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Doctors MetroDoctors THE JOURNAL OF THE EAST AND WEST METRO MEDICAL SOCIETIES

Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines WMMS CEO Jack G. Davis EMMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the East and West Metro Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, East and West Metro Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote their objectives and services, the East and West Metro 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 EMMS or WMMS. Send letters and other materials for consideration to MetroDoctors, East and West Metro Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. 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.

CONTENTS VOLUME 10, NO. 4

Health Reform—What Happened and What’s Next?

Capitol Rounds Connects Members With Legislators

SPECIALTY UPDATE

The State of the Struggle Against HIV

9 11

MetroDoctors

Reinventing Primary Care YOUR VOICE

What About Single Payer?

The Promises—and Perils—of Electronic Health Records

Classiﬁed Ad

Universal Pediatric Inﬂuenza Vaccination—How Will We Accomplish This?

COLLEAGUE INTERVIEW

Jon S. Hallberg, M.D.

Intentional Culture Change: Working Better Together

Creating a Better Experience for our Caregivers

Index to Advertisers

St. Francis Serves Scott and Carver Counties

Career Opportunities Member News EAST METRO MEDICAL SOCIETY

28 29 30 31

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.

J U LY / A U G U S T 2 0 0 8

President’s Message Foundation Works on Advance Directive Project/Caring Hearts Caucus/Sr. Physicians/New Board Members/In Memoriam Asthma and Tobacco-Free Supporters Team Up with Saint Paul Saints/Legislators Presented with Defender of Clean Air Awards/Dakota County Smoke-Free Communities Partnership WEST METRO MEDICAL SOCIETY

32 33 34

Chair’s Report

Alliance News

WMMS In Action Congressman Ellison Participates in Community Internship Program/Sr. Physicians Association/In Memoriam

The Journal of the East and West Metro Medical Societies

On the cover: Although progress is being made, there is still no cure for HIV. Article begins on page 7.

July/August 2008

Health Reform— What Happened and What’s Next?

ON A JUNE AFTERNOON in 2007, a handful of representatives and senators met at the Capitol to begin charting a new course toward health care reform. Nearly one year later, the legislature approved a bill that seeks to contain the rapidly rising costs of health care. Approved the night before adjournment and signed by the governor shortly thereafter, the ﬁnal bill gives more than 12,000 Minnesotans without health insurance access to health coverage via MinnesotaCare eligibility expansions and newly authorized tax credits for money spent on insurance premiums. Expansions and outreach efforts tied to MinnesotaCare include: s Authorizing coordination with the free school lunch program to identify uninsured families eligible for medical assistance or MinnesotaCare. s Making applications for state programs available online. s Increasing the incentive bonus from $20 to $25 for assisting MinnesotaCare enrollees in applying for coverage. s Making single adults at or below 250 percent of the Federal Poverty Guidelines (FPG) eligible for MinnesotaCare (current level is 215 percent of FPG). s Effective 7/1/09, children in families at or below 250 percent of FPG are eligible for MinnesotaCare. s Authorizing a sliding fee scale pegging MinnesotaCare premiums to families’ annual income. The purpose of this provision is to deﬁne and achieve affordable MinnesotaCare premiums.

B Y M AT T S C H A F E R , Lockridge Grindal Nauen, P.L.L.P.

July/August 2008

The bill strives to make it easier for consumers to understand the health care services they are purchasing, and lays the groundwork for eventually rewarding providers for helping patients manage chronic conditions, such as diabetes, asthma and congestive heart failure. The Health Care Home provision in the bill seeks to accomplish this by authorizing per-person, per-month “care coordination” payments to reward preventive and coordinated care. Rep. Tom Huntley (DFL-7A), who authored the House version of the reform bill, often cites the St. Mary’s/Duluth Clinic Health System’s Heart Failure Disease Management Program as the type of program he would like to see rewarded. This program places a heavy emphasis on coordination of care by having nurse practitioners maintain frequent communication with patients and closely monitor their health conditions. The program, according to Huntley, has been successful in keeping patients out of the operating rooms, but the provider loses hundreds of thousands of dollars each year because its preventive care efforts are not reimbursed. The reform bill also includes language that requires health plans and third party administrators to submit encounter data to a private entity designated by the commissioner of health. These data will eventually be used MetroDoctors

to help the commissioner of health develop a peer grouping system for providers based on a combined measure that incorporates the risk-adjusted cost of care and quality of care. Beginning in July 2010, MDH will disseminate to physicians peer grouping data on their cost of care, quality of care, and the results of the grouping. Physicians will have 21 days to appeal if they do not agree with the findings before the information is publicly disseminated. The commissioner of health will also be required to develop a uniform method of calculating physicians’ relative cost of care, defined as a measure of health care spending including resource use and unit prices, and relative quality of care. The bill authorizes the Commissioners of Health and Human Services to form a minimum of seven baskets of care for which providers can voluntarily submit bids in 2010. The commissioners will use the services of a nonprofit entity to aid in crafting these baskets, and form work groups consisting of “members appointed by statewide associations representing relevant health care providers and health plan companies and organizations that work to improve health care quality in Minnesota.” Once the baskets are formed, and the aforementioned entities have developed a mechanism for determining uniform prices for the services identified in these baskets, participating physicians would not be allowed to vary the price of services for these services. The commissioners are not allowed to factor services provided to patients through workers compensation insurance, no-fault auto insurance or public programs into the calculation of these single prices. Physicians will have the option of submitting bids for these baskets of care in 2010.

The Journal of the East and West Metro Medical Societies

While these changes lay the foundation for changing the way health care is paid for, the final measure was a product of multiple compromises. Authors Huntley and Sen. Linda Berglin (DFL-61) made no secret that the bill was a shadow of the original proposal leaving some advocates under-whelmed. The original bill contained a number of controversial items that physicians, insurers and employers cautioned would have generated a host of unintended consequences, including a payment reform proposal, which essentially would have capitated health systems. To further complicate matters, the bipartisan political desire for health reform made the act of questioning the contents of the bill a precarious engagement as nobody wanted to be perceived as “anti-health reform.” The stakeholders’ concerns led to an unlikely alliance of Republican Representatives who felt the state was being asked to take on too much responsibility, a surprisingly large coalition of Democrats who believe health reform can be achieved by some form of a single payer system, and rural legislators who felt the bill failed to consider issues and challenges unique to Greater Minnesota. This unlikely alliance of liberals and conservatives aligned against the DFL leadership and the governor led to House leadership adopting an amendment that delayed the implementation of the payment reform section of the bill. The amendment also authorized establishing an advisory council consisting of members of a host of stakeholder groups including the Minnesota Medical Group Management Association (MMGMA), the Minnesota Medical Association (MMA) and the Minnesota Hospital Association (MHA). In addition to the politics at play, legislators needed to grapple with a projected budget deficit of $935 million that significantly reduced resources that could have been invested in health reform. More than 70 percent of the spending cuts in the supplemental budget passed on the last night of session came out of the Health and Human Services Departments. Hospitals bore the brunt of the cuts with a 3 percent outpatient rate reduction, and a 3.46 percent inpatient rate reduction in 2008 which will be phased down to 1.9 percent in July 2009, and to 1.79 percent in July 2010. MetroDoctors

Additionally, the rebasing for hospital rates has been delayed by two years. Bruce Rueben, President of the Minnesota Hospital Association, was recently quoted saying the cuts to hospitals’ reimbursement rates alone will likely offset many of the savings achieved by the health reform bill. This is because some hospitals may have to shift costs to patients with commercial insurance to make up for the money lost from the rate cuts. Reflecting a request from the governor, the Supplemental Budget “borrows” $50 million from Health Care Access Fund (HCAF) to balance the budget, but backfills the money using projected savings resulting from the Health Care Reform Bill. The $50 million used out of the HCAF replaced money the legislature planned to raise by reinstating caps on health plan reserves, and implementing an assessment on the monies above that cap. Among the proposed cuts that did not make the final bill was a 3 percent reduction in physician reimbursement rates for public programs. Legislators also decided against using federal funds set to be allocated to Minnesota hospitals that deliver a higher amount of

uncompensated care under the Federal Disproportionate Share Hospital (DSH) program. Another proposed amendment stated that more than 60 services listed in the Oregon Health Plan would no longer be covered by MA, GAMC or MinnesotaCare. Sold to conferees by Sen. Berglin as a “technical amendment” dropping reimbursement for “obsolete medical procedures,” the list of services included multiple medical procedures across numerous medical specialties that are used frequently. Fortunately, this proposal was also unceremoniously scuttled. Because of the ﬁscal and political challenges, the health reform bill passed in 2008 is already being characterized as a step toward bigger objectives, including universal health coverage across the state and achieving as high as 20 percent cost savings from the system. So what does this say about future debates? First, the work groups, commissions and advisory committees authorized in the health reform bill will hold their meetings and attempt to ﬁnd a more effective way to pay (Continued on page 4)

You take care of your patients, we’ll take care of you.

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July/August 2008

Health Reform (Continued from page 3)

In the wake of the debate over the appropriate use of the Health Care Access Fund, Sen. Linda Berglin (DFL-61) introduced and started actively pushing SF3835, which prohibits using the Health Care Access Fund to supplant general funds. Introduced late in the 2008 session, Sen. Berglin has already expressed an interest in pursuing this legislation in future years.

wishing to build a new 144 bed facility in the Twin Cities. MDH reviewed Prairie St. Johns’ proposal and found the project was not in the public interest. According to Julie Sonier, Director of the Health Economics Program with the Minnesota Department of Health, there is significant room for improvement regarding the mental health system in Minnesota, but additional capacity does not fill that need. Sonier said there is currently not a need for additional mental health beds in the Twin Cities, but there is a need for additional mental health professionals. Adding another provider to the network, according to MDH, would likely have a negative impact on existing hospitals’ ability to maintain their staff. These concerns were also echoed by several health systems in the Twin Cities Metropolitan Area. Additionally, the department considered the fiscal implications of the state being unable to use federal Medicaid funds for any patients treated there. Undaunted, Prairie St. John’s attacked the credibility of MDH and attempted to advance its bill regardless of the analysis. When that wasn’t successful, PSJ started asking for 66 beds. This bill eventually passed the House, but was unsuccessful in gaining comparable momentum in the Senate. While no beds were authorized, the Prairie St. John’s debate was tremendously successful in compelling legislators to have a serious discussion about the availability of mental health beds and providers in Minnesota. This is an issue that has often been paid lip service in recent years, but the bill prompted more discussion than previously seen. Missing from the discussion, however, was any reference to the role that outpatient mental health services plays in Minnesota. The dialogue is certain to continue in future sessions, and Prairie St. John’s may very well be a part of the equation.

Prairie St. John’s

Medical Debt Privacy Act

Legislation requesting an exception to the hospital moratorium to build an inpatient psychiatric facility in Woodbury proved to be a bill to watch through the 2008 legislative session. At the eye of the storm was Prairie St. John’s, a Fargo-based for-proﬁt hospital

Introduced by Rep. Diane Loefﬂer (DFL-59A) in the House and Sen. Linda Scheid (DFL-46) in the Senate, the Medical Debt Privacy Act would prohibit health care providers from disclosing an individual patient’s ﬁnancial or medical debt information to another entity.

for health care. Physician organizations have argued this can be accomplished by improving coordination of care, which they hope can be achieved through the implementation of the Health Care Home section of the bill. Republicans remain committed to relying on the private sector to contain costs, but remained stumped by the market’s perceived inability to deliver affordable coverage to a growing number of citizens. Democrats generally believe the state has an obligation to step in and provide coverage to people when the market does not offer a viable option. Defining who potential public program enrollees are and what the role of government should be remains an evolving debate even within the Democratic Party. This health reform bill may very well save money in the long run. However, in an era of instant gratification, it is often difficult to quantify and implement long-term objectives. The question remains whether the legislation passed in 2008 will truly contribute to lower health insurance premiums in a timely fashion, and what will happen if it doesn’t. Other Bills

In addition to the Health Reform bill and the Supplemental Budget, there were a host of other initiatives that surfaced this session. Some were successful, while others are sure to resurface. Constitutional Amendment

July/August 2008

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This bill was an initiative led by the attorney general, and its purpose was to restrict companies that assign credit scores to a consumer’s medical debt, and then sell that information to health care providers. Although the bill was introduced with the best of intentions, its contents had some potential negative ramifications. The attorney general’s staff attempted to alleviate the concerns of health care providers with a number of modifications, but the final product still had some problems, and was ultimately vetoed by the governor. It is sure to return in 2009. Modified Physical Therapist Bill Becomes Law

The legislature passed, and the governor signed into law legislation changing the requirement that physical therapists refer patients to a physician after 30 consecutive days of treatment to 90 days, and requiring physical therapists to maintain communication with the referring physician. Known as the “Physical Therapist bill,” this measure in previous years deleted the physician referral requirement all together — a proposal the MMA opposed. This 90-day referral compromise and ultimately the bill’s success was attributed to off session negotiations between the Physical Therapists Association, the MMA, the Minnesota Orthopedic Society and the Minnesota Academy of Family Physicians. Moratorium on Construction of Radiation Facilities

Legislation became law this session imposing a moratorium on the construction of any radiation facility located in 14 counties across the state. The new policy would not apply to the relocation or reconstruction of any facility owned by a hospital if the relocation or reconstruction is within one mile of the existing facility. Legislation was passed in 2007 imposing a two-year moratorium on the construction of new radiation facilities in these counties, and this bill made the moratorium permanent. Matthew S. Schafer, grassroots coordinator and lobbyist, Lockridge Grindal Nauen P.L.L.P.

The Journal of the East and West Metro Medical Societies

East Metro and West Metro Members Flex Legislative Muscle Capitol Rounds Connects Members with Legislators

AFTER A SUCCESSFUL Day at the Capitol in

early March, East Metro and West Metro members took the power of advocacy to the next level and participated in Capitol Rounds — a personalized, member-driven discussion with local legislators. More than a dozen physicians from the Twin Cities area took the time to sit down faceto-face with their legislative representatives over the past two months to deliver a united message on protecting the Health Care Access Fund, well-reasoned health care reform, and a host of other issues. Capitol Rounds offers participants a chance to discuss issues, lobby on behalf of organized medicine and develop long-term relationships with their local legislators. “I found Sen. Michel (R-Edina) to be very open to me as a health care professional,” remarked Peter Dehnel, M.D. of his visit to St. Paul. “He has reached out since our visit for advice and opinions.” While some physicians found a role as advisor, others got into the middle of things like Jack Bert, M.D. “It was great. Rep. Swails (DFL-Woodbury) asked me to be a part of a press conference on the Health Care Access Fund,” wrote Dr. Bert of his Capitol Rounds visit. “I think getting directly involved is vital.” Later that week, Dr. Bert would publish an Op Ed piece in the Star Tribune on preserving the HCAF. Other physicians had the opportunity to get directly involved in inﬂuencing policy during their Capitol Rounds. The Minnesota Senate and House recently advanced public health and safety provisions to strengthen Minnesota’s Graduated Drivers License law. Forty-six states have nighttime and/or passenger restrictions to address the issue; Minnesota has neither. The provision included in the Transportation Policy MetroDoctors

Nathan Noznesky, M.D. met with Representative John Berns (R) on the Minnesota House ﬂoor. (Photo courtesy of the Minnesota House of Representatives.)

Bill (HF3800) restricts for the first six months the number of passengers a newly licensed teen driver may have in their vehicle to one other person under the age of 20, and it prohibits them from driving between midnight and 5 a.m. unless for work or a school function. The day the measure was going to be debated on the House floor, West Metro member Laurie Drill-Mellum, M.D., worked to persuade her representative, Rep. Paul Kohls, (R-Victoria), to support the bill, HF2628, to toughen Minnesota’s existing Graduated Drivers License law and save teen lives. She offered her perspective as an emergency room physician on the bill to place restrictions on teen drivers during the first six months they have their license. She told him that no state in the country has a higher percentage of teenagers behind the wheel in deadly crashes than Minnesota. Previously uncommitted on the issue, Rep. Kohls voted with the majority in the House that night to enact the new legislation. This was not her first Capitol Rounds. Drill-Mellum, who is a member of the board

The Journal of the East and West Metro Medical Societies

John Wust, M.D., and daughter, visit with Representative Melissa Hortman (DFL) at MMA’s Day at the Capitol. (Photo by Scott Smith, MMA.)

for MEDPAC, is no stranger to ﬁghting for better public health. She played a role in securing the passage of Freedom to Breathe in the Legislature last spring, and has been part of other efforts as well. Drill-Mellum also discussed the importance of using the Health Care Access Fund to help those in need of health care, and urged Rep. Kohls to oppose using it to balance the (Continued on page 6)

July/August 2008

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July/August 2008

MetroDoctors

budget. During her April 24 Capitol Rounds, Drill-Mellum also met with Senate Majority Leader Larry Pogemiller, (DFL-Minneapolis) as well as her local senator, Julianne Ortman, (R-Chanhassan). â&#x20AC;&#x153;Rep. Kohls voted with us in large part because of Dr. Drill-Mellumâ&#x20AC;&#x2122;s visit,â&#x20AC;? said MMA Lobbyist Sara Noznesky. â&#x20AC;&#x153;It makes a huge difference when legislators hear directly from their constituentsâ&#x20AC;&#x201D;especially those with the respect that a physician garners. It clearly made the difference.â&#x20AC;? Participating in Capitol Rounds during the 2008 session: Jack M. Bert, M.D. (Rep. Swails, DFLWoodbury) Peter F. Bornstein, M.D. (Rep. Garner, DFLShoreview & Sen. Rummel, DFL-White Bear Lake) Nadia A. Sam-Agudu, M.D. (Sen. Pariseau & Rep. Garofalo, R-Farmington) James J. Jordan, M.D. (Sen. Cohen & Rep. Murphy, DFL-St. Paul) Abraham K. Jacob, M.D. (Rep. Knuth, DFL-New Brighton & Sen. Chaudhary, DFL-Fridley) Peter J. Dehnel, M.D. (Sen. Michel, REdina) Amy C. Burt, D.O. (Sen. Bonoff, DFL-Minnetonka) Lisa D. Erickson, M.D. (Rep. Hornstein, DFL-Minneapolis & Sen. Dibble, DFLMinneapolis) Michael D. Smith, M.D. (Rep. Hornstein, DFL-Minneapolis) Nathan M. Noznesky, M.D. (Sen. Olson, RMinnetrista & Rep. Berns, R-Wayzata) Richard Morris, M.D. (Rep. Berns, R-Wayzata) Laurie C. Drill-Mellum, M.D. (Rep. Kohls, R-Victoria & Sen. Ortman, R-Chanhassen & Sen. Pogemiller, DFL-Minneapolis) Kristin A. Benson, M.D. (Sen. Bonoff, DFLMinnetonka & Rep. Benson, DFL-Minnetonka) Want to know more about Capitol Rounds? To schedule your own personalized day at the Capitol that includes a tour and meetings with your lawmakers, contact the Capitol Rounds team at (612) 378-1875. The Journal of the East and West Metro Medical Societies

SPECIALTY UPDATE

The State of the Struggle Against HIV: The Good, the Bad and the Ugly

TWENTY SEVEN YEARS after AIDS first surfaced, there continues to be rapid development in knowledge about this difficult challenge to our species. Unfortunately, while some of the news is favorable, other findings are quite the opposite. I’ll proceed from the good to the bad in this update. The Good The most salutary arena is the science and biology of HIV. In 1983 we had only an electron micrograph. Now, this pathogen is understood better than any other. I’ll touch on three aspects, hoping readers will permit me a bit of oversimplification: reconstruction of the history of HIV using genetic sequence analysis, recruitment of our cellular systems in the course of viral replication and discovery of innate antiretroviral defenses suggesting that our and our ancestral species have been repeatedly assaulted by retroviruses. Comparing genetic sequences of HIV-1, group M, the cause of the global AIDS epidemic, with sequences of multiple strains of simian immunodeficiency virus (SIVcpz) collected from wild chimpanzee stool have established with certainty the ancestral virus has long been established in two of the four chimp subspecies. Furthermore, after collection of hundreds of different SIVcpz samples from the entire range of these two subspecies it has been shown that different sequences cluster in different locales. This is known as phylogeographic clustering. By comparison of these variants with HIV, it can be determined which SIVcpz strain is the most like HIV-1. It turns out that the species jump responsible for HIV most likely occurred in a small area of southeastern Camaroon, just up the Congo

BY FRANK S. RHAME, M.D.

MetroDoctors

River from Kinshasa. The fact that the greatest variation in HIV sequences is present in isolates from Kinshasa supports the belief that the virus has been circulating the longest there. Two other HIV-1 groups, responsible for few cases, probably represent separate species jumps. So far, three human defenses against retroviruses have been found. Most likely we long ago evolved them to fight off retroviruses. I’ll describe the APOBEC system because two University of Minnesota scientists, Hiroshi Matsuo and Reuben Harris, have been major contributors to its characterization. The APOBEC proteins are a series of cytoplasmic cytidine deaminases that had been identified independently of HIV. By clipping an amine from cytidine they convert it to uridine. Soon after HIV was sequenced, one of its accessory genes was found to be necessary for efficient HIV replication. It was named vif for “viral infectivity factor.” But how vif worked took a decade to unravel. It turns out that one of our ABOBECs, ABOBEC3G targets retroviral RNA. It converts it into nonsense. It’s long been in our genome in wait for the next retroviral attack. And HIV has acquired vif specifically to counteract this defense!

The Journal of the East and West Metro Medical Societies

Since HIV has only three major structural proteins, three replicative proteins and three accessory proteins, it might not be surprising that HIV depends on our cellular systems for replication. But evidence published this spring, using small interfering RNAs to knock out thousands of human proteins indicates that more than 200 of our proteins might be needed. Even more remarkable is how these proteins are often specifically recruited by HIV. For instance, the way vif works is to add ubiquitin molecules to APOBEC3G. Ubiquitination is the universal signal for protein destruction. Ubiquitindependent degradation utilizes cytosolic systems to efficiently cart marked proteins off to the proteosome for destruction and recycling. Anyone who imagines that HIV was manufactured decades ago out of malevolence has no idea how complex this virus is. It uses systems that were wholly unknown even a few years ago. Also falling into the “good” category is the remarkable advancement in antiretroviral therapy. Say what you will about Pharma, there has been steady advancement in treatment. I would have lost a bet made three years ago that there would be significant improvement in antiretrovirals. After watching nothing but death from 1981 to 1996, what we had three years ago seemed remarkably good. But even in the last year we’ve had licensure of three new drugs that have much reduced toxicity and improved efficacy: raltegravir (Isentress), etravirine (Intellence) and maraviroc (Selzentry). Etravirine and darunavir (Prezista) are important advancements within the original three antiretroviral drug classes. Raltegravir and maraviroc obstruct HIV replication in brand new ways; no HIVs could have had resistance prior to their usage. (Continued on page 8)

July/August 2008

Specialty Update (Continued from page 7)

I’m now convinced that patients who have HIV strains with little resistance who also take their meds well will not die of HIV in the former way: progressive CD4 cell depletion with immunosuppression and opportunistic infection. To be sure I can’t be certain without more time. And HIV positive persons do seem to get many of the ills that afﬂict us all at a more rapid rate: arteriosclerotic cardiovascular disease, a tendency to diabetes, bone mineral loss. Whether this is due to HIV itself, the antiretrovirals or both is under active investigation. The Bad Into the “bad” category, I’ll put two elements: achieving timely detection and treatment and transmission prevention. Even in Minnesota we are too often late in diagnosing HIV infection. In spite of all the publicity about HIV, as much as 40 percent of HIV positive Minnesotans don’t know of their diagnosis. In 2007, 96 Minnesotans were ﬁrst diagnosed HIV positive at the stage of AIDS (30 percent of all new HIV diagnoses). Every one of these diagnoses is a failure: a properly managed HIV infection is diagnosed and treated long before the CD4 count gets into the hazardous range or any HIV-associated symptoms occur. The failures are multiple: patients who know of their risks who don’t seek testing and health care systems that don’t recognize risk histories and promote testing. Even more disturbing, 63 patients who already had an HIV diagnosis progressed to AIDS (40 percent of all AIDS diagnoses). These cases represent failure to get treatment started at the right time. With respect to prevention of HIV transmission, we have two solid achievements: prevention of transfusion transmission and substantial reduction in mother-to-child transmission. In the U.S., the addition of nucleic acid testing (NAT) to antibody testing has largely eliminated transmission during the “window period” between infection and the development of anti-HIV antibody. NAT has been made economical by the testing of 20 unit pools. Aggressive testing of all pregnant women and strong intervention programs to achieve high rates of antiretroviral treatment of HIV positive pregnant women have brought the transmission rate to <1 percent of pregnant women. In Minnesota, we’ve 8

July/August 2008

had only five mother-to-child transmissions in the last eight years. Rates of HIV transmission by needle transmission have also been sharply reduced—there’s little disincentive to using clean works. But rates of sexual HIV transmission remain depressingly high. HIV is an infection that should never occur. Sexual restraint and use of condoms should rapidly eliminate it. But HIV successfully exploits powerful human impulses. In fact, the CDC is about to declare an increased national incidence of new HIV infection. Rates of chlamydia, gonorrhea and syphilis remain high. Our ability to change behavior is dismal. The Ugly I have two entrants into the “ugly” category: the underdeveloped world and vaccination. HIV has always been a probe for many things: attitudes to sexuality, homophobia, and access to health care, to name a few. Likewise it sharply illustrates the disparities in the provision of health services in the prosperous and non-prosperous worlds. In sub-Saharan Africa to a great extent and in the former Soviet states, South & Central America and much of Asia to a lesser extent, antiretrovirals are unavailable for a large fraction of those persons who need them, response monitoring by viral load testing is unavailable and second line regimens are non-existent. This is true notwith-standing large donations from the U.S. and Europe. President Bush, for all the dissatisfactions many find in him, has, in fact, successfully pushed for large U.S. donations. The President’s Emergency Plan for AIDS Relief (PEPFAR) will have provided $28B by the end of 2008 and is seeking $30B more. This support may well be one of the most positive aspects of his legacy. The vaccine situation is indisputably ugly. Last September a large randomized trial of a promising vaccine consisting of three HIV genes in an adenovirus carrier was halted for lack of efficacy. Even worse, there was greater rate, possibly statistically significant, of infection in recipients who had pre-existing adenovirus antibody. This has prompted great soul searching in the HIV vaccine investigators’ community. Many feel that our understanding of what it will take to produce a successful vaccine is so lacking that we should shift resources to basic science. The NIH has been roughly dividing funds 50:50 between basic sci-

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ence and clinical trials. Undoubtedly, there will be a change. We need to recognize that a successful vaccine may not be possible. Vaccines against viral infection generally don’t prevent early, silent re-infection. Recipients of measles vaccine get re-infection on re-exposure. A few viral replications occur, but the immune response is prompt. The exposed person doesn’t get ill; there is just a boost in antibody titer. But that may not be good enough for HIV. All the immunity we can muster doesn’t seem to keep it from killing us. A vaccine may never prevent the ﬁrst few HIV replications and that may be all HIV needs. Many HIV “superinfections” (HIV infection with a new strain in a person already infected by a different strain) have now been described, to reinforce the point. It’s hard to imagine how a vaccine could better stimulate immunity than a natural infection. If that’s not good enough to prevent a new infection, what could be? On a personal note, as a physician involved in HIV care and research from the beginning, this has been an amazing experience. I can’t imagine anything scientiﬁcally more exciting. I’ve seen HIV bring out the best in many and the worst in others. The patients I’ve worked with — successfully and not —have been wonderful, frustrating, inspirational, instructive, entertaining, demanding, grateful and generous. And it doesn’t look like the pace of change is going to slow down for a good long while. Frank Rhame, M.D. received his medical degree from Columbia University’s College of Physicians and Surgeons, did internal medicine residency training at Harlem Hospital Center, the University of Michigan Hospital and Stanford Hospital and Infectious Diseases fellowship at Stanford University. He served for two years in the Epidemic Intelligence Service at the Centers for Disease Control. He joined the University of Minnesota faculty in 1979 rising to Associate Professorship with tenure; he is now an Adjunct Professor in Infectious Diseases, Department of Medicine, School of Medicine and an Adjunct Associate Professor in the Division of Epidemiology, School of Public Health. He established the HIV Clinic at the University Hospital in 1987. In 1996, he moved to the Allina Medical Clinic – The Doctors and the Infectious Diseases Clinic at Abbott Northwestern Hospital, where he maintains an active research program in HIV treatment. The Journal of the East and West Metro Medical Societies

Reinventing Primary Care

FOR PRIMARY CARE, change is in the air. It

is not simply the evolution of time or even the winds of a political season; it is a deep, organic change growing out of the very foundations of our health care system. Change is coming to primary care and it is inevitable. The change will be nothing short of a transformation. The patient relationship, the role of the primary care physician, reimbursement for primary care, and relationships with specialists and facilities — all will be substantially different in the coming years. This article describes why these changes will occur, speculates about key characteristics of the transformation, and suggests what primary care organizations should be doing now to prepare. Primary care will transform because it must. The first force requiring change is that the supply of primary care physicians is insufficient to meet demand. People seeking the services of a primary care physician have a hard time finding one who will accept new patients, especially if their insurance coverage does not reimburse well. According to U.S. News & World Report, in 2007, 29 percent of people covered by Medicare reported trouble finding a primary care physician willing to accept them — up from 24 percent in 2006. A 2006 California HealthCare Foundation survey suggests that almost one-half of emergency room patients could have been cared for by a primary care physician and that difficulty getting a physician appointment was the most frequent excuse for using the ER instead. Projections by the U.S. Department of Health and Human Services suggest that the shortage of primary care physicians will get worse, not better, in the coming years (see Table 1). Yet it is not simply a shortage of primary B Y D AV I D W. A L L E N , J R .

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care physicians forcing change; it is a fundato see high volumes of patients as quickly as mental deficiency in the way primary care is possible. Additionally, the sizeable number of provided. Service is often abominable in compeople without insurance or the ability to pay parison to the service levels of other professions for care combined with the low reimbursement or, for that matter, most other industries. Apfrom government programs leads many physipointments may not be available for weeks, cians to avoid accepting new patients who don’t locations are frequently inconvenient, parking have private insurance. is often a problem, and many find that the The fact is that no one is being well served uncertainty of when their appointment will by the current primary care situation. Physistart and finish leads them to take a half day cians would undoubtedly be happier if they off from work for what may turn out to be a could spend more time with each patient, care 15 minute appointment. for them more completely, and be better comIn addition to the service deficiencies aspensated as well. Patients generally like their sociated with the current way primary care is physicians, but are deeply concerned about delivered are quality deficiencies. For many prithe costs of health care, access to services and mary care physicians, the pressure to produce service levels. Health plans recognize that they RVU’s (Relative Value Units) limits the time are an integral part of a system that is not costthat can be spent with any individual patient. effective and does not deliver good quality or Patients with multiple or complex problems, service. Employer sponsors of health plans are patients who have trouble understanding, or frustrated with rising costs and perceptions of patients needing education or guidance (in poor value. The government is facing a crisis as other words, most patients) get inadequate the cost of programs like Medicare and Medattention. Perhaps the most serious quality icaid consume ever-larger portions of our tax issue is the emphasis on dealing with the imdollars. And all of us are concerned about how mediate problem at hand, at the expense of to care for people who don’t have insurance or long-term issues like prevention and wellness; the means to pay for care. many physicians see their role as treating a dis(Continued on page 10) ease or condition, rather than helping a patient avoid future Table 1: Primary Care Physician (PCP) problems. Supply and Demand Certainly, the finger of PCP PCP blame for the problems in priPhysician Physician mary care can be pointed in Supply Demand Shortage many directions. Primary care 2000 214,810 267,100 (52,290) physicians are, to a large extent, 2005 228,660 281,800 (53,140) prisoners of a system that gives 2010 244,370 297,500 (53,130) them little opportunity to fix 2015 259,910 316,300 (56,390) these problems. The prevalent 2020 271,440 337,400 (65,960) procedural-based reimbursement structure leaves little Source: “Physician Supply and Demand: Projections to 2020”; U.S. alternative to primary care Department of Health and Human Services, Health Resources and physicians but to endeavor Services Administration, Bureau of Health Professions; October 2006.

The Journal of the East and West Metro Medical Societies

July/August 2008

Reinventing Primary Care (Continued from page 9)

Collectively, these are the conditions that will force primary care to transform. This transformation will come from two directions: ﬁrst, from payers changing reimbursement and contracting methods, and second from physicians or health systems proactively changing their method of delivery. Payers are starting to change the way they reimburse and contract with primary care providers. One large Minnesota health plan has initiated several pilot projects to compensate primary care physicians directly for doing “disease management” (engaging, educating and coaching patients on the management of chronic health conditions) — instead of relying on the more widespread practice of having an internal health plan department or separate organization perform this function. At least one large Twin Cities’ employer is in negotiations with a primary care organization to open a work site clinic for the purpose of providing employees and dependents more accessible care. The Institute for Clinical Systems Improvement (ICSI), a collaboration between health plans and clinical groups, is currently promoting the DIAMOND project as an effort to pay primary care physicians a ﬁxed monthly coordination fee for managing patients diagnosed with depression. At this writing, the Minnesota Legislature is in negotiations with the governor regarding legislation that would introduce per-patient monthly care coordination fees, payable to primary care physicians, for MinnesotaCare insureds that enroll in a primary care “medical home.” In the long run, it will probably be the actions of those who provide health care services who actually effect the greatest transformation. In addition to responding to the opportunities brought to them by the payer community, change is occurring within primary care. Academic medicine is promoting the medical home concept as a way to put the primary care physician with their patients at the center of all medical care. New ancillary primary care givers are entering the scene, such as the new doctoral level nurse practitioner. And new business models are also joining the party, with convenience care centers staffed by nurse practitioners sprouting up in pharmacies and other retail outlets across the country. As this transformation occurs, here are

July/August 2008

some of the changes we believe primary care physicians will see: s The role of the primary care physician will evolve to become the captain of a team of caregivers. s The physician-patient relationship will be restored to a more permanent and holistic status as the medical home develops to become the dominant primary care treatment model. s Wellness, prevention and management of chronic health needs will become as important to primary care physicians as providing episodic care. s Physician extenders will provide much of the routine care to patients, sometimes at other locations such as work sites or retail outlets. s Care Coordinators will play an important role in maintaining communications with patients and keeping them engaged in managing their health. s Care Tracks staffed by ancillary personnel following protocols and supervised by primary care physicians (for individual patients) and specialists (for the overall protocol) will manage a myriad of health issues (e.g., diet and exercise, nicotine addiction, diabetes, depression, chemical dependency, asthma and allergies, spine care, pain management, and healthy heart care). s Home Visits will be an important treatment option for many primary care teams and telemedicine devices will be used to monitor at-home patients’ health metrics. s Electronic Health Records will become an essential tool for keeping the primary care physician informed and communicating information between team members and locations. s Reimbursement will evolve as health plan sponsors partner with providers (e.g., to promote wellness or manage chronic disease), health plans move disease management back to primary care, and patients themselves increasingly pay out-of-pocket for what they perceive as superior value. s Compensation of primary care physicians will increase as they transform from being cogs in a production machine to becoming lead caregivers for a panel of patients. As more primary care is delivered in this way, a tipping point may be reached and all of health care could be affected. Emergency de-

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partments may operate at much lower volumes as primary care provides 24/7 access for urgent care. Certain specialty services and facilities may also see declines in volume as prevention has its effect and treatment becomes more conservative. Competition between primary care teams may become focused at a market niche level, such as by geography, age, gender, health issues, language or ethnicity. Service levels may become an important competitive factor; appointments may not be required for many services and some care teams will compete by offering value-added benefits like transportation, exercise facilities or dietary programs. Implementation of a significantly different form of primary care will not be easy for any health care organization. Full transformation will impact a wide cross-section of clinical, administrative, staffing, financial, facilities, marketing and informatics systems. The saving grace is that complete transformation is not something that can or should occur immediately. Transformation will be gradual, allowing systems a chance to evolve and, importantly, changes in the way primary care is reimbursed to keep pace. The essential task at this time for a primary care organization is to develop and begin implementing a plan that maps the critical path from the present to the future. Primary care physicians who recognize the inevitability of this transformation and act first to embrace, plan and implement it will have a significant advantage in the marketplace. It will be difficult for physicians who fail to prepare to catch up later, as the first movers secure contracts and employ the available ancillary work force. Change is always difficult and often unpleasant. The changes that will be occurring in primary care, however, are desperately needed. These changes will help address the shortage of primary care physicians by allowing an individual physician to oversee care for a larger population of patients. These changes will improve the quality, accessibility, service levels and value of primary care. Primary care physicians should embrace these changes not only for these reasons, but also because they should make being a primary care physician more fulfilling and rewarding. David W. Allen, Jr. is a managing partner and consultant with The Chancellor Group, LLC, a consulting firm that helps health care organizations implement and cope with change. He can be reached at (952) 746-1309. The Journal of the East and West Metro Medical Societies

YOUR VOICE

What About Single Payer? An Answer to the Question About How to Reform Our Health Care System

n discussions of health care reform, consensus is rapidly developing around the urgent need for universal health care coverage in the United States. There is also an almost universal understanding that this coverage is not feasible without cost containment. Given the facts that over 47 million people in the U.S. are uninsured and an even greater number are underinsured and that the percentage of the U.S. Gross Domestic Product (GDP) going to health care is over 16 percent, it’s not surprising that the issues of access and cost have become priority issues in our country. An increasing number of health care professionals and policy makers are claiming that a single-payer system is the only rational approach that can actually contain costs, achieve universal coverage, and maintain or improve quality. They argue that only a single-payer approach can address the economic pressure on businesses and the rising costs of health care for individuals and still be able to expand coverage to everyone. However, these statements are guaranteed to bring forth a series of questions about single payer. Here are responses to some of the questions that are frequently raised.

1) What is single-payer health care? “Single payer” means that there is one payer — one insurer — who reimburses health care providers for their services. This is in contrast to the current system that provides payment through multiple insurance companies. This one payer has the authority to negotiate limits on what providers, pharmaceutical companies, and equipment manufacturers charge just as insurance companies do now. This payer could be either the state or the federal government. Every industrialized country in the world, other than the U.S., has some form of nationally administered health coverage. Medicare is a single-payer system that has been in place in the U.S. since 1966. However, Medicare is a less than ideal single-payer system because it cannot set budgets for hospitals nor negotiate prices with pharmaceutical companies. 2) Is single payer socialized medicine? Single payer is not socialized medicine because hospitals and clinics would still be privately owned, rather than owned by the government,

and doctors would still be in private practice. “Single payer” simply refers to the taking in and paying out of the health care dollars, which would replace the current multiple-payer system dominated by private insurance companies. Single payer refers to the mechanism used to pay for health care services not how the services are delivered. Many industrialized countries have a single-payer system; some provide services through a national health service, but most provide services through physicians in private practice. All of the leading single-payer bills introduced in the U.S. at the federal and state level would leave the health care provider sector in the hands of private practitioners. 3) Doesn’t Medicare have big problems? Traditional Medicare has worked very well for patients and they have been happy with it. Because the traditional Medicare program spends a lot less money on administrative functions than private-sector insurers, Medicare is the most efficient health insurance program, public or private, in America. However, the partial privatization of Medicare since the 1980s and the recent total privatization of the Medicare drug benefit have raised costs and brought prosperity to many health plans and insurance companies. Their administrative costs have created an economic burden for the program of billions of dollars per year. Subsequently, payments to doctors, the actual providers of care, have been cut. In many ways it is the actual need for Medicare that is causing some concern. As the U.S. population ages, there will be an increase in demand for Medicare services. That means there will be an increased need for funding to provide those services. This is not a crisis but a predictable occurrence that needs to be addressed by policy makers and health care planners. There is a need to find a way to finance that increase in services. Reducing administrative waste through a single payer would be one of the mechanisms of doing that. Funding Medicare Part B (which is the primary revenue source for the physician and drug parts of Medicare) from general revenues rather than payroll taxes would also help eliminate the illusion that somehow Medicare Part B could “go bankrupt.” Imminent bankruptcy is never a concern for government programs, like the Pentagon, which are financed by general revenues.

B Y E D WA R D P. E H L I N G E R , M . D . , M S P H , AND SUSANNE KING, M.D.

(Continued on page 12)

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July/August 2008

The Journal of the East and West Metro Medical Societies

Your Voice (Continued from page 11)

4) Can we afford single payer, if that means covering 47 million uninsured people? Compared to other countries, the United States already pays enough to provide comprehensive coverage for everyone. However, coverage for everyone isn’t realized because 31 percent of our health care spending goes for administration through the patchwork of private for-profit and not-for-profit insurance companies and health plans. Potential savings from eliminating the administrative waste and marketing expenditures of insurance carriers have been estimated at $350 billion per year. 5) Won’t there be waiting lines or rationing with single payer? A poll done in the late 1990s showed that rationing was worse in the United States than in Canada, which has a single-payer system. At that time, 12 percent of Americans said they couldn’t get necessary health care in the previous year compared to 8 percent of Canadians. In 2005, the median wait for specialists or elective surgery was four weeks. A 2007 study highlighted the fact that 37 percent of Americans reported being unable to get necessary medical care “because of cost during the past year” versus 12 percent in Canada. The United States already rations care based on ability to pay and 18,000 Americans die every year because they lack health insurance. Canadians live longer and are more satisfied with their health care than Americans, while paying half as much per person. If waiting problems in Canada are an issue, it’s because the health care system is underfunded rather than because it is single payer. No single-payer advocate is proposing that the United States lower health care spending to Canadian levels.

ers find their coverage fails when they get sick: 75 percent of the one million Americans experiencing medical bankruptcy each year were insured when they got sick. Insurance premiums are going up every year for policies that cover less and less. 8) How would single payer be financed? There are a variety of ways that a single-payer system could be financed. Currently, about 60 percent of our health care system is publicly financed (via our taxes), 20 percent is financed by private employers, and 20 percent is financed by individuals. With a state or national single-payer health program, that funding formula could be maintained as a way to finance universal access. Another option would be a payroll tax on employers (approximately 7 percent) and an income tax on individuals (approximately 2 percent). The payroll tax would replace all other employer expenses for employee health care. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and any other out-of-pocket payments. For the vast majority of people, a 2 percent income tax is less than what they now pay for insurance premiums and out-of-pocket payments. This is particularly true for anyone who has had a serious illness or has a family member with a serious illness. Small employers would also benefit from this payroll tax approach since many now have to pay 25 percent or more of payroll for health insurance compared to the 8.5 percent currently paid by large employers. While most people and businesses would pay less with a singlepayer approach, everyone would have more comprehensive coverage. In addition to medical care and drugs, benefits would include mental health care, dental care, and long-term care.

6) Won’t our aging population break the bank in a single-payer system? Japan and European countries have a higher percentage of elderly citizens, yet they spend much less on health care than we do — and have better outcomes. Universal access to health care will improve the health of the population. The issue is what is the best way to get to that universal access in a way that is economically sustainable? A single-payer approach is the most likely approach to achieve that goal. A single-payer system that provides universal access would also be better able to address the lifestyle and behavior issues, like obesity and tobacco and alcohol use that are major contributors to health care costs.

9) Who would run a single-payer plan? It is a myth that with national health insurance the government will be making the medical decisions. The government would only be the administrator of the health care funds. In a publicly financed, universal health care system, medical decisions are left to the patient and doctor. Cost containment measures like negotiating limits on what providers, pharmaceutical companies, and equipment manufacturers could charge would be publicly managed by an elected and appointed body. This body, in consultation with medical experts in all fields of medicine, would decide on the benefit package, negotiate doctor fees and hospital budgets, and be responsible for health planning and the distribution of expensive technology. Right now, insurance companies make many health care decisions behind closed doors. Their primary interest is in profits, not the health of the people.

7) Some people believe that their insurance is meeting their needs; why should they change? While some people may be comfortable with their present insurance coverage, that coverage is unstable and often inadequate when it is most needed. Because our current system is tied to employment, if people change or lose jobs, their coverage and care is disrupted. Oth-

10) Won’t doctors dislike a single-payer system? Because of its administrative burdens and the hurdles to care created by insurance companies, most physicians are very dissatisﬁed with the current health care system. Physicians would like to make medical decisions with their patients, without the intrusion of proﬁt-motivated insurance companies. In addition, when patients are unable to

July/August 2008

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The Journal of the East and West Metro Medical Societies

pay because they are uninsured or underinsured, doctors often provide care for which they don’t get reimbursed. More and more physician groups are also supporting single payer. In 2007, almost 60 percent of physicians supported government legislation to establish National Health Insurance — a 10 percent increase in support since 2002. This level of support is similar to that found among physicians in Minnesota and Massachusetts where two-thirds of physicians support single payer. This increase in support for National Health Insurance is distributed across every medical specialty. The largest increase was seen among physicians who “strongly support” National Health Insurance; now almost twice as many physicians support it as oppose it. It has been reported that the number of physicians currently supporting National Health Insurance is much larger than the entire membership of the American Medical Association. In addition to individual physicians, a single-payer approach is supported by multiple professional organizations like the American College of Physicians, the American Medical Student Association, the National Medical Association, the American Public Health Association, and the American Nurses Association to name just a few.

for all” approach at the national level. National single-payer legislation (HR676) has been introduced and has more supporters than any other proposal for health care reform. While a full-scale conversion seems unlikely in the short-term, there are steps that could move the country and states in that direction. One approach at the national level would be to add children to Medicare followed by adults. In Minnesota, single-payer legislation could be adopted for children with adults gradually added. Another Minnesota option would be to open MinnesotaCare to small employers and individuals and then expand it to large employers. Single-payer legislation for Minnesota (SF2324) has been introduced in the Minnesota legislature by Senator John Marty and has garnered a great deal of support. In Canada, single-payer health legislation was introduced province by province, rather than at the national level which gives credence to this state-based approach as a way of moving toward a national single-payer system in the U.S. Support for single-payer health care is increasing as people learn about the beneﬁts of this solution for our ill-conceived health care system.

11) How would we get to a single-payer system? There are multiple paths to achieving a single-payer system. The most logical would be to develop an expanded and improved “Medicare

Edward P. Ehlinger, M.D., MSPH is the director of Boynton Health Service in Minneapolis, MN. Susanne L. King, M.D. is a child and adolescent psychiatrist in Lenox, Massachusetts.

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July/August 2008

The Promises — and Perils — of Electronic Health Records IMAGINE THE FOLLOWING courtroom

Dr. Smith: “We are a small practice and the electronic record has been very costly, far beyond the initial purchase of the equipment. We couldn’t afford anyone else, and even if we had hired someone with a medical background, there is not a way to incorporate outside documents in a way that effectively catalogues their source and diagnosis.”

scenario played out in the life of one of your close associates: Plaintiff ’s Attorney: “Dr. Smith, you performed a pre-operative exam on this child prior to his dental cleaning and extraction on December 10, 2007, is that correct?” Dr. Smith: “Yes, the record indicates that I did.” Attorney: “And on the pre-operative form, you failed to mention that the child had a congenital heart condition that necessitated the use of antibiotic prophylaxis before dental work, is that correct?”

know it was there, much less review it at the time of the pre-op examination.” Attorney: “How does a report of this importance get buried within what should be a much safer system than a paper-based chart?”

Dr. Smith: “That is correct.” Attorney: “Why is that Dr. Smith? It is information clearly indicated on the consultant’s report that is contained within your electronic health record.” Dr. Smith: “I was unaware of that consultant’s report at the time that I ﬁlled out the form.” Attorney: “Doctor, do you not thoroughly review the record at the time that you are ﬁlling out a form as important as a pre-operative exam, especially for a child that has a number of underlying medical conditions such as my client?” Dr. Smith: “The consultant’s report I got was, I will use the term, electronically buried within our record and there was not a way to even

BY PETER DEHNEL, M.D.

July/August 2008

Dr. Smith: “The report gets scanned in as a JPEG image into our electronic record, without a standardized way to catalog the nature or source of the report. It was also scanned in on the same day as some physical therapy authorization and an orthopedic report, and the person who scanned in the document combined them all together as a single document.” Attorney: “What is the training level of the person you have scanning in these important documents?” Dr. Smith: “It is a high school graduate we’ve hired to do the work of scanning in documents.” Attorney: “And so, Dr. Smith, as you sit there today, can you defend to this court or my client’s family why you chose to delegate such an important job to someone with no medical training?” MetroDoctors

Attorney: “Does this also account for why you did not include any mention from the hematologist about the inherited clotting disorder and the child’s likely predisposition to thrombotic events at the time of anesthesia?” Dr. Smith: “That one is a little more complicated. We had some original reports from the hematologist about the child’s iron deficiency anemia, and that history, as you will notice, was included on the pre-op form. The Factor V – Leiden mutation report was on a letter that was inadvertently shredded prior to getting scanned into our system. Someone in the office must have thought that it was simply a duplicated report and would take up excessive memory within our system.” Attorney: “So Dr. Smith, do you have anything else to say to this family whose child has suffered the complications of bacterial endocarditis and a major stroke related to a dental procedure under anesthesia?” Dr. Smith: “I am so terribly, terribly sorry. If we had been using our old paper-based system, this would not have happened to your child………..” Electronic health records (EHRs) are going to happen, regardless of what any of us in the medical field say. It “happened” in my own The Journal of the East and West Metro Medical Societies

ofďŹ ce nine months ago. At this point in their development, however, EHRs are not going to automatically bring increased patient safety, efďŹ ciency and effectiveness of care or signiďŹ cant cost savings. All of these are, however, assumed in the popular press and in legislative bodies at both the state and federal level. These systems are expensive, both in terms of purchase and initial training as well as the required constant â&#x20AC;&#x153;tweakingâ&#x20AC;? for their continued performance. Interoperability is still a distant promise â&#x20AC;&#x201D; information cannot ďŹ&#x201A;ow easily between different systems at this point. Security and privacy are challenges yet to be mastered. Interacting with a patient is now at least partially replaced by interacting with a laptop in the exam room. Finally, signiďŹ cant problems with â&#x20AC;&#x153;wrong sited surgeryâ&#x20AC;? can remain in spite of the established use of electronic records. This assessment comes to you by someone who has also seen the very best side of an electronic system. Through my 11-year experience with a nurse triage service that uses a computerized decision support system and electronic patient record, I have seen that patient care can be almost â&#x20AC;&#x153;mistake-free.â&#x20AC;? The collective

experience of pediatric nurse triage programs across the country over the last several years that utilize this technology has resulted in literally several million telephone care encounters without even one serious adverse patient outcome. That is beyond â&#x20AC;&#x153;six sigmaâ&#x20AC;? in terms of quality of care and is on par with the safety of commercial airliners and nuclear power plants. This level of quality has not been automatic or easy. This has taken the very hard and dedicated work of many committed professionals both within health care as well as in IT services. Even then, the scope of this care is limited relative to what we encounter within a primary care ofďŹ ce on a day-to-day basis. So what is the take home message of this â&#x20AC;&#x153;personal reďŹ&#x201A;ectionâ&#x20AC;?? Electronic records are almost as certain as death and taxes, and can be just as painful. While there is a signiďŹ cant future â&#x20AC;&#x153;upsideâ&#x20AC;? potential to patient safety, we are a long way from the functionality that is currently assumed by politicians and the public. The complexity of electronic-based quality patient care is far greater than any other information systems application in either business or government. Even the full

extent of the complexity is yet to be deďŹ ned, much less mastered. At the end of the day, my personal opinion is that this is a challenge that we, as physicians, must embrace to ensure that it meets the needs of the patients that we serve. There is no one else who can do that for us, for this is a professional responsibility that is uniquely ours. Peter Dehnel, M.D., is the medical director for Childrenâ&#x20AC;&#x2122;s Physician Network and is in private practice at All About Children Pediatrics, Eden Prairie.

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July/August 2008

Universal Pediatric InďŹ&#x201A;uenza Vaccinationâ&#x20AC;&#x201D; How Will We Accomplish This?

BEGINNING THIS FALL, annual inďŹ&#x201A;uenza

vaccine is recommended for ALL children, 6 months to 18 years of age unless they have egg allergy or other medical contraindication.1 This historic vote was taken by the Center for Disease Controlâ&#x20AC;&#x2122;s Advisory Committee on Immunization Practices (ACIP), on February 27, 2008. One of the main points discussed was the issue of implementation of such a sweeping policy. How will we accomplish this? I had the honor of being one of the 15

B Y PAT R I C I A K . S T I N C H F I E L D , RN, MS, CPNP

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July/August 2008

members to vote for this new recommendation that moves us closer to a universal inďŹ&#x201A;uenza recommendation for all Americanâ&#x20AC;&#x2122;s, regardless of age or risk. I was convinced we had met the major hurdles of establishing the disease burden (need), the efďŹ cacy and safety of annual inďŹ&#x201A;uenza vaccine in children, and the manufacturersâ&#x20AC;&#x2122; ability to create adequate vaccine supply to meet demand (a record high of 130 million doses will be available in 2009-2010).2 The last hurdle that was greatly discussed at the ACIP as well as the National InďŹ&#x201A;uenza Summit was implementation of the policy. Questions included: â&#x20AC;&#x153;Who will vaccinate every child in America? Medical home? Schools?â&#x20AC;?; â&#x20AC;&#x153;How will we accomplish this in such a short time?â&#x20AC;?; and â&#x20AC;&#x153;How will we communicate with patients about this change in policy?â&#x20AC;? In actuality, many clinics are reaching most of these patients who are in the current age recommendation (6-59 months, have high risk conditions or are household contacts â&#x20AC;&#x201D; siblings â&#x20AC;&#x201D; of these high priority patients). Many clinics in the Twin Cities already provide inďŹ&#x201A;uenza vaccine to all children. This new recommendation now affords insurance and government coverage through the Vaccine For Children (VFC) program. For those clinics that have not begun to vaccinate all children in their practice, there are many speciďŹ c interventions we can engage in to immunize all children against inďŹ&#x201A;uenza annually. They include: 1. Change the paradigm about inďŹ&#x201A;uenza vaccine being a late fall activity only. We must extend the vaccination season in the front end by beginning to vaccinate all children as soon as we receive vaccine, which manufacturers tell us will begin as early as August and September. Also, extend the season by vaccinating through the entire inďŹ&#x201A;uenza season. In Minnesota, our season peaks in February but can be present

MetroDoctors

well into April and May as is noted for this year with sporadic inďŹ&#x201A;uenza.3 2. Reduce missed opportunities to vaccinate. Consider all visits an inďŹ&#x201A;uenza vaccine visit from late summer through spring. If not to vaccinate, a discussion about inďŹ&#x201A;uenza vaccine and the need to make an appointment for one should be a year-round conversation. Vaccinating hospitalized patients prior to discharge is also effective. 3. Use multiple creative approaches to provide inďŹ&#x201A;uenza vaccine. In addition to vaccinating during well-child checks and scheduled ill visits, consider â&#x20AC;&#x153;vaccine-only visitsâ&#x20AC;? which are parallel track vaccine appointments during regular clinic hours. Special evening and weekend hours or large mass inďŹ&#x201A;uenza vaccine only clinics are an efďŹ cient way to reach numerous patients. Standing orders, a reminder/recall system and strong provider recommendations are proven ways to increase immunization rates.4 4. Communicate well with patients. This can be done through reminder post-cards, a message on the appointment line as patients wait, posters in waiting rooms stating how your clinic advocates inďŹ&#x201A;uenza vaccine, and an inďŹ&#x201A;uenza information line during the peak of inďŹ&#x201A;uenza season that gives updated information about supplies, clinic times, etc. are all helpful ways to increase demand. 1. Tentative MMWR publication scheduled for June, 2008. 2. National InďŹ&#x201A;uenza Summit presentation, May 12, 2008. Euler, Gary, Dr.Ph, MPH. 3. Minnesota Department of Health InďŹ&#x201A;uenza Web site at http://www.health.state.mn.us/divs/idepc/diseases/ ďŹ&#x201A;u/stats/index.html). 4. Centers for Disease Control and Prevention (CDC). Vaccine-preventable diseases: improving vaccination coverage in children, adolescents, and adults: a report on recommendations of the Task Force on Community Preventive Services. MMWR Morb Mortal Wkly Rep 1999: 48(RR08): 1-16.

Patricia K. StinchďŹ eld, RN, MS, CPNP, director Infectious Disease & Immunology Infection Control Childrenâ&#x20AC;&#x2122;s Hospitals and Clinics of Minnesota.

The Journal of the East and West Metro Medical Societies

COLLEAGUE INTERVIEW

Jon S. Hallberg, M.D.

Jon S. Hallberg, M.D. received his medical degree from the University of Minnesota and was a participant in the Rural Physician Associate Program (RPAP). He completed his residency at the Department of Family Medicine and Community Health, Riverside-University Family Practice (Smiley’s) Unit, University of Minnesota, Minneapolis and served as a Bush Medical Fellow. He is board certiﬁed in family medicine. Dr. Hallberg is an assistant professor, Department of Family Medicine and Community Health, University of Minnesota and cofounder and creative director, Center for Arts and Medicine, University of Minnesota. Dr. Hallberg is a regular health and medical analyst on the regional All Things Considered, Minnesota Public Radio. His performing arts medicine includes clinic and on-call coverage for: the Guthrie Theater, Historic Hennepin Theater Trust, JAM Productions, Minnesota Opera, Minnesota Orchestra, Northrup Dance Series, Ordway Center for the Performing Arts, St. Paul Chamber Orchestra and ValleyFair. Questions were provided by: Drs. Lee Beecher, Kathleen Brooks, Edward Ehlinger and Jo Ann Wood.

Q A

What was your major in college? I majored in chemistry, though I really consider myself a liberal arts major. Like many of my freshman classmates, I went to St. Olaf College as a pre-med, and, like some, I was freaked out by all the competition. I spent my ﬁrst year taking care of a lot of distribution requirements rather than typical pre-med classes. Then in the summer of 1985, my grandfather died. It was that experience that convinced me I had to pursue medicine. I was a little behind with the courses I needed, but I found that if I majored in chemistry I could take care of a lot of the required courses, get a major, and still have room for a lot of electives. Most of those electives were in English, biology and religion, and some of my absolute favorite (and most applicable) courses were Expository Writing, Poetry, Religious Traditions of the World, and Shakespeare Seminar.

Your medical career has been unique. Have you had any role models for the path you are taking? If so, who are they? I’ve had (and have) a lot of role models. Since starting med school, I’ve always admired the physician-writers and the physician-poets — indeed, all physicians who live in “two worlds,” the world of medicine and the sciences and the world of the arts and humanities. My early heroes MetroDoctors

The Journal of the East and West Metro Medical Societies

were Lewis Thomas, David Hilﬁker, William Carlos Williams, Richard Selzer, Oliver Sacks, Gerald Weisman, and Sherwin Nuland. Lately, I’ve been inspired by Rafael Campo, Pauline Chen, Danielle Ofri, and David Watts. But I’ve also been inspired by physicians who “simply” practice the art of medicine. These heroes include my medical school advisor, Nancy Baker; residency teachers like Greg Gepner and Patricia Fontaine; my ﬁrst practice colleagues Jerry Mullin and Bill Hedrick; consultant colleagues like Dan Zydovicz, Vic Sandler, Dan Stein, and the late Tom Cheng; and med school colleagues like Greg Vercelotti. From them I learned and saw how to practice, how to listen, and how to care.

Given that you were in the RPAP program, I assume that you were, at one time, considering a more rural practice. What caused you to change that plan? Well, I was born in New Ulm and lived there for almost eight years. Then I lived in Northﬁeld for college. So I felt that living and practicing in a smaller community (especially a small college town) was a very real possibility. I also knew that RPAP was one of the jewels in the crown of the med school; I really wanted to participate in that amazing program. At some point during residency, I realized that for my wife, a band director, to have the best possible job opportunities and ﬂexibility, we’d need to be in the Cities. I also realized that I wasn’t going to do OB, and I was starting to get interested in caring for the creative and performing arts communities. (Continued on page 18)

July/August 2008

Colleague Interview (Continued from page 17)

You have an impressive CV and you’ve done a variety of things…but I’m wondering, can you read a map? (This is an “in-joke” with some of the folks who went with him to help with Hurricane Katrina.) Yes! I’ve always loved geography and maps. I think I get this from my dad and from living in Belgium as a child (from 1973-76). Virtually every weekend and every school break we’d travel somewhere in Western Europe. My wife (jokingly) calls me “compelius,” god of directions, for my uncanny ability to ﬁnd places I’ve never been, to ﬁnd shortcuts I’ve never taken, to get un-lost. When I was in Louisiana, providing relief after hurricane Katrina, I was dubbed (affectionately, I hope!) “Map Boy” by my team. I loved riding shotgun and being the team’s navigator.

Your talents seem to take you regularly to the intersection of medicine and the arts where you are on the edge for both. Do you ever feel “out of the mainstream” of those areas? If so, how do you maintain your unique focus? I never set out to find a way to literally combine a career in medicine and the arts. Had I done so, I think I would’ve failed miserably. It’s all happened in an amazing, serendipitous, organic way. And it’s been great fun! But I do find it difficult at times to stay focused, to not be pulled in too many different directions. I think it’s hard because I don’t see clear distinctions between medicine and the arts, between my life as a physician and as a creative person. I really believe that medicine is easily half science, and half “art.” I’ve been very intentional about keeping patient care as my top priority; it’s never been less than 60 percent of my commitment. One of the hardest things for me, as a clinician-scholar at the medical school, has been trying to make my work “scholarly.” I love to create and try new things; I love to “do.” I’m much less interested in writing about these things for the sake of publishing an article.

Doing the work you do requires high energy. You have to stay current in medicine, and up-to-date in the arts world. How do you maintain your energy? The simple answer is that I love what I do. I love patient care, I love teaching, I love working with MPR, and I love learning. Working with MPR, recording a new piece each week, forces me to review the medical literature, use Up To Date (and a number of other resources), and talk to colleagues. (I know a lot of medical people listen to MPR, so I have to know the material well.) As to keeping up in the arts world, that’s easier. Many of our friends are artists and musicians and we’re very close to several arts organizations, especially the Guthrie and the St. Paul Chamber Orchestra. (We have season ticket packages with each.) But we also love to attend Rose 18

July/August 2008

Ensemble and Minnesota Orchestra concerts when we can — as well as a number of other plays and concerts. As a family, we love movies and we watch several dozen a year. We also read voraciously; I typically read over 20 books a year myself and several more with my kids. Also, since my wife is a high school band and orchestra director, the kids and I attend many musical events to support her. Finally, our kids sing in choirs, take piano lessons, and now our son plays trombone in band. Not a day goes by that we aren’t participating in some kind of artistic, creative endeavor or event.

How does your performing arts background inﬂuence the way you practice medicine? I played the saxophone through college; unfortunately, I’m not really playing anymore. But having that background, being married to a musician-conductor, and having many musician friends, I’m certain that I relate better to performing artists because of it. I can speak their language in a way; I understand the pressures they face; I know the show must often go on. I really admire the level of professionalism I see in performing artists; they’re perfectionists, yet they’re also incredibly creative. I try to apply that to my practice. And because of this background, I think of medical practice in general more creatively than I used to.

What triggered your interest in medicine (given your strong background in the performing arts?). My interest in medicine precedes my interest in the arts by many years. I somehow knew I wanted to be a physician when I was a child, perhaps 9 or 10 years old. (I don’t know why; no one in my family was in medicine.) I didn’t really become aware of my passion for the arts until I was in the St. Olaf Band, making incredible music with amazing musicians, many of whom have become professional musicians and many of whom remain friends. But I suppose my love of the arts was always there. My dad was an engineer and executive at 3M, but he was always making art: paintings, string art, leaded-glass windows. My mom, an elementary school teacher, was and is incredibly creative. And I created my own darkroom in an empty closet at home when I was 12, a couple years after I started playing the saxophone.

What advice do you have for doctors who have little time to spend and listen to their patients? I think we’ve all been there — or are there. I mean really, there’s never enough time to do everything we could or should do for every patient, every time. So the trick is to maximize the time we have. I love the idea of medical homes in primary care — and I really do feel that the more I know a patient, the more efficient I can be with the time we have together. I try to be present, I try to listen carefully. (Through my work with MPR, I’ve learned to listen to the human voice more carefully; I find I now listen more intently, more carefully.) But I’m still trying to figure out how to practice medicine in the best and most efficient ways. MetroDoctors

The Journal of the East and West Metro Medical Societies

I’m constantly learning from colleagues I admire, and, as a result, I’m always trying new things, ﬁguring out new ways to listen, trying to be more efﬁcient.

Do you ﬁnd your celebrity clientele different from your “regular” patients and lessons about modifying current family medicine practices? For example, do you recommend house calls to accommodate patients? First, I should note that my celebrity clientele is a small fraction of my primary care base. For the most part, these patients are more “regular” then we might imagine. The biggest difference is that someone from out of town, who’s here to perform, has an enormous amount of pressure on him or her for the show to go on; there’s little time to get better. That’s challenging. But I try to treat everyone the same. I’m truly interested in people, no matter what they do, where there’re from, or who they are. And yes, I love doing house calls, whether it’s in an arena, backstage, in a hotel, or in someone’s home. When I make one, I feel like a “real” doctor, like I’m returning to the roots of medicine.

How do you get paid for this work and does this inﬂuence your accessibility?

I understand you are building a new clinic across from the Guthrie. What will the focus of this clinic be? The University of Minnesota Physician (UMP) Mill City Clinic is scheduled to open sometime this fall. It will be a full spectrum primary care clinic. It’s going to be in a beautiful space in the new Zenith condominium complex, with the waiting room looking onto the Gold Medal Park. We’ll have extended hours, same-day scheduling, and it will be staffed by an inter-professional team of providers. Our task is to create an outstanding clinic with high patient satisfaction and to be a leader and innovator in what clinics can be. As it gets established, I’d love to see it have a strong sub-focus on caring for the creative and artistic community. All the pieces are falling into place to make this the best performing arts medicine clinic in the country outside of New York City.

Where do you see yourself professionally in 10 years? What will you be doing? In 10 years my new clinic (The Mill City Clinic, across from the Guthrie) will be thriving; I’ll be doing all my patient care there, with a larger amount of my time taking care of performing artists. I hope that I’ll still be working with MPR, possibly with NPR, doing creative health-related work. I also hope that I’ll be expanding the work I do with the arts community, helping to produce lasting creative works that address medical and social issues (like I did with the actor Charles Keating and his piece on aging entitled, “I and I: A Sense of Self”). I’d like to be doing more teaching in the medical school as well.

For lots of reasons I prefer to see all my patients in the clinic. I like this for billing, documentation, liability, and diagnostic reasons. But if I see someone off site (which is rare), I typically don’t charge for the visit. In exchange, I’ll often get tickets for the show, a CD…or a sincere thanks. With my new clinic, I’ll work with UMP to ﬁgure out an easier way to register a new patient off-site and arrange for billing. So far, doing off-site visits has never affected “Remarkable my accessibility; I always do them after hours.

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As a psychiatrist I am interested in your take on helping your celebrity artists from a psychological perspective — how this relates to “spirituality” doctoring and mental therapies? I am awed by performing artists. Their ability to perform with near perfection day after day, night after night, while playing, speaking, singing, dancing, is simply amazing. They are perfectionists, yet they’re creative and adaptable. Though they seem fearless on stage, many deal with anxiety and stage fright. Though some take medications for this, many of them focus instead on pre-performance rituals, such as deep breathing exercises, meditation, yoga, or exercise. I (we) can learn a lot from them.

Charles E. Crutchﬁeld III, M.D. Board Certiﬁed Dermatologist

Psoriasis &

Acne Specialist Your Patients will Look Good & Feel Great with Beautiful Skin www.CrutchﬁeldDermatology.com

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July/August 2008

Intentional Culture Change: Working Better Together

ALTHOUGH RECENTLY retired I am still

associated with Suburban Radiologic Consultants, a large private radiology practice in the Twin Cities. My journey into this topic actually began over four years ago, when St. Catherine’s College sponsored a conference entitled: “An Abuse-Free Work Place in Medicine.” It was rather fortuitous that I wound up attending that conference, as it has really made a significant difference in our practice. We started with a process of culture change, naming our project a “Healthy Environment Initiative” or HEI. It is somewhat unique in that it is cross-corporate, spanning both Suburban Radiology and the Fairview Hospital System whom we invited to partner with us in this effort. The Fairview side of the equation includes the radiology departments at Fairview Ridges in Burnsville, Fairview Southdale, Fairview University Riverside Campus and Faiview Lakes Hospital in Wyoming. Our radiologists wanted to include this hospital component because a large part of our practice is carried out in the hospital setting. We have been very gratified by this decision as Fairview has been a very willing and actively helpful partner with us in HEI. The question commonly comes up… “Why are you doing this?” The implication is that we must have had some horrific problems in our practice. The answer is “No, we did not.” Suburban and Fairview were already good places to work, but there is always room for improvement. Every work place has issues and it is best not to ignore them. In my experience, abusive behaviors in the workplace are commonly ignored as irritations that blend into the routine. Only the less com-

BY ROB LUND, M.D.

July/August 2008

mon “blow-ups” get people’s attention. Still the destructive effects are there under the surface just the same. It is like friction in a machine you would like to think is well oiled. The ﬁrst step for us was to recognize and name these for what they really are. Suburban Radiology is a busy practice with about 400 employees who work at numerous sites. If some of those points of friction were going to get addressed, there needed to be: s More clarity on what really constitutes abusive or healthy behavior. s Recognition of abusive behavior when people see it. s Conversation about this issue. s Raised expectations for how we will be treated at work. s And, these new expectations needed also to apply to how we treat others. Our job as the HEI committee was to help this process of change actually happen across the whole continuum of job descriptions. One of the strategies we used to accomplish this was our skits program. For each of the last two years we have written six skits that illustrated abusive situations at work with respectful resolutions. Volunteers from Suburban and from Fairview were our actors and actresses. The skits were videotaped and made into a DVD that was shown at numerous small employee meetings. We had great fun doing the skits and people loved seeing their co-workers acting parts. They especially enjoyed seeing radiologists and managers who took roles. The skits have been a wonderful icebreaker technique for engaging people in this conversation about abusive behavior. In my own experience, the radiologists in our practice have a much more powerful role in setting the tone for an ofﬁce or department than they realize. None are ever out to MetroDoctors

be “nasty” to the technologists, but on a busy day, poorly chosen words or a sharp comment made under stress, can easily lead to a bad outcome. The radiologist will probably be oblivious to the ripple effects that change the mood of the whole ofﬁce for the rest of the day. The radiologist is stressed. The technologist may feel unjustly chastised and worse, probably feels powerless to change the situation. We will return later to this scenario. A couple of years ago our HEI committee developed what we call our “One-on-One” algorithm for conﬂict resolution. We did training for employees on how to use it as a guide in preparing to speak to that one co-worker whose behavior is a problem. It might just be grouchiness, or a cubicle radio that is too loud. We presented this as a workable alternative to just reporting the problem to a supervisor. Supervisors spend way more time than we would ever imagine dealing with squabbles between employees. Encouraging people to try a Oneon-One resolution has not only relieved some of the burden on supervisors, but results in

The Journal of the East and West Metro Medical Societies

a much more satisfying resolution. The “offender” doesn’t feel reported, and the one who initiated the “can we talk” conversation is usually surprised at how easy it was and gets a boost in self-esteem for having pulled it off! I’ve heard many stories about such encounters. These resolutions, however, don’t work in a vacuum; they very importantly happen in a context. Everyone in our practice knows what HEI is all about. It is about a level playing field when it comes to treating others with respect. It is a part of our culture now and an expectation we have for ourselves and each other. The simple mention of HEI immediately brings all this to mind and it undergirds those Oneon-One conversations in a way that tends to shepherd them to a good conclusion. Now in our fourth year of HEI, I’ve heard story after story of technologists who, on a stressful day (remember the scenario we left earlier?), venture forth to talk to a radiologist about his or her behavior, and are surprised and gratified to find a receptive attitude on the part of the radiologist. Again it is the HEI context that gives the technologist the courage to speak up, and the radiologist the receptivity to listen. The radiologist is typically a bit surprised, chagrined to be so clueless, but pleased for the opportunity to clear the air and make amends. The technologist, on the other hand, feels elated and newly empowered to be a respectful agent of change when such situations arise. “HEY, we can talk to each other!” That sort of attitude can be infectious in a department and everyone benefits. New employees at Suburban Radiology and in Fairview radiology departments are now getting some HEI training to help them transition into their new positions. The HEI culture is something we want new employees to understand and embrace, as they are in many ways our future.

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So, have we solved all the problems? Certainly not! Do bad interactions still happen? Yes they do. Is life at work better? Absolutely! We are encouraged, but there is certainly much yet to be done. Does HEI have a future? Very deﬁnitely! Even the most entrenched (Continued on page 22)

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July/August 2008

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ivotPointâ&#x20AC;&#x2122;s beginning started at Hennepin Medical Society in 1984 with the creation of Responses, Inc. Its mission was to prevent family abuse. In 1990 Responses, Inc. evolved into Respond 2, Inc. focusing on behavior at work. In 2008 Respond 2, Inc. was renamed PivotPoint, changing business by changing behaviors. Consistently applied throughout all these years of experience, a 5-stage, 18month process has driven success. Drs. Rob Lund and Lorraine LaRoy co-lead the SRC/Fairview Radiology 5-Stage Process with stellar results. The 5-Stage Process is not a clinical trial, nor is it a traditional quality improvement project. It is a collaborative model, based on action learning and action research theory. The goal is to increase healthy behavior and eliminate harmful behavior at work. Healthy behavior drives it allâ&#x20AC;&#x201D;engagement, innovation, open communication, respect, and performance. How we treat each other

July/August 2008

Intentional Culture Change (Continued from page 21)

skeptics are now starting to come forward and express appreciation for what this process has done for our workplace.

skeptics. Without tenacity the whole project might collapse. A critical part of tenacity is a committed core of workers. It may be only one or two, but you need those people to carry the project across the ruts and hard times.

In conclusion, I thought it might be helpful to outline what I see as key elements to building and maintaining a healthy interpersonal work environment.

4. Patience: Donâ&#x20AC;&#x2122;t expect glowing results in six months or even a year. Culture change is slow, so be patient.

1. A Vision of the Goal: What do you want your workplace to look like in two, four or six years? This is a combination of both deďŹ ning hopes and reigning in unrealistic expectations.

5. Long-Term Commitment: That new culture of respect will never be selfmaintaining. It will need nurturing. Like your house, if you donâ&#x20AC;&#x2122;t maintain it, it will gradually fall apart.

2. A Plan to Get to the Goal: Suburban Radiology addressed this by contracting with a consultant for developing a plan. This worked beautifully for us. Trying to do it on our own would have been much more difďŹ cult.

6. Have Fun Doing This! If it ever deteriorates to drudgery, your project is on its way to extinction. New people on the team add new energy. There is plenty of room for creativity, so keep it fresh.

3. Tenacity: Expect ruts in the road and challenging roadblocks. Expect naysayers, pessimists and

Rob Lund, M.D. is a retired radiologist with Suburban Radiology and has served as co-chair of the HEI project from its inception.

at work is measurable and is directly linked to patient experience and care. This is all about engaging the brainpower of everyone, ďŹ rst-line to senior leadership.

Stage 4: EVALUATION â&#x20AC;&#x201C; Concrete outcomes are identiďŹ ed, measured and used for tracking, trending, and analysis. 3-24 months

Stage 1: TEAM BUILDING â&#x20AC;&#x201C; A 12-18 member team is formed which reďŹ&#x201A;ects the job, role and staff diversity of the health care workplace. The team meets once a month for an hour over an 18-month period. 1-3 months Stage 2: ASSESSMENT â&#x20AC;&#x201C;The staff is surveyed and the results are shared and used to develop an action plan. (62,000 survey respondents in database) 2-6 months Stage 3: IMPLEMENTATION â&#x20AC;&#x201C;The team develops an action plan with a timeline and measurable outcomes. 4-18 months

Stage 5: HARDWIRING â&#x20AC;&#x201C;The work of the team is used in hiring, employee orientation, performance reviews, accountability and improving patient care and experience. Begins month 4-ongoing The following outcomes have been experienced in 125 health care organizations, large and small: broad engagement by 90 percent of staff; 50 percent drop in turnover; $90,000 yearly savings in recruitment; 85 percent drop in grievances; 15-25 percent drop in reported employee medical problems; 25 percent increase in employee satisfaction; and 40 percent increase in patient satisfaction. Deborah Anderson, PivotPoint.

MetroDoctors

The Journal of the East and West Metro Medical Societies

Creating a Better Experience for our Caregivers

PHYSICIANS, DOES THE following sce-

nario sound all too familiar? “You’re busy seeing Margaret, a longstanding patient in the middle of a busy afternoon schedule. As you’re finishing up with her, she begins to ask your professional advice on obtaining home-based services for her elderly father who has multiple needs. You quickly discover that Margaret has become the primary caregiver for her aging parent who wants to remain independent in his home. You sincerely want to help your patient, but you know this conversation will cause you to be 15 more minutes behind your appointment schedule, and other than limited exposure to some senior services organizations or home care companies; you likely won’t have the kind of specific information Margaret will need. Both you and your patient leave this encounter dissatisfied; you because you couldn’t be more helpful to a longstanding patient, and your patient because she remains frustrated and unsure about where to get help. Margaret’s situation is becoming all too familiar and will become even more so as Minnesota’s baby boomers begin to reach age 65. In fact, the number of Minnesotans over age 65 is expected to double to 1.3 million by the year 2030. As this number of Minnesotan’s over 65 increases, so will the number of Minnesota caregivers, currently estimated at 610,000. Family members, community organizations, and commercial businesses will scramble to meet people’s desire to age independently and safely in their own homes. For physicians in many practices, if you have not yet experienced the type of questions suggested above, chances are good you will in the future. Until now there has not been a single, B Y M I C H A E L P. C O R N E L I S O N A N D STEVE J. KNUTSON

MetroDoctors

comprehensive resource that gives your patients who fulfill this important caregiver role, the tools needed to effectively manage and resource their caregiving needs. This is one reason underlying Margaret’s inquiries during her visit. This is not to suggest that there are not good resources in the market today that provide assistance to caregivers and seniors — there are. However, the task of being a caregiver continues to be much more difficult than necessary. Fragmentation of resources, uncoordinated services and the lack of meaningful tools all contribute to common complaints such as high stress, problems in the workplace, financial difficulties, diminished health status and life balance issues to name a few. Well, there’s a new and unique product being introduced that might make your next such encounter with a caregiver patient a bit more satisfying for both of you. Independent Home Living, LLC (IHL) is a new organization that has been designed specifically to create better experiences for our caregivers. This is accomplished through a comprehensive one-stop solution that will assist caregivers in assessing their needs, identifying resource options, choosing a course of action and accessing services. The system also provides mechanisms to effectively manage the day-to-day details of caring for a loved-one. This unique approach to addressing caregiver needs is based upon the following fundamental principles: s Empowering the Caregiver.

Many people are unwilling or ﬁnancially unable to pass caregiving responsibilities for loved-one’s along to a hired, professional caregiver. These individuals desire to be closer to the daily/weekly provision of care. And, like other important aspects of

The Journal of the East and West Metro Medical Societies

our lives, want to exercise a certain amount of control over this activity. However, historically this option has been very difﬁcult for a caregiver to achieve due to a number of factors including the fragmented nature of resources and lack of meaningful tools. We strongly believe that individuals should have a realistic option in caring more directly for their loved ones by eliminating many of the barriers typically associated with this activity. s Making Sense of Available Resources.

When faced with the responsibility of being a caregiver, almost everyone attempts to identify helpful resources. These resources often include family members, friends and neighbors who are often times willing to participate in caregiving activities. There are also religious groups and numerous other non-profit organizations currently available to provide services to seniors. And, of course, there are also a wide variety of commercially-based senior service organizations. We are fortunate that most communities in our 11 county metropolitan area have numerous resources available to support those wishing to live in their homes. However, finding and accessing the right resources for a given loved-one’s particular needs is a guaranteed problem for caregivers. Especially for new caregivers. The market is simply too fractured and confusing for non-professionals to navigate (in fact, even some industry experts experience this difficulty). In response, we have worked extensively to identify all resources available today and created an easy-to-understand approach to determine and access the right services for each individual (Continued on page 24)

July/August 2008

Better Experience for Caregivers (Continued from page 23)

s Managing Daily Caregiver Details.

situation. Linked with certain educational components, the caregiver simply indicates her loved-one’s zip code and the full array of available resources are displayed. Remember that your family, friends, neighbors and community-based organizations can all be considered resources and are included in this approach. We have also made accessing services easier as well. Through the use of the integrated calendar and e-mail tools, arranging for Aunt Maria to provide an every-Tuesday meal, or arranging a ride to the doctor’s ofﬁce from a transportation vendor, is just a few clicks of the mouse away. Using these tools, caregivers will be less burdened from making a large volume of telephone calls to arrange for services and can do so at a time more convenient to the caregivers schedule. Also available is a mechanism to understand the quality and cost of vendors who provide services to seniors.

July/August Index to Advertisers Advanced Skin Care Institute ...........................22 Billing Buddies ......................................................27 Burnet Birkeland ................... Inside Back Cover Children’s Physician Network ............................... Outside Back Cover Classified Ads.........................................................15 Crutchfield Dermatology...................................19 Healthcare Billing Resources, Inc. .................... 6 Hennepin County Medical Center...................... Inside Front Cover Lockridge Grindal Nauen P.L.L.P. .................... 6 Medical Billing Professionals, LLC.................21 Minnesota Physician Services, Inc. .................13 Minnesota Epilepsy Group, P.A.......................21 The MMIC Group ..............................................15 Neurosurgical Associates, Ltd................................ Inside Back Cover ProSource .................................................................. 3 Uptown Dermatology & Skin Spa, P.A. .......26 Weber Law Office ................................................16

July/August 2008

Many caregivers are employed full-time and have children of their own living at home. As a result of their additional responsibilities, many caregivers report increased stress levels and a diminished quality of daily life. Although it is not feasible to eliminate all drivers of increased stress, we believe many can be positively impacted. We have created a number of Web-based tools that are designed to assist in the daily management of care. For example, a scheduling and calendar system keeps track of all care activities, including details of the speciﬁc activity. This calendar is automatically updated when Aunt Maria agrees to provide an every-Tuesday meal or when the transportation service agrees to provide that ride to the doctor’s ofﬁce. This utility can be made available to multiple parties (security enabled) in order to coordinate multiple care activities. Communication tools have also been developed to limit the time commonly spent repeating the same update message to those involved in your loved-one’s care. Now, communicating between your family, friends, neighbors and other care providers is made easy. s Educating the Caregiver.

Education is absolutely critical in helping individuals assess their own unique caregiving challenges, create realistic options and choose an appropriate course of action. The needs of loved-ones can vary greatly based on a number of factors — there is no single formula for successful caregiving. Robust education and checklist tools are a must, in addition to links to deeper, more speciﬁc information that a caregiver may desire (e.g. disease speciﬁc sites such as Parkinsons, Alzheimers, etc.) s Safety and Security.

There is a signiﬁcant and legitimate concern over the safety and security of our vulnerable loved ones. Today, if you contact an organization to transport your mother to her doctor visit, you don’t always know who will be showing up or if they have potentially fraudulent motivations. We are committed to integrating the right safeguards and security features to protect both the caregiver and the care recipient.

MetroDoctors

The following are a few additional facts that could apply to your patient Margaret, and her caregiver situation. s Margaret fits the average age/sex profile of a caregiver; 46 years old, female, some college education. 80 percent of all caregivers are female. s Margaret may be experiencing negative health related issues of her own as a result of her caregiving activities. According to one recent study, 41percent of caregivers say their health has gotten “a little worse;” 44 percent say their health has gotten “moderately worse;” and 15 percent say their health has gotten “a lot worse.” s Margaret is part of a caregiver group that provides over $7.1 billion in unreimbursed care in the state of Minnesota annually ($350 billion nationally). In Minnesota, for every 1 percent decline in family caregiving, it costs the public sector $30 million. s There is a good chance Margaret is employed. Almost one in five (19 percent) of the national workforce is in a caregiving role. Now let’s return to your exam room encounter with Margaret. Wouldn’t it be great if you could immediately respond to Margaret’s inquiries with an easy answer? Imagine if you could direct Margaret to an IHL link located on your practice’s Web site to answer her questions and to provide her with a onestop spot to obtain additional resources. You would have the professional satisfaction of meeting the needs of your patient, enhancing the quality of care for your patient’s loved one and you would not find yourself running further behind your afternoon’s schedule due to an unanticipated patient conversation. Look for more information on this product in the coming weeks. Michael P. Cornelison is the Founder and CEO of Independent Home Living, LLC, an organization dedicated to empowering caregivers to create successful caregiving experiences. Mike can be reached at: mcornelison@ihlcaregiver.com. Steve J. Knutson is a partner with ConsentiaHealth, Inc., serving the health care industry by providing a variety of business and managed care services. Steve can be reached at (651) 247-6726.

The Journal of the East and West Metro Medical Societies

St. Francis Serves Scott and Carver Counties The MetroDoctors editorial board has invited several hospitals located in the east and west metro communities to submit an article that would “showcase” their hospital and community health outreach initiatives. St. Francis Regional Medical Center is the third hospital to be highlighted in this series.

intensive care rooms, 17 family birth rooms, eight children’s care pediatric rooms, 18 sameday surgery rooms, ﬁve operating rooms and one C-section suite, 21 emergency room treatment bays and two endoscopy rooms. Partners’ Commitment

St. Francis entered into a unique partnership to build a hospital whose foundation consisted of more than bricks and mortar...our hospital was built on partnerships. This commitment simply stated that we would make lives better by providing the ﬁnest health care services in the area. This reality — of health care partners working hand in hand to bring state of the art facilities and technology to our communities — is one of which we are very proud. Our mission is to provide all people the healing experience we would expect for ourselves and our families. After recent years of explosive growth within our communities, we’ve completed expansion projects that bring even greater capabilities for services our patients previously had to leave the community to get. A History of Partnership

We are proud of our rich history of cooperation. Founded by community members and the Franciscan sisters in 1938 out of a spirit of care and concern, we were entrusted to the Benedictine Sisters of St. Scholastica in 1987. Knowing that partnership was a good way to address the increasing complexity of health care, the Benedictines partnered with the organization that became Allina Hospitals and Clinics in 1993. Allina serves as our managing partner on campus. To meet the increasing demand for specialty services in our area, Park Nicollet B Y M I C H A E L B A U M G A RT N E R , C E O St. Francis Regional Medical Center

MetroDoctors

Health Services also became a partner in 2001. Today, the Benedictines continue their ownership of St. Francis through Essentia Community Hospitals and Clinics. Partnership in this complex environment cannot be mere ideology, it must be intentionally nurtured. As Dr. Brian Prokosch, medical director has said, “When you have three partners, you have to walk the walk.” We must put the patient ﬁrst, and that will always involve working together. Partnerships Bring Greater Access to Care

This unique structure enables us to combine the caring and compassion of a community hospital with the modern medical technology, specialties and services found in the metro area. We provide a full range of inpatient, outpatient and emergency care services on a collaborative medical campus with more than 30 other providers. St. Francis primarily serves residents in Scott and Carver Counties, including Shakopee, Jordan, Chaska, Prior Lake, Savage, Belle Plaine, and Carver. We currently have 86 private hospital rooms (private bedroom and bathroom) (93 licensed), 53 medical/surgical rooms, eight

The Journal of the East and West Metro Medical Societies

We value the contributions of our physician and clinic partners, not only as providers of quality health care, but as community and organizational leaders. Recognizing the need for strong medical services in this rapidly growing area, they have committed to meeting that growth with added resources and services. We currently have 400 total medical staff. This is an increase of over 100 percent since 1996, illustrating the rapid growth we have experienced in this part of the Twin Cities metro area. And we continue to grow. We will welcome a Hospitalist program, new OB/Gyn practice and neonatal nurse practitioners in the next few months. Our oncology and spine surgery programs continue to grow as well. Partnership Strengthens Mission

We maintain our identity as a ministry in caring partnership with our sponsors, the Sisters of St. Scholastica Monastery in Duluth. We continually look for ways to increase the understanding of our identity and make it visible to our employees, volunteers, medical staff, patients, families and the community. Our identity inspires each of us to live our mission more fully. Community Beneﬁt; Living the Mission in the Community

Although our rapidly growing community is quite prosperous, as a faith-based hospital (Continued on page 26)

July/August 2008

St. Francis (Continued from page 25)

we are called to give special concern for those in need. The strength of our community benefit program is one way we demonstrate this concern. We rely on the Catholic Health Association (CHA) and VHA guidelines for tracking community benefit, using these standard guidelines; we have estimated our annual community benefit for 2007 to be $5,442,000. Our real community benefit story is about the lives we touch through our varied programs. Community Partnerships Yields Big Payoff for the Uninsured and Underserved

We are proud of the innovative way we are able to help provide access for the uninsured and underinsured through the River Valley Nursing Center. Our partners on the Nursing Center include Scott and Carver County Public Health Agencies, our campus clinic partners, the Allina Medical Clinic, and Park Nicollet Clinic-Shakopee, St. Mary’s Health Clinics, and the CAP (Community Action Program) Agency.

The Nursing Center is a unique model we would like replicated in other places; combining public health nursing care with social service referrals. In this model there is an emphasis on prevention, with an independent public health nurse and bi-lingual outreach worker providing public health nursing care, education, and social service referrals in a warm, compassionate and friendly environment. Since opening, the Nursing Center has

Uptown Dermatology & SkinSpa

Welcomes Phil M. Ecker, M.D. Mayo Trained Dermatologist. Dr. Phil Ecker joins the staff of Uptown Dermatology & SkinSpa and specializes in Medical, Surgical and Cosmetic Dermatology. Same week appointments available. We are conveniently located in Uptown Minneapolis-one block east of Calhoun Square. We accept all major insurance and offer free parking. Call us at 612-455-3200 to schedule an appointment. Treat your skin. Transform yourself.

Phil M. Ecker, M.D. Dermatologist

Uptown Row, Suite 208 & 1221 W. Lake Street & Minneapolis, MN 55408 612-455-3200 & www.UptownDermatology.com

July/August 2008

MetroDoctors

helped over 1,000 uninsured and underinsured clients. Even though the majority of the clients are working, the cost of insurance continues to be a barrier to obtaining care. Although visits to the Nursing Center are often prompted by the client’s unmet health need, due to the unique partnership that has been developed, a vast number of clients also have a need for housing, food and fuel. The social service referral component of the project is able to help clients meet these needs. Soon after the Nursing Center opened, an unemployed and uninsured gentleman was leaving the Shakopee Workforce Center (located adjacent to the Nursing Center), on his way to the St. Francis Emergency Department. He was suffering from an oral infection that began in his mouth and was spreading down his neck. Seeing the Nursing Center sign, he decided to see what it was all about. The Nurse Coordinator was able to schedule an appointment for the client at a dental clinic at the University of Minnesota. The cost of the visit would be $300. The client had $300, but it was his rent money. Because the partnership includes the social services sector, the on-site outreach worker knew of a program providing emergency services funds through the CAP Agency. These funds are not available to people for dental bills, but they are available for housing assistance. The client was ultimately granted $300 toward his rent, used his own $300 for his dental bill and, most importantly, received appropriate care. This story gives all of us a glimpse into the daily life and challenges of our uninsured and underinsured patients. St. Francis has been a proud partner and supporter The Journal of the East and West Metro Medical Societies

of the Nursing Center since its inception. Our physicians refer patients to the Nursing Center, our staff members sit on its board and the hospital and St. Francis Foundation have donated over $100,000 to this project in the past and for the coming year. We are conďŹ dent that the Nursing Center will continue to be a very important part of the safety net for uninsured and underinsured people living and working in our community. Partnering for Community BeneďŹ t

We ďŹ nd working collaboratively with others in the community leads to increased ease of use for our community members. Listening to our local public health agencies and other community health and social service providers allows us to address additional community health needs. A sampling of additional programs and services offered to our community include: s As part of the Partnership for a Smoke Free Scott County, St. Francis provided support to pass the stateâ&#x20AC;&#x2122;s Freedom to Breathe legislation. We continue to support efforts to prevent erosion of this law. s Emergency department nurses are trained in EnCARE, a program to educate teens about the dangers of drinking and driving,

using stories and footage of real people and real events. This program has been experienced by thousands of young people in our community because of our partnership with our local driversâ&#x20AC;&#x2122; education programs. In 2007, alone, it was seen by over 450 students. s We offer a Breast Feeding Support Group to aid breastfeeding mothers before, during and after the birth of their babies. This group is open to all members of the community, regardless of where they delivered their baby. The Breast Feeding Support Group is staffed by a lactation consultant from our Breastfeeding Support Center and builds on work done through the Carver/ Scott Breastfeeding Coalition. s Our community health fairs have unique themes. Weâ&#x20AC;&#x2122;ve hosted a Community Wide Family Safety Fair and will host our second Community Baby Fair this year, with sessions on a wide array of topics offered, from Car Seat Safety (a compliment to our Car Seat Safety Classes and Clinics) to Pre/Postnatal Yoga, Baby Sign Language, and childrenâ&#x20AC;&#x2122;s behavioral issues. s This summer we will partner with local daycare providers to share the Power Hour

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program, which combines fun physical activities and challenges with learning about health and nutrition for elementary age students. s Physical therapists from St. Francis are on hand at local sporting events through our Sports Care Program. Over 12,000 students beneďŹ ted from these services in 2007. s Our nutrition services staff continues to prepare nutritious meals each day to support our local Mobile Meals program. In 2007 over 4,600 meals were prepared for delivery by local volunteers. s We knew that due to our large Emergency Department volume we would be able to assist a large number of currently uninsured patients with enrollment into government sponsored health care programs. Our ED ďŹ nancial counselors help hundreds of people with these complicated applications. The partnerships we form in our community are as valuable to us as the partnerships we have on our campus. We are excited to be strengthening healthy communities, creating healthy workplaces and partnering with patients and families to provide access to the ďŹ nest health care services in the area.

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The Journal of the East and West Metro Medical Societies

July/August 2008

PRESIDENT’S MESSAGE PETER B. WILTON, M.D.

Minnesota’s New Health Care Legislation EMMS Ofﬁcers

President Peter B. Wilton, M.D. President-Elect Ronnell A. Hansen, M.D. Past President V. Stuart Cox, M.D. Treasurer Thomas Siefferman, M.D. EMMS Elected Board Members

Arthur A. Beisang III, M.D., Director Peter J. Boosalis, M.D., Director Peter J. Bornstein, M.D., Director Katherine M. Clinch, M.D., Director Charles E. Crutchﬁeld III, MMB, M.D., At-Large Director Laura A. Dean, M.D., Specialty Director, Obstetrics & Gynecology Andrew S. Fink, M.D., At-Large Director James J. Jordan, M.D., Director Nicholas J. Meyer, M.D., Director Robert C. Moravec, M.D., At-Large Director Anthony C. Orecchia, M.D., Director Jerome J. Perra, M.D., Director Lon B. Peterson, M.D., Director Scott A. Uttley, M.D., Director Marie L. Witte, M.D., Director EMMS Appointed Board Members

Stephanie D. Stanton, M.D., Resident Physician Linnea K. Engel, Medical Student Jo Ann Wood, M.D., Young Physician MMA Ofﬁcers and Board Members

Lyle J. Swenson, M.D., MMA Speaker of House Todd D. Brandt. M.D., MMA East Metro Trustee Charles G. Terzian, M.D., MMA East Metro Trustee David C. Thorson, M.D., MMA East Metro Trustee EMMS Ex-Ofﬁcio Board Members & Council Chairs

*Arthur A. Beisang III, M.D., Public Policy Council Co-Chair Blanton Bessinger, M.D., AMA Alternate Delegate *Peter J. Boosalis, M.D., Public Policy Council Co-Chair *Peter F. Bornstein, M.D., MPS, Inc. Chair Richard J. Burton, M.D., Sr. Physicians Association President Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., Professionalism & Ethics Council Chair Neal R. Holtan, M.D., Community Health Council Chair Frank J. Indihar, M.D., AMA Delegate, Chair of MN Delegation Mark Kleinschmidt, Clinic Administrator *Anthony C. Orecchia, M.D., Education Resource Council Chair Kent S. Wilson, M.D., EMMS Foundation President *Also elected EMMS Board Member EMMS Executive Staff

Sue A. Schettle, Chief Executive Ofﬁcer Katie R. Snow, Executive Assistant Doreen M. Hines, Manager, Member Services

July/August 2008

HEALTH CARE REFORM was a major focus of the recent legislative session. After the governor rejected a health care reform bill from the House and Senate, intense last-minute negotiations produced a compromise — a process complicated by the budget deﬁcit of almost a billion dollars. The Health Care Reform Bill addresses public health, advances the concept of “health care homes,” begins the process of reimbursement reform to reward complex care coordination, and increases care access. Most of the provisions of the new bill were aligned with the MMA’s “Physicians’ Plan for a Healthy Minnesota,” the reform plan outlined by the MMA in January 2005. The major components of the bill are: s Standards for “health care homes’’ are to be developed and implemented, focusing initially on chronic conditions. Provision is made for reimbursement based on care coordination for these conditions. Ambiguously—and possibly ominously—if savings do not accrue from this model, the commissioner of human services “may make recommendations to the legislature on reallocating costs within the health care system.” s Access to MinnesotaCare is expanded to another 13,000 uninsured patients. s Payment reform to give providers incentives to reduce health care costs, improve quality and provide more price transparency. This includes a peer grouping system that ranks providers based on cost and quality of care, to be operational by 2010. s “Baskets of care” will be established for at least seven chronic diseases. Providers billing for these baskets must use a single price for all private payers. s Employers with 11 or more employees must offer Section 125 Plans, allowing their employees to purchase health care insurance with pretax dollars. The bill was also notable for what it did not contain. Missing from the ﬁnal package was the so-called “Level 3” provision, under which physicians and health care entities would submit bids to cover the total cost of medical MetroDoctors

care for a population — a return to the failed concept of capitated care. This proposal was opposed by the medical community, and vigorous advocacy efforts were made by the EMMS, WMMS and MMA to explain the pitfalls of this approach and oppose its passage. We are gratiﬁed that our efforts were rewarded. But though it was missing from this year’s bill, the concept still has support at the legislature and it may well reappear in the future. Other objectionable proposals omitted from the ﬁnal package include a 3 percent cut to physician outpatient services, new prior authorization requirements for services and procedures, and a licensing fee increase for professional licenses. In addition to opposing the Level 3 provisions, advocacy efforts prevented a raid on the Health Care Access Fund for general budget balancing. There will be a one-time transfer of $50m from the fund to the General Fund, to be repaid once cost savings due to measures in the bill reach the $50m mark. This “loan” is certainly better than the original proposal (a transfer of $250m, and $48m annually thereafter). Nonetheless, we remain adamantly opposed to the Provider Tax, and if we are to be saddled with this unfair tax, we continue to insist that the Fund be used for its named purpose: health care access. Cost concerns will not be solved by this legislation alone, and we anticipate further reform initiatives. Commissions, work groups and advisory councils authorized by the current bill will monitor the health care system and attempt to improve it. Future changes are unlikely to be favorable to the physician community, with increasing demands in the face of diminishing reimbursement. It will require vigilance from physicians and their representative societies to inform the debate, and to protect our patient’s interests from misguided legislative initiatives. The EMMS stands ready to act on your behalf. The Journal of the East and West Metro Medical Societies

EMMS Foundation Works on Advance Directive Project

sites could serve as the training ground for a more impactful program. This collaborative concept originated in La Crosse, Wisconsin in the mid-1990s and came together as a result of a community need. Their model is called “Respecting Choices” and it effectively takes the wishes of the patient and puts it in the hands of the health care workers who need the information.

ast Metro Medical Society Foundation and HealthEast Care System, have jointly sponsored the “Caring Hearts for Homeless People,” supply drive for 16 years. It was held this year from February 1 through February 28, 2008 and was very successful. We collected medication and personal hygiene items for St. Paul programs that offer services to homeless people. In addition to area clinics and HealthEast’s staff, faith congregations and area schools participated in the drive. This year 11 medical clinics, 20 congregations, the HealthEast Care System, and many volunteers from the former Ramsey Medical Society Alliance, Thrivent Corp., Boy Scout Troops, and Scandia Elementary pitched in to collect and sort over $43,054 (5,058 lbs.) worth of hygiene and medical supplies. Supplies are distributed to Health Care for the Homeless, Listening House of St. Paul and SafeZone. In addition, over $6,000 in cash contributions was collected. These organizations rely heavily on donated medications, hygiene supplies, toys, juice and monetary donations to help meet the physical, emotional and mental health needs of their clients. This drive contributes the majority of their supplies needed for the entire year. Carole Nimlos coordinated the activities of the former RMS Alliance members who donated their time by picking up the donations from the 11 participating medical clinics and delivering items to the main drop-off site at St. Joseph’s Hospital. Organizations interested in participating in the February 1-29, 2009 supply drive should contact Doreen Hines at (612) 362-3705 or e-mail: dhines@metrodoctors.com. Cash donations can be sent anytime to the EMMS Foundation, P.O. Box 131690, St. Paul, MN 55113. Please indicate that it is for Caring Hearts.

MetroDoctors

The Journal of the East and West Metro Medical Societies

Caring Hearts Planning Committee members help with the sorting of donated items. From left: Doreen Hines, East Metro Medical Society, Sister Marian Louwagie, HealthEast Care System, Helene Freint, program director, and Kali Aro, ofﬁce coordinator, Health Care for the Homeless.

Thank you to the clinic managers, staff, and physicians of the following clinics that participated: s Advanced Skin Care Institute s Allina Medical Clinic – Shoreview s Aspen Medical Group – Highland s Associated Nephrology Consultants, P.A. s Dermatology Consultants, P.A. s Minnesota Medical Joint Services Organi-

zation (MMA, WMMS, EMMS) s Partners Obstetrics and Gynecology, P.A. s St. Croix Orthopaedics, P.A. s St. Paul Infectious Disease Associates, Ltd. s St. Paul Surgeons, Ltd. s University Afﬁliated Family Physicians

– Phalen Village Clinic

July/August 2008

Metro Medical Society

Next steps… The EMMS Foundation will work over the summer months to identify key stakeholders who may be interested in this type of collaborative effort. Key stakeholders include physicians,

hospitals, hospice programs, faith based organizations, nursing, social workers, and many others. The EMMS Foundation will then convene a conference in the late summer where key stakeholders can come together in a room where the issue can be discussed further with a goal of having the group come to a consensus as to next steps. If the conferees feel as though there is merit in pursuing a more formal collaborative, the EMMS Foundation will serve as the catalyst for making this happen. The date for the conference is tentatively set for August 5, 2008 at the U of M Continuing Education Conference Center.

East

he East Metro Medical Society Foundation recently received support and a matching dollar for dollar ﬁnancial commitment from the EMMS board of directors to be used for a project that has the potential to have a signiﬁcant impact in the way that advance directives are carried out in the east metro. The goal of the project is to make accessible the wishes of the patients by coordinating across systems information that is needed in the course of a patient’s treatment. Realizing that this would be a long-term commitment for EMMS, it would be the goal to start small, in the east metro, with pilot sites. These pilot

East Metro Medical Society Holds Caucus

In Memoriam

JESSE E. EDWARDS, M.D., a physician who revolutionized cardiology by using pathology to identify heart disease, died of heart failure on May 18 at the age of 96. Dr. Edwards earned his medical degree from Tufts University Medical School. He commanded an Army medical lab unit in Europe during World War II and was part of a war crime team that surveyed the Dachau concentration camp three days after it was liberated. Dr. Edwards worked at the Mayo Clinic in Rochester from 1946 to 1960 and then at Miller (now United) Hospital in St. Paul. He started a registry (Jesse E. Edwards Registry of Cardiovascular Disease) of cadaver hearts in the 1960s, and the collection at the St. Paul Heart and Lung Center now includes 22,000 donated cardiac specimens. It is one of the largest collections in the world, and Edwards’ organization made it one of the most useful. Dr. Edwards has written 16 books and nearly 800 medical journal articles. He retired in 1987, but doctors worldwide still consulted with him. Dr. Edwards was a past president of the American Heart Association. He joined EMMS in 1961.

he East Metro Medical Society held its caucus on Wednesday, May 21 at United Hospital in St. Paul. The resolutions discussed included efforts to educate physicians and patients about the Mental Health Parity Act of 2007; asking the MMA to explore their advocacy outreach efforts; asking the MMA to support, help develop and lobby for the use of high deductible health plans for applicable Medicaid populations and for other public sector programs; asking that the MMA work with the Minnesota Hospital Association, the Minnesota Department of Health and others to incorporate the collection of immunization historical information on physicians into the licensure process; asking the AMA to work

with the Joint Commission to clarify the low volume credentialing and privileging standards for physicians applying for privileges at hospitals; asking the AMA to lobby for federal legislation prohibiting contracts between physicians and insurance corporations in which clinic payments are contingent on underwriting the cost of patient services and referrals. These resolutions and others will be submitted to the MMA at their annual meeting September 19-21 in St. Paul.

Sr. Physicians Association

he EMMS Senior Physicians Association met in April to hear a presentation on “Public Health Issues and the Homeless Population” from Sue Grosse Macemon, CNP. Ms. Macemon works with Health Care for the Homeless and HouseCalls, which are programs sponsored by West Side Community Health Services. The group learned some of the reasons behind homelessness and the dif-

ﬁculties that the population faces. Health Care for the Homeless served nearly 550,000 men, women and children in 2007 and partners with other community outreaches to provide excellent care and services with an ultimate goal of helping people ﬁnd long-term solutions to homelessness.

Meet Two New EMMS Board Members KATHERINE CLINCH, M.D. joins the EMMS board as a director. She is an anesthesiologist practicing primarily at United Hospital in St. Paul. She’s employed by Associated Anesthesiology, PA. Dr. Clinch received her medical degree from St. Louis University Medical School where she also completed her internship. She then moved to Minnesota and completed her residency at the University of Minnesota. Dr. Clinch lives in St. Paul. 30

July/August 2008

MS. LINNEA ENGEL joins the EMMS board as our medical student representative replacing Kimberly Viskocil. Ms. Engel is a 2nd year medical student at the University of Minnesota — graduating in 2010. She is a Mounds View High School graduate and attended Carleton College in Northfield where she received her undergraduate degree. She also studied abroad for a semester at the University of Sydney in Sydney, Australia. MetroDoctors

RICHARD B. EDWARDS, M.D., age 76, died April 25. He graduated from the University of Manitoba Medical School, specializing in orthopedics at the University of Minnesota. Dr. Edwards joined his father in family practice and later practiced in orthopedics in the Twin Cities and Grantsburg, WI. He served as the medical director for Summit Orthopedics and was Chief of Surgery for HealthEast. Dr. Edwards joined EMMS in 1973. LEONARD O. LANGER, M.D. died March 7 of complications from Alzheimer’s disease at the age of 79. He graduated from the University of Minnesota Medical School and trained in radiology at the University of Michigan. Dr. Langer’s career included private practice with Suburban Radiologic Consultants and years spent in research and teaching at the Universities of Minnesota and Wisconsin. He achieved worldwide recognition for his expertise in bone deformities and co-authored the Atlas of Bony Dysplasias. Dr. Langer acted as a medical advisor for the Little People of America and was awarded L.P.A.’s ﬁrst honorary life membership for his contributions to the understanding of dwarﬁsm and the care of people with this condition. He also established a bone dysplasia registry at the University of Minnesota Hospital.

The Journal of the East and West Metro Medical Societies

Asthma and Tobacco-Free Supporters Team Up With Saint Paul Saints May 23

Each organization had a representative throwing out the ﬁrst pitch. Representing Smoke Free Washington County was Dr. Peter Wilton, surgeon and president of the East Metro Medical Society. Smoke-Free Dakota County also had a supporter throw out the ﬁrst pitch.

Legislators Presented With Defender of Clean Air Awards

he Defender of Clean Air awards were presented to the seven Legislators who voted “Yes” on the Freedom to Breathe Act which was implemented October 1, 2007 making all of Minnesota work places smoke-free. Two of the legislators were presented their awards at the

Cynthia Piette and Representative Marsha Swails (DFL-56B).

Senator Katie Sieben (DFL-57) and Sue Schettle.

MetroDoctors

six month anniversary event hosted by Smoke Free Washington County. For those legislators that were not able to attend the event, Cynthia Piette, Project Coordinator for the Smoke Free Washington County project and Sue Schettle, CEO of the East Metro Medical Society, visited the remaining ﬁve at their Capitol ofﬁce. Senator Charles Wiger was not Representative Nora available for a photo. Slawik (DFL-55B).

he Dakota County Smoke-Free Communities Partnership has had an active winter and transition to spring. The Partnership has continued to engage community members, elected officials, and East Metro Medical Society physicians in its activities. They have encouraged healthy lifestyle activities, hosting events ranging from snow tubing to bowling to having a life coach discuss getting rid of one’s gremlins. The Partnership has also mobilized its core volunteers throughout the legislative session, in response to the smoking shack amendments and the so-called “theatrical productions.” Numerous phone calls and e-mails have been sent to elected leaders and letters to the editor published. The Partnership continues to table at local fairs and festivals, speaking to community and civic groups, to share recent studies indicating 76 percent of Minnesotans support the smoke-free law. The impact on hospitality worker health has also been compelling for showcasing the beneﬁts of smoke-free workplace policies — levels of cotinine and NNAL, a cancer-causing agent, decreased by 83 percent and 85 percent respectively, after the smoke-free law was implemented. As the Partnership looks forward to its fourth year, its objectives will remain focused on thorough implementation of the Freedom to Breathe provisions to the Minnesota Clean Indoor Air Act, through connecting to the business community, leveraging earned media, and encouraging those who wish to quit smoking to enroll in cessation programs. The Partnership’s funder, ClearWay MN, encourages organizing campaigns on college campuses, efforts around the exciting political and election season ahead, as well as collaboration with their Native American funded community programs. The Partnership welcomes physician advocates and spokespersons to become involved with their efforts throughout Dakota County. Please contact Diane Tran, Project Coordinator, at dtran@smokefreedakota.org or (651) 789-0036.

Senator Kathy Saltzman (DFL-56) and Anne Harris (Woodbury Resident).

The Journal of the East and West Metro Medical Societies

July/August 2008

Metro Medical Society

Dr. Peter Wilton throws out the ﬁrst pitch at the Saint Paul Saint’s game on Friday, May 23, 2008 in St. Paul.

East

moke Free Washington County and Smoke Free Dakota County partnered with asthma, tobacco-free and other smoke-free groups across the metro to sponsor a smokefree St. Paul Saints baseball game Friday, May 23, 2008. In celebration of Asthma Awareness Month, these eight organizations have joined forces to raise awareness about asthma and secondhand smoke through trivia, exhibits, on-ﬁeld activities and announcements at the game. “Almost 400,000 Minnesotans have asthma, and a large number of people with asthma and other respiratory conditions attended this game,” said Cynthia Piette, project coordinator for Smoke Free Washington County. “We appreciated how cooperative the St. Paul Saints have been in agreeing to go smoke-free for this game.”

Dakota County SmokeFree Communities Partnership

CHAIR’S REPORT ANNE M. MURRAY, M.D.

Physicians Came to the Table

WMMS Ofﬁcers

Chair Anne M. Murray, M.D. President Richard D. Schmidt, M.D. President-elect Edward P. Ehlinger, M.D. Secretary Peter J. Dehnel, M.D. Treasurer Eric G. Christianson, M.D. Immediate Past Chair Paul A. Kettler, M.D. WMMS Board Members

Alan L. Beal, M.D. Edwin N. Bogonko, M.D. Carl E. Burkland, M.D. J. Paul Carlson M.D. Laurie Drill-Mellum, M.D. Kenneth N. Kephart, M.D. Stephen MacLeod, M.B. J. Riley McCarten, M.D. Robert Mittra, M.D. S. Rita Puri, MB, BS Frank S. Rhame, M.D. Thomas C. Tunberg, M.D. David J. Walcher, M.D. WMMS Ex-Ofﬁcio Board Members

Michael B. Ainslie, M.D., MMA Trustee Martha Arneson, Co-Presiding Chair, WMMS Alliance Beth A. Baker, M.D., MMA Trustee Richard E. Burman, M.D., Sr. Physicians Association Representative David L. Estrin, M.D., AMA Alternate Delegate Donald M. Jacobs, M.D., MMA Trustee Roger G. Kathol, M.D., MMA Trustee Chad E. Roline, M.D., Resident Representative Candace S. Simerson, MMGMA Representative Wade G. Swenson, Medical Student Representative Karin M. Tansek, M.D., MMA Trustee Trish Vaurio, Co-Presiding Chair, WMMS Alliance Elizabeth R. Vogel, Medical Student Representative Benjamin H. Whitten, M.D., AMA Alternate Delegate James A. Young, II, M.D., MMA Trustee WMMS Executive Staff

Jack G. Davis, Chief Executive Ofﬁcer Jennifer Anderson, Smoke-Free Project Coordinator Nancy K. Bauer, Assistant Director, and Managing Editor, MetroDoctors Kathy R. Dittmer, Executive Assistant

July/August 2008

ALL WAS NOT LOST in the latest turbulent legislative session that drew to a close on May 18. It ended literally with a bang as the 150th anniversary of the State of Minnesota was celebrated at the Capitol between last minute negotiations. The greatest accomplishment from our perspective throughout the Health Care Reform Bill negotiation process was the tremendous amount of bipartisan physician input. Physician involvement grew more intense as the session deadline approached, and ended only hours before the final documents were signed by the governor. Physicians truly staked out a place at the table and defended it with passion. The joint efforts of East Metro and West Metro Medical Society members also played a major role in last minute negotiations with legislators. The coming together of seemingly unlikely physician and legislator bedfellows in a bipartisan effort to avoid the inclusion of level 3 language was impressive. It was also a pleasure to see the skillful hand of House Speaker Margaret Kelliher behind many of the governor’s compromises. Although in the end the Health Care Access Fund was still raided, it wasn’t the grand larceny the governor initially threatened, at $50 million instead of $250 million. Some of it may eventually be repaid if any of the promised health care savings via the reform legislation appear. Somewhat surprising, but encouraging, was the single-payer movement that gained momentum across party lines, and will likely continue to gain steam before the next legislative session. Although there are clear advantages to a single-payer system such as slashing administrative costs and leveling the playing field of the “non-profit” HMOs, the ability to maintain high quality medical care without competition in the classic sense is a formidable challenge. Competing on baskets of care may eventually be part of the answer, but many details need to be worked out before physicians will MetroDoctors

be ready to come on board with this business model. Although there has been much positive lingo employed regarding the need to reward physicians and their staff adequately for care coordination and preventive care, we have yet to see it happen in Minnesota. We need to be conﬁdent that physicians and their support staff will be adequately compensated for the large amount of time needed to maintain a medical home for chronically ill complex patients, and that our care coordination will be acknowledged as truly valuable. In any case, the fact that support for a single payer system not only survived but ﬂourished is a sign that some walls between previously polarized groups have been torn down and that we are clearly moving forward in a positive direction toward health care reform. Physicians must maintain our high level of involvement in preparation for the fall legislative session. We no longer have to start from scratch. Now that initial steps in health care reform have been taken and relationships established, we know which issues Governor Pawlenty and other stakeholders hold dearest. We will come armed. Especially important is the need for the East Metro and West Metro Medical Societies to continue their successful collaborative efforts together with the MMA to craft more optimal health care legislation next year. Physicians need to reinforce their place at the health care reform table in Minnesota. Stay involved. If you’re not involved, get involved. There is an ideal opportunity this fall at the annual MMA House of Delegates meeting. Become a delegate and bring your resolutions for change. As one physician you can truly affect change in health care reform in Minnesota. The Journal of the East and West Metro Medical Societies

WMMS IN ACTION JACK G. DAVIS, CEO

Jack Davis, chair of the Minnesota Provider Coalition (MPC) reported that the MPC met throughout the legislative session on an every three-week basis. Issues that were closely monitored included: health care reform, language interpreter bill, worker’s compensation, HSA direct assignment, use of health care access funds, scope of practice and other issues as they arrived. The MPC plans to meet regularly for the balance of 2008 in anticipation of the 2009 session.

attendees were briefed on AMA positions on issues currently in debate on the Hill and made several visits to the ofﬁces of our Senator and Representatives. Attendance provides good insight into the legislative process and emphasizes the importance of advocating for patients and physicians. At its May Annual Meeting, the Hennepin Medical Society Alliance ofﬁcially approved its name change to the West Metro Medical Society Alliance (WMMSA). Tom and Mary Kay Hoban were in

town on May 15 to attend the 2008 Hoban Scholarship Educational Event chaired by H. Thomas Blum, M.D. Several of this year’s

Many WMMS physician members participated in the MMA Capitol Rounds as reported elsewhere in this issue of MetroDoctors. Please consider participating during the 2009 legislative session.

Hoban Scholars provided a presentation on a project or paper prepared in the course of their studies. Tom and Mary Kay reside in Bonita Springs, Florida and they warmly greet all their friends and former associates. WMMS Caucus was held on May 21.

A number of resolutions were discussed and approved for submission to the MMA Annual Meeting, which is scheduled for September 17-19, 2008. It’s not too late to sign up as a delegate. Carl Burkland, M.D., Caucus Chair, encourages his colleagues to become a delegate and participate in setting the policies and agendas for the future work of the MMA.

Jennifer Anderson continues her work as WMMS project coordinator for Partnership for a Smoke Free Scott County.

Jennifer’s focus is implementation of the statewide Freedom to Breathe law in Scott and Carver Counties. In celebration of May Asthma Awareness Month, the Partnership for a Smoke-Free Scott County and seven asthma and smoke-free organizations co-sponsored the Saint Paul Saints game against the Fort Worth Cats on Friday, May 23, 2008. All eight organizations joined forces to raise awareness about asthma and secondhand smoke. Through trivia, tabling, on-ﬁeld activities and announcements they spread the word about chronic lung disease and that asthma can be controlled. Richard Schmidt, M.D., Edward Ehlinger, M.D. and Jack Davis were in Washington D.C. in April to attend the AMA National Advocacy Conference. While there, MetroDoctors

Attending the WMMS Caucus: Drs. Benjamin Chaska, David Estrin, Michael Anslie; and Dr. Mary Kathol in back.

Several WMMS physicians attended the Caucus and discussed resolutions.

Current and former Hoban Scholars attended the 2008 Educational Event. From left: Thomas Hoban, Mary Kay Hoban, Debra Thingstad Boe (2005 Scholar), Azza A. Zarroug (2005 and 2007 scholar), Kara O. Mitterholzer (2005, 2006, 2007 scholar), Christina Servetas (2007 scholar), and Darla Morris-Preble RN (2003-2004 scholar and member, Hoban Scholarship Selection Committee).

The Journal of the East and West Metro Medical Societies

July/August 2008

W e st M e t r o M e d i c a l S o c i e t y

WMMS in Action highlights activities that your leadership and executive ofﬁce staff have participated in, or responded to, between MetroDoctors issues. We solicit your input on these activities and encourage your calls regarding issues in which you would like our involvement.

Congressman Ellison Participates in Community Internship Program

Senior Physicians Association

obert E. Doan, M.D., president, opened the April 22 meeting of the Senior Physicians Association with Jane Eastwood, director, External Relations and Partnerships from the Minneapolis Public Library. We learned that T. B. Walker, a Minnesota lumber magnate and art collector —yes Walker Art Center, had a vision to share his books with the citizens of Minneapolis so it could become the educated city that it is. A horse and buggy “library” traveled throughout the area. Did you know that the city of Minneapolis refused to accept his art collection as a gift?

ongressman Keith Ellison along with his Constituent Services Coordinator Mike Siebenaler, participated in a surgical care team observation at Abbott Northwestern Hospital under the auspices of the West Metro Medical Society’s Community Internship Program. Congressman Keith Ellison and staff participate in Community The purpose of the Internship Program at Abbott Northwestern Hospital. From left: experience was to provide Mike Siebenaler, constituent services coordinator; Congressman T. Michael Tedford, M.D.; and Jeffrey Peterson, president, the Congressman and Ellison; Abbott Northwestern Hospital. staff with an opportunity to see what really goes on attorney for Health Billing Systems, and Jack in a hospital, how patients receive care, and Davis, CEO of WMMS. to “walk in the moccasins” of the physicians, Congressman Ellison and Mr. Siebenaler nurses and other professions as they provide were exposed to surgery through an observacare to our citizens. tion of procedures and learned a lot about surThe Congressman was greeted by Dr. gical care teams at ANW, the daVinci robot, Michael Tedford, past president of WMMS and the use of iMRI in neurosurgery. and Abbott Northwestern Hospital medical Special thanks to Jim Sieben for his asstaff, Dr. Robert McKlveen, Northwest Anessistance in recruiting Congressman Ellison and thesia, Jeffrey Peterson, Abbott Northwestern his staff for this observation experience. president, Jim Sieben, government relations

In Memoriam MILTON ETTINGER, M.D., died recently at the age of 77. He graduated from the University of Minnesota Medical School. Dr. Ettinger specialized in neurology and served as the Chief of Neurology at HCMC. He cofounded the multidisciplinary MN Regional Sleep Disorders Center in 1978. WILLIAM R. FIFER, M.D., 84, died April 30, 2008. He received his medical degree from Columbia University College of Physicians and Surgeons, New York, and he completed graduate training at the University of Minnesota. He was certiﬁed by the American Board of Internal Medicine, made a Fellow in the American College of Physicians, was a practicing internist for 15 years at St. Louis Park Medical Center, and served as president of the medical staff at Methodist Hospital in 1969. His second career was in academic administration at the University of Minnesota, where he directed the University’s 34

July/August 2008

Regional Medical Program and Area Health Education Center. Dr. Fifer spent two years in health policy analysis at InterStudy, following which he directed the North Central Regional Medical Education Center. In 1980, he founded Clayton, Fifer Associates, with a commitment of teaching and consulting with hospitals, health care institutions and professional societies nationwide. GLENN E. NELSON, M.D. died on April 30, 2008. He was 90. He graduated from the Medical College of Wisconsin, Milwaukee. Dr. Nelson specialized in family medicine. GLENN L. “SKIP” PETERSEN, M.D. died May 23, 2008 at the age of 89. He graduated from the University of Minnesota Medical School. Dr. Petersen specialized in anesthesiology.

MetroDoctors

Robert E. Doan, M.D., with Jane Eastwood.

SUMMER OUTING: The 2008 Summer Get-Together is scheduled for Tuesday, August 12. The event will include Lunch at Pracna On Main — the oldest restaurant (built in 1890) on the oldest street in Minneapolis. And then we will board the Twin City Trolley for a tour of Minneapolis, including stories from the drivers. Think you know all about Minneapolis? We challenge you! Watch your mail for more information to be mailed to members of the Senior Physicians Association. Not a member of the Senior Physicians Association? If you are 62 years or older or may have just retired, we invite you to become a member and take advantage of the mutual support, the social opportunities of meeting with your peers, and the opportunity to hear interesting and informative talks. Meetings are held four times a year for lunch and guest speaker at the Zuhrah Shrine Center. Upcoming meetings: June 10: Patricia Porter, program director, Minnesota Medical Foundation September 16: Senator David Durenberger November 11: speaker to be conﬁrmed. For more information, contact Kathy Dittmer, (612) 623-2885 or kdittmer@metrodoctors.com. The Journal of the East and West Metro Medical Societies

ALLIANCE NEWS

Celebration and Change for the HMS Alliance

THE HMS ALLIANCE held their 98th Annual

Marlene Ellis presented the names of Alliance members deceased this past year.

Martha Arneson expresses her appreciation to Kathy Dittmer, executive assistant, WMMS, for her untiring support and assistance of the Alliance.

Candy Adams, MMAA president, addressed the Alliance.

go to: www.metrodoctors.com, click WMMS, and then click WMMS Alliance. Minnesota Medical Association Alliance (MMAA)

The MMA Alliance held their 85th Annual Meeting on May 17, 2007 at the Duluth Women’s Club. Martha Arneson, WMMSA, received the MMAA Karen A. Tourdot Award in honor of her years of community service. June Cavert and Janice Kleven, WMMSA members were recognized as new MMAA Forty-Year members. In addition, the following WMMSA members were installed on the 2008/2009 MMAA Board of Directors: Dianne Fenyk, treasurer and Eleanor Goodall, recording secretary.

Eleanor Goodall, Trish Vauria, Martha Arneson and Diane Gayes are installed as “presiding presidents” of the Alliance by MMAA president-elect, Linda Wiig. (Not pictured: Dianne Fenyk and Peggy Johnson.) Becky Finne recognized Marion Kelsey, long time Alliance member.

Dianne Schottler is congratulated by Becky Finne as a 40 year member. Not pictured: Shirley Kaplan and Carol Nelson.

(WMMS photos by Janet Cardle.)

MetroDoctors

Trish Vaurio and Martha Arneson, co-presiding presidents, 2007-08.

The Journal of the East and West Metro Medical Societies

Martha Arneson received the MMAA Karen A. Tourdot Award.

Eleanor Goodall and Dianne Fenyk, WMMS Alliance, Judy Bernhardt and Linda Wiig, Lake Superior Medical Society Alliance.

MMAA Past Presidents.

July/August 2008

W e st M e t r o M e d i c a l S o c i e t y

Meeting and luncheon on May 2, 2008 at the Edina Country Club. It was a day of change, celebration and education. HMS Alliance members voted to change their name to West Metro Medical Society Alliance (WMMSA) to maintain their identiﬁcation with the West Metro Medical Society (formerly Hennepin Medical Society). In addition to the name change, the West Metro Medical Society Alliance will be chaired by six past-presidents. Each past president will be responsible for presiding over meetings and other Alliance activities during a two month period from July 1, 2008 to July 1, 2009. All other WMMSA Board of Directors positions remain unchanged. The Alliance celebrated their new fortyyear members Dianne Schottler, Shirley Ka-

plan, and Carol Nelson, Dianne Fenyk’s year as AMA Alliance President, and recognized the Alliance’s ongoing good work of community health education and other health related projects. Charles and Lara Foley presented an update on their elephant study in Tarangire National Park, Tanzania, East Africa. Lara is the daughter of member Peggy Johnson. Charles and Lara have been studying the elephant population of Tarangire National Park in northern Tanzania for 15 years. Tarangire is home to 3,000 elephants and has become one of the best parks in Africa to see large herds of elephants. For information regarding this event, membership, projects, newsletters etc. please

Career Opportunities

CAREER OPPORTUNITIES

Introducing the new “Career Opportunities” section of MetroDoctors! A great avenue for professionals to learn about job opportunities AND a perfect place for recruiters to promote openings! Recruiters, call for our special recruitment rate. Betsy Pierre, ad sales 763-295-5420 betsy@pierreproductions.com

Members in the News The Members in the News section recognizes the appointments, presentations, awards, honors and other professional accomplishments of EMMS and WMMS members. Submit physician news by fax (612) 623-2888, e-mail (dhines@metrodoctors.com) or mail to Editor, MetroDoctors, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413 for consideration by the editorial board. Questions? Call Doreen Hines at (612) 362-3705.

Allina Hospitals & Clinics. Dr. Goering has been afﬁliated with United Hospital in St. Paul for more than 15 years. LYNNE LILLIE, M.D. has been selected as the new medical director for Woodwinds Health Campus. She has been practicing family medicine for more than 10 years in Minnesota and is a family medicine physician at the HealthEast Woodbury Clinic.

JAMES GAGE, M.D. was honored at the Gillette Children’s Specialty Healthcare Neuroscience Conference for his work as the former medical director at Gillette and pioneer of the gait and motion laboratory technology used in medicine. Dr. Gage is currently the director of the Center for Cerebral Palsy at Gillette and has written several books on the analysis and treatment of gait problems in children with cerebral palsy.

Minnesota Physician Publishing honors physicians who have volunteered medical services in communities here in Minnesota and abroad. The Community Caregivers recognized in 2008 are: JAMES T. YOUNG, M.D., a family physician and hospitalist at United Hospital, for his involvement with the American Cancer Society. He began volunteering with the Cancer Resource Network and is currently on the board of directors for ACS’ Minnesota division and spends much of his time getting the word out about ACS and the Cancer Resource Network. DOUGLAS PRYCE, M.D. is director of the Somali Medical Clinic at Hennepin County Medical Center (HCMC) and a board member of the Somali Health Project. He was recognized for his efforts in educating the Somali on health care with community meetings that are then broadcast on Somali radio and the Somali language programs on cable access channels. He also gives talks to health care providers on how to best care for Somali patients.

PAUL GOERING, M.D. has been appointed executive medical director of mental health for

LAKEVIEW HOSPITAL was named one of the nation’s 100 Top Hospitals by Thomson Health-

CHARLES E. CRUTCHFIELD, III, M.D. was recognized in the May issue of Black Enterprise as one of the 140 physicians named in “America’s Leading Doctors.” Dr. Crutchﬁeld is adjunct clinical professor at the University of Minnesota and the founder of Crutchﬁeld Dermatology. ROBERT W. EMERY, M.D. has joined St. Joseph’s Hospital as medical director of cardiovascular surgery. He was most recently the head of the Division of Cardiovascular Surgery at Regions Hospital in St. Paul.

July/August 2008

MetroDoctors

care, a leading provider of information and solutions to improve the cost and quality of health care. The award recognizes hospitals that have achieved excellence in clinical outcomes, patient safety, ﬁnancial performance, and efﬁciency. The Minnesota Academy of Family Physicians elected PATRICIA FONTAINE, M.D., a University of Minnesota Physician as their president. LYNN LILLIE, M.D., a family medicine physician at Woodwinds Health Campus is their immediate past president. DAVID THORSON, M.D., family medicine at Family Health Services Minnesota was elected AAFP Delegate and CAROL FEATHERSTONE, M.D., family medicine at Park Nicollet Clinic – Brookdale was elected AAFP Alternate Delegate. Also receiving awards were: GWEN HALAAS, M.D., M.B.A., director of Interprofessional Education at the University of Minnesota Academic Health Center; assistant professor, University of Minnesota Department of Family Medicine and Community Health received the Teacher of the Year; MICHAEL HERVEY, M.D., third-year resident, University of Minnesota – St. Joseph’s Hospital Family Medicine Residency Program received the Resident of the Year. Allina’s UNITY HOSPITAL has earned a Level III trauma designation from the Minnesota Statewide Trauma System of the Minnesota Department of Health (MDH). Unity is one of only seven hospitals in Minnesota to receive this designation.

The Journal of the East and West Metro Medical Societies

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This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Minnesota Medical Association and

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