and do not engage in constructive debate with other major participants, we will not be invited to the bargaining table and, chances are, will feel like we’re getting something shoved down our throats in the very near future. ✦ Lyle Swenson, M.D. Cardiologist, St. Paul Cardiology

The Journal of the Hennepin and Ramsey Medical Societies

Minnesota Health Plan Contracting Act Unexpectedly Defeated 29 to 25 Editor’s Note: The following letter regarding the failure of the Minnesota Legislature and, in particular the Minnesota Senate, to pass the Minnesota Health Plan Contract Act was mailed to each HMS and RMS member. The bill represented three years of work by the Minnesota Fair Health Plan Contracting Coalition, a coalition of 15 provider organizations including: Advocates for Marketplace Options for Mainstreet, Hennepin Medical Society, MN Chapter American Physical Therapy Association, Minnesota Chiropractic Association, Minnesota Dental Association, Minnesota Medical Group Management Association, Minnesota Nurses Association, Minnesota Occupational Therapy Association, Minnesota Pharmacists Association, Minnesota Physician Patient Alliance, Minnesota Podiatric Medical Association, Minnesota Psychiatric Society, Minnesota Rural Health Cooperative, Northwestern Health Sciences University, and Ramsey Medical Society. Please note that the bill was defeated in the Minnesota Senate by a vote of 29 to 25 with 13 Senators out of the chamber. The opposition of the Minnesota Chamber of Commerce and a message from the Minnesota Department of Employee Relations and Governor Tim Pawlenty to oppose the bill while the vote was being cast caused its defeat.

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May 30, 2003 Dear Colleague: The Minnesota Health Plan Contracting Act (S.F. 394/H.F. 606) was unexpectedly defeated 29 to 25 on May 16 in the Minnesota Senate. The legislation was the product of three years of work by the Minnesota Fair Health Plan Contracting Coalition organized by the Hennepin and Ramsey Medical Societies, which grew to include 15 organizations representing providers in Minnesota.

Why did this legislation fail? The Minnesota Health Plan Contracting Act failed due to strong opposition from the Minnesota Chamber of Commerce and the Department of Employee Relations (DOER). The Chamber claimed that the bill would increase costs to employers. We must assume that the Chamber’s position is based on the premise that any bill that includes the rights of providers increases costs. The bill also failed because Governor Pawlenty and his commissioner of the Department of Employee Relations (DOER) developed a fiscal note that was based on totally erroneous assumptions. Even though we amended the bill to eliminate those fiscal concerns, the governor remained opposed. He apparently was also MetroDoctors

responding to the Chamber’s position. The votes against the bill in the Senate came from Republicans who were complying with the governor’s message to oppose the bill.

We are very disappointed in the actions of the Minnesota Chamber of Commerce, the governor, and the Republicans in the Senate.

The Hennepin and Ramsey Medical Societies look forward to continuing to collaborate in the future with the members of the Minnesota Fair Health Plan Contracting Coalition and with the Minnesota Medical Association, who decided to support the bill after it was amended in response to their concerns.

We welcome your comments and we hope you will unite with your colleagues to support the Minnesota Health Plan Contracting Act and the work of the Hennepin and Ramsey Medical Societies as we plan for the 2004 Session. It is obvious that we will need an excellent strategic plan for the 2004 Session if we hope to succeed. ✦ Sincerely, J. Michael Gonzalez-Campoy, M.D., Ph.D., President, Ramsey Medical Society, and T. Michael Tedford, M.D., Chair, Hennepin Medical Society

The Journal of the Hennepin and Ramsey Medical Societies

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July/August 2003

3

COLLEAGUE INTERVIEW

Deborah E. Powell, M.D. Editor’s Note: Deborah E. Powell, M.D., is dean of the Medical School and assistant vice president for clinical affairs at the University of Minnesota. Dr. Powell is a board-certified surgical pathologist and medical educator with more than 30 years of experience in academic medicine.

She received her medical degree from Tufts University School of Medicine and completed her residency training at Georgetown University Medical Center and the Clinical Center of the National Institutes of Health (NIH).

Dr. Powell served as the vice chair and director of diagnostic pathology at the University of Kentucky in Lexington before being named the chair of the department of pathology and laboratory medicine at that same institution. In 1997, she was named executive dean and vice chancellor for clinical affairs at the University of Kansas School of Medicine. She came to Minnesota in the fall of 2002 to lead the University of Minnesota Medical School with a goal of moving the institution back into the top 20 in research rankings. In 2000, she was elected to the distinguished National Academy of Sciences Institute of Medicine, which advises the federal government on national health and science policy.

Q A

What attracted you to the University of Minnesota Medical School?

I was happy at the University of Kansas School of Medicine, where I had been dean for five years. Yet, I was intrigued by the opportunity to apply for the position of dean of the University of Minnesota Medical School because Minnesota has so much to offer.

The intellectual environment is rich in the Twin Cities and at the University. More so than in Kansas, faculty at the University of Minnesota’s Medical School enjoy all the advantages of a major research university, including proximity to colleagues in other fields. One of my goals is to promote projects, based on our new understanding of biology, that transcend the usual barriers between disciplines. We can foster new research by drawing from mathematics, physics and engineering, and from social sciences and computational sciences. Breakthrough innovations will come by connecting with fields that have not been traditionally part of our basic science departments in schools of medicine.

I saw great accomplishment and great potential to do even more here. The school has encountered many challenges in the last decade. In response, it has revamped its curriculum, established a strategic plan, and realigned its finances. Yet work remains to be done, which I welcome.

We are in the process of building a continuum of medical education because we know that the first four years of medical school are just the 4

July/August 2003

start of making a doctor. While I have long been committed to this goal, our school has the benefit of additional prodding because in spring 2004, we will be reviewed by both the Liaison Committee for Medical Education and the Accreditation Council for Graduate Medical Education. The preparation for these site visits gives our faculty the opportunity to thoroughly review our programs. Ours will be the first medical school to experience these accreditation reviews simultaneously, thereby sending a strong message to other schools around the country that this is the way accreditation will be done in the future.

We have also taken a hard look at continuing medical education (CME), as medicine requires the cultivation of life-long learners. A blueribbon panel composed of individuals from inside the Medical School, as well as many of our colleagues from the community, reviewed our CME program in the fall and made recommendations for substantial changes.

With the guidance of their review, we have restructured CME programs and leadership in the last few months, and thus laid the groundwork for new non-traditional approaches to CME. We have been rebuilding the reputation of the University of Minnesota Medical School in the last few years. Nationally, research-funding rankings count for a great deal. We are in a very competitive environment, however, and even as we have increased the amount of funding we have received, we have seen our National Institutes of Health ranking drop from 27th to 29th. We have a large number of very fine, very productive researchers. To return to the top 20 medical schools in research, however, we will need to be more focused and build on the very best among our many fine programs. Unlike some medical schools, we are continuing to hire physician-scientists in those areas that hold the most promise for breakthroughs and growth.

Obviously, the state’s budget cuts to the U create problems for us in all our efforts. But the state’s history of support for the University and especially for its Medical School has been impressive. I believe that the people of Minnesota recognize the value of what we do here, preparing the next generation of doctors, discovering new treatments and cures, and contributing to the health of the state.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

How is medical education at the University of Minnesota changing to better prepare new physicians for the new health care environment?

Going forward on our work to build a continuum of education at the University of Minnesota Medical School, we are guided by the ACGME core competencies. Although these competencies were first established as guidelines for residents and fellows, I believe they will be very useful in shaping how our medical students are being educated in the first four years.

The six core competencies provide a flexible framework for educators and for students as they face an ever-changing health-care environment.

• The first is patient care: to provide compassionate, appropriate, and effective patient-focused care.

• The second is medical knowledge: to apply knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences to patient care.

• The third is practice-based learning: to evaluate patient care practices, appraise and assimilate scientific practices, and improve patient care practice.

• The fourth is interpersonal and communication skills: to demonstrate effective information exchange and teaming with patients, their families, and professional associates.

• The fifth is professionalism: to demonstrate commitment to professional responsibility, adherence to ethical principles, sensitivity to diverse patient populations.

• And the sixth is systems-based practice: to develop an awareness and responsiveness to the larger context and system of health care and to utilize this effectively to provide care of optimal value.

These competencies should be the backbone for our continuum of medical education. That continuum would involve our medical school, our medical-education partners and affiliates, and the broader community. This represents a very exciting leadership opportunity for our University of Minnesota Medical School.

The core competencies incorporate the concept that students must learn to practice as part of health care teams. Incorporating interdisciplinary teamwork into the education process has long been a goal of mine, and we’re uniquely positioned in Minnesota to make that a reality with the Academic Health Center and its schools—the College of Pharmacy, the School of Nursing, the School of Public Health, the School of Dentistry, and the College of Veterinary Medicine.

Understanding and improving systems of health care will require greater training in informatics. Using information technology to better understand health care and health systems is something we have been promoting at the school. Indeed, we recently instituted a joint degree program for medical students who want a master’s in health informatics.

(Continued on page 6)

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MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2003

5

Colleague Interview (Continued from page 5)

Given that the profession of medicine has become so technology oriented, is there an effort to offer experiences in the humanities in the Medical School curricula to again emphasize the “art and science of medicine”?

It’s easy to be dazzled by all the technology in this century, with its databases, electronic medical records, personal digital assistants, and so on.

But, I believe that these technological aids, while very sophisticated, are simply tools. We, on the Medical School faculty, have a firm commitment to educate our students to be fully aware, well-rounded physicians. Before they matriculate, for instance, we give them a reading list to encourage them to study issues of cultural diversity (The Spirit Catches You and You Fall Down) and the life of a physician (Complications).

Starting in 1997, we have been revamping our curriculum to cultivate physicians who care deeply about patients, understand their backgrounds and cultures, and apply the best biomedical and epidemiological knowledge to prevent, treat, and cure their maladies. One example of how our coursework has changed is the addition of “Physician and Society” during the first two years of medical school. In a small-group setting with master tutors as leaders, Physician and Society covers issues of cultural dynamics, health systems, ethics, professionalism, clinical inquiry, and medicine and law.

While in medical school, our students also are encouraged to take part in “On Doctoring,” a series on science, medicine, and the social fabric. The all-afternoon events, which take place quarterly, include presentations by expert faculty members and discussions by panels that include faculty, community experts, and medical students. Recent topics have included genomics, performance-enhancing drugs, adolescent health in America (“From Poodle Skirts to Body Piercings”), and a session on sleep, stress and the new ACGME work rules. We invite and encourage members of the medical community to join us for the “On Doctoring” series.

Another way our educational approach has changed is incorporating Objective Structured Clinical Exams. These clinical exams are expected to be instituted as a graduation requirement for the class of 2005, so we are giving our students opportunities to participate in them. But even though this requirement is new, the skills that come together in a good physician remain the same: the emotional sensitivity to patients as well as the intellectual and technical tools of diagnosis and treatment.

How are the Medical School and University working to help current medical students maintain their compassion, humanity, and caring in a busy world?

No one is exempt from the harried pace of today’s world but it is a pace that physicians have long known all too well. We do focus on the students’ well-being through many avenues—including having an assistance service available 24 hours a day to help them with personal, academic, or other problems. In our transition programs, introducing them to the clinical rotations of third year and to the life of residents, we emphasize the need 6

July/August 2003

to take care of oneself, to manage stress from whatever cause, to know what they don’t know, and to ask for help when it’s needed.

I feel our Medical School has also done a good job in creating a culture that is collaborative and nurturing of students. Over and over again, the faculty beat the drum of professionalism and respect for colleagues and patients. And our students have heard this drumbeat and have begun their own; last year, they drafted their own rather stringent code of professional conduct.

We continue to emphasize service—the new free clinic in the Phillips neighborhood is an example of the students’ commitment to service. I will be seeking ways that we can do more to provide service opportunities to our students.

We tell them to take care of themselves, but we don’t have to shout.

They tend to be different from students who attended Medical School 30 or 20 years ago—not any less talented, smart, or dedicated to medicine.

But many are committed to having a balanced life. Some are married and starting families—and they are making sure that family comes first. So when they start practice, they might make different choices than the older generation did.

How do you see the Medical School preparing future physicians in their work with patients—working with other healers who practice non-allopathic medicine— acupuncture, homeopathy, holistic, chiropractic, naturopathic, and other medicine?

Our Medical School has an unusual advantage over some others because we are connected with the University of Minnesota Center for Spirituality and Healing. The center has an NIH grant to develop competencies in complementary and alternative medicine that can be integrated into our curriculum. We have made some progress in that integration.

The “Physician and Society” course offered during the first two years of medical school provides an opportunity to weave integrative medicine into discussions of cultural and spiritual diversity, ethics, end of life issues, and mastering clinical information. The new Minnesota Virtual Clinic also weaves integrative medicine topics into the virtual patients’ panels.

And all “Physician and Patient” clinical interviewing and clinical skills courses include instruction on how to ask about spirituality and use of complementary and alternative medicine.

During the second half of medical school, the required Primary Care clerkship includes four half-hour sessions to introduce students to selfcare and meditation techniques. The complementary and alternative medicine elective for third- and fourth-year students continues to be very popular; it includes experiential visits to CAM practitioners. This elective is completely filled for the 2003-2004 academic year.

We are partnering with directors of required clerkship programs to design learning activities to enrich the existing content of each clerkship, with the ultimate goal of achieving the competencies of both the clerkship and integrative medicine.

In addition, the Center for Spirituality and Healing works with residency programs to integrate this understanding of complementary and alternative medicine—pediatrics residents all rotate through a CAM proMetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

gram—develops online CAM sources for medical students and faculty, and offers the Inner Life of Healers seminars and retreats for students and community health care providers.

The traditional promotions systems at academic centers rewards faculty research activity but often penalizes faculty who excel in clinical care and administrative activities.

Given the need to improve the efficiency and quality of care provided to patients, how would you suggest aligning faculty incentives and rewards to meet those needs?

The clinical practice of medicine is integral to a medical school because teaching of medical students cannot occur except in an environment of direct observation and learning about patient care in the various specialties of medicine. Medical schools require faculty who are able to carry out all parts of our mission, which also includes education, research, and outreach. Increasingly, because of the sophisticated types of research that we do, it is more difficult to find individuals who can excel in all areas.

About 10 years ago, the Medical School faculty voted to develop more fully the clinical scholar track to recognize individuals who excelled primarily in outstanding clinical practice and education, while not neglecting scholarship related to their field of practice and to education.

These clinician-scholars are some of the most dedicated faculty of the Medical School, with many serving as course or residency program directors. They are highly valued by the school and by their faculty colleagues, as well as by the students.

Realigning the system of promotion and tenure in the Medical School to recognize the clinical practice faculty is an ongoing project under the leadership of Anne Taylor. Dr. Taylor has made a great deal of progress.

We hope to introduce a system that will appropriately reward faculty for their work in the coming year.

In looking at applicants, how do you balance the need to supply the state with good clinicians with the need for good researchers? Are the two mutually exclusive?

Teaching top-quality clinical care is one of our medical school’s core values.

More than half of our alumni end up practicing in Minnesota—and we feel they are above average in caring for patients with skills and compassion.

Yet I do not believe that excellence in research and excellence in clinical care are mutually exclusive. On the contrary, the two can complement one another so that the breakthroughs made in research improve the care given by physicians. We have on our faculty clinicians who are also researchers—Roby Thompson in orthopedics, Jeffrey Miller in oncology, Michael Maddaus in minimally invasive surgery, and Soon Park in organ transplant, to name just a few—and I feel they are terrific role models for our students.

In an era in which science makes advances so quickly, I would hope that our students learn the value of research. We strive to create life-long learners at the University of Minnesota Medical School and I hope that we succeed in that. But the only way to demonstrate is to educate physiMetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

cians who can understand, access, and apply research breakthroughs to benefit their patients.

In addition, we are one of 39 schools that offer a joint M.D./Ph.D. degree. Enrolling about 10 students a year since 1986, the program aims to create physician-scientists who are at the very top of their fields, whether pathology, pediatrics, immunology, neurosciences, infectious disease, or another discipline. Throughout the M.D./Ph.D. program, we relate research to practice, as in the clinical basic sciences seminar that links biomedical research problems with recent advances in clinical thinking. These are students of high talent who have the potential to contribute greatly to the advancement of human health—and to the lives of individual patients. Of the students who have completed this long and arduous program, some are in practice, some are researchers, and some have entered academic medicine, which potentially combines the two aspects of medicine.

I personally have a commitment to academic medicine and would like to encourage our students, especially our female students, to consider it as a career path. We are seeing medical school classes at the University of Minnesota, as well as other schools, who are approximating half women.

Yet, so far many of these talented young women are not choosing to enter academic medicine or, if chosen, to stay in it. This is a trend I would like to help change.

What measures will you be considering regarding the tuition levels at the Medical School in view of the reductions in funding by the Minnesota Legislature and how will those measures affect the medical student debt load?

We know that the public supports a strong Medical School but that support has not translated to public funding for the U. We, in the Medical School, see the reduced state contribution to our budget as challenging but not impossible. While news about double-digit tuition increases at the U are very alarming, those increases will apply primarily to undergraduates. The Medical School will not be relying on tuition increases to support its finances in the near future.

Our students already carry a very high debt load. While the Minnesota Medical Foundation provides more than half of our students with scholarships, that aid averages only about $2,500 a year for each student.

The cost of schooling and living expenses, on the other hand, adds up to about $45,000 a year. Our students now, on average, graduate with nearly $100,000 of debt. Then they face relatively low salaries during their residency years.

Recognizing that students already face a rocky financial road, we will not raise Medical School tuition in the coming year. While no, or only modest, increases to Medical School tuition are planned for the near future, we cannot control the fees charged by the University of Minnesota.

Those fees will rise and that will increase costs for our medical students, residents, and fellows.

We have done a great deal in the last decade to streamline operations and make our school as efficient as possible. Still, educating the next generation of doctors, while expensive, is essential to the health of our state. I hope that Minnesota’s Legislature will recognize this in coming years and grant greater support to our institution and our students. ✦ July/August 2003

7

FEATURE STORY

New Priorities for Action

Transforming Quality from the Institute of Medicine

We must re-design care delivery and transform care systems to enable physicians to provide the high level of quality we all want for every patient in our care.

Editor’s Note: In January 2003, the Institute of Medicine (IOM) issued a new report, Priority Areas for National Action: Transforming Health Care Quality. The report sets forth 20 priority areas that establish a starting point to fix the nation’s broken health care system. George J. Isham, M.D., medical director and chief health officer of HealthPartners, chaired the committee that produced the report. In this article for MetroDoctors, Dr. Isham describes the committee’s process, discusses the 20 priority areas, and shares his views on the implications for physicians.

MetroDoctors is interested in receiving our reader’s comments on ways that their respective clinics or health care organizations are dealing with the 20 areas listed at the end of this article. Send your comments to HMS or RMS, 3433 Broadway Street NE, Minneapolis, MN 55413; or e-mail: jdavis@metrodoctors.com; rjohnson@metrodoctors.com.

Defining the Quality Problem Priority Areas is one in a series of reports coming out of IOM’s quality initiative. One of the key predecessor reports, Crossing the Quality Chasm: A New Health System for the 21st Century, was issued in 2001 and set the stage for my committee’s endeavors last year.

Crossing the Chasm is enormously important. Its main conclusion is that poor quality is not due to the absence of effective treatments, or any lack of knowledge about them, but to disjointed care systems and ineffective processes that fail to put them into practice.

To be absolutely clear, we do not have serious quality problems in health care today because physicians lack knowledge, expertise, commitment or compassion. And, the issue is certainly not that physicians do not work hard enough. We do. Quality is a systems problem. We must re-design care delivery and transform care systems to enable physicians to provide the high level of quality we all want for every patient in our care.

The Committee on Identifying Priority Areas for Quality Improvement Crossing the Chasm called for the Agency for Healthcare Research and Quality to identify not fewer than 15 priorities for the purpose of developing strategies, goals, and action plans for achieving significant improvements in quality. In response, IOM was awarded a contract to convene a group of experts to set criteria for determining priorities and recommending a comprehensive set. IOM established the Committee on Identifying Priority Areas for Quality Improvement to take on the challenge, and in February 2002, I was given the opportunity to chair the committee.

BY GEORGE J. ISHAM, M.D.

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The Journal of the Hennepin and Ramsey Medical Societies

We met three times, starting in April 2002. We held a public workshop to hear from experts in the areas of mental health, child and adolescent health, long-term care, and many other areas. The committee made extensive use of subgroups and set out to refine a framework for targeting priority areas and craft criteria and a process for identifying and assessing them. We reviewed and screened all the candidate areas, and then came up with our final list of 20 in June 2002. The report was written in the fall and evaluated by external reviewers before IOM issued it in January 2003.

It should be underscored that Priority Areas is a scientific study based on good evidence. Consistent with every IOM study process, our committee consisted of independent health care professionals who volunteered to do the work. Then, a second group of outside experts, who we did not know until our entire process was completed, reviewed all our work. They ensured that the committee complied with all IOM guidelines, including rules of scientific evidence.

Targeting Priority Areas The committee adapted a framework originally developed by the Foundation for Accountability. This consumer-focused framework touches on four domains of care: staying healthy (preventive care), getting better (acute care), living with illness and disability (chronic care), and coping with the end of life (palliative care). Thus, we sought to identify priority areas across the full spectrum of health care.

We then added what we called “cross-cutting systems interventions”—care coordination and support for patient self-management. We did so for two reasons. First, these are elements that apply to all other specific domains and need to be addressed in order to break down system barriers in the management of different diseases and classes of diseases.

Second, improvements in these added areas will benefit everyone, even those without particular priority conditions.

The three criteria used to select the final set of priorities were impact, improvability, and inclusiveness. As the committee examined hundreds of possible priorities, we asked a set of focused, and tough, questions: How big, and costly, is the problem? What’s the clinical burden and psychosocial impact? Is there evidence on valid best-practice standards that, if followed, would improve care? In addition, we pondered whether addressing a particular area would improve quality for a broad spectrum of Americans (across age, gender, race, economic status, and so on).

I hope we will see health plans, hospitals and physicians working together and achieving measurable improvements in quality.

(Continued on page 10)

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Transforming Quality (Continued from page 9)

Priority Areas: Diabetes as an Example The table accompanying this article lists the 20 areas. Diabetes offers a helpful example of one of the 20 priorities. Diabetes affects 17 million Americans and is the fifth leading cause of death in the U.S. AfricanAmericans are three times more likely than Caucasians to die from diabetes-related causes. The death rates for other minority groups are not quite as bad, but are still significantly worse than for whites. Accordingly, there is no doubt that in terms of impact and inclusiveness that diabetes is a critical priority.

Moreover, there is a huge opportunity to improve the quality of care for diabetes.

Too many people with diabetes have poor control of blood glucose levels, lipids and blood pressure, and too many still do not receive services that physicians know make a real difference, like blood sugar monitoring and annual eye and foot exams.

Priority Areas recognized HealthPartners as a model for diabetes care. Our program includes deployment of multi-disciplinary care teams, a diabetes registry that provides clinicians with automated reminders for needed services, and several education and counseling programs on self-management, diet and exercise. It works. In cooperation with physicians, we have achieved significant health improvement for our members with diabetes.

The Potential Impact of Priority Areas All the organizations, here in Minnesota and across the country, working on quality and toward implementing performance measures truly need a shared conceptual framework, like the priority areas. Today, we have, at best, a patchwork of measures that send inconsistent and confusing signals to physicians. If groups adopt a focus on the priority areas, we could get more standardization and consistency and much 10

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more comparable data. That would be very helpful—reducing the complexity and costs of change and supporting greater, and faster, improvement in the quality of care for our patients.

I hope that physicians, nurses and clinic administrators will read the report and review it together. They should look at the 20 priority areas and assess which ones touch most directly on their practice.

Then, I hope that they will work together and figure out what incremental changes they can make themselves, and what tools they can apply locally, to make a difference and advance improvement on the front lines of clinical practice. And, we certainly need practicing physicians to share the lessons they are learning along the way.

At HealthPartners our “Partners for Better Health” population health initiative runs in five-year cycles. Our current cycle continues through 2005. Presently, we target six goal areas: heart health, diabetes, depression, tobacco control, healthy eating habits, and physical activity. So, we have already been working on many of the priority areas. Our implementation teams for each of our areas establish their own specific goals and objectives, and they have already been reviewing Priority Areas and fine tuning their efforts. Therefore, we are already seeing the impact, and the influence will surely continue to grow.

The HealthPartners Medical Group & Clinics is also conducting two projects under a Robert Wood Johnson Pursuing Perfection grant, an initiative that grew out of the Crossing the Chasm report. These projects include implementation of a planned care model and improvements in appointment and information access for providers and patients. These projects are designed to fundamentally redesign the “chassis” of health care. Our approach to this work can be summarized as “prepared practice teams interacting with informed, activated patients through continuous healing relationships, supported by health information availability.” Our work on these

projects is taking place at three R&D clinic sites in our system. These clinics are focused on providing primary and specialty care consistent with the six aims of Pursuing Perfection.

Our planned care project is designed to make fundamental changes in the traditional model of providing health care, with a focus on meeting the medical and psychosocial needs of each patient as a unique individual. To accomplish this goal, our R&D sites have broken the patient care process into segments (pre-visit, visit, postvisit and between-visit) and used rapid design sessions to identify workflow, process and training, and development needs. The project relies heavily on patient involvement in the design process.

Our goal is to transform our entire organization, so that perfect care is provided to all patients all the time. We currently have developed a sentinel measure in five of the six dimensions of Pursuing Perfection—safe, timely, efficient, equitable and patient-centered.

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Concluding Comments From my experience as chairman of the Committee on Identifying Priority Areas for Quality Improvement, I came away with a deeper appreciation of the importance of systems and changing systems in order to transform health care. I developed a profound understanding of the importance of basic concepts of social justice in setting priorities to ensure genuine inclusiveness. And, I have a deeper feeling for how tough, complex, and critical it is for us to change care systems and care delivery to make real progress toward lasting quality improvement.

I hope we will see continued development and refinement of systems and tools– like electronic medical records systems, knowledge-based software for clinical decision support, and patient registries. I hope we will see health plans, hospitals and physicians working together and achieving measurable improvements in quality. And,

I hope all stakeholders will see that we are transforming health care to deliver sciencebased services that are safe, effective and responsive to the needs of the patients in our care.

Finally, I want to conclude with a strong note of optimism about our local medical community. We have distinct advantages that enable us to work together to transform health care in order to improve quality. For example, the Institute for Clinical Systems Improvement (ICSI) involves 30 medical groups, which include 4,500 physicians (representing well over half of all practicing physicians in our state).

Five health plans, including HealthPartners, financially support and participate in ICSI’s collaborative efforts to develop, implement and evaluate best-practice guidelines. ICSI exemplifies the spirit of cooperation and commitment to shared endeavors that makes our medical community special and enables us to lead the nation in transforming health care. ✦

Institute of Medicine (IOM): Twenty Priority Areas for Quality Improvement 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20)

Care coordination Self-management and health literacy Asthma Evidence-based cancer screening with a focus on colorectal and cervical cancer Children with special health care needs Diabetes (especially management of at an early stage) End-of-life with advanced organ system failure Frailty associated with old age Hypertension Immunization of children and adults Ischemic heart disease (prevention, reducing recurring events and improving functional capacity) Screening and treating major depression Medication management Preventing nosocomial infections and improving surveillance Pain control in advanced cancer Appropriate care for pregnancy and childbirth Severe and persistent mental illness Early intervention and rehabilitation for strokes Tobacco dependence treatment in adults Obesity

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July/August 2003

11

Safest in America Creates Community Focus on Patient Safety

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Setting the Stage for Safety In the early months of 2001, the CEO’s of several Minnesota hospitals and health care organizations signed a memorandum of understanding, agreeing to collaborate on process improvements to enhance patient safety. Their vision created a project called Safest in America— an initiative with the goal to make our community the safest place in America for patients to receive hospital care.

Setting competition aside, these participants forged a powerful vision to improve local health care. They set a collective vision for hospital patient safety, providing broad direction and oversight. Every participant was there to learn jointly about safety issues, barriers, and solutions that would create better processes and policies. They believed that working together would achieve sustainable widespread results.

Participating organizations included Allina Health System, Children’s Hospitals and Clinics, Fairview Health Services, HealthEast, HealthPartners, Hennepin County Medical Center, Mayo Clinic, Park Nicollet Health Services, and North Memorial Medical Center. The Institute for Clinical Systems Improvement (ICSI) provided staff support for the project and helped facilitate the collaboration. The initiative would be peer review protected with no overlap with the work of Minnesota Alliance for Patient Safety, MHHP Patient Safety Committee, or the Minnesota Executive Series.

Setting Goals The CEO’s launched Safest in America by identifying topics for collaborative participation, based on input from clinical experts. The group wanted to identify topics that exhibited suffi-

B Y J U D Y M O S E L E Y , R.N., M.S.

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cient commonality across organizations, as well as topics that would yield greater results with collaboration than what could be achieved by organizations individually. They focused on topics that truly would have an impact on safety.

They prioritized a list of safety concerns and selected two for the initial focus of the campaign. The goals were: 1) To standardize the correct site surgery policies and procedures; and 2) To improve the safety of medication practices.

A task force of chief operating officers, chief medical officers and safety officers from member hospitals, called the Operations Group, then led a task force of groundwork activity. The Operations Group at each hospital and system appointed a representative to work on the surgical site collaborative, as well as the medication practice collaborative. Subgroups developed the aims and goals while ICSI facilitated a specific plan for each of the collaboratives. The collaborative plan included a mix of face-to-face meetings, conference calls, progress reports and the development of a timeline.

The purpose of the collaborative was to seek agreement on best practices strategies, determine a measure of attainment, and foster MetroDoctors

shared learning as the hospitals pursued implementation of best practices. Once the aims were structured for both collaboratives, they were presented to the Safest In America Operations Group for discussion and approval. Each participating member of the Operations Group was then asked to sign on to both of the collaboratives, assuring that the necessary resources were in place within their respective organizations to accomplish the goals. If a participating hospital agreed to the collaborative, they had to pursue all of the aims. It was not permissible for a hospital to work on selected aims only.

Kick-off meetings were then held to launch the surgical site collaborative and the medication collaborative. There were presentations from the CEO and COO groups to articulate leadership agreement and commitment to making Minnesota the safest place to receive care.

Following the kick-off meetings and the reaffirmation to the goals, the work groups for the collaboratives began to meet on a monthly basis. The designated collaborative leader/facilitator had responsibilities for overseeing the entire collaborative. In partnership with ICSI, the leaders organized the agendas, coordinated timelines, communicated to the content expert groups as well as to the chair of the operations group. Clinical providers from all participating hospitals were solicited to engage in the content expert groups. The recommendations of best practice from the content expert groups were then proposed to the overall collaborative in an effort to reach consensus, allowing each hospital team one vote. Each organization was charged with implementing and measuring the agreed upon process and providing monthly written reports of progress and data.

The Journal of the Hennepin and Ramsey Medical Societies

Targeting Areas of Improvement Safer Surgery The aim of the surgical site collaborative included eliminating harm to surgical patients resulting from clinicians performing the wrong procedure or performing the procedure on the wrong surgical site or on the wrong person, within six months of the start date of adopting the recommended practices. The team identified key practices to help achieve the aim after reviewing relevant literature, review of leading medical institutions, research from the Advisory Board, and discussion among collaborative representatives.

The Key Practices Recommended by the Team Included: • Implement a standardized process for the identification of the intended and consented procedure; • Implement a reliable process for identification of the patient; • Implement a standardized process for identification of the correct surgical site; • Implement a standardized process for identification of correct level or segment of the body.

Status on Key Practices: Recommendations have been made to the Operations Group on all of the key practices. The most controversial has been the identification of the site and by whom. Following are the details of the site marking recommendations.

• Organizations are required to mark the surgical site in cases involving right/left distinction, multiple structures such as fingers or toes, or levels such as the spine.

• Ultimate responsibility for site verification and laterality lies with the surgeon and may not be delegated. The operative site must be marked by a physician with their initials or an “X” by a member of the procedural team who is either a privileged and credentialed provider as defined by the institutions medical staff bylaws or who is a physician in residency training.

• Active communication with the patient in getting informed consent and marking of the site.

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• The entire team (nurse, anesthesia provider, surgeon) should be focused on identifying and verifying the correct site.

• Implementation of prescribed steps such as “pause for the cause” and standardizing the identification and verification process.

Safer Medications The aim of the medication safety collaborative was to eliminate all harm in participating hospitals related to the following practices by one year from the start date. As in the surgical site collaborative, the medication team identified key practices to help achieve the aim after review of relevant literature, review of leading medical institutions, research from the Advisory Board, and discussion among collaborative representatives.

The Key Practices Recommended by Teams: • Development of a list of unacceptable abbreviations.

• Implementation of standard concentrations and protocols for pediatric medication and a recommendation for mg/kg dosing for all pediatric high-risk drugs.

• Development of a list of recommendations for the use of two highly dangerous drugs; heparin and insulin.

• Development and utility of a self-evaluation tool for each hospital to use to determine its strengths and improvement opportunities.

• Universal agreement on the use of a tool to measure medication harm rate in the collaborative.

Status on Key Practices: The medication safety collaborative’s first project focused on the use of dangerous yet commonly used abbreviations, such as “U” for units. A list of unsafe abbreviations was developed and approved by the collaborative. Each hospital was challenged to educate and implement action plans designed to reduce or eliminate the use of these abbreviations at each participating site.

Recommendations have been approved around all of the other key practices and are in various stages of implementation.

Both teams realized the importance of setting targets and measuring results to see if the procedural changes make a difference. Measur-

The Journal of the Hennepin and Ramsey Medical Societies

ing outcomes is a critical element of the Safest in America plan and they’re measured monthly.

Moving forward This describes the background of the creation and evolution of Safest in America, and how the recommendations were developed. Great progress has been made, but there is much work left to be done.

We know that achieving widespread implementation of these practices requires changes in existing practices, cultures and strong leadership from all of the organizations involved. It is often difficult to let go of one way of practicing to adopt a new way but we believe that implementing these new recommendations will indeed increase the safety of patient care in our state.

There is a quote by John Galsworthy, an English novelist that says, “Beginnings are always messy,” and I know this to be true. The Safest in America leadership team knows we are at the beginning of making these changes, and that reaching our goals will be challenging.

We believe that we need to move away from individual organization variations toward the recommended best practices. Reducing variation reduces the risk of confusion and streamlines decision-making for practitioners who work at multiple sites and builds in community standards for all providers.

The good news is that the collaborative recommendations have been accepted by a majority of the organizations. The CEO’s of theSafest in America project have discussed the issue of whether it is possible and necessary to have 100 percent of the hospitals adopt the recommendations in order to move ahead. They have concluded that where consensus is not possible, that a recommendation can move ahead with an overwhelming majority of hospitals in agreement (at least eight of the 10 member organizations). Those organizations that do not adopt a recommended practice will still track and report on the measures associated with the recommendation. This approach allows for comparison of outcomes and continued learning.

Since the publication of the Institute of Medicine’s reports, To Err is Human in 1999 and Crossing the Quality Chasm in 2001, patient safety has become a high priority for the public and within the health care industry. It (Continued on page 14)

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Safest in America (Continued from page 14)

remains one of the biggest challenges that hospitals and the overall health care system need to address.

We have made great progress both in terms of creating a community collaboration focused on patient safety, and in identifying best practices that will help us improve safety. We are excited about making the vision of Minnesota

the safest place in America to receive care a reality. The organizations involved in Safest in America are committed to working together for the benefit of all patients. Together they are setting the standard for using teamwork and collaboration to solve problems and improve care and outcomes. ✦ Judy Moseley, R.N., M.S., is vice president for patient care services and newly appointed patient

safety officer for Regions Hospital. Ms. Moseley acts as the organization spokesperson for patient safety issues and oversees the development and implementation of plans to position Regions Hospital as a leader in patient safety. Ms. Moseley collaborates with other regional health care organizations to position Minnesota as the safest state in the nation for patients to receive health care.

Ms. Moseley is currently the chair of the Safest in America Operations Group for the region.

Safest in America: One Surgeon’s View The Safest in America project has many laudable goals. I don’t think anyone would argue with the concept of making healthcare delivery in hospitals as safe as we can, and any physician with a practice involving hospitalized patients knows that the hospital can be a dangerous place.

The key to achieving the goals laid out in this project are to get physician buy-in and to not make changes that are so intrusive or confusing as to nullify the positive impact of the changes.

One of the first projects to be implemented was assuring proper identification of both the patient and procedure being performed. While this was certainly being performed on a routine basis, there was no uniform system from hospital to hospital or surgeon to surgeon and unfortunate errors were being made. The Safest in America project has outlined several areas where we can make improvements. The first of these occurs when the patient is in the holding room. A checklist is run through by the nursing personnel which includes proper identification of the patient, the surgery to be performed, the side (if applicable) on which the surgery is to be performed and verification of the above by the surgeon, who is responsible for verifying the operative permit and any mark on the operative site. Once in the operating room, there is a “pause for the cause,” which again verifies the identification of the patient and the procedure being done.

This system has been implemented in most hospitals across the Twin Cities. However, it has not happened as smoothly as everyone would have hoped and there are still bugs to be worked out. A lot of the problems have arisen from a lack of common sense and hospitals unilaterally implementing rules without being clear to the surgeons what these rules fully entail. This has also been a process in evolution so that what was routine yesterday is changed tomorrow, with new consent forms and mandates about what is considered adequate markings on the patient.

Let me give a few actual examples of why there is frustration among many surgeons.

Case #1 The policy at hospital A on 1/1/03 is that the surgical site must be marked by the patient or nurse and verified by the surgeon. On 2/1/03 the surgeon is told that they must now mark the site themselves and also indicate on the permit which side they marked. On 3/1/03 the surgeon is told that an X will no longer suffice as an identifying mark and that the surgeon must place their initials on the spot. Nurses refuse to take the patient into the OR until the surgeon initials the patient.

Many surgeons feel uncomfortable placing their initials (i.e. branding) on a patient and why an X wouldn’t suffice is unclear. Yet, because this is the recommendation from the Safest in America group, many operating rooms are trying to accept only initials.

Case #2 A patient comes in for a mastectomy and reconstruction. A pre-operative localization wire has been placed in radiology and the plastic surgeon has placed several markings on the breast for the reconstructive aspect of the surgery, yet the case is held up because the general surgeon (who has verified and signed the consent) has not placed his/her initials on the site.

This happens as well with cases such as vein stripping where the patient’s leg is marked in the holding room but the case is held up if the surgeon didn’t also initial the leg. Common sense would dictate that the proper site has been adequately identified and the case should move forward.

I think that the overall objectives to the Safest in America project are worthwhile and we should be undertaking all measures to decrease mistakes made in hospitals. However, these changes need to be made in a clear and concise manner without becoming punitive to the physicians. ✦ Peter H. Kelly, M.D., is a surgeon with Saint Paul Surgeons, Ltd., and a past president of RMS.

B Y P E T E R H . K E L L Y, M . D .

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Canadian Prescription Importation — an Answer for High Drug Prices?

“A drug that is not affordable is neither safe nor effective”

I

available through the Federation prescription drug program for $33, a savings of 85 percent.

Paxil, made by GlaxoSmithKline, sells for $108 (30mg-30) in the Twin Cities and $47 through the Senior Federation importation program, a 55 percent savings.

IN JANUARY THE MINNESOTA Senior Fed-

eration publicly launched its Canadian Prescription Drug Importation program and became the center of state and national debate over controlling the cost of prescription drugs, particularly under Medicare.

Until now, Canadian prescription drug prices have generally been limited to those willing to go to Canada, pay additional payments to doctors, or have access to the Internet. Recognizing that some older people will find this intimidating or impractical, the Federation has established a Prescription Drug Cost Information Center as a community service. Federation staff and trained volunteers now provide the public and physicians with ordering information and price quotes for the MSF program, and other options for reducing prescription drugs costs.

Capturing headlines in the Star-Tribune, Pioneer Press, AARP Bulletin, and US News and World Report, MSF’s Prescription Drug Program has brought consumers, providers, and payers together to control the cost of prescription drugs and to provide decent prescription drug benefits under Medicare.

Prescription drug importation is not without controversy. Coincidently with the launching of the MSF program, GlaxoSmithKline (GSK) announced it would not supply prescription drugs to Canadian wholesalers and pharmacies that export medicines outside Canada.

GSK stated its action was for safety and legal reasons. “GSK understands the concerns of Americans without prescription drug coverage but believes that ordering medicines over the Internet from Canada or other countries…puts

B Y P E T E R T. W Y C K O F F

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patients at risk.” They neglected to mention a possible third reason, unbridled greed.

Three issues surround prescription drug importation: savings, safety and legality.

Savings Surveys released on announcement of the program (www.mnseniors.org) revealed a 62 percent savings on a basket of commonly prescribed medications and a 52 percent overall savings on GlaxoSmithKline prescriptions. While not all drugs are available through importation, and some drugs are more expensive through Canada, most national studies indicate a 45 percent average savings through importation. Surveys by AARP and MSF also revealed that, as the first consumer negotiated Canadian importation program, Federation prices were 14 to 42 percent lower than other Canadian exporters.

For many Minnesotans that difference is quite literally between life and death, and illness or wellness. Tamoxifin, largely developed by public funding, costs $227 (20mg-100) in the Twin Cities for a three-month supply. It is

The Journal of the Hennepin and Ramsey Medical Societies

Safety The FDA obviously cannot guarantee the safety of the medications purchased in Canada. Consumers rely on the oversight of the Canadian Ministry of Health, a counter part of the FDA. Drugs manufactured for the Canadian market come from FDA approved facilities, as do prescriptions destined for the American market.

In May, the Canadian government officially stated it would be responsible for safety and quality of prescription drugs coming across the border to American consumers. The Canadian Ministry of Health said “All imported drugs must be equally safe and effective whether they are for use by Canadians or for export.”

“We appreciate that [Canadian officials] are stepping up to this difficult challenge where we don’t have the regulatory authority, and they might,” FDA Commissioner Mark McClellan, who worked with Health Canada officials, said in the Washington Post. “The fact that they are explicitly stating that they are trying to assure safety and effectiveness not only for Canadians, but for the millions of prescriptions sold to Americans through Canada, is a potentially useful step.”

While the argument against importation is primarily one of safety, one should heed the wisdom of Dr. Stephen Schondelmeyer, Ph.D.,

(Continued on page 16)

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Canadian Prescription Importation (Continued from page 15)

University of Minnesota School of Pharmacy: “A drug that is not affordable is neither safe nor effective.”

Legalities of Importation In 2000, Congress passed legislation specifically allowing importation of prescription drugs from Canada and other countries. However, a “killer

provision” was inserted at the behest of the pharmaceutical industry, which required the FDA to guarantee safety of reimported prescriptions.

Because safety of medications, in this case is overseen by the Canadian government, it is impossible for the FDA to guarantee safety and the legislation was not implemented.

While Congress has approved importation through the mail of a 90-day supply of prescription drugs for personal use, legality remains a

gray area. FDA officials have given assurances that individuals importing prescription drugs from Canada for personal use need not fear that the federal government will interfere in Canadian drug purchases.

With the leadership of Congressman Gil Gutknecht, (R-1st District MN) and Senator Mark Dayton (D-MN), legislation to specifically allow for importation of prescription drugs from industrialized countries is again under consideration by Congress. According to Gutknecht, clearly allowing for prescription drug importation from industrialized countries is not only safe but would “allow the free markets to work.” Full importation would save consumers and payers $630 billion over the next 10 years, according to Gutknecht. This is $200 billion more than what is currently considered as the cost of a Medicare prescription drug benefit.

Strong Cooperation with Minnesota Physicians Cooperation and support of the MSF Importation program has been excellent. Physicians are not only willing to participate but also in many cases, as they learned about the program, they encouraged patient participation. Clinics wishing to provide materials for patients at no cost may call the Federation office.

Response to GSK –– “Tums Down” Boycott Responding to GSK actions to cut off the supply of its products to Americans needing affordable medications, the Senior Federation joined with organizations in 20 states calling for a consumer boycott of Glaxo’s OTC products. In a news conference covered by media on both sides of the border, MSF leaders announced the “Tums Down” Boycott. Senator Dayton said, “Glaxo’s actions are a direct attack on American Citizens.”

In response to the “Tums Down” Boycott, Republicans and Democrats, at a raucous U.S. House subcommittee hearing in April, accused the FDA of protecting the drug industry rather than U.S. consumers by acting to prevent importation of lower-priced drugs from Canada.

“Many of us in the Congress believe they [drug firms] do have undue influence,” said Rep. Dan Burton, (R-Ind), Chairman of the House Government Reform subcommittee that held the hearing. He stated the drug industry has

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given members of Congress and other candidates more than $20 million in the last two election cycles, and has more than 600 lobbyists on Capitol Hill.

Subcommittee member Bernie Sanders, (IVt), was blunter still. “This is payback time. The industry wants to force Americans to pay outrageously high prices in this country,” he said.

“Tragically, the FDA and this Administration have chosen to represent the interest of the industry and not the American people.”

But FDA Associate Commissioner for Policy, Planning and Legislation, William K. Hubbard, told the subcommittee that the FDA’s primary concern is safety. “We are not a price agency,” he said. Hubbard defended the agency’s recent crackdown on Internet pharmacies that purport to be selling drugs from Canada. One, he said, turned out to be located in Thailand, and another in Israel. “Buying drugs online can provide savings and convenience,” Hubbard said, “but also unknown risks.”

Lawmakers at the hearing, however, were

unconvinced. Arguments about safety “are grossly overstated,” said Rep. Gutknecht. He pointed out that the FDA allows imports of food, including some that turn out to be contaminated. “We should not permit our FDA to stand between American consumers and lowerpriced pharmaceuticals,” he said.

Physicians are caught in the ethical quandary between needs of their patients and greed of the pharmaceutical industry. To date, the vast majority is siding with needs of their patients and assisting patients in getting prescriptions from Canada. Galen Stahle, M.D., in private practice in Deephaven, Minnesota, is taking a more aggressive position. “Prices are out of control,” he told the Psychiatric News publication.

He supports the work of MSF and distributes to his patients a list of selected U.S. and Canadian Internet sites where they can purchase prescription drugs. Stahle also protested to GlaxoSmithKline. “I wrote them and said their drug reps would not be welcome in my office unless they changed their policy,” he said.

Buying prescription drugs from any mail order source is not ideal, but for hundreds of thousands of Americans, buying from licensed Canadian pharmacies is the best way to get affordable, safe and effective medications. Seniors do not need Internet access to participate in the MSF Importation program nor is there an age restriction, however one must be an MSF member. ✦ Peter Wyckoff is executive director of the Minnesota Senior Federation-Metropolitan Region, now celebrating its 30th anniversary. The MSF is the primary advocacy and educational organization of older Minnesotans. It is composed of more than 400 affiliated organizations, 25,000 members, and serves more than 60,000 annually. It has been a key player in health policy debates and is leading the multi-state Medicare Justice Coalition. MJC is working to end injustices in Medicare funding that penalize beneficiaries and providers in states like Minnesota, which provide generally cost effective, quality health care.

For more information on the Minnesota Senior Federation Canadian Prescription Drug Importation Program, contact 651/645-0261, or www.mnseniors.org.

FDA Warns Against Drug Importation The FDA is warning Internet pharmacies, employer-sponsored health plans, pharmacy benefit managers, Canadian pharmacies and doctors, and health plan members that they could be found criminally and civilly liable for aiding and abetting the importation of prescription drugs from Canada. The FDA has said that “any party participating in this kind of import plan does so at its own legal risk.”

Many patients ask their physicians to write prescriptions that will be filled by Canadian pharmacies. The Minnesota Senior Federation helps seniors order prescriptions from Canadian pharmacies and take bus trips to Canada to purchase medications—actions that the FDA has deemed illegal.

“Physicians are concerned about their patients,” says Christina Rich, MMA director of health law. “They don’t think of this situation as a long-term solution, but Congress has failed to pass a prescription drug benefit for seniors.” Rich says that physicians must use their own judgment when deciding whether to fill out prescriptions that may be filled by a foreign pharmacy and recommends that they do not have prescription drugs from foreign pharmacies sent to their clinics.

The FDA maintains that medications purchased from unregulated drug outlets are a danger to U.S. consumers, especially because many outlets claim that the FDA condones their activities or that their prescriptions are FDA approved. ✦ From Minnesota Medicine, May 2003. Copyright © 2003 Minnesota Medical Association.

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17

Minnesota Legislature’s Health and Human Services Appropriations Decisions Reprinted from the MMA Legislative Alert THE HEALTH AND HUMAN Services Budget Bill was one of the most contentious bills this session. In order to balance the budget without tax increases, significant cuts were necessary in the health care and welfare programs.

The final bill is a compromise in the sense that it maintains both the General Assistance Medical Care (GAMC) and MinnesotaCare programs for adults without children, but the benefits under both programs are limited.

For adults earning between 75 percent and 175 percent of poverty, GAMC is a catastrophic program, covering hospitalization only with a

$1,000 deductible per occurrence. For adults with the same income level who enroll in MinnesotaCare, it covers hospitalization up to $10,000 per year and outpatient services up to $2,000 per year.

Physician payments are reduced by 5 percent for GAMC only while hospital payments are reduced 5 percent for MA and MinnesotaCare and 10 percent for GAMC. In addition, there are a series of co-payments for MA, GAMC, and MinnesotaCare. For adults without children earning under 75 percent of poverty there is a $3 office visit co-pay for GAMC and a $5 co-pay for MinnesotaCare.

For families on MA there is a $3 office visit

co-pay for the parents, and no co-pay for MinnesotaCare. There are also co-pays on nonemergency use of the emergency room ranging from $6 to $50, and co-pays on prescription drugs of $1 for generic drugs and $3 for brand name drugs.

These co-payments will be very difficult for providers to collect from recipients, so in practicality this is a reimbursement cut. There is language in the bill that says the provider cannot deny services for patients who are unable to pay the co-payment, unless a clinic has a policy to not provide services to patients with uncollected debt and informs the patient of that prior to providing future services. ✦

HMS/RMS Exhibit at PriMed CME Conference HENNEPIN AND RAMSEY Medical Societ-

ies recently participated as an exhibitor at a local PriMed CME conference. HMS and RMS also served as a sponsor of the event and were asked to kick off the conference with some opening remarks.

Dr. Peter Daly, RMS president-elect opening the PriMed Conference.

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Peter Daly, M.D., president-elect of Ramsey Medical Society, provided welcoming words and also some key messages about the impact of organized medicine in Minnesota. Sue Schettle, director of marketing and member services for

Dr. Ben Chaska discusses a resolution with Sue Schettle, director of marketing and member services for RMS/HMS/MMA.

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HMS/RMS/MMA spoke with approximately 40 physicians who stopped by the exhibit. ✦

Sean Flood, M.D., Columbia Park Medical Group, Peter Daly, M.D., and Sam Seltz, M.D., East Metro Family Practice—Inver Grove Heights at the RMS/ HMS/MMA booth.

The Journal of the Hennepin and Ramsey Medical Societies

Advocates and Adversaries Childhood Immunization in the 21st Century

T

THE TRANSFORMATION of health and life

expectancy in the 20th century derived from multiple factors but none more important than childhood immunization. While the dreaded scourge of smallpox was completely eradicated by massive international immunization efforts, numerous other serious diseases were dramatically reduced. Mandatory universal childhood immunizations against diphtheria, pertussis, tetanus, measles, mumps, rubella, polio, H. influenzae type b, and hepatitis B have saved tens of thousands of lives. Minnesota will soon join the majority of states in requiring varicella and pneumococcal vaccines for all young Minnesota children, and further enhance their health and survival.

Despite the self-evident gains for child health and survival made possible by vaccines, a persistent strain of resistance to immunization persists in American culture. Its roots are found in the 19th century, when anti-vaccine sentiment was monothematic and directed against smallpox inoculation. Indeed, the frequency and severity of adverse events associated with smallpox vaccine raised considerable concern both in the public realm and in medical literature. The observation of waning vaccine immunity prompted vigorous debate over longterm efficacy in individuals and in society. Suspicion of vaccine constituents and physician motives compounded these concerns. As the United States now mobilizes against potential agents of bioterrorism, it again confronts the inadequacies and dangers of the antiquated vaccine, proceeding with a necessary but limited national smallpox immunization program.

Throughout the 20th century, a broadening of anti-vaccine activity accompanied the

BY RICHARD ANDERSEN, M.D.

MetroDoctors

widening number of vaccines. Diphtheria, tetanus, and to some extent, pertussis, were brought under control by mid-century. Adverse events from the whole-cell pertussis component were noted but did not become the focus of antivaccine sentiment until the final decades of the 20th century. Early in the second half-century, the injectable Salk (1955) and oral Sabin (1961) vaccines were dramatic breakthroughs in the fight against polio. They ended annual waves of fear of the summer plague, and were precursors of another worldwide eradication program. At the dawn of this triumph, however, there occurred the much-publicized 1955 Cutter incident, wherein over 250 cases of paralysis and 11 deaths resulted from inadequate inactivation of one lot of the new Salk vaccine. While it highlighted the shortcomings of the young science of virology, the episode did not derail vaccine production nor did it provide substantial or sustained opposition to immunization. Importantly, the American scientific community and general public acknowledged the tragedy of “friendly fire,” sought to understand its causation, and resumed vigorous immunization against polio.

The late 20th century saw more organized and vocal anti-vaccine activity, arguing particularly that the pertussis component of the DPT caused neurologic injury. Dissatisfied Parents Together, as a national organization, sought to highlight the dangers of DPT and was at the center of the DPT controversy. While subsequent analysis of DPT adverse events has suggested an unmasking of underlying disease rather than true causation, public apprehension and legal actions against manufacturers threatened vaccine production. Several countries suspended pertussis immunization, only to see increased cases and deaths from pertussis, prompting resumption of their pertussis vaccine

The Journal of the Hennepin and Ramsey Medical Societies

programs. In 1986, the United States, with the Vaccine Injury Compensation Act, created a special legal framework with a liberal and inclusive definition of vaccine injury, thus preempting convention litigation. It proved successful in providing an orderly system for adjudicating alleged vaccine injury and served as well to preserve vaccine production.

The advent of immunization against Hemophilus influenzae type b in the late 1980s brought with it the hope of curtailing the most important bacterial pathogen of infants and toddlers. Physicians in Minnesota and across America rapidly and almost universally utilized the Hib vaccine. The disappearance of Hib-related disease was unexpectedly rapid and complete as well. While nearly 250 Minnesota children encountered invasive Hib disease in 1988, only a single confirmed case occurred five years later in 1993.

Coincident with this stunning success, however, was the St. Paul-based measles outbreak of 1990, affecting hundreds of children and killing three—a reminder of the shortcomings of existing vaccine strategies.

Soon thereafter emerged for the first time substantial physician ambivalence toward a newly proposed universal infant vaccine. The failure of high-risk-oriented hepatitis B programs in the 1980s—targeting by occupation, sexual orientation, and intravenous drug use— led to this new public health consensus. While some physicians advocated redirecting hepatitis B vaccine efforts to adolescents, others more broadly objected that with so many injections “our babies are becoming pin-cushions.” After legislative mandates in Minnesota and elsewhere, compelling universal hepatitis B immunization, the debate proved evanescent.

(Continued on page 20)

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Immunization Controversy (Continued from page 19)

More sustained levels of physician ambivalence were manifest with the approval of the long-awaited varicella vaccine in 1995. Despite full endorsement by several national vaccine advisory bodies, physician advocacy was weaker than with any universal vaccine previously recommended. Many physicians echoed the parent presumption of the benign nature of chickenpox. Others, despite Japanese data to the contrary, expressed concern that waning vaccine immunity would predispose to foster or increase adult—and presumably more severe— chickenpox. In contrast to the Hib experience, less than half of eligible Minnesota children received timely varicella vaccine in the five years following its approval. Not until 2003—eight years after varicella vaccine approval—did it appear that mandatory immunization would become law in Minnesota.

In 1998, Wakefield et al. fueled parental and provider anxiety about immunization with an article postulating a linkage between the increasing diagnosis of childhood autism and the measles-mumps-rubella vaccine. The hypothesis gave rise to intensive, large-scale objective investigations, which found no evidence to support the association. Predictably, while physicians found reassurance in continuing MMR vaccine advocacy, some parental concerns lingered beyond the 1990s.

In assessing the landscape of the 21st century, then, one finds three new and troubling realities. First, physicians will now deal with the first whole parent generation in history with no personal or vicarious experience with polio or similar serious epidemic diseases, AIDS and SARS notwithstanding. The plagues that swept into American communities claiming tens of thousands of children are absent. Parental anxiety about vaccine safety thrives in such a milieu and is exacerbated by Internet misinformation and media misrepresentations. Few examples are as revealing as that of a recent Miss America, whose deafness arose following Hib meningitis in early childhood. Her story, which might have made her a virtual advertisement for the benefits of the Hib vaccine, instead became the subject of a very different front-page story when her mother announced soon after the Miss America pageant that vaccines had caused her deafness.

The MMR-autism association story offers 20

July/August 2003

insight into contemporary parents’ apprehensions. While the scientific discussion has subsided, parental concern over the MMR persists, enabled by the heterogeneity, diagnostic complexities and the idiopathic nature of autism.

Paradoxically, the Cutter incident of 1955 showed clear causation, serious vaccine injury or death, and remediation, and then provoked little long-term anti-vaccine sentiment. In striking contrast, the MMR-autism connection fills an intellectual and emotional void for some parents, despite the lack of proven causation, and provides an attractive alternative to any hypothesis relating to intrinsic attributes of the

The age of consumerism and high premium on patient/parent satisfaction may undermine physicians’ will to contend with parents who refuse to immunize. child or parent-child milieu. As such, the argument may persist for years. As the counter-argument relating to MMR and autism begins to prevail, we now witness the inevitable shifting of position—i.e. perhaps it is not the MMR but “all these shots together that overwhelm the immune system,” suggest vaccine opponents.

The second major new reality—the provider ambivalence seen with hepatitis B and varicella vaccine—may prove transient and vaccine-specific. The rapid embrace of the pediatric pneumococcal vaccine may be evidence of MetroDoctors

new provider clarity and resolve. But it is premature to conclude this, as it may only reflect an increased level of comfort with more familiar vaccine components, i.e. the adult pneumococcal vaccine. The age of consumerism and high premium on patient/parent satisfaction may undermine physicians’ will to contend with parents who refuse to immunize. Time constraints on every physician work against the detailed discussion and patience such encounters demand.

It is highly likely that the consequences of weak physician advocacy of the varicella vaccine will soon be evident. Specifically, by spending a full decade from vaccine approval to full vaccine utilization, an unnecessarily large number of individuals will enter adulthood without antibody because of lower exposure to wild-type virus, while not receiving the “optional” vaccine. The great irony which emerges is that providers who deferred or under-utilized varicella vaccine, fearing that waning immunity would later yield adult varicella, are creating precisely the situation they sought to avoid.

The third and relatively permanent reality of the new century is the threat of bioterrorism.

At present, anthrax and smallpox top the list of potential agents, but the complexities of both vaccines appear to preclude universal immunization. For the foreseeable future, the chief challenge to the scientific community is to unleash the remarkable technology available to develop better, safer vaccines to agents of terror, while continuing to pursue mainstream pediatric vaccine challenges such as respiratory syncytial virus and cytomegalovirus.

From a low point—the St. Paul-based measles outbreak of 1990—Minnesota has ascended to its present status of having the secondhighest childhood immunization rates in the United States. Going forward, Minnesota physicians can expect continued challenges to full immunization of children. Atavistic and naturalistic anti-vaccine arguments will persist. At the same time, biotechnology promises not only new vaccines but also refinement and continuing consolidation of existing vaccines. Whatever the competing trends in the larger society, Minnesota children will depend heavily on the vigorous and consistent assertion of vaccine merits by physicians and other health care providers. ✦ Richard Andersen, M.D., is an infectious disease/ pediatrics physician at Children’s Hospitals and Clinics.

The Journal of the Hennepin and Ramsey Medical Societies

PHYSICIAN'S SOAP BOX

Physician Leadership and Tobacco Reduction

I

IF SARS, OR SMALLPOX, or food borne illnesses, or motor vehicle

accidents were prematurely killing 400,000 Americans a year, the physician community would be mobilized in a second to combat these very important health threats to the public. If personal decisions like consuming alcohol or carrying a handgun were killing 50,000 to 60,000 innocent bystanders each year, again, the physician community would be up in arms (no pun intended) about “secondhand alcohol deaths” or “secondhand gunshot deaths.”

Then we come to tobacco. Tobacco is associated with 400,000 premature deaths each year in this country among tobacco users, including 125,000 lung cancer deaths. In light of its very poor prognosis, the only effective “treatment” for lung cancer is tobacco prevention.

Secondhand smoke causes the premature death of 50,000 to 60,000 people each year who have decided not to use tobacco products. In spite of these figures, the medical community continues to tolerate the harm tobacco does to the health of many of our patients and families. Why should this situation exist?

There are several plausible reasons why physicians have traditionally not been more active in tobacco reduction efforts, which include tobacco use prevention, tobacco cessation, and secondhand smoke reduction. These include: • Intense efforts on the part of tobacco companies to “normalize” tobacco use; • A well-organized “disinformation” campaign to discredit the scientific evidence regarding the harm caused by tobacco; • Lack of physician training in effective tobacco reduction; • Lack of resources for physicians and clinics to help in tobacco reduction; • The misconception that this is a “personal choice” issue and not a health issue; • Not knowing that up to 70 percent of current smokers want to quit, but would benefit from physician guidance to be successful; • No awareness that 90 percent of current adult smokers started before they were adults and unable to make a fully informed decision about using tobacco in the first place; and • No awareness that teenagers are highly targeted by the manufacturers of tobacco products.

Tobacco use is all about nicotine addiction. Cigarettes are nothing more than a “highly refined nicotine delivery system.” Our patients who

continue to use tobacco are, for the most part, addicted to nicotine and need our help to end this dependency. They most likely started using tobacco as a teenager, at a time when their developing neuropathways were more susceptible to the powerful influence of inhaled nicotine. For most smokers, tobacco use stopped being a “personal choice” a long time ago, and now they have to continue using it to prevent withdrawal symptoms.

A related issue is the harm caused by secondhand smoke. Tobacco is a complex mixture of 4,000 chemicals, including 200 toxins and 40 to 50 carcinogens. Eighty-five percent of the smoke generated by a given cigarette is released into the air around a smoker. While there is a dose-related effect, there is no “safe” level of secondhand smoke exposure—it is in the EPA’s “Class A Carcinogen” category.

Secondhand smoke exposure has a variety of health problems associated with it—heart disease, stroke, lung and other cancers, asthma, pneumonia, bronchitis, sinusitis, and otitis media. Prenatal exposure to tobacco smoke leads to prematurity, low birth weight, the subsequent development of asthma, and infants subsequently dying of SIDS. In this regard, 2001 marked the first year when tobacco-related SIDS deaths equaled the number of childhood motor vehicle deaths— both about 2,500 infants.

What is needed now is for physicians to “step up to the plate” and lead efforts to reduce tobacco use and secondhand smoke exposure in the Twin Cities. This starts with first leading efforts in your own clinic with all your patients, regardless of age. It then extends to leading efforts in your community. This may mean placing one or two calls or e-mails to your city council members or supporting local groups that are working on tobacco reduction. A number of communities have begun the process of considering ordinances for smoke-free restaurants and other workplaces. These initiatives have stalled for the most part. New physician engagement would go a long way to reinvigorate these efforts.

In terms of leading efforts at the state level, it is extremely easy to e-mail your state senator and representative on issues related to tobacco reduction such as the $1 tobacco tax increase that was considered during the most recent session. A relatively small number of physicians are needed to be on the “front line,” interfacing with the media, testifying at city council meetings, writing letters to the editor and other similar activities. For these physicians, the importance of this issue is compelling enough for them to leave the safety and security of their clinic settings.

BY PETER DEHNEL, M.D., A l l A b o u t C h i l d r e n P e d i a t r i c s , P. A . , a n d M e d i c a l D i r e c t o r, C h i l d r e n ’s P h y s i c i a n N e t w o r k

(Continued on page 22)

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The Journal of the Hennepin and Ramsey Medical Societies

21

Do you need support treating patients with eating disorders? We can help.

The Eating Disorders Institute (EDI) offers residential, inpatient, partial-day and intensive outpatient programs in a newly expanded space. EDI is a partnership with Methodist Hospital and University of Minnesota physicians.

Call for information — 952-993-6200 6490 Excelsior Blvd.

St. Louis Park, MN 55426 www.parknicollet.com

Soapbox (Continued from page 21)

There are numerous groups, resources and organizations that can help practitioners lead their office-based tobacco cessation efforts. The U.S. Public Health Services’ “Treating Tobacco Use and Dependency” is an evidence-based approach to tobacco cessation, and is available to all physicians free of charge. MPAAT’s (Minnesota Partnership for Action Against Tobacco) Helpline (1-877-270-STOP) can direct smokers to telephone-based resources for tobacco cessation. Each of the health plans have their own resources for helping subscribers reduce and stop their tobacco use. Cessation treatment is neither easy nor quick, and physicians need to approach it like you would manage any other long-term or chronic condition.

Tobacco is first and foremost a health issue, and physicians are the logical candidates for leadership in the efforts to reduce the harm caused by tobacco. Please decide what your “next steps” will be in terms of leading efforts in your clinic and/or community. If you are looking for opportunities for involvement or resources to carry this out, please contact me at 612-8138098 or e-mail peter.dehnel@childrenshc.org. ✦

Membership Advantages for Metropolitan Physicians and their Practices Medical Garments and Supplies — Are you unhappy with your current medical garment rental or cleaning service?

Are you looking at other options? Try AmeriPride Linen and Apparel Services. AmeriPride is a local company serving physicians in and around the Twin Cities area.

HMS and RMS have negotiated a discounted pricing structure for our members. For a free price quote, contact Steve Severson from AmeriPride at 612-362-0334.

OSHA Compliance Training — Almost every medical office setting has OSHA requirements that they must adhere to. Staff need to be trained, education needs to be provided. We recently partnered with SafeAssure to supply our members and their staffs with OSHA compliance training at a discounted rate. To learn more, contact HMS/RMS at 612-623-2889.

Coffee Service — If you are looking for a competent, reliable coffee vendor, you can’t go wrong with Berry Coffee Service. HMS and RMS have negotiated up to a 25% discount on their products and services for our members. To receive a free price quote, contact Bob Dilly from Berry Coffee at (952) 937-8697.

On-line Educational Tools — AchievMed has partnered with HMS and RMS to offer our physicians and their clinic administrators with on-line educational tools at a discounted rate. AchievMed offers assistance with strategic planning, marketing, communications, human resource management and financial management. To learn more, simply click on their website at www.achievmed.com.

Call HMS or RMS at 612-623-2889 for details.

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The Journal of the Hennepin and Ramsey Medical Societies

Minnesota’s New Conceal-Carry Act: What Every Medical Facility Needs to Know

Introduction On April 28, 2003, Governor Tim Pawlenty signed into law the Minnesota Citizens’ Personal Protection Act of 2003 (“Act” or the “ConcealCarry Act”). The Act, which went into effect on May 28, 2003, permits individuals to conceal and carry firearms so long as they obtain a permit to carry from an appropriate county sheriff. An individual typically will be granted a permit if he/she: 1) is trained in firearm safety; 2) is 21 years of age or older and a citizen (or permanent resident) of the United States; 3) completes a conceal and carry application; 4) is not prohibited from carrying a concealed gun; and 5) is not on the criminal gang investigative data system.

The Conceal-Carry Act affects all private businesses, including clinics, hospitals, and other health care facilities (collectively, “medical facilities”) across Minnesota. Indeed, absent affirmative steps by each medical facility to prohibit persons, including employees, from possessing or concealing firearms on the facility’s premises, individuals who obtain a permit will have the unrestricted right to possess and conceal firearms on that facility’s premises beginning on May 28, 2003.

This article provides a general overview of the requirements of the new Conceal-Carry Act and addresses how public and private medical facilities may restrict the possession and concealment of firearms on their premises by their employees and other individuals. In addition, it summarizes the sanctions/penalties applicable to individuals who violate firearm policies.

Public vs. Private Medical Facilities Private Medical Facilities The Conceal-Carry Act permits “private establishments” to prohibit persons from bringing firearms into an establishment’s building. A “private establishment” is essentially any building that is owned, leased, controlled, or operated by a nongovernmental entity for a nongovernmental purpose. A private establishment would, therefore, include private medical facilities such as for-profit and private nonprofit clinics and hospitals that own their facilities or lease their facilities from a public or non-public entity.

The Act allows private medical facilities, acting in their capacity as employer, to implement a policy prohibiting their employees from possessing and concealing firearms while “acting in the course and scope of employment.”

This means that a private medical facility may prohibit the carrying and concealment of firearms by its employees both on its premises and away from the premises so long as the employees are performing employment-related functions. However, the Act expressly prohibits a private establishment from restricting an employee’s ability to possess or conceal a firearm in a “parking facility or parking area.” Thus, employees may possess and conceal firearms in their cars when they are on their employer’s parking property. The Act allows employers to impose “employment related civil sanctions…for a violation” of the employer’s firearms policy.

B Y S U S A N E . E L L I N G S TA D , J . D . , H E N R I G . M I N E T T E , J . D . , M . P. H . , AND CHRISTINA RICH, J.D.

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The Journal of the Hennepin and Ramsey Medical Societies

If a private medical facility wishes to prohibit other persons, such as vendors, patients, and visitors, as well as employees, from bringing firearms into its building, the facility must post a sign within four feet laterally of each entrance of its building with the following language: “[Insert Name] BANS GUNS IN THESE PREMISES.” The bottom of the sign must be four to six feet from the floor. The lettering must be in black arial typeface that is at (Continued on page 24)

WEBER

LAW OFFICE Focusing on the legal needs of the health professional!

• Licensure

• Employment Law

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Michael J. Weber, J.D. • Former Attorney for the Board of Medical Practice • Over Six Years as an

612-296-8080 www.weber-law.com “Committed to the Best Legal Outcome Possible Through Diligence and Resourcefulness!”

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23

Conceal-Carry Act (Continued from page 23)

least one-and-one-half inches in height. The background of the sign must be bright contrast with the typeface, and must also be 187 square inches in area.

If an individual disregards the sign and enters the facility with a concealed firearm, the facility must personally inform the individual of the facility’s gun ban and demand that the individual comply with the policy. If the individual does not comply after these steps are taken, the individual will be guilty of a petty misdemeanor trespass violation for remaining on the facility’s premises and would be subject to a $25 fine.

An argument could be made that private establishments may effectively restrict employees from carrying guns into the workplace by enacting a policy in lieu of the posting described above. However, to ensure that the prohibition applies to non-employees entering the premises as well, the safer course is to post a notice and enact a policy prohibiting employees from carrying weapons in the course and scope of their employment.

Public Medical Facilities The Conceal-Carry Act does not appear to afford public establishments the same ability to prohibit the possession and concealment of firearms on their premises as it does private establishments. The Act also does not provide a special prohibition of firearms and weapons for medical facilities as it does for schools, for example. Accordingly, unlike a private medical facility, a public medical facility may only prohibit its employees from possessing or concealing firearms on its premises or in the scope of employment by enacting a policy. The Act does not allow a public entity to prohibit individuals who are not employees and who properly possess a permit to carry, possess, or conceal a firearm on the public entity’s premises.

If a public medical facility wishes to ban the carrying and concealment of firearms on its property, it should first determine whether it is a private establishment for purposes of the statute. For example, a for-profit or a private nonprofit clinic that leases property from a government entity most likely still qualifies as a private medical facility, despite the fact that the lease arrangement may suggest otherwise. Ac24

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cording to floor debate comments by Senator Pariseau, chief author of the Act, a private business that leases a facility from a public entity, such as a public stadium, can demand a posting of a gun-ban sign for its event. A private clinic that leases a building from a public entity could, therefore, preclude employees and outside individuals from carrying firearms on the facility’s premises. A public medical facility, on the other hand, may only prohibit its employees from possessing and concealing firearms, not outside individuals, including patients.

Sample Employment Policy [INSERT NAME] strictly prohibits the possession or concealment of firearms by its employees on [INSERT NAME]’s premises and elsewhere while the employee is acting within the course and scope of employment. Any employee or other person who possesses or conceals a firearm on [INSERT NAME]’s premises shall be asked to leave the premises. Refusal to comply with [INSERT NAME]’s request to leave could result in criminal sanctions, including a petty misdemeanor trespass charge. Additionally, a [INSERT NAME] employee who violates this policy shall be subject to disciplinary action up to and including termination.

Conclusion If a medical facility wishes to prevent or at least limit the extent to which individuals can carry firearms onto the premises, both private and public medical facilities should enact a policy prohibiting their employees from carrying firearms both on the premises or anywhere if they are acting within the scope of their job. In addition, private medical facilities should post signs as described above to restrict facility vendors, patients, and visitors from entering the premises with a concealed firearm. ✦ Disclaimer: This information is provided as a general educational resource and is not intended and should not be construed as legal advice specific to any situation.

Susan E. Ellingstad, J.D. and Henri G. Minette, J.D., M.P.H., are with Lockridge Grindal Nauen P.L.L.P., and Christina Rich, J.D. is director, department of health law for the Minnesota Medical Association.

The Journal of the Hennepin and Ramsey Medical Societies

PRESIDENT’S MESSAGE J . M I C H A E L G O N Z A L E Z - C A M P O Y, M . D . , P h . D .

Errors and the Practice of Medicine RMS-Officers

RMS-Board Members

Victor S. Cox, M.D., Specialty Director Gretchen S. Crary, M.D., At-Large Director Laura A. Dean, M.D., At-Large Director James J. Jordan, M.D., Specialty Director Robert V. Knowlan, M.D., At-Large Director Bradley C. Linden, M.D., Resident Physician Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Robert C. Moravec, M.D., At-Large Director Jane C. Pederson, M.D., M.S., Specialty Director Lon B. Peterson, M.D., At-Large Director Thomas D. Siefferman, M.D., Specialty Director Stephanie D. Stanton, Medical Student Lyle J. Swenson, M.D., MMA Trustee Charles G. Terzian, M.D., Specialty Director & MMA Trustee David C. Thorson, M.D., Specialty Director Peter B. Wilton, M.D., At-Large Director RMS-Ex-Officio Board Members & Council Chairs

Brent R. Asplin, M.D., AMA Young Physician Section Blanton Bessinger, M.D., AMA Alternate Delegate John M. Brown, M.D., Sr. Physicians Association President Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., Ethics & Professionalism Council Chair *J. Michael Gonzalez-Campoy, M.D., Ph.D. Education Resource Council Chair Rebecca Gonzalez-Campoy, Alliance President Frank J. Indihar, M.D., AMA Delegate Neal R. Holtan, M.D., Community Health Council Chair William E. Jacott, M.D., U of MN Representative Melanie Sullivan, Clinic Administrator *Lyle J. Swenson, M.D., Public Policy Council Chair *Also elected RMS Board Member RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Doreen M. Hines, Membership & Web Site Coordinator Sue Schettle, Director of Marketing & Member Services

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FIRST DO NO HARM. This is part of the oath we all take as physicians. It implies that we will intervene in the illness that is affecting our individual patient.

Patients get sick, and patients die. Physicians can treat everyone, but can cure only some.

The recognition of disease, the timing of interventions, and the choice of treatments all play a role in the final outcome of individual patients.

Two years ago, Dr. Robert Moravec highlighted in his inaugural address as Ramsey Medical Society president, that in the management of patients there are many opportunities for inefficiencies. When omissions, delays, or mistakes happen, and patient care is suboptimal, are we still doing no harm?

To err is human, to forgive is divine!

This issue of MetroDoctors deals with medical errors. Physicians, like everyone else, make mistakes in their professional work. Sometimes they are trivial, and no harm is done. Sometimes errors have dire consequences and result in major events, including death. This issue serves as a reminder to us all that, when it comes to patient care, we frequently have a very small margin of error. We cannot allow ourselves to be arrogant when it comes to the implementation of checks that lead to improved patient safety. Frankly, we can use all the help we can get!

My son, David, has become a major hockey fan. This comes from spending hours on skates, with a stick in his hand. He plays it, he watches it, he seeks it. We were watching a Mighty Ducks movie together, and a speech by a coach in the film caught my ear: “It’s easy to play when you have control of the puck. It is much harder to play when you don’t—it requires confidence.”

What happens to our colleagues when a mistake is made? The hockey game is now being played without control of the puck. The only way to overcome an incident like this is to have confidence that the rest of us support them, and that the practice of medicine will continue to provide the rewards that it should. There is nothing more devastating than the realization that a bad outcome could have been different, and that the “puck” stops with the physician. The only

The Journal of the Hennepin and Ramsey Medical Societies

people who look forward to situations like these are lawyers, who in the name of “justice” use the patient for tremendous personal gain.

Lawyers are driving doctors out of their practices. The malpractice insurance rates for some specialties in some parts of the country are unaffordable. Tort reform seems like the only reasonable solution for this problem. Locally, we are fortunate. Minnesota physicians are selfinsured, and the high quality of care we provide has allowed our premiums to remain affordable.

Yet, we are only human, and sooner or later we each will be touched by a medical error in our practice.

Moving forward, our Ramsey Medical Society remains committed to support all physicians regardless of their practice environment.

Advocacy for the profession involves improving the environment we work in, and removing extraneous factors that distract us from the practice of medicine. Allowing physicians to do what they were trained for—treating patients—will surely decrease errors.

The legislative session this year left us feeling like we are playing hockey without possession of the puck. Our Joint Contracting Coalition Bill failed. This means Health Plans will continue to abuse their power in contracting with physicians and other providers. Our efforts to derail legislation granting optometrists full prescribing rights were only partially successful. Optometrists now may write for certain medications, without the training that we, as physicians, require. The current Governor, who our own MMA-MEDPAC endorsed, has been unsympathetic to our pleas not to burden patient care. The provider tax will be going back to 2 percent. We are playing without the puck.

So let’s remain confident. The Ramsey Medical Society is a team that needs your support. Please join in the effort for physician advocacy, as this game continues to be played out. ✦

July/August 2003

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Ramsey Medical Society

President J. Michael Gonzalez-Campoy, M.D., Ph.D. President-Elect Peter J. Daly, M.D. Past President Peter H. Kelly, M.D. Secretary Jamie D. Santilli, M.D. Treasurer Charles E. Crutchfield III, MMB, M.D.

New Members RMS welcomes these new members to the Society.

Schools listed indicate the institution where the medical degree was received.

Active Ramalingam Arumugam, M.D. Pediatric Gastroenterology Minnesota Gastroenterology, P.A. Omar Essam Awad, M.D. University of Minnesota Ophthalmology Lufkin Eye Clinic Lawrence D. Callanan, Jr., M.D. Duke University Internal Medicine Allina Medical Clinic - Internal Medical Specialties Joshua B. Colton, M.D. University of Minnesota Gastroenterology/Internal Medicine Minnesota Gastroenterology, P.A.

Vijay R. Eyunni, M.D. Kasturba Medical College, India Occupational Medicine Minnesota Occupational Health

Alexandra L. Muschenheim, M.D. University of Minnesota Diagnostic Radiology St. Paul Radiology, P.A.

Amy L. Gilbert, M.D. Northwestern University Family Practice Family Tree Clinic

Irfan K. Sandozi, M.D. Gandhi Medical College Gastroenterology/Internal Medicine Minnesota Gastroenterology, P.A.

Lael M. Luedtke, M.D. University of Minnesota Pediatric Orthopaedic Surgery Gillette Children’s Hospital

Paul T. Yellin, M.D. Howard University College of Medicine Orthopedic Surgery Summit Orthopedics

Robert D. Mackie, M.D. University of Minnesota Gastroenterology/Internal Medicine Minnesota Gastroenterology, P.A.

1st Year Practice Christopher W. Luhman, M.D. University of Minnesota Family Practice Rosedale Medical Center

Michael P. McGrail Jr., MPH, M.D. University of Minnesota Occupational Medicine/Toxicology/Family Practice HealthPartners, Regions Hospital Bronagh P. Murphy, M.D. University of Dublin, Ireland Oncology Minnesota Oncology Hematology, P.A.

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July/August 2003

1185 Town Centre Drive Suite 101 Eagan, MN 55123

Appointments 651-209-3600 Prompt Appointments via Physician Requests

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Medical Student (University of Minnesota)

Scott A. Bentz Jason D. Byers Aaron J. Crowser Brad D. Hilger Chris H. Jokinen Matthew J. Mouser Benjamin D. Nelson Sonja A. Uselman ✦

In Memoriam WERNER W. AMERONGEN, M.D., died at the age of 85 on May 3, 2003. He graduated from the University of Minnesota Medical School in 1946. Dr. Amerongen was a family practice physician at St. Joseph’s and Bethesda hospitals. He joined RMS in 1950.

NEIL M. PALM, M.D., died May 3, 2003 at the age of 81. Dr. Palm served in WWII as an A-20 Army Air Corps pilot. He graduated from the University of Minnesota Medical School in 1940 followed by his surgical residency at the VA Hospital in 1955. Dr. Palm was a Board Certified Surgeon and practiced in the Lowry Building for 28 years.

He completed his medical practice at the VA for 11 years before retiring at the age of 70.

Dr. Palm was a lead physician in the merger of Miller and St. Luke’s hospitals into United Hospital. He joined RMS in 1957. ✦ The Journal of the Hennepin and Ramsey Medical Societies

R M S U P DAT E

RMS Leadership Meets with Betty McCollum ON FRIDAY, MAY 2 several members of the

RMS leadership met with Congresswoman Betty McCollum of the Fourth District to dis-

cuss Medicare medical liability problems, and other national issues. Representative McCollum has been meeting regularly with RMS leader-

Ramsey Medical Society

From left: Peter Daly, M.D., J. Michael Gonzalez-Campoy, M.D., Ph.D., Congresswoman Betty McCollum, Charles Terzian, M.D., Robert Geist, M.D., and Roger Johnson, RMS CEO.

ship to provide an exchange of ideas and insights regarding health care. âœŚ

Congresswoman Betty McCollum (far left) and her staff person Katie Delmore (center) address a question presented by Dr. Charles Terzian (second from right).

Dr. Asplin Addresses RMS Board DR. BRENT ASPLIN, ER Regions Hospital

and HealthPartners Research Foundation, gave an excellent presentation on the state budget crisis to the RMS Board of Directors on Tuesday, May 13 at United Hospital. His presentation included the implications for physicians and

hospitals that the proposed cuts in the state budget for health and human services would create. At that time, the Minnesota Legislature continued to debate the provisions of the 700 page Omnibus Health and Human Services Appropriations bill. Please refer to page 18 for a

RMS Board members are being updated on the state budget crisis by Dr. Brent Asplin.

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The Journal of the Hennepin and Ramsey Medical Societies

summary of the Health and Human Services bill provided by the Minnesota Medical Association in a Legislative Update. âœŚ

Brent Asplin, M.D. addressing RMS Board Members on the state budget crisis.

July/August 2003

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RMS ALLIANCE NEWS REBECCA GONZALEZ-CAMPOY

Making a Difference

L

LET ME INTRODUCE YOU to a new mem-

ber of Ramsey Medical Society Alliance, Laura Richardson. Her story reflects perfectly how organized medicine and its Alliance can, and should, work to be at its most effective.

It all started last August 18, the day Laura’s son, Cole, died from a rare form of cancer at the age of 13. He was an incredible son, nephew, grandson, and friend. He died with courage and inspiration for us all. Laura wanted to keep Cole’s memory alive and, at the same time, help families who face the same devastating tragedy she and her husband, Bruce, experienced. (A family physician, Bruce is a member of the Ramsey Medical Society.) After consulting with many friends and family, Laura established the Cole Richardson Trust for Pediatric Oncology in March of this year.

A five physician, independentlyowned, primary care clinic, established in the 60 s, is seeking a full-time physician to assume the practice of a departing doctor.

Please contact:

Cami Swanson

Southdale Internal Medicine, P.A. 6545 France Ave. S., Suite 225 Edina, MN 55435

952-927-7079

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July/August 2003

The goals of the Trust are to: Help parents stay home with their dying children; • Fund pediatric oncology awareness in the Twin Cities; • Fund pediatric sarcoma research; and • Establish a scholarship at St. Joseph’s Catholic School in West St. Paul.

First, Laura wanted to raise money to buy a statue in memory of Cole to place by the Virgin Mary at the Catholic Church of St. Joseph’s in West St. Paul—where Cole attended school and Laura created and taught the Spanish program. Cole’s brother, Conor, is still part of this school community. She also wanted to host a black tie gala, complete with silent auction, dinner and live entertainment. And she wanted to accomplish all this between March and the end of May 2003.

Not only did Laura’s banker look at her askance, but also so did a dear friend who is a veteran fund-raiser for St. Joe’s. They assured Laura she couldn’t possibly pull these events off in such a short time. However, she did. Here’s how.

Laura and a circle of friends get together every Thursday and put their love of beading to work creating bookmarks in all colors and designs. They sell them to friends who take some and sell to their friends. To date, they’ve made hundreds of bookmarks and have raised more than $5,000 in the process. This money more than covered the cost of the statue for St. Joe’s.

When someone is diagnosed with cancer— or worse yet, dies from the disease—people want to help, but often don’t know what to do. People were eager to help Laura plan for the gala held May 30 at the Wabasha Caves in St. Paul. Finally, they could do something.

Each one of us brought different skills and connections to the table, which led to unbelievable success—results that came from true grassroots efforts.

Friends and neighbors contributed 60 plus baskets full of top quality stuff, ranging from garden equipment to baby blankets, from office supplies to golf clubs. Local businesses also •

MetroDoctors

provided donations. So did the Wild—which isn’t so amazing, but the story around their gift is.

The Wild sent Laura a signed hockey stick for the silent auction. However, she couldn’t identify the signature on the stick. Laura remembered she had a program signed by the team President and COO when he had visited with Cole at Children’s Hospital in St. Paul. Laura called the number on the program, thinking she’d get his secretary. Turns out she got Todd Leiweke directly. Unfazed, Laura explained who she was and why she had called and he remembered Cole. Todd shared a moving story about experiencing the impact of cancer in his own family and promised to play a key role not only in this fund-raiser but also in the years to come.

Combined, the events Laura and her cadre staged raised at least $22,500 after expenses. Not bad for the first time out.

I’m also pleased to say the first recipient of funds from the Cole Richardson Trust is Spare Key of South St. Paul, an organization dedicated to providing parents with mortgage or rent payments, allowing them to take time from work to be with their terminally ill children. RMSA raised about $20,000 for this worthy group two years ago. This connection was one of the few I could provide Laura.

Laura did what RMSA as a whole needs to do more often. She brought together the talents of many whom then had fun while working on an important cause. She didn’t lose sight of her vision, nor did naysayers sidetrack her. In the end, she made a difference.

For more information about CRT, contact Laura Richardson at 651-552-8614. Contact the University of Minnesota Cancer Center at www.cancer.umn.edu for more information about pediatric sarcoma. ✦

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT T. M I C H A E L T E D F O R D , M . D .

Creating a Better Healthcare System

W

WHEN I READ THE COLLEAGUE Interview

Chair T. Michael Tedford, M.D. President Michael B. Ainslie, M.D. President-elect Michael B. Belzer, M.D. Secretary James F. Peters, M.D. Treasurer Paul A. Kettler, M.D. Acting Past Chair Virginia R. Lupo, M.D.

with Dr. Maureen Reed in last month’s issue of MetroDoctors I wanted to cheer. How fortunate we are to have Dr. Reed exercising physician leadership in our state. Years ago a friend, one of the staff physicians at the Fremont Community Clinic, told me that Dr. Reed’s work there is not a token gesture by an administrative physician to dabble in clinical medicine. If she is in town, she is in the clinic seeing patients according to the schedule. We have a committed, sensitive, intelligent, insightful physician leading one of the major healthcare organizations in our state as well as holding the highest governance position at the University of Minnesota. And she is using the Institute of Medicine’s template to create a better healthcare system for the 21st century.

HMS, RMS, and the MMA have faced major setbacks in the recent legislative session.

The legislature: passed a state budget that will create more uninsured by restricting eligibility to state-funded healthcare; failed to pass our very important Fair Contracting bill; and passed a law that significantly compromises the safety of Minnesotans by expanding the scope of practice for optometrists. Even so, with leaders like Dr. Reed, other colleagues interviewed in every issue of MetroDoctors, and the rest of us inside and outside organized medicine working with the Institute of Medicine’s aims for improvement and rules for redesign, the profession and our patients will benefit from a better healthcare system.

Six specific aims for improvement built around the core need for healthcare are to be: • Safe: avoiding injuries to patients from the care that is intended to help them.

• Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.

• Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

HMS-Board Members

Eric G. Christianson, M.D. Peter J. Dehnel, M.D. Drew Dietz, Medical Student Donald M. Jacobs, M.D. Jan Musich, Alliance President Ronald D. Osborn, D.O. James A. Rohde, M.D. Edwin H. Ryan, M.D. David F. Ruebeck, M.D. Richard D. Schmidt, M.D. Michael G. Thurmes, M.D. D. Clark Tungseth, M.D. Michael J. Walker, M.D. HMS-Ex-Officio Board Members

Roger W. Becklund, M.D., Senior Physicians Association Lee H. Beecher, M.D., MMA-Trustee Carl E. Burkland, M.D., Member-at-Large Karen K. Dickson, M.D., MMA-Trustee David L. Estrin, M.D., MMA-Trustee John W. Larsen, M.D., MMA-Trustee Henry T. Smith, M.D., MMA-Trustee David W. Allen, Jr., MMGMA Rep. HMS-Executive Staff

Jack G. Davis, Chief Executive Officer Kathy R. Dittmer, Executive Assistant Sue Schettle, Director, Marketing & Member Services

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The Journal of the Hennepin and Ramsey Medical Societies

• Timely: reducing waits and sometimes harmful delays to both those who receive and those who give care.

• Efficient: avoiding waste, including waste of equipment, supplies, ideas and energy.

• Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

The Institute of Medicine formulated a set of 10 simple rules, or general principles, to inform efforts to redesign the health system. These rules are: 1. Care is based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This implies that the health-care system must be responsive at all times and access to care should be provided over the Internet, by telephone, and by other means in addition to in person visits.

2. Care is customized according to the patient needs and values. The system should be designed to meet the most common types of needs but should have the capability to respond to individual patient choices and preferences.

3. The patient is the source of control. Patients should be given the necessary information and opportunity to exercise the degree of control they choose over healthcare decisions that affect them. The system should be able to accommodate differences in patient preferences and encourage shared decision making.

4. Knowledge is shared information flows freely. Patients should have unfettered access to their own medical information and clinical knowledge. Clinicians and patients (Continued on page 30)

July/August 2003

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Hennepin Medical Society

HMS-Officers

Chair’s Report (Continued from page 29)

should communicate effectively and share information.

5. Decision making is evidence based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

6. Safety is a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

7. Transparency is necessary. The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice or when choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence based practice, and patient satisfaction.

8. Needs are anticipated. The system should anticipate patient needs, rather than simply react to events.

9. Waste is continuously decreased. The system should not waste resources or patient time.

10. Cooperation among clinicians is a priority.

Clinicians and institutions should actively collaborate and communicate to insure an appropriate exchange of information and coordination of care.

HMS, collaborating with RMS, created an Advocacy Committee to “support the missions of HMS and RMS and coordinate legislative and public affairs activities of the MMA, HMS, and RMS.” The Advocacy Committee is comprised of members of the executive committees of HMS and RMS and the representatives from the two societies who sit on the MMA Legislative and Practice & Planning Committees. This group coordinates the work of all three societies and moves more action to a grassroots level with the membership.

In Minnesota, organized medicine’s mechanism for the widest sharing of new ideas and discussion to improve the health care system is the MMA House of Delegates. Members throughout the state submit resolutions through the county societies to guide MMA 30

July/August 2003

Thomas W. and Mary Kay Hoban Scholarship Educational Event HMS MEMBERS established the Thomas W. and Mary Kay Hoban Scholarship in 1994 in recognition of Tom and Mary Kay’s 25 years of involvement with the Hennepin Medical Society. Each year through the Hennepin Medical Foundation, scholarships are awarded to applicants who are pursuing graduate level education in health care management/administration and applicants in graduate level education in nutrition. Since 1995, the Scholarship Committee has awarded 38 scholarships totaling $110,500.

As part of the commitment, the scholarship award winners are asked to participate in an

educational forum where they can describe a project or a paper they prepared as part of their studies. Hoban Scholars Hez Obermark with classmates Matthew Hedtke and Pramoda Ramachandra and Ben Nielsen each made informative presentations. Mark Fisher, CEO of Minnesota Healthcare Network provided a keynote presentation examining medical group decision-making. Included in the event was a special presentation by the winning team in the CLARION Interdisciplinary Case Competition held at the University of Minnesota Academic Health Center. ✦

Pictured from left are: Ben Nielsen, Hoban Scholar; H. Thomas Blum, M.D., Chair of the Hoban Scholarship Committee; Thomas W. Hoban; Mark Fisher; Clarion team members Leslie Carranza and Christine Platt; Hez Obermark, Hoban Scholar; and Mary Kay Hoban.

policy and major projects, the resolutions are discussed in reference committees, in personal conversations in hallways, over dinner socializing with friends, and ultimately on the floor of the House of Delegates, where they are adopted, not adopted, or referred to the MMA Board for further consideration. This year the MMA Annual Meeting will be held September 17-19 in Rochester. Do you face daily frustrations deliv-

ering care to your patients? Is there something HMS, RMS, and the MMA can do in their work at the legislature or in the regular meetings with the plans that would help you and your patients? Attending the annual meeting is a first step to guide the use of our resources, as Dr. Reed has shown us with the aims and rules of the Institute of Medicine, to create a better healthcare system for this century. ✦

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

HMS NEWS

New Members HMS welcomes these new members to the Society. Schools listed indicate the institution where the medical degree was received.

Juan C. Angelats, M.D. University of Illinois College of Medicine Obstetrics & Gynecology Haislet, Wavrin, Wright, Lehrman & Associates, P.A. Ronald M. Bateman, D.O. University of Osteopathic Medicine and Health Sciences, Des Moines Physical Medicine & Rehabilitation Ronald M. Bateman, D.O., P.A. Roger A. Clausnitzer, M.D. University of Minnesota Medical School Anesthesiology Metropolitan Anesthesia Edward P. Ehlinger, M.D., MSPH University of Wisconsin Medical School Pediatrics University of Minnesota Boynton Health Service Thomas C. Guyn, M.D. University of Rome, Faculty of Medicine and Surgery Internal Medicine North Memorial Clinic- Elk River Physicians Craig R. Hildahl, M.D. University of Manitoba Faculty of Medicine Family Practice Quello Clinic, Ltd. Carol J. Nelson, M.D. Washington University School of Medicine Family Practice University of Minnesota Boynton Health Service MetroDoctors

Pamela R. Rath, M.D. State University of New York at Buffalo School of Medicine Ophthalmology University of Minnesota Scott Thomas Schaefer, M.D. University of Minnesota Medical School Ophthalmology Columbia Park Medical Group-Andover Clinic Cynthia A. Sherman, M.D. Yale University of School of Medicine Gastroenterology Minnesota Gastroenterology, P.A. - West Metro Division

Resident Vincent J. Gimino, M.D. Albany Medical College of Union University Internal Medicine University of Minnesota Physicians Kenneth Reed McMillan, M.D. Wayne State University School of Medicine General Surgery American Indian Housing & Community Development Corp.

Student Transfer to HMS Jason Rogness Bisping University of Minnesota Medical School, Duluth ✦

In Memoriam LAURA BIGLOW, M.D., died May 4. She was 43. She graduated from the University of Minnesota Medical School in 1985 and completed an internship at HCMC. She practiced family and emergency room medicine at the U.S. army base in Frankfurt, Germany for three years. Upon returning to the U.S., she worked as a medical writer for 3M with aspirations for involvement in further medical research. She joined HMS in 1998.

The Journal of the Hennepin and Ramsey Medical Societies

HEINRICH K. BRUCKER, M.D., died April 16 at the age of 63. He graduated from Medizinische Fakultaet Eberhard Karls Universitaet Tubingen Germany. He was an HMS member from 1979-1996.

DONALD D. ETZWILER, M.D., a pediatric endocrinologist, died April 6. He was 76. He graduated from Yale Medical School. Dr. Etzwiler was known around the world for helping to revolutionize the treatment of Type I, child-onset diabetes. He advocated for an approach that taught patients how to do selfmanagement—a revolutionary concept 35 years ago. In 1967, he founded what would later become the International Diabetes Center at Park Nicollet Clinic. In 2000, he received the Shotwell Award. Dr. Etzwiler traveled around the world teaching medical professionals about diabetes, and established about 60 diabetes care programs around the world. For 25 years he served as medical director of Camp Needlepoint, a summer camp for children with diabetes in Hudson,Wis. Dr. Etzwiler joined HMS in 1958.

B.J. KENNEDY, M.D., an internationally known oncologist, died April 6 at the age of 81.

He graduated from the University of Minnesota Medical School and completed an internship at Massachusetts General Hospital. In 1968, he founded the Division of Medical Oncology at the U of M, which he led until his retirement in 1991. He made significant contributions to the medical management of cancers, and received many awards for his efforts including: the 1996 HMS Charles Bolles Bolles-Rogers Award, and the 1996 Medal of Honor in Clinical Research from the American Cancer Society. In his honor, the University of Minnesota Medical Foundation established the B.J. Kennedy Lectureship in Oncology, the B.J. Kennedy Oncology Scholarships, and the B.J. Kennedy Chair in Medical Oncology. Dr. Kennedy joined HMS in 1957.

DANIEL J. MOOS, M.D., died February 20.

He was 87. He graduated from the University of Minnesota Medical School.

ALBERT WALONICK, M.D., died in May at the age of 77. He graduated from the University of Minnesota Medical School. He was a U.S. Navy veteran of WWII. He was a general practitioner for 16 years and a urologist for 17 years. Dr. Walonick joined HMS in 1951. ✦ July/August 2003

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Hennepin Medical Society

Active Allyson R. Ambrose, M.D. University of Maryland School of Medicine Family Practice Hennepin Care South

Deborah E. Powell, M.D. Tufts University School of Medicine Administration Dean, University of Minnesota Medical School

HMS ALLIANCE NEWS JANICE B. MUSICH

Meeting the Challenges of the Alliance

S

SOON AFTER THE LADIES Auxiliary to the Hennepin County Medical Society was founded in 1910, the group was providing pajamas for patients in local tuberculosis sanatoriums. This spring, more than 2,400 third-graders participated in the Alliance’s 20th Body Works. For almost a century the priorities of community, advocacy, responsiveness, education, and service have been the hallmarks of this group! I would like to praise our recent group of leaders who have been tireless to exceed all expectations in the quality and breadth of the work that represents the Alliance.

Challenges Unfortunately, the Alliance is not without serious challenges. Our membership numbers and dues income have declined, a phenomenon common to many volunteer organization (see Bowling Alone, Robert D. Putman). Our projects are driven by the volunteer time and energy of our members. In the past, dues income was high enough to fund many of our health-promotion activities. We will make changes that will allow our smaller group to work with reasonable commitments of time and energy. We now need to pursue project-funding from foundations, corporations, and others.

Corporate documents will be updated to reflect the size of the organization, allow for easier decision-making, and yet maintain provisions that our nonprofit corporation requires.

The 2002-2003 financial records for both the Alliance and Philanthropic Fund will have certified audits in preparation for grant proposals.

Body Works Initiative The number and scope of health promotion projects also need to fit the size of our organization. Right now the strongest center of energy is in the Body Works project—providing a healthfair experience for Minneapolis third-graders to reinforce healthy choices. We will focus on Body Works to update its content and strengthen its funding base and staffing. We will explore questions that touch on our priorities of commu32

July/August 2003

nity, advocacy, responsiveness, education and service.

Should we focus Body Works for those with greater need, such as those with language barriers, or lower reading and math skills? Can we enhance the health literacy skills of these children? Could we be more culturally competent?

What about a day for adults—immigrant women, teen mothers—to support their parenting?

Should the “stations” be re-defined; could they become stand-alone modules for separate use? What “props” do we need to replace or add to enhance the children’s understanding? The activity book given to each student will be updated.

Where can we incorporate messages from the AMA Alliance’s non-violence campaign, SAVE? While maintaining its message of respect and self-esteem, how can the “Very Important Kid” component be updated? Would spending more time with fewer students and more interactive learning, be appropriate? Will a consistent format in the scripts assist information retention?

What can the teachers and school nurses suggest to us? How can we coordinate with other health programs in which the kids participate, such as Blue Cross/Blue Shield’s Fitness Fever?

What guidelines would be needed to increase our collaborative relationships? Would other organizations like to provide volunteers?

Effectiveness/outcome measures will need to be designed and implemented to satisfy most funding sources. And we will be preparing applications for funding. So, as you can see, there is much to be done with just this one project.

And how exciting to see this historic program move to an even higher level!

nership to support the family of medicine during the training years. And, in the midst of revisions, Body Works will be presented next spring—for the 21st year!

Our current focus on Body Works means that we will need to postpone work on some other projects, such as the HIV/AIDS awareness folders, the Worldscope stethoscope collection, and a fund-raising event like last year’s spectacular “Evening with Dickens.” With so many issues impacting the health of our community, there will always be more to do!

Membership and Leadership Simplified procedures and fewer projects will help in the immediate future; but the Hennepin Medical Society Alliance still has major issues to address. Members need to rotate through the leadership functions to share the work and bring fresh ideas. The regular membership can help with a few hours of talent, their professional expertise, connections to potential community partners, or materials and funding. And we must bring new members to our organization. A shared mission and a strong membership are crucial to our survival!

I am excited about the work ahead. The Hennepin Medical Society Alliance’s commitment to our community’s health remains constant! ✦ (Adapted from remarks at the Alliance Annual Meeting, May 2003)

Other projects Again this year we will sponsor awards for both junior and senior high school students in the Regional Science Fair. The Alliance, University of MN Medical School deans, and medical students’ partners are creating an enthusiastic partMetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

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Continuing Medical Education Medical School

Providing quality physician education for more than 65 years...

CARDIOLOGY COURSES HEART FAILURE SOCIETY OF AMERICA: 7TH ANNUAL FALL MEETING september 21-24 mandalay bay resort & casino, las vegas 9TH ANNUAL VASCULAR DISEASES: A PRIMARY CARE PERSPECTIVE october 24-25 P R I M A RY C A R E C O U R S E S 34TH ANNUAL AUTUMN COURSE: OBSTETRICS & GYNECOLOGY september 8-9 EVIDENCE-BASED MEDICINE HEALTHCARE: FROM LEARNING TO TEACHING september 24-28 6TH ANNUAL TWIN CITIES MARATHON SPORTS MEDICINE CONFERENCE october 3-4 INTERNAL MEDICINE REVIEW october 8-10 CURRENT ISSUES IN GERIATRIC PSYCHIATRY november please contact our office for more information... continuing medical education 200 oak street se, suite 190 minneapolis, mn 55455 tel: 612.626.7600 or 1.800.776.8636 fax: 612.626.7766 email: cmereg@umn.edu web: w.med.umn.edu/cme