2008 Mar/Apr

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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 Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines 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: (952) 903-0505 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com.

CONTENTS VOLUME 10, NO. 2

2

MN BMP Report on Appropriate Prescribing of Controlled Substances for the Management of Pain

3

Mayo Clinic Health Policy Center Summary of Recommendations on Health Care System Reform

4

FEATURE STORY

A. Stuart Hanson, M.D. Receives Shotwell Award

A Testimonial to Freedom to Breathe

6 9

YOUR VOICE

11

Summary of e-Health Initiatives

16

Queen of Peace Leads Efforts to Keep Community Healthy

18

Transition Medicine: Helping Youth With Special Health Care Needs Transition from Pediatric-Based Care to Adult-Based Care

20

Index to Advertisers

22

The Case for Adaptive Leadership (Part 3)

24

Members in the News EAST METRO MEDICAL SOCIETY

25 26

President’s Message

27

Outgoing Board Members/Meet Dr. Peter Bornstein/Paul Verret Addresses Foundation Board/Call for Resolutions

28

Wisconsin Gov. Meets with EMMS Smoke-free Staff/Tales of a Smoke-Free County/Smoke-Free Dakota Celebrates/ EMMS Wants Your E-Mail Address

EMMS Annual Meeting/Legislative Updates/ Rep. Greiling Meets with Hamm Clinic Physicians

WEST METRO MEDICAL SOCIETY

29 30 31 32

MetroDoctors

COLLEAGUE INTERVIEW

Penny Wheeler, M.D.

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.

MARCH/APRIL 2008

Chair’s Report Dr. Reichert Receives Charles Bolles Bolles-Rogers Award/ American Legion Fundraiser a Smokin’ Success In Memoriam/Call for Resolutions HMS Alliance News

The Journal of the East and West Metro Medical Societies

On the cover: A. Stuart Hanson, M.D., Shotwell Award recipient, played an important role in creating a smoke-free Minnesota. Article begins on page 4.

March/April 2008

1

MN Board of Medical Practice Report on

Appropriate Prescribing of Controlled Substances for the Management of Pain

L

LEGISLATION WAS introduced during the 2006 Session of the Minnesota Legislature to create an online, real-time electronic database containing all controlled substance prescriptions, including the drug, the dosage, the amount, the identity of the prescribing and dispensing health care professionals, and the identity of the patient. This database was to be funded by federal grants established by federal legislation known as the National All Schedule Prescription Electronic Registry, or NASPER. This legislation was defeated in the 2006 Session, but reintroduced in the 2007 Session. During the course of legislative debate regarding this measure, a rider was included in the Omnibus Health and Human Services Appropriation bill requiring the Minnesota Board of Medical Practice to convene a Work Group to discuss the appropriate prescribing of controlled substances for the management of pain, and to report to the Legislature by December 15, 2007. The group convened by the Board consisted of two pain management specialists, one oncologist, one family practice specialist, one internist, one consultant to the Minnesota Department of Labor and Industry, which manages workers compensation expenditures for the state, two Board staff members, and one representative from the Minnesota Office of the Attorney General. The group adopted the following principles: 1) Appropriate pain management is the treating provider’s professional, legal, ethical and moral responsibility. 2) Controlled substances, especially opioid analgesics, are legitimate and necessary tools for the provider to use in carrying out this responsibility. B Y R I C H A R D A U L D , P h. D . Assistant Director, MN Board of Medical Practice

2

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3) There is compelling evidence that acute pain due to trauma or surgery, and chronic pain, whether due to cancer or non-cancer origins, remains either under-treated or untreated due to professional fear of legal and regulatory reprisals. 4) The prescribing of controlled substances for the management of pain must be done on a case-by-case basis, utilizing a thorough clinical methodology to determine the individual patient’s cause and severity of pain, based on history, examination, appropriate testing, diagnosis, a treatment plan based on the diagnosis, appropriate follow-up to determine response to treatment, appropriate adjustment of treatment, and other clinical processes necessary to monitor and document the treatment. 5) Untreated pain or under-treated pain is as serious a departure from the standard of care, and as serious a violation of the Minnesota Medical Practice Act as is excessive prescribing of controlled substances or prescribing of controlled substances for non-therapeutic purposes. 6) Health care providers are insufficiently educated and trained in appropriate pain management, and professional schools should be required to work toward more adequate education and training curricula. 7) Recent Minnesota legislation requiring that Class II and III controlled substances prescriptions be recorded and monitored in an electronic, real-time database continues to have the potential to create a “chilling effect” on health care providers’ willingness to use controlled substances when they are medically necessary, and thus should be monitored closely by the Legislature. The Work Group also issued the following statements regarding the use of controlled substances for the management of pain:

MetroDoctors

1) A statement of proper clinical methodology for patient selection and use of controlled substances for the management of pain. For this, the work group adopted in its entirety The Model Policy for the Use of Controlled Substances for the Treatment of Pain (http: //www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf ) adopted by the House of Delegates of the Federation of State Medical Boards of the United States, Inc., May 2004. 2) A statement that under-management, or non-management of pain is as serious a departure from medical standards and as serious a violation of the Minnesota Medical Practice Act as is inappropriate prescribing of controlled substances. 3) A statement that the Minnesota Legislature should require the health professional schools for the prescribing professions in Minnesota to form a joint task force to explore how students and residents can be taught and trained to manage pain commensurately with the volume and type encountered in their practices. 4) A statement that the Minnesota Legislature should monitor the effect of recent legislation requiring the state to initiate a controlled substance prescription data bank under the Federal NASPER requirements over a five year period after implementation of the data bank. 5) A statement of the Minnesota Board of Medical Practice’s efforts over the past two decades to educate the Minnesota practice community in the appropriate use of controlled substances in the management of pain. This report was accepted by the Minnesota Board of Medical Practice at its November 10, 2007 meeting, and transmitted to the Minnesota Legislature.

The Journal of the East and West Metro Medical Societies

Mayo Clinic Health Policy Center

Summary of Recommendations on Health Care System Reform

M

MAYO CLINIC BELIEVES America’s health

care system urgently needs reform to ensure the future of quality patient care. Over the last two years, Mayo Clinic Health Policy Center has convened more than 400 national thought leaders for a series of events to help develop new, consensus-driven principles to guide the reform process. This report summarizes these activities to date. To reform health care, providers, academics, medical industry leaders, business people, insurers, political leaders and patient advocates recommend four areas of focus: universal insurance coverage, coordinated care, value and payment reform. Individual Ownership of Insurance for All

Provide health insurance and access to basic health care for all Americans — regardless of their ability to pay. s 2EQUIRE ADULTS TO PURCHASE PRIVATE HEALTH insurance for themselves and their families. Employers could still help ďŹ nance a portion of their workers’ health care expenses and should be encouraged to promote employee wellness. s #REATE A SIMPLE MECHANISM SIMILAR TO THE Federal Employees Health BeneďŹ t Plan) to offer private insurance packages to buyers. s 0ROVIDE SLIDING SCALE SUBSIDIES FOR PEOPLE with lower incomes. s !PPOINT AN INDEPENDENT HEALTH BOARD (similar to the Federal Reserve) to deďŹ ne essential health care services. Allow people to purchase more services or insurance, if desired. Coordinated Care

Patient care services must be coordinated across people, functions, activities, sites and time in order to increase value. Patients must be active participants in this process.

MetroDoctors

s #ENTER CARE AROUND THE NEEDS OF THE PAtient. s 2EALIGN THE HEALTH SYSTEM TOWARD IMPROVING health rather than treating disease. s &ORM COORDINATED SYSTEMS TO DELIVER EFFECtive and appropriate care to patients. s $EVELOP A hPORTFOLIO OF INCENTIVESv TO encourage teamwork among health care professionals. s )NCREASE SUPPORT FOR HEALTH CARE DELIVERY SCIence, which generates new knowledge by using common tools such as information systems, process improvement techniques and outcomes measurement. s 0ROVIDE COMPLETE AND ACCURATE INFORMATION so patients can make informed decisions about their care.

s #REATE PAYMENT SYSTEMS THAT PROVIDE INCENtives for colleagues (physicians, hospitals) to coordinate care for patients, improve care and support informed patient decisionmaking. s 0AY PROVIDERS BASED ON VALUE 3EE ITEM in “Value� section.) s &URTHER DEVELOP AND TEST MODELS OF PAYMENT based on chronic care coordination, shared decision-making and mini-capitation (i.e., one bundled fee for the physicians and hospital delivering acute care). For more information visit their Web site at www.mayoclinic.org/healthpolicycenter.

Value

Increase quality and patient satisfaction. Decrease medical errors, costs and waste. s $EVELOP A DElNITION OF VALUE BASED UPON the needs and preferences of patients; and measurable outcomes, safety and service; compared to the cost of care over time. s -EASURE AND PUBLICLY DISPLAY OUTCOMES patient satisfaction scores and costs as a whole. Create competition around results through pricing and quality transparency. s #REATE A TRUSTED MECHANISM TO SYNTHESIZE scientiďŹ c, clinical and medical information for both patients and providers. s 2EWARD CONSUMERS FOR CHOOSING HIGH QUALity health plans and providers. s (OLD ALL SECTORS IN HEALTH CARE ACCOUNTABLE for reducing waste and inefďŹ ciencies. Payment Reform

Change the way providers are paid in order to improve health and minimize waste. s $ESIGN PAYMENT SYSTEMS TO PROVIDE PATIENTS with no less than the care they need and no more than fully informed, cost-conscious patients would want.

The Journal of the East and West Metro Medical Societies

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March/April 2008

3

FEATURE STORY

A. Stuart Hanson, M.D. Receives Shotwell Award “The 2007 Minnesota Freedom to Breathe Act is a capstone on a 32-year process that began with the first in the nation Minnesota Clean Indoor Air Act in 1975. Resistance to change came in many forms especially from smokers, business leaders, politicians and some physicians. ‘Legislating behavior’ was the cry from opponents. The legislative success this year brings to completion a long effort and deserves to be celebrated. Physicians and their professional organizations are to be congratulated for the major role they played in keeping the issue alive and collaborating with health plans and other professional groups to effect a major social change.” — A. Stuart Hanson, M.D. What Dr. Hanson failed to include in the above quote is the fact that he played an important role in this 32-year journey. It is through his vision, leadership, testimony and enduring drive for a smoke-free Minnesota that the State Legislature passed the Freedom to Breathe Act. For this and his contribution to other public health issues critical to the welfare of his patients and the citizens of Minnesota, Dr. Hanson was presented the 2007 Shotwell Award at the Abbott Northwestern Hospital Annual Medical Staff meeting on January 8, 2008. Dr. Hanson attended Dartmouth Medical School from 1958 to 1960 and graduated from the University of Minnesota Medical School in 1963. He completed an internship in 1965 at Hennepin County General Hospital and a residency in internal medicine at the University of Minnesota in 1970. From 1965 to 1968, Dr. Hanson served in the U. S. Navy in Southeast Asia and Japan. In 1971, he completed a pulmonary fellowship at the University of Minnesota. For the last 37 years, he has practiced internal medicine, sub-specializing in pulmonary and critical care medicine at Park Nicollet Clinic in St. Louis Park. 4

March/April 2008

He is the former president of Park Nicollet Institute, and (former) vice chair of ClearWay and the Minnesota Health Data Institute. Dr. Hanson continues to practice pulmonary medicine and attends at Park Nicollet Methodist Hospital. He is a clinical assistant professor of internal medicine at the University of Minnesota Medical School and serves on the Admissions Committee of the University of Minnesota Medical School as the representative from West Metro Medical Society.

“I want to thank the West Metro Medical Society and the Abbott Northwestern medical staff and especially the legacy of the Shotwell Family for this award. To be recognized by your peers is the highest honor a physician can receive.” A. Stuart Hanson, M.D. MetroDoctors

WMMS Board Chair Anne Murray, M.D., presents A. Stuart Hanson, M.D. with the Shotwell Award.

Among his other accomplishments, Dr. Hanson is past president, Minnesota Medical Association; past chair, West Metro Medical Society (formerly Hennepin Medical Society); past chair, Minnesota Delegation to the American Medical Association’s House of Delegates; and past president, Minnesota Coalition for a Smoke Free Society 2000. Background The Shotwell Award was established by Metropolitan Medical Center in 1971 in recognition of the support and dedication of the Shotwell Family. The late Mr. and Mrs. James D. Shotwell established the Louise Shotwell Smith Leukemia Fund for research and the Louise Shotwell Smith and Grace R. Shotwell Nursing Scholarship Funds, of Metropolitan Medical Center. Their gifts to the hospital amounted to more than $670,000. Upon the closing of MetropolitanMount Sinai Medical Center in 1991, the Hennepin Medical Society requested and received approval from Metropolitan-Mount Sinai Medical Center to assume responsibility for selecting the recipient of The Shotwell The Journal of the East and West Metro Medical Societies

Award. Nicholas Legeros is the creator of the award entitled “Asclepius and Hygieia.” Rising from the logo base of the West Metro Medical Society is the symbol of medicine, the staff of Asclepius representing the healing aspect of the medical arts. Grasping the staff and suspended by it are the figures of Asclepius and Hygieia, his daughter, who is associated with the prevention of sickness and the continuation of good health. These figures represent the dynamic pursuit of innovation in medicine. Abbott Northwestern Hospital has generously provided funding for the Shotwell Award since 2003. A plaque recognizing all of the award recipients resides in the Sister Kenny Lobby on the Abbott Northwestern Campus.

Shotwell Award Criteria 1. Dedicated service to mankind; 2. Significant break-through in some form of research or, significant contribution to the field of medicine; and 3. Innovations and/or improvements in health care delivery, including health care physicians. The award is not limited to physicians or other professionals in the health care field, though, of course, such persons are likely candidates. The Shotwell Award is presented annually to a person within the State of Minnesota for a noteworthy effort in any or all of the above areas of health care. For a complete listing of previous Shotwell Award recipients and to read the acceptance remarks of A. Stuart Hanson, M.D., please visit our Web site: www.metrodoctors.com.

A Testimonial to Freedom to Breathe On December 15, Stacey Hoskins celebrated being smoke-free for three months. “It was the best thing I ever did,” she reflected. The medical assistant from St. Francis gave up smoking in a very public way and with lots of support from her family and friends. After smoking half-a-pack a day for 11 years, and after several failed attempts to quit, she finally Stacey Hoskins is a got the push she needed to quit once and medical assistant at the Columbia Park for all — from a physician. Medical Group Clinic For Stacey, smoking was primarily a in Andover. social activity. She started smoking at age 18 to fit in with her peers and continued smoking especially when out with friends. “On the weekend I went out to the bar,” she said. That’s where the temptation was strongest. Smoking was “kind of what you did,” Stacey says. Having worked in a medical clinic for 11 years, Stacey understood the deadly health effects of smoking. She had quit smoking several times, during her two pregnancies, but then started again. So what made her ready to quit on Sept. 15, 2007? Despite years of nagging by her husband and co-workers, and two small children at home that forced her to take her smoking outside, it was her employer, William Sypura, M.D., who challenged her in just the right way. “He wrote up a contract for me to sign,” she said. Sypura chalBY REBECCA THOMAN, M.D. MMA Grassroots Coordinator

MetroDoctors

The Journal of the East and West Metro Medical Societies

lenged her to choose a quit date and sign a contract, which he then posted on the clinic cabinet door. Chantix, a partial nicotine agonist that helps reduce cravings and symptoms of withdrawal, also helped. After three months on Chantix, Stacey no longer physically craved cigarettes. How did she do it? “There were a lot of factors” that Dr. William Sypura influenced Stacey to take the step to stop is a Family Physician at the Columbia Park smoking. The Freedom to Breathe Act Medical Group Clinic may have been the final component. in Andover. “What’s the point in smoking if I can’t go out and smoke any more?” Stacey told herself. With fewer places to smoke, Stacey experiences fewer triggers. When socializing with friends, she didn’t feel the need to smoke, since her friends no longer could. Stacey still gets the urge to smoke occasionally, especially when under stress. But her family is happier, her health is better and she can breathe easier. “I’m not huffing and puffing as much as I used to.” Socializing for Stacey at work, at home and with friends, now means not smoking. Sypura, the physician who challenged Stacey to quit, believes that personal motivation and life experiences provide the greatest incentives for patients to quit. But Stacey’s case also shows that taking the right approach—setting a date and making a public commitment in the presence of a supportive community — in the context of community smoking restrictions, provides a motivated patient with the tools to succeed.

March/April 2008

5

COLLEAGUE INTERVIEW

Penny Wheeler, M.D.

Penny Wheeler, M.D. is the chief clinical officer (CCO) of Allina Hospitals and Clinics. She is a board-certified obstetrician/gynecologist with Women’s Health Consultants in Minneapolis and an associate professor of OB/GYN at the University of Minnesota. Her educational background includes an undergraduate degree with honors from the University of Minnesota, and she completed her doctor of medicine degree and residency training at the University of Minnesota Medical School. As CCO, Wheeler is responsible for leading Allina’s clinical quality and improvement agenda by collaborating with medical staffs, the board’s Physician Practice Council and the medical directors. As well, she is responsible for ensuring best-of-practice approaches and ongoing innovation and excellence in care and supporting the development and retention of effective clinicians.

Q A

Why, as a young physician at the peak of your career with outstanding clinical and personal skills, did you change course and become an administrator? Good question and thanks for calling me young as well as the other compliments. I was struck by the Institute of Medicine Report, Crossing the Quality Chasm, which spoke to the need to transform health care in dramatic ways to benefit our patients and community. Like many, I couldn’t fathom that it takes 17 years on average to implement best practices and that the cost of American health care was twice that of other nations with our quality appreciably lower in many cases. Despite everybody trying to do their absolute best for patients, numerous barriers to improving care are present for doctors and other caregivers. I saw this role as an incredible opportunity to close that gap for patients and make it easier for those who provide their care to do the right thing.

Contrast your personal “rewards” or job satisfaction from your bedside practice of medicine and your duties as CCO of a large complex organization. I still practice one day a week so the contrast is very clear to me on a weekly basis. In medical practice we are incredibly fortunate to have the opportunity to improve at least one person’s life and perhaps several others during the course of the day. As a physician leader the results are sometimes less tangible and there is a longer time frame needed to see the results of initiatives intent on improving quality. Seeing the care measures rise through the collaboration of many and knowing hundreds of people 6

March/April 2008

are positively affected is very powerful. There is as much of a science to supporting the best delivery of care as there is to pathophysiology. It is a campaign reliant on the commitment of many — very powerful but complex to pull off.

What have been some of the biggest adjustments in moving to an administrative role with Allina, and were you able to anticipate these prior to making the change? I always make the analogy that it was like landing on a different planet. Coming from full-time practice and being comfortable with complicated cases in the operating room, to not knowing how to run my Outlook e-mail account. It has been a very humbling experience and has stretched my learning in ways in which I couldn’t have anticipated, but none-theless, feel fortunate. It took a lot to learn the organization in terms of work needed and how to navigate the system but ultimately, just like in my practice with patients, it’s all about continually developing skills and primarily about developing trusted relationships.

Is there any training or preparation that would have better prepared you for your administrative duties? I think when I entered the role I was quite humbled with what I didn’t know. One of the most important things was for me to realize all that I did know about the delivery of care and the science of improving that care and I needed to realize that what you need to bring to the organization are your strengths. My strengths are not doing financial analytics, but I know whom to call. My goal is advancing quality and safety for patients, and bringing the voices of patients, doctors, caregivers and administrators to guide improvement. MetroDoctors

The Journal of the East and West Metro Medical Societies

What has been your biggest challenge in dealing with physicians as their leader and policy advisor as opposed to partner and compatriot? It’s tough to go to the administrative side and still be seen as a doctor advocate. If a misstep is made, there is a faster rush to assumption of intent. As long as the focus remains on improving care and words are followed with action to that end, perceived conflicts melt away. All physicians want is to improve the lives of those around them, which is why they initially went into the profession. It is uniting to have goals to make it easier for talented and committed doctors to do just that.

Do you foresee any conflicts of interest with the Allina management team regarding Allina’s bottom line economics vs. the medical/clinical needs of doctors and patients? I think there will always be tensions as long as reimbursement does not line up with the needs of the patients. For example, we get reimbursed more for a leg amputation in a diabetic than we do to coordinate care of the patient and prevent either the diabetes or secondary complications ahead of time. I do see some clear movement to align reimbursement with the management and coordination of the care required to promote wellness and lessen the burden of illness for our patients. I also think there is an increasing awareness that improved collaboration between physicians and organizations will benefit the care that we give.

Do you see yourself as primarily accountable to Allina medical staff or the administrative management at Allina? I feel primarily accountable to the patients and the physician-patient relationship. I always strive to bring the patient perspective into the room. Improving clinical care and experience at prices more people can afford unites all of us who care for patients, either directly or indirectly, in the case of the administrative management.

What can Allina do to improve cost and insurance payments transparency in its hospitals and clinics? Putting out results for people to see in comparable and in meaningful ways is a very powerful change force. I think that degree of public scrutiny on the value of care (quality and experience of care at affordable prices) will reduce the cost of care. I also think there are numerous ways to use talents of doctors and nurses more wisely. Studies show a doctor or nurse spends 30 percent of their time during the day for duties not matched to their skills. Much of this time is spent hunting, gathering and doing data entry or scheduling. They can be better supported with other team members or by making their lives easier with other support. I also strongly believe we need to support patients in more dramatic ways so that they become the principal agent in their own healing. If we can partner with patients and make them a more active participant in their health and wellness through support of chronic illness and prevention of illness I believe we will dramatically reduce the cost of care. With increasing capabilities of care teams to support them and tools like personal health records, this support is more feasible now than ever. MetroDoctors

The Journal of the East and West Metro Medical Societies

What evidence is there that the electronic medical record improves patient care quality at Allina? The medical record has been a key enabler for us to spread best practices for patients. For example, we have embedded decision support tools making certain that doctors can have ready access to best practice information. In the past year nearly 4,000 more patients in our clinics were in optimal control for their diabetes. Much of this improvement was because of the diligence of care teams, but it was enabled by doctors being able to readily look at all patients with diabetes under their care through the EMR and work with patients with higher risk factors. We need to find a way that all our affiliated physicians are linked to this record so care can be integrated for patients.

How does the EMR change the nature of clinical documentation? Do you see limitations or disadvantages to EMRs, as documentation checklist cookbooks? The EMR does change the nature of clinical documentation without a doubt. In its current form, it sometimes relies too much on cumbersome data entry for caregivers. It will continually mature. That being said, after some growing pains, no one wants to go back to paper. In terms of checklists, prompts and decision support tools are something that, when appropriate, are desired by all physicians to provide best care. If I, for example, know that there are four interventions that will benefit patients in terms of their care for congestive heart failure and six “must haves” for a smooth discharge transition from the hospital, I want to be as certain as possible that I am giving each and every patient those interventions. The electronic medical records ability to prompt best care practices and appropriate interventions for a particular patient is something that will benefit all.

How do you envision opportunities for Allina patients to interact with their EMR medical records and providers? I think this is one of the most powerful parts of the electronic medical record initiative. In the future, I envision patients having access to their complete medical record and they will work with their caregivers to develop shared care plans. Then everyone with whom they have an interaction will have the patients’ history, needs and preferences. I also think that these records will become far more interactive in the future including the ability to connect with home monitoring devices and check on the patient’s health remotely. This will allow us to go away from visit-based health care systems to one where home really becomes a center of care. (Continued on page 8)

March/April 2008

7

Colleague Interview (Continued from page 7)

How will Allina protect and safeguard medical records privacy and confidentiality? We have been rigorous about data protection. We are able, when required, for sensitive data to limit the views of those logging onto the system and have strict polices and enforcement of those polices to ensure that the patients’ data is not shared with anybody who is not a legitimate member of their care team. In contrast to the paper world, we can track who is looking at these records.

In your view, how important is preserving and protecting doctor-patient relationships in the Allina system? I think this is a sacred relationship and preserving, protecting and enhancing it is our obligation. I wish to see more decisions — both clinical and financial — made closer to where the care is delivered.

Is there, or will there be, a simple to understand, clinically-relevant and fair measure of quality that can apply to all caregivers for all patients or payers? I think we are getting there. I think measurement is incredibly important; you really can’t improve what you can’t measure. That being said, not all that we are focusing on in measure leads to an outcome that is meaningful for our patients and their care. I applaud Minnesota in taking the leadership in this area for the Institute for Clinical Systems Improvement (ICSI) and through the Minnesota Community Measures as well as legislative efforts that resulted in us being the first state to report adverse health events. I think this degree of openness only leads to improvement and there will be increasing maturity of our quality measures so that they have meaning for patients.

In your role with the Allina Board, how do you translate your bedside clinical judgment of Quality (I know it when I see it) into objective evidence your Board can understand and appreciate? We have found that patient stories are incredibly important, as are system level objective measurements of care improvement. Our Board is very committed to quality and that is demonstrated in many ways. We start every Allina Board meeting with quality, beginning first with a patient story. We talk about patients whose care could have been improved and celebrate cases where exceptional care was given. We have a “Measures of Caring” scorecard that shows how we are fairing on system quality metrics. Additionally, we hold a quality summit annually for the Board and for our physician and administrative leaders to come together and 8

March/April 2008

craft the quality work plan for the upcoming year. The level of Board engagement has accelerated our quality work.

How do “pay-for-performance” goals affect the day-to-day practice in Allina clinics, and is there any data on cost/ benefit outcomes? In the Allina Medical Clinics, clinical performance, primarily on Minnesota Community Measures, is looked at clinic by clinic, and we are always looking for ways to improve the care of patients collaboratively. There is no financial incentive placed to improve the care, rather we have focused on intrinsic motivators to improve care finding that no doctor wants to be a laggard in the care they provide for their patients. When they see somebody who is doing care exceptionally well, they all want to elevate their performance. I personally feel like we may have over emphasized pay-for-performance too quickly and there is some mixed evidence as to whether it is effective or not. At the end of the day, whatever improves the quality of care we provide, be it the intrinsic motivation of doctors to continually improve or financial incentives tied to that improvement, I endorse whatever gives us the most movement.

From your perspective — one very familiar with the clinical side and now the administrative side of medicine — how can we do a better job of defining “quality” for consumers who really want to know where or how to get the best care possible? I think we need to define it in terms that are meaningful and not underestimate the capabilities of the patient to understand measures that have value. Movement toward comparable measures for patient satisfaction rate and patient outcomes will be more meaningful than an A1C level.

Even though the St. Thomas-Allina Medical School project did not go forward, what can be done to do a better job in supporting primary care in the Twin Cities? I think we need to look at new ways of caring. A primary care team is key to the support and coordination of patient care and a foundation for improving the community’s health. I do think that a focus on increasing primary care and those in high needs specialties like psychiatry and geriatrics is important, in the context of expanded care teams. With a burgeoning aging population, a demographic shift is going to mean huge things in terms of chronic illness management and preventative services. Primary care is at the front and back end and is really the coordinator for patients across that continuum. I also think that proper support of those already in practice and realignment of incentives to pay for care coordination and continuity will be key. With the population changes, we need to move quickly to look at new models of care and team members — nutritionists, behaviorists, nurse practitioners, pharmacists, etc.— capable of extending the doctor’s reach. We cannot afford to do less.

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YOUR VOICE

Managed Care Transformation to “Managed Competition:” Enhancing the Status Quo

T

he Governor’s Minnesota Transformation Task Force created by the Legislature apparently believes that medicine’s ailments of insurance premium inflation and diminished quality are due to irresponsible provider and citizen life-style behaviors. The treatment is to attack provider behavior with “Payment Reform” that makes doctors pay the “total cost…for the population they care for.”1 This is intended to produce statewide savings of 10 percent. Meanwhile Minnesotans will be subjected to a behavior education and training blitz to produce savings of 5.7 percent. The final goal of 20 percent savings and reduced size of the health care sector would be attained by cutting administrative costs. Evidence is that, for nearly two decades, the managed care system has failed to control insurance costs while quality has diminished. Nonetheless, the Task Force still has faith in managed care and in its theory that bad behavior causes medicine’s ailments. What is wrong are the beliefs and theory. After 1965, 85 percent of Americans have had cheap politically subsidized tax-free insurance, the tipping point in time for four decades of a subsequent 17.5 fold increase in the medical CPI compared to a 6.3 fold increase in the rest of the economy.2 Demand inflation due to cheap insurance was predictable when a market with a quality good has little price information to guide customer decisions. The misfortune is that demand inflation driven by politically popular tax subsidies has, in the long run, proved hazardous for family and national budgets.2,3 In addition, diminished quality is driven by socioeconomic and cultural status factors4 over which clinics and many citizens have no control. The Task Force, secure in its belief of a sudden post 1965 moral lapse into irresponsible provider and citizen behavior, has produced a faith-based prescription to “transform” bad behaviors using “managed competition.” Managed Competition stormed into Washington in 1993.5 It was widely endorsed by the lay press and formed the core of President Clinton’s health reform proposal. Managed Competition was designed to address the problems of cost and access, with a strong emphasis on creating efficient systems of health care delivery.6 John K. Iglehart defined the Clinton version:7 “…As applied to practitioners, its central idea is to divide physicians B Y R O B E RT W. G E I S T, M . D . ,

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The Journal of the East and West Metro Medical Societies

and hospitals into competing economic units, called “accountable health partnerships,” that would contract with insurance-purchasing cooperatives to provide standardized packages of medical benefits for fixed per capita rates. Thus, Managed Competition would hasten the demise of fee-for-service payment, require providers to bundle their care into defined benefit plans, and by remunerating providers at fixed rates, place them at financial risk for their performance. Taken together with other proposed reforms — presumably some form of global limit on expenditures — managed competition would lead to a restructuring of the health care system unprecedented in the U.S. experience.” Managed Competition is a planners’ vision of an efficient cartel-like arrangement between state and managed care organizations (MCOs) to control market functions and prices; the status quo writ more powerful. Resurrection. The Clinton Managed Competition bill died in Congress in 1993 without a hearing. But it has been resurrected in a number of new incarnations in presidential campaigns and states. The MN state version would use a Health Insurance Exchange (HIE) programmed to function like a stock exchange where insurance buyers and sellers can meet. What is bought and sold may be insurance policies, but it could also be blocks of “insured lives” (private sector workers and public sector clientele). Would then the HIE be a platform for “Payment Reform,” the auction system of Managed Competition? Payment Reform. “Payment Reform” is the working principle of the Transformation Task Force Report:1 “Providers should be accountable for the total cost and quality of care for the population they care for (100 percent capitation)...Providers and care systems will submit bids on the total cost of care for a given population.” This is the ultimate pay-for-financial-performance (P4P) to induce gatekeeper behavior that restricts care when the alternative is clinic bankruptcy. The prior gatekeepers, the far more powerful MCO corporations, have failed, but we are to believe that threatening professionals with bankruptcy and report cards of a few population statistics can be a panacea for cost control. New Incarnations. Fashionable 2008 Managed Competition versions have the usual elements: mandates of insurance for all with guaranteed (Continued on page 10)

March/April 2008

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Your Voice (Continued from page 9)

issue (sick or not and at any time); and community rating of insurance, i.e., similar premium prices for all, which the state ordinarily will allow to vary by age, sex, geography, and so forth. Further state controls are: “play or pay” (a penalty) to “incent” employer funding; transfer of population underwriting risk to clinicians to create gatekeepers; state control of mandated insurance with creation and approval of benefit sets; state determination of “affordability;” and, in some proposals, certificate of need (CON) franchising to politically favored (or powerful) producers of technology, specialty services, or of all services. “Competition” is envisioned as taking place between a few huge HMOs or other forms of MCO Corporation capable of underwriting risk when bidding a capitation price to service populations of “insured lives” auctioned by employer and government agency “buyers.” Populations could in turn be further carved out for bidding by diseases (CHF, diabetes), by organ systems (orthopedic, eye), by procedures (prostate, chemotherapy), or conceivably by individual patient. Providers bidding a capitation price would be akin to a clinic or group being a mini HMO without reserves. New Managed Competition variations also claim to offer choice of insurance (“you can keep your current plan”), whereas in 1993 you could only have an HMO policy. Choice between HMOs may be no real choice, but competing inexpensive major medical policies with large tax-free deductibles (HSAs) have already broken the price barrier of insurance for many uninsured folks. By speciously vilifying tax-free deductibles as “unfair barriers to care,” the HMO industry, masters of real barriers, has been successful in enabling policy maker addiction to HMO “full coverage” for subsidized families. For example, Massachusetts’ subsidies for the poor are insurance vouchers good only at one of four HMOs. The state has already found program expense a serious problem and has put a moratorium on mandates setting back the state’s goal of reaching Universal Health Insurance (UHI). Maybe a forecast of other managed care “cures.” Commercials. Selling the new managed care panacea might appear difficult after failure of the old (the “broken system”). The difficulty has been overcome by echoing empty but successful slogans from the 1970s: “well care, not sick care” has morphed into “pay for quality, not volume;” “health maintenance” into “prevention;” and “coordination and efficiency” into “accountable health partnerships” incented for “quality.” To these have been added “best practices” measurement, i.e., process snapshots of a few medical encounters and financial profiling of a clinic’s “cost of care index” of “resource utilization” (of corporate money) under the guise of “cost/quality” insurance tiers to determine pay-for-performance (P4P) “bonus rewards” or punishments. The “blame, name, shame” game8 being played to find “bad apples” for financial punishment means that there is little interest in measurement for investment in maintaining the quality of an enormously complex system through academic research and continuous education at all levels.

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Pitfalls. A public policy transformation that creates cartel-like arrangements between the state and its corporate agents has three significant pitfalls. First, corporate/state cartels are very powerful combinations that create the potential of industry capture — which controls the other?9 Some think that industry capture is close to being finalized. Second, managed care rationing of medical care supply has failed to control costs despite powerful state and corporate means: state/ federal price fixing of services; CON (defunct); DRGs; and powerful corporate queuing techniques including referral guidelines, networks, power to coerce (“negotiate”) low service prices, and prior attempts to transfer underwriting risk to physicians at the bedside with capitation contracts. The result has been clinic and academic infrastructure erosion, a demoralized workforce, and clinicians running too fast.10 Third, political forces favoring popular subsidized “free” (low copay) care drive demand inflation,2,3 while socioeconomic and cultural status factors drive population quality statistics.4 Both are complicated by futile state and corporate rationing schemes. These are forces and factors over which clinicians have no control from the bedside. Conclusion. Clinicians can treat the ailments of patients, but not the ailments of a system gone awry and battered by futile efforts to control supply when the problem is demand. The “back to the future” prescription to “transform” a failed managed care system into a more powerful cartel-like Managed Competition behavior modification treatment is a case of public policy malpractice.11 There is a better way to achieve affordable insurance for all American families. (Footnotes) 1) Minnesota Health Care Transformation Task Force, Recommendations for the transformation of health care in Minnesota. Ver. 10.2. January 13, 2008. p. 17. 2) Phelps CE. Chap. 2: An overview of how markets interrelate in medical care and health insurance. In: Health Economics. Addison Wesley, Boston MA 2003:48. 3) Feldstein, MS. Chap. 6: Summary and conclusions. In: The Rising Cost of Hospital Care. The National Center for Health Services Research and Development; U.S. Department of Health, Education and Welfare. Washington D.C.: Information Resources Press; 1971:74, Herzlinger R. Who killed health care? Mcgraw-Hill, NY;2007:198-205. 4) Kawachi I, Kennedy BP. Chap. 3: Prosperity and health. In: The health of nations: why inequality is harmful to your health. The New Press NYC, NY; 2002:58-60, Marmot M. The status syndrome: how social standing affects our health and longevity. N Engl J Med. 2005;352(11):1159, Sapolsky RM. The influence of social hierarchy on primate health. Science. April 29, 2005;308:648-652, Asch SM et al. (RAND) Who Is at Greatest Risk for Receiving Poor-Quality Health Care? N Engl J Med. 2006;354 (11): 1147-1156. 5) Green A. J., Sutton S. K., Sconyers J. M., Reiter B., Adams R. L., Emanuel E. J., Brett A. S. Managed Competition and the Patient-Physician Relationship. N Engl J Med. 2007;352(12):1171-1173. 6) Enthoven AC, Kronick RA. A consumer-choice health plan for the 1990s: universal health insurance in a system designed to promote quality and economy (in two parts). N Engl J Med. 1989;320:20-29, 94-101. 7) Iglehart JK. Managed competition. N Engl J Med. 1993;328(16):1208-1212. 8) Hsia DC. Medicare quality improvement: bad apples or bad systems. JAMA. 2003; 289(3):354-356. 9) Newhouse JP. The Economics of Medical Care. The Rand Corporation. Addison-Wesley Publishing Co. Reading, MA. 1978:102. 10) Zuger A. Dissatisfaction with medical practice. N Eng J Med. 2004;350:69-75, Epstein AM, Lee TH, Hamel MB. Paying physicians for high-quality care. N Engl J Med. 2004;350: 406-410, Sandy LG. Homeostasis without reserve — the risk of health system collapse. N Engl J Med. 2002;347(24):1971-1975, Salgo P. The doctor will see you for exactly 7 minutes. NY Times. Wednesday 3-22-06. 11) Geist RW. The New Pay-for-performance Prescription for What Ails Medicine — Is This Public Policy Malpractice? MetroDoctors July/August 2006:17-18.

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The Journal of the East and West Metro Medical Societies

Summary of e-Health Initiatives

T

Introduction

The pace of electronic health (e-health) innovation and implementation is accelerating at a very rapid rate due to market forces and legislative mandates both on a national and state level. On a national level there are numerous organizations directing policy regarding electronic health information. They include, but are not limited to: s Healthcare Information Technology Standards Panel (HITSP); s American Health Information Community (AHIC); s Nationwide Health Information Network (NHIN); s Consolidated Health Informatics (CHI); s The National Committee on Vital and Health Statistics (NCVHS); s U.S. Department of Health and Human Services: Health Information Technology (DHHS: Health IT); and s The Public Health Data Standards Consortium (PHDSC). There are also organizations developing standards for health information technologies and exchanges. Generically they are called Standards Development Organizations (SDOs). SDOs include: s International Standards Organization (ISO); s American National Standards Institute (ANSI); s ASTM International; s National Institute of Standards and Technology (formerly Bureau of Statistics); s Organization for the Advancement of Structured Information Standards (OASIS);

B Y D I A N E D AV I E S , M . D . A N D JOEL ACKERMAN

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s National Council for Prescription Drug

Programs (NCPDP); and s X12N.

The State of Minnesota has passed legislation that requires that all hospitals and health care providers have interoperable electronic health records by January 15, 2015. By January 1, 2009 uniform health information technology standards need to be adopted and a status report has to be submitted to the Legislature by January 15, 2008. By January 2008 a standardized Minnesota patient consent form for the release of health records is due with standard instructions that inform providers and consumers on how to interpret and use the standardized consent form. The National Landscape

The Office of the National Coordinator for Health Information Technology (ONC) within the Department of Health and Human Services (HHS) is responsible for the development and implementation of a strategic plan to guide the nationwide implementation of interoperable health information technology in both the public and private health care sectors. It has sponsored demonstration projects in support of the development of a National Health Information Network (NHIN). ONC has established principles that provide guidance on statewide health information exchanges (HIEs): s There should be at least one HIE in each state. s For the states that have more than one HIE, an overarching state-level HIE should coordinate HIEs across the state and set a state-level framework for health information exchange. s Each state-level HIE should meet a minimum set of best practices for governance,

The Journal of the East and West Metro Medical Societies

financing, operations, policies and transparency. s HIEs should follow goals and recommendations from the American Health Information Community (AHIC), as recognized by the Secretary. The national e-Health Initiative is a non-profit organization that has been tracking the progress of HIE efforts. Their recent 2007 survey of 130 community-based efforts produced the following results: s 20 are just getting started. s 68 are in the process of implementation. s 32 are operational. s five are no longer moving forward. Minnesota e-Health Activities

As in other areas of health care, Minnesota is taking a leadership role in e-health and many other states and communities are actively watching what is being developed here. The formation of the MN e-Health Initiative Advisory Committee is an example of such leadership. The Minnesota e-Health Initiative was created to accelerate the use of health information technology to improve health care quality, increase patient safety, reduce health care costs and enable individuals and

(Continued on page 12)

March/April 2008

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Hennepin County Medical Center Minneapolis, MN

e-Health Initiatives (Continued from page 11)

CHIEF OF OPHTHALMOLOGY Hennepin County Medical Center, Minneapolis, MN. Hennepin County Medical Center, an affiliate of the University of Minnesota, is inviting applications for the position of Chief of Ophthalmology. Qualifications: Board Certified or Board eligible in Ophthalmology. Interest in serving an urban, indigent population. Demonstrated interest and ability in teaching and knowledge of residency training programs and clinical ophthalmology care delivery. Candidates must be eligible for an academic appointment at the University of Minnesota. Hennepin County Medical Center, Hennepin Faculty Associates (physician practice group), and the University of Minnesota are Affirmative Action employers and specifically invite and encourage applications from women and minorities. Send letter of interest and curriculum vitae to Theresa McCabe, at e-mail: theresa.mccabe@hcmed.org or Office of the Medical Director, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415. Telephone: 612-873-3629. Application deadline: Postmarked no later than April 15, 2008.

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March/April 2008

MetroDoctors

communities to make the best possible health decisions. The MN e-Health Initiative is a private/public collaboration and is distinctive in its broad support and comprehensive vision, which is focused on consumers and provides value to people and communities. The Minnesota e-Health Advisory Committee makes recommendations to the Commissioner of Health on policies and strategies that: s Empower consumers with information to make informed health and medical decisions. s Inform and connect health care providers so they have access to the information and decision support they need. s Protect communities with accessible prevention resources, and rapid detection and response to community health threats. s Enhance the infrastructure necessary to fulfill the e-Health vision. The Committee’s charge by statute is to: s Create a statewide plan to implement health information technologies including the requirement that all hospitals and health care providers have interoperable electronic health records systems by January 1, 2015. s Develop, adopt and/or refine uniform standards for the use of health information technologies, including sharing and synchronizing patient data access across interoperable electronic health record systems. s Ensure that the statewide plan for health information technologies fully considers patients’ privacy and the security and confidentiality of individual patient data. s Ensure that the statewide plan for health information technologies includes a path for upgrading local and state public health information systems to be fully interoperable with hospitals and health care providers. s Identify and suggest communication and educational activities necessary to advance health information technology activities in the State of Minnesota by increasing the support and collaboration by all health care organizations, providers and consumers. (Excerpted from the Minnesota e-Health Initiative datasheet dated September 2007.) The Journal of the East and West Metro Medical Societies

MnHCC

The Minnesota Health Care Connection (MnHCC) was created by the Minnesota e-Health Initiative Advisory Committee as a way to drive adoption of health information exchanges across the state. In January 2006 the MnHCC Board of Directors met for the ďŹ rst time. These volunteer directors represented 10 major stakeholder groups (health plans, large hospitals, community hospitals, pharmacists, consumers, physicians, local public health, the Minnesota Quality Improvement Organization (QIO), purchasers and the state of Minnesota. Their initial charter was to develop the basic framework for MnHCC, including the initial Business Work Plan. The results of this planning were presented at a statewide e-Health conference in June 2006. MnHCC’s vision is to improve the quality and safety of health care in Minnesota for individuals and populations, add value to the health care delivery system, and enable more efďŹ cient and cost effective health care. MnHCC embraces a “statewide HIEâ€? model and it received a planning grant from the Minnesota

e-Health grant program to develop a “readiness assessment toolkit� for HIE organizations. One of MnHCC’s goals includes guiding the development of a secure, shared patient information system by 2012 so that caregivers have more of the information they need to make decisions about patient care — and so patients have a safer, more seamless health care experience, regardless of which Minnesota provider or hospital they go to for care. (MnHCC Web site: www.mnhcc.org) Core MnHCC functions include: s Convening stakeholders; s Communicating knowledge; s Educating and advocating for stakeholders; s Conducting analysis and research; s Assessing needs of stakeholders; s Coordinating and assisting stakeholders; and s Facilitating common services for health information exchange. MnHCC board members are actively participating in the MN e-Health Initiatives and workgroups. Currently the Minnesota e-Health Initiative has workgroups on the

following topics with the following charges: (Excerpts from the Minnesota e-Health Initiative Workgroup Charges fact sheet 20072008). Statewide Health Information Technology Implementation Plan Workgroup: Create a plan to guide statewide adoption of interoperable electronic health records and related health information technologies to improve the quality and safety of health care and improve the health of communities. This includes addressing how health care, public health and other organizations will meet the legislative mandate of having interoperable electronic health record systems by January 1, 2015. Health Data Standards Work Group: Develop, adopt, and/or reďŹ ne speciďŹ c standards for the use of health information technologies across the spectrum of care, including sharing and synchronizing patient data across interoperable electronic health record systems and HIT certiďŹ cation. (Continued on page 14)

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March/April 2008

13

e-Health Initiatives (Continued from page 13)

Privacy and Security Workgroup: Ensure that the statewide plan for health information technologies fully considers patient privacy and the security of individual patient data and to develop a standardized patient consent form for the release of health records that when used must be accepted by any health organization in the state. Communications, Education and Collaboration Workgroup: Identify and implement communication and educational tasks necessary to advance health information technology efforts in the State of Minnesota, and increase collaboration between health and health care organizations, providers and consumers. Population Health and Minnesota Public Health Information Network Workgroup: Identify the local and state public health information systems that are required to be updated to meet the 2015 mandate to be fully interoperable with health care providers, hospitals, laboratories, the Centers for Disease

Control (CDC), other states and other partners. To also identify population health and prevention indicators that can be incorporated into decision support systems and other HIT to improve both population health assessment (summary data) and clinical practice. Additional Examples of Minnesota e-Health Activities s Itasca County Health Network (ICHN)’s

goal is to improve consumer access to coordinated care through implementation of health information exchange among all the health care providers in the Itasca County area. ICHN was organized in 2003 with funding from the OfďŹ ce of Rural Health Policy, HRSA, Rural Health Network Development grant. Members are representative of all the health care providers and Itasca County Health and Human Services, including IMCare, a public payor for Medical Assistance, General Assistance Medical Care, MnCare, and the Minnesota Senior Health Options (MSHO). These providers and the county have collaborated in provid-

ing health services in the IMCare program since the early 1980s. s The Northern Minnesota Network (Cambridge) consists of three members that operate 20 sites providing primary health care services to the uninsured, underinsured, migrant and seasonal farm workers in rural areas of Minnesota and eastern North Dakota. Their centers are often the only primary care providers in the area. The health centers in the Network provide care to approximately 25,800 people annually with over 102,200 patient encounters. The combined service delivery areas of the Network centers encompass more than 14,000 square miles. s Central Minnesota Health Information Network (CMHIN) in Alexandria, Minnesota is a seven county consortium of rural health care providers composed of 10 hospitals and three medical centers. CMHIN was formed to respond to the tenuous survival of rural health care facilities in central and west central Minnesota. s Community Health Information Col-

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laborative (CHIC) serves 18 counties in northeast and north central Minnesota, including: Aitkin, Beltrami, Carlton, Cass, Chisago, Cook, Crow Wing, Isanti, Itasca, Kanabec, Koochiching, Lake Mille Lacs, Morrison, Pine, St. Louis, Todd and Wadena. The area covers 29,711 square miles and is home to some 650,000 residents. The area’s population is primarily white, non-Hispanic with a significant Native American population. There are six tribal communities located within the project area. Compared demographically with the rest of Minnesota, the region’s population is poorer and older than the state averages. s Staples/Motley HIE serves five counties in central Minnesota (Todd, Wadena, Morrison, Cass and portions of Crow Wing) and includes the community of Staples and the surrounding communities of Wadena, Ferndale, Aldrich, Hewitt, Motley and Pillager. Since 1936 the major health care organization in Staples and Motley is Lakewood Health System. Located in Staples, Lakewood Health System’s service population is 97,001. The Minnesota Health Information Exchange (MN HIE)

Planning for the Minnesota Health Information Exchange (MN HIE) started in early 2006, funded and guided by four member organizations of the MN HIPAA Collaborative: BlueCross and BlueShield of Minnesota, Fairview Health System, HealthPartners and Medica. This private sector initiative expanded upon the foundational work done by the MN e-Health Initiative. MN HIE architected a network to support a broad range of the health care information exchange needs of large and small hospitals, clinics, health plans, pharmacies, laboratories, etc. In September 2007, Governor Pawlenty formally announced the MN HIE, as well as the participation of the State in the Exchange. MN HIE is structured as an independent legal entity based on a notfor-profit model, with a two-tier structure for sponsors and subscribers. As of October 2007, the list of participants included: s Allina Hospitals and Clinics; s BlueCross BlueShield of Minnesota; s HealthPartners; MetroDoctors

s Medica; s Minnesota state government (DHS); and s UCare.

MN HIE has identified four Guiding Principles: 1. Consumer/Patient Focus — An emphasis on saving lives and improving health care through timely access to information at the point of care. 2. Accommodate Expansion — To include other participants as Sponsors, Subscribers, etc. 3. Collaboration with other e-Health efforts in Minnesota — Seek input from key stakeholders, e.g., consumers, physicians, employers, state government, etc. 4. Provide leadership through successful implementation of the vision established by the MN e-Health Initiative. The initial plan for the MN HIE identified four sets of services (“use cases”) to be supported by the Exchange: 1. Emergency Department Medication History; 2. e-Prescriptions; 3. e-Lab; and 4. Communicable Disease Reporting. MN HIE successfully completed in March 2007, a proof-of-concept demonstration of the Emergency Department Medication History capability. The demonstration included the development of a Master Patient Index (MPI) and Record Locator Service (RLS) for over four million members, a patient identification process, and a patient consent process for obtaining permission prior to accessing patient information. The patient medication information was accessed from multiple EMR and other sources, and aggregated only when needed. These capabilities will be piloted beginning first quarter of 2008. The other three use cases will be built and implemented during 2008-2010. Discussion

There are many initiatives and organizations involved in the development and implementation of e-health and health information exchange. Since there are no definitive paths for these endeavors, successful implementation of e-health and health information exchange requires ongoing commitment by all stakeholders in health care including health plans,

The Journal of the East and West Metro Medical Societies

providers, employers, the government and patients to stay informed. Short term it is important to maximize the learnings of the various e-health living laboratories across the country with a focus on Minnesota. There are various ways to stay informed of the status of this transformation; the simplest way is to periodically go to Web sites such as the Minnesota e-Health Initiative, www.health.state.mn.us/e-health or the Minnesota Health Care Connection, www.MnHCC.org. Also, consider participating in workgroups offered through the Minnesota e-Health Initiative and other organizations. The future of optimal patient care depends on how well we collectively make the transition to e-health and e-health exchange. Diane M. Davies, M.D., M.S. is president, Davies and Associates, LLC. She has over 25 years of experience as a strategic advisor to multiple health care stakeholders including providers of care, health plans, employers, business coalitions, policy makers, medical device companies, pharmaceutical companies and venture capital firms. Her education includes an M.D., a M.S. in Human Genetics, a B.S. in Public Health, Biology and Chemistry and training in Internal Medicine. She recently completed post-doctoral training in health informatics, all from the University of Minnesota. Dr. Davies can be reached at davies@visi.com. Joel Ackerman is president of Ackerman Concepts, LLC, and the Founder of Health Information Masters, a consortium of health care’s leading independent management consultants. He currently serves as director of the non-profit organization, CaringBridge. He holds a B.A. in Computer Science and an MBA in Management Information Systems from the University of Minnesota Carlson School of Business, and is currently pursuing a Ph.D. in Health Informatics at the University of Minnesota. Mr. Ackerman can be reached at JoelA@AckermanConcepts.com or (612) 396-6521.

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Queen of Peace Leads Efforts to Keep Community Healthy 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. Queen of Peace Hospital in New Prague, MN is the first hospital to be highlighted in this series.

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QUEEN OF PEACE HOSPITAL is a 25-bed critical access hospital located in New Prague, Minnesota, serving a patient base of roughly 60,000 in the counties of southern Scott, Rice, LeSueur and Sibley. Queen of Peace contributes to the health of the communities it serves by providing inpatient, outpatient, emergency and home health care services, family practice clinics, women’s health center, community health education, community food shelf, senior housing, community fitness center and athletic trainers, Lifeline services and EMT training for community volunteer ambulance services. Twenty primary care physicians and seven ER physicians make up the Queen of Peace active medical staff: Specialty services are provided by 113 consulting specialists including Allergy, Cardiology, ENT, Gastroenterology, Infectious Diseases, Internal Medicine, Nephrology, Neurology, Oncology, Oral/Maxillofacial Surgery, Orthopedics, OB/GYN, Ophthalmology, Pulmonology, Radiology/Tele-radiology, Rheumatology, Urology, Dentistry and Podiatry. The mission of Queen of Peace is to serve others in need of health care as if they were Christ Himself. Part of the vision statement of Queen of Peace states that we are a progressive, caring community health system offering a variety of services that allow us to B Y M A RY K L I M P, C E O Queen of Peace Hospital

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meet the growing demand for wellness in the community. A focus on medication safety is a piece of our strategy to do this. In the summer of 2006 Queen of Peace developed a personal medical card for distribution throughout the community. “We created a long-lasting, durable, personal medical card for people to keep all their medical information with them in one place,” says Marla Mayer, director of community relations for the 25-bed hospital in New Prague, MN. About the size of a business card when closed, the personal medical card folds out to reveal a full-page where users can record their provider information, medical history, and all medications, including dosages and reasons for taking them. The card is a part of a medication safety campaign to encourage patients to be partners with their health care team. An interdisciplinary team met to develop what information was to be included on the card. They believe that keeping a list of medicines is a simple step everyone should take. The hospital has partnered with local clinics and pharmacies to distribute the cards and has educated local ambulance service providers, nurses and physicians to look for the cards. The message passed on to each and every patient is: 1. No matter which health care provider patients see, ALWAYS take this list of medications to every appointment. 2. Be sure to update the list as soon as a medication is added or a dose is changed. 3. Over the counter medications and herbal medications should be included on the list. Queen of Peace has held a number of Senior Expos and “Educate Before You Medicate” sessions to educate area seniors on medication safety. MetroDoctors

Mayer says that over the last year nurses report lots of people from the community are coming into the hospital with their cards. “We have distributed over 10,000 of these cards,” says Mayer. “It’s something we want everyone to have and use. With everyone on board we are working hard to ensure that medication errors do not happen.” In cooperation with Mayo Health System, Queen of Peace opened the Women’s Health Center on its campus in 2005. The clinic is operated by two OB/GYN physicians and a staff solely committed to the health needs of area women. In-office ultrasound services, birthing classes, complimentary massage, and even warmed robes are just some of the special services pregnant women can expect when choosing the Women’s Health Center at Queen of Peace Hospital. It is staffed by Dale Sundwall, M.D., and C. Nic Moga, M.D., from Cannon Valley Clinic Physicians of the Mayo Health System, and offers leading-edge diagnostics, procedures and care in an aesthetically pleasing and comforting environment. Prior to the opening of the Women’s Health Center, area women had been using consulting OB/GYN physicians or Queen of Peace family practice physicians for obstetric care. However, the Women’s Health Center The Journal of the East and West Metro Medical Societies

offers an additional scope of specialty OB/ GYN services. Women now have the choice of going to their family practice physician or one of the new Women’s Health Center specialists — without leaving the convenience of Queen of Peace. “We are providing women with the choice of Mayo Clinic-afďŹ liated OB/GYN specialists who can provide a level of care that they previously had to travel further to receive,â€? says Mary Klimp, CEO, Queen of Peace Hospital. “The Women’s Health Center is also an easy, convenient access point to the array of services—such as cardiology and oncology—offered at Queen of Peace Hospital.â€? Beyond delivering babies, Dr. Sundwall and Dr. Moga also serve the health care needs of all women, from adolescents to post-menopausal women. The Women’s Health Center offers a free continuing education series on women’s health. A wide variety of health care topics that affect women are presented by the physicians with a question and answer session that follows each session. Hundreds of area women have attended these sessions since they began offering them in 2006. The Fitness Center in New Prague is operated by Queen of Peace Hospital to combine outpatient rehab services with a community ďŹ tness center. Over 800 area residents have ďŹ tness memberships. Queen of Peace employed physical therapists and athletic trainers also provide services for student athletes at area schools. The Fitness Center provides health and wellness programs to non-members, as well as members. In its second year, The Fitness Center currently has over 160 people enrolled in their Biggest Loser contest. Last year the participants lost over a ton of weight combined. The participants are placed on teams led by a personal trainer. Training sessions, weekly weigh-ins, nutrition and exercise journaling, and motivational speakers are all a part of the program. The title of “Biggest Loserâ€? goes to the person losing the largest percentage of body weight. “The contest is a great way to generate interest and excitement,â€? said Jill Rohloff, director at The Fitness Center, “but most importantly, we are trying to build healthy diet and exercise habits that will last long after the challenge is over.â€?

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Queen of Peace Hospital is also committed to helping train their local ďŹ rst responders. In partnership with North Memorial, approximately 500 area volunteer police, ďŹ re and ambulance EMTs are trained annually at Queen of Peace. These volunteers provide emergency transport services in the communities of New Prague, LeCenter, LeSueur, Montgomery, Lonsdale, New Market, Elko, Shakopee and Belle Plaine. “We are not just medical providers in the community,â€? commented Tim Halloran, M.D., of LeSueur Medical Clinic, and a (retired) scout master with Boy Scouts for seven years. New Prague Parkview Medical Clinic physician, John Berg, M.D., has been coaching the area’s youth wrestling program for 28 years, and has been a Minnesota State High School League state tournament physician for almost as long. Dr. Berg’s sons, Mark Berg, M.D. and Dan Berg, M.D., also of Parkview Clinic, have followed in his footsteps. They, too, are youth wrestling coaches as well as state tournament physicians. “Our physicians are also community members who are involved in and support local organizations.â€?

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Transition Medicine Helping Youth With Special Health Care Needs Transition from Pediatric-Based Care to Adult-Based Care Transition (or Transitional Medicine) is the process by which Youth with Special Health Care Needs (YSHCN) transition their health care from pediatric-based care to adult-based care.

Developing a Transition Plan

Background Data:

Due to advances in medical technology and therapies, more children than ever before are surviving cancer, illness and disability to live well into adulthood. Here are some numbers: s 77 percent of children treated for cancer survive five or more years.(1) s By 2010, one in 250 adults <55 years old will be a childhood cancer survivor.(2) s In 2006, the mean age of survival of cystic fibrosis (CF) was 37 years.(3) s 40 percent of the 30,000 people with CF in the United States are over 18 years old.(3) s Up to 80 percent of adults with Down syndrome reach the age of 55.(4) s Approximately one million Americans have congenital heart disease (CHD).(5) s Today the risk of dying from surgery for CHD is about 5 percent.(5) s 90 percent of YSHCN will reach 21 years of age.(6) These medical successes have improved the quality of lives of thousands of patients and their families. They should be celebrated. But the victories have produced an unsuspected problem: How do children with complex medical problems transition from pediatric-based to adult-based medical care? Problems with Transitioning:

There are multiple barriers for YSHCN in transitioning into adulthood. Many patients

B Y D A N I E L A L B R I G H T, M . D .

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March/April 2008

and their families are not prepared for this transition.(7) They may be unwilling to switch providers. There may be inadequate communication between their current pediatric and future adult care provider. Pediatric care providers may follow these patients well into adulthood being unable to identify a provider to assume care. The adult care provider may struggle with the lack of exposure and experience in treating childhood disabilities and chronic illnesses. YSHCN may not feel like they are treated like an adult because of their disease or disability. They may not be prepared to take ownership of their own illness or disability. These patients may lack access to adult specialists. In fact, nearly one-half of all YSHCN lack access to a physician who is familiar with their health condition.(6) YSHCN may lose health insurance or be dropped from their parents insurance. Young adults (18-24 years old), in general have a low rate of insurance coverage — 37.7 percent of males and 30.7 percent of females.(7,8) They may lose Medicaid eligibility. For instance, the SSI eligibility changes at age 18 from a condition that causes severe functional limitation to a condition that prevents gainful activity.(7,8) Many also have difficulty transitioning from school to the workforce. MetroDoctors

Transition Medicine represents one part of the comprehensive health care management identified in the medical home. Such transitioning of care for YSHCN within a medical home is a major goal of The U.S. Department of Health and Human Services’ Healthy People 2010 project, along with employment assistance and developing greater personal independence.(9) This need was also recognized in 2002 when there was a joint consensus by the ACP-ABIM, AAP and AAFP that children with chronic illness need transitioning of their health care when they become adolescents or young adults.(10) The idea of transition in health care fits with other active initiatives promoted by these primary care societies, including chronic disease management. Medical schools and residency training programs are also beginning to incorporate transition in medical care within their curriculums and learning objectives. In many communities, Transition Medicine takes the form of formal adult-based clinics for once considered childhood diseases and disabilities. For instance, adult-based clinics for cystic fibrosis, Down syndrome and congenital heart disease provide specific and ongoing subspecialty care. Designated transition medicine clinics may provide more general care for complex patients transitioning into adulthood. Long term survivor clinics may help to monitor the late effects of cancer treatment on childhood cancer survivors.(1) For the individual provider, Transition Medicine starts first with the establishment of a medical home for a child with complex medical health care needs. In a medical home a comprehensive care plan is developed, which includes the medical summary, emergency treatment plan and working care plan.(11) These plans are designed to be a portable medical record, which

The Journal of the East and West Metro Medical Societies

help to coordinate care, plan medical visits, and assist in transition of care. Many types of transition readiness tools give patients, parents and providers a checklist of skills needed to manage their own medical, educational, vocational and housing needs. (7,12,13,14,15) In this respect, the ultimate goal of transitioning for YSHCN is more about a patient’s self-reliance and growing independence than the actual transfer of care to another provider. For physicians who care for all age groups (Family Medicine or combined Internal Medicine/Pediatrics), the major objectives of transitioning are patient independence and age-appropriate care. Additionally, YSHCN carry their child-based illness, disease or late effects of treatment with them into the realm of adult medicine where they may also develop adult illness and disease. Adult care providers must then continue with chronic disease management along with other age-appropriate screening.

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Example of Transition Planning and Age-appropriated Medical Care

In my practice, I care for a significant number of young adults with Down syndrome. I will give an example of transition planning for such patients. Before the age of 16 a student’s Individualized Educational Plan (IEP) should include a formal transitional plan that identifies specific goals and anticipated services or post-secondary needs. This is required under the Individuals with Disabilities Education Act (IDEA) in order to receive support for future post secondary education, employment and housing. (16,17) Students, parents, teachers, social workers and health care providers all may contribute to the transition team. Young adults with Down syndrome encompass a large spectrum of functional and cognitive abilities. A transition plan is specific to each individual and should consider individual strengths and needs in identifying long-term goals along with developing self-advocacy skills. With each objective, a team member is made responsible to ensure it is completed and a goal date is set. The transition plan should also attempt the following.(16,18) s Outline vocational or academic programs of interest.

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The Journal of the East and West Metro Medical Societies

March/April 2008

19

Transition Medicine (Continued from page 19) s Discuss community-supported employ-

ment opportunities. s Review available housing options, such as community living arrangements. s Discuss financial planning and guardianship if applicable. s Discuss prevention of abuse. In a similar way, the medical evaluation of an adolescent or young adult with Down syndrome also needs a transition plan and age-appropriate care. First, the medical record should be reviewed and updated with the patient’s significant past medical history, current medical problems and medications, ongoing specialists involved and other significant social issues. In my health system this is done on an electronic medical record, which may be readily accessed by patients and family when needed using Patient Online (POL). The transfer of care from pediatric to adult specialists should be coordinated. A management plan for each associated chronic disease should be performed and results reconciled when completed. Health care guidelines have been established for individuals with Down syndrome for

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different age groups.(18,19) For patients ages 1318, annual history and exam is recommended. It should focus on previous medical problems along with other potential medical issues. These include symptoms of airway obstruction, vision and hearing concerns, cervical spine instability, celiac disease, diabetes, behavioral and mental health concerns, sexuality issues and functional status or declines in functioning. The complete physical exam should include an assessment for obesity using Down syndrome growth curves and a general cognitive and behavior evaluation. Other screening tests are as follows: s Annual CBC and thyroid function tests. s Annual Audiology and Ophthalmology evaluations. s Cervical spine x-rays as needed for involvement in Special Olympics or with signs or symptoms. s For sexually active females: pelvic exam and Pap smears every one-three years (practitioner/gynecologist experienced with special needs patients). s Overnight sleep study if symptoms of airway obstruction. s Celiac Disease antibodies if not previously checked or with symptoms. s Dental evaluations every six months. Screening for patients > 18 years is as follows: s Annual thyroid function testing. s Audiology and Ophthalmology testing every two years. s Dental evaluations every six months. s Other standard screening labs for diabetes, cholesterol, anemia. s Cervical spine, Celiac testing and sleep studies if indicated. s For sexually active females: Pelvic and Pap smears every one-three years. s For females not sexually active (exam every two-three years). Single-finger bimanual exam with single finger cytology exam or pelvic ultrasound. s Annual breast exams and mammograms beginning at age 40. For patients with a decline in function, a more thorough evaluation should be undertaken with differential diagnosis including: depression, early-onset dementia, cerebral vascular disease (especially Moyamoya), Atlanto-axial instability and others. Testing could include:(20)

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s Lab: thyroid function, Vitamin B12 and

folate, CBC, chemistry profile. s Brain MRA/MRI. s Cervical spine films. s Specialty referral depending on testing re-

sults. With each identified problem needing chronic disease management an action plan is undertaken. The problem is identified; a plan is made and carried out, and the results are reviewed and reconciled. For instance, if a young adult with Down syndrome is obese, the following treatment plan may be pursued. The medical care provider would test for associated conditions like diabetes and hyperlipidemia. Counseling on diet and exercise could include an evaluation by a nutritionist. The patient would be made responsible for changes in activity, documenting type and amount of exercise, quantifying TV use, documenting dietary changes with a food diary. Caregivers could be made responsible for finding an appropriate exercise facility, changing food purchases, ensuring exercise and dietary logs are kept. Every party involved (the patient, caregivers, and medical care providers) takes an active role in the health care management. Summary:

Transition Medicine is a process within the framework of the medical home model, which attempts to provide continuity of care and support for children with disabilities or chronic illness who have grown too old for pediatricbased care. These patients need assistance with, not only health care, but also employment and independence. Multiple types of formal transition checklists, transitional tools and care plans may be used for the purpose of transitioning YSHCN. Providers may construct individualized personal transition care plans using their own models. Every provider who cares for YSHCN plays some part in this transitioning. Providers can discuss transition of care with colleagues. They can identify other providers who have experience in the care of young adult patients with certain illnesses or disabilities. Temporary co-management between current pediatric and future adult care providers may provide a more seamless transition for these young adults. Adult care providers could offer to meet with patients and families free of charge as a way to establish rapport and ensure compatibility for The Journal of the East and West Metro Medical Societies

all involved. Providers should not forget, however, to simply listen to young adult patients and their caregivers. They often are experts in their illness or disability and may offer ongoing and meaningful contributions to the quality of care provided. Health care systems may also play a major role in developing Transition Medicine. These systems may help develop improved medical record templates for establishing the Medical Home for YSHCN. Internal methods of transitioning care between pediatric and adult care providers could be established. Shared medical records between health systems would also facilitate the management and transfer of care of YSHCN between providers. Transition Medicine is mostly an idea or a concept. We begin to practice Transition Medicine when we ďŹ rst recognize its value in our care for patients.

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Daniel Albright, M.D., is board certiďŹ ed in pediatrics and internal medicine, and practices at Park Nicollet Clinic, Maple Grove.

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Footnotes: 1. American Cancer Society. Childhood Cancer: Late Effects of Cancer Treatment. http://www.cancer.org/ docriit/CRI. 2. Transition Medicine: Baylor College of Medicine Clinics. http://www.bcm.edu/medpeds/transitonal.html. 3. Cystic Fibrosis Foundation. What You Need to Know. http://www.cff.org/AboutCF/. 4. National Down Syndrome Society. http://www.ndss.org/ index. 5. American Heart Association. Congenital Heart Disease Defects in Children Fact Sheet. http: //www.americanheart.org/presenter. 6. http://www.medicalhomeinfo.org/health/trans.html. 7. Assessment of Readiness for Health Care Transition in Adolescents. JaxHats Program (Jacksonville Health And Transition Services). http://jaxhats.u.edu. 8. Callahan ST, Cooper WO. Uninsurance and health care access among young adults in the United States. Pediatrics 2005;116:88–95. 9. www.hhs.gov/newfreedom/ďŹ nal. 10. Gesensway Deborah. Internists wanted for complex adolescent care. http://www.acponline.org/journals/ news/dec04/adolescents.html. 11. Medical Home Learning Collaborative’s Medical Home Action Plan. http://www.medicalhomeimprovement. org/newtools.html. 12. http://www.medicalhomeinfo.org/tools/assess.html. 13. http://depts.washington.edu/healthtr/. 14. http://www.fvkasa.org. 15. http://www.hrtw.org. 16. National Down Syndrome Society-Transition Planning. http://www.ndss.org. 17. http://www.goldcoastdownsyndrome.org/new-website-dev/education/transition.html. 18. AAP: Health Supervision for Children with Down Syndrome: Pediatrics Vol. 107, No. 2 February 2001. 19. Health Care Guidelines for Individuals with Down Syndrome: Down Syndrome Quarterly, Vol. 4, No. 2, September 1999. http://www.ds-health.com/ health99.html. 20. Adults with Down Syndrome: Specialty Clinic Perspectives. http://www.ds-health.com/adults.html.

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The Case for Adaptive Leadership

Personal Aspects of Leadership

Editor’s Note: This is the third of a three part series discussing a model for addressing the difficult problems that health care organizations face. The first article described the principles of the model of Adaptive Leadership as developed by Dr. Ron Heifetz,(1) while the second article demonstrated the principles as applied to the complex challenge facing health care organizations as they attempt to implement the electronic medical record.

A

AFTER CONSIDERING the myriad adap-

tive challenges that health care faces today, a physician may well ask why he or she should accept the call to exercise leadership in helping individuals and systems make progress on the work before us. It would seem to be easier to just sit back and do the work we were really trained to do in medical school, residency and fellowship…see our patients and treat them as best we can, even if handicapped by a broken system that seems beyond help. And yet, as physicians, we are in the best position to see the challenges before us in both the broadest perspective across systems and in that intimate perspective that comes from the physicianpatient relationship. The challenges embedded in adaptive work versus technical work (as discussed in the first article in this series) require us to bring our whole selves to the work. These adaptive challenges involve navigating the chasm between where we are now and where we believe we need to be. It involves work where the final result and the course to get there are unknown. It involves understanding and appreciating that our deeply held values and beliefs may be in conflict with others’ values and may even in-

BY

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volve some ambivalence within ourselves. We each struggle with our own issues regarding time and money, being present wholly to our patients and protecting our own emotional health. Our health systems are paralyzed by similar values conflicts between health care financing and care for the patients and staff, between administrative and medical staff, among the various clinical and administrative factions fighting to protect turf. The principles discussed in the two previous articles showed the different roles that authorities play when there are technical problems to be solved and when there are adaptive challenges on which to make progress. Physicians act as authorities in both formal positions and in informal roles. We exercise leadership in those roles both in the technical problems that surface in our organizations and in the adaptive challenges that are confronting us. It is in that role of effecting transformative change and exercising leadership in the murky, muddy adaptive challenges that seem beyond hope that we think physicians are called to be today. In the previous article of this series we used implementing the electronic medical record as an example of an adaptive challenge affecting how we practice. Unfortunately, there are dozens of other examples (pay-forperformance, the legitimacy of evidence-based medicine, aligning incentives within health care systems, addressing access to health care) that require creative dialogue in safe environments in order to make progress. Each physician exercising leadership in such challenging situations must understand his or her role and be able to help our colleagues and other stakeholders move forward by: 1) providing and forming the tough questions rather than by fulfilling their expectations MetroDoctors

for answers; 2) letting them feel the pinch of reality, rather than protecting them from the outside threats; 3) disorienting them so that new role relationships develop, rather than orienting them to their current and usual roles; 4) drawing the tough issues out, rather than attempting to quell conflict; and 5) challenging the way to do business, distinguishing those values and norms that must endure from those that we must let go of, rather than maintaining the current norms of the status quo. We all have the opportunity to exercise such leadership, whether through formal or informal authority, in our work with county/state/national professional associations, hospital committee and department meetings or in our work in our own clinics and practices. Inevitably, these actions can raise the heat and stress in the systems as well as in ourselves and colleagues. Leading others in this work is both challenging and, in a sense, dangerous. We are asking our colleagues to relook at their deeply held values of independence, autonomy, prestige and unquestioned authority and we are asking them to accept interdependence, shared decision-making, and teamwork. There is a great sense of loss as we find that where we are going is not necessarily what we signed up for when we began our training as physicians. When we attempt to exercise leadership in these challenging times we need to be aware of the risks and dangers to ourselves, both personally and professionally and be prepared to address them with increased self-awareness and by using sanctuaries, allies and confidantes. Awareness of our basic fallback positions or default modes and reactions when we are under increasing stress is an important first item in our increasing sense of self-awareness. Some of us react quickly in anger, others in withdrawal. Some of us notice the tension as The Journal of the East and West Metro Medical Societies

a knot in our gut or a throbbing in our heads. What are our first clues that tell us to get on the balcony and take stock of the situation before we say or do something that puts the work back a step or two? We can observe others and ourselves and interpret what we notice before we make our next intervention to move the work forward. Do we need to decrease the distress (turn the heat down a bit) to allow the work to proceed or do we need to expose other threats to the group (turn the heat up) so that they are aware of the dangers of doing nothing…of work avoidance. Becoming adept and facile at these observations, interpretations and interventions require that we do some work…the work of self-discovery and the work of understanding group dynamics. In order to continue our work of selfdiscovery, we need to set aside time and energy and find a place of sanctuary. This should include time each day for reflection and an extended time away from the fray on a regular basis for renewal and consideration of our greater purpose and meaning. Often these times in our day or our year are the first to be given up as “unproductive” because meetings and reports and crises consume our time and energy. But without regular therapeutic doses of reflection, we can lose our way and be seduced by power, our own hungers and desires and the pursuit of quick technical fixes to the looming adaptive challenges confronting us. We need help in becoming more selfaware as well as needing help seeing other perspectives. We need to have allies and confidantes — relationships with others who are either in the work and understand the work or care about us as individuals. The two relationships should not be confused because they have different roles and come from different places in our lives. Allies are colleagues, other physicians, administrators or stakeholders, who are in positions that understand the issues and can help us to assess our view of the situation. They can help us to fill in gaps in our knowledge or understanding…but they also have a stake in the outcome and may cross boundaries between systems, ideologies, or constituencies and therefore cannot be completely loyal to us only or to our initiatives. They have their own initiatives, goals and work within the health care arena. Confidantes on the other hand, may not know the issues that we are dealing MetroDoctors

with well and really don’t have any skin in the game…but they know us and our vulnerabilities well. We can think out loud with them and expect them to help us see our own limitations and prejudices and stressors. Confidantes are invaluable when we feel lost…and when we feel self-righteous, or angry or hopeless. We can easily be seduced by our own hungers—our desire for power and control, affection and esteem, security and survival. We rely on our developing self-awareness and our confidantes to help us recognize when our hungers are getting in our way. Sometimes, when we don’t know what we are feeling, they help name it for us and then we can move again. People that can fulfill these roles include close friends, spouses or significant others and life partners, coaches and spiritual directors. As we look back to why we chose our profession of practicing medicine, we begin to rediscover our earlier passion for caring for our patients. We find that many of our patients seeking care are left out of our systems of health care. As we look back on the years of practicing within our profession, we may rediscover a respect and caring for our colleagues, some of whom are hurting deeply from practicing within this broken “system” of health care. Perhaps we can rediscover our own purpose and meaning as experienced physicians by bringing our perspectives to the table where the practice of medicine meets the business of delivering health care services. We bring unique skills, talents and experiences to this arena that can benefit the individual patient, our colleagues and the communities in which we live. We would like to conclude our three part series on exploring adaptive work in health care by inviting and encouraging our physician colleagues to become engaged in this work during these challenging times. We need to not only be at the table, but we also need to be exercising leadership at the table for our patients, colleagues and organizations. Just like the practice of medicine, the practice of exercising leadership requires thoughtful and rigorous preparation. It is our profession of medicine who has professed publicly an oath “…[to] apply…measures for the benefit of the sick according to my ability and judgment; [and to] keep them from harm and injustice.”(2) We think that we as individuals and as a profession are up to the task of protecting our patients from

The Journal of the East and West Metro Medical Societies

the harm and injustice of a broken health care system. We think that we are also up to the task of healing ourselves and our colleagues, as well as our organizations when we step forward to exercise leadership in these troubled times. We need to do this together. Footnotes: 1) Heifetz, Ronald, Leadership Without Easy Answers (Cambridge, MA: The Belknap Press of Harvard University Press, 1994). 2) Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

CascadePartners offers leadership education and coaching to health care professionals and the organizations they serve. With three-hour sessions or in depth assessment and guidance, CascadePartners will prepare you to make meaningful progress on difficult problems. Principals are: Kathleen Brooks, M.D., MBA, MPA; Tom Gilliam, R.N., MBA; Mary Jo Lewis, M.D., M.A.; Michael Tedford, M.D., MBA; and Valerie Ulstad, M.D., MPA, MPH.

Southside Community Health Services Join a team of caring individuals, providing quality healthcare to a culturally diverse patient population. Southside Community Health Services is seeking Full-time/Parttime Family Practice Physicians to work in our family practice/community clinic locations in Minneapolis. We provide a full range of medical services, including OB care, to the underserved community. Practice is clinic based only, with weekends and holidays off. Great benefits and salary with paid malpractice. Applicants may qualify for student loan repayment programs. Please fax or email resumes to: Nikki Kluver, Human Resources Telephone: 612-821-3552 Fax: 612-821-2818 Email: nikki.kluver@southsidechs.org.

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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.

DONALD S. ASP, M.D. was the recipient of the HealthEast Physician Community Service Award. This award recognizes physicians who are active volunteers and generous contributors in the community and utilize their medical

backgrounds, training and resources to make a meaningful, positive impact on the health and well-being of the community. Dr. Asp is the Medical Director for HealthEast Medical Care for Seniors. FRANK INDIHAR, M.D., CEO of Bethesda Hospital in St. Paul, retired in February 2008. Dr. Indihar has served as CEO of Bethesda Hospital since 2002. He also held the role of medical director at Bethesda from 1997 until recently. Prior to serving as Bethesda’s CEO and medical director, Dr. Indihar practiced medicine with St. Paul Internists for 27 years.

The East Metro and West Metro Medical Societies Want Your E-mail Address! In the modern world of fast paced actions we need to have a fast paced network system to send and receive information.

JOHN H. LINNER, M.D. has published a book on WWII, Normandy to Okinawa. Dr. Linner, who saw action in both the European theater (Normandy invasion, Omaha Beach, D-Day), and the Pacific-Okinawa as a Navy medical officer and ship’s photographer, kept a daily diary. More information can be found at www.normandytookinawa.com. Dr. Linner is a retired surgeon now residing in Edina, Minnesota and Arizona. DAVID THORSON, M.D. was appointed to the AAFP Commission on Health of the Public at their December meeting. Dr. Thorson practices family medicine at Family Health Services Minnesota. MARGO TOLINS-MEJIA, M.D. was the recipient of the William Carr, M.D. Leadership Award. The award is given to a Unity physician who is regarded by peers as an excellent clinician, has been on staff for a minimum of 10 years and has a history of service to the hospital and community. Dr. Tolins-Mejia is the medical director for Unity’s Cardiovascular Short Stay unit, lead physician for Unity’s Heart Catheterization Laboratory and medical advisor for the Women’s Heart Center at Mercy Hospital in Coon Rapids.

We have the capability to send mass e-mails about: s ,EGISLATIVE .EWS s -EETINGS s #ONFERENCES s 2EQUESTS FOR )NFORMATION

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Send your EMMS e-mail address to: dhines@metrodoctors.com, or call (612) 362-3705.

Visit us at

Send your WMMS e-mail address to: kdittmer@metrodoctors.com, or call (612) 623-2885.

www.metrodoctors.com

March/April 2008

MetroDoctors

The Journal of the East and West Metro Medical Societies

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

Become Involved in Your Society 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

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

MetroDoctors

The Journal of the East and West Metro Medical Societies

sion” and that there are rewards for patient care that cannot be had in any other walk of life. We are in the midst of a great sea-change in our profession — from a cottage industry of self-employed practitioners who were largely unsupervised, to a situation where doctors are predominantly salaried employees of large corporations, increasingly subjected to governmental regulation and corporate oversight. Where physicians previously enjoyed autonomy and independence, these bulwarks of our profession are being eroded by economic and social forces beyond our control. Previously doctors only needed to be able, affable, and available; in the future, practitioners will have to be affordable and accountable as well. The fact that change is coming is not necessarily bad. It is clear that there is much that needs to improve in our medical system. There are 47 million Americans who do not have health insurance. We spend extraordinary sums on high-tech medical care at the end of life, rather than on preventive measures earlier. Our practices need to be evidence-based and our results quantified and transparent. In this election year, health care is clearly a major issue in the mind of the public and hence in the rhetoric of the politicians. We may be certain that health care policy will remain in the center of the political stage for some time, and it is crucial that our opinions be represented. What is the role of our Medical Society in such an environment? How do we remain relevant to our membership, and protect the interests of our patients? What difference can we make, faced by the complexities of the medical system? I see several important functions for the society. We serve as a forum for the collegial exchange of health policy ideas within the profession and as a vehicle by which the concerns of the members are taken to our state and national organizations and thence to the legislature. We function as something of a watchdog, to safeguard the (Continued on page 27)

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Metro Medical Society

EMMS Appointed Board Members

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its name to East Metro Medical Society. It was a decision that was reached after much careful thought and significant discussion. While we are mindful of the origin and long history of the society, the change reflects the reality that the reach of the society extends far beyond Ramsey County. And just as the society has changed its name, perhaps it is appropriate that we reflect on the changes occurring in our profession and on the role of our society today and in the future. In his book Future Shock, Alvin Toffler noted that not only did change occur but that it also did so at an accelerating pace. Most physicians are well acquainted with the rapidity of change. When I consider the days of my surgical residency, it is striking that today there is almost no general surgical condition that is treated as it was during my training. Peptic ulceration was still a surgical disease, the minimally invasive surgery revolution lay years ahead, and exploratory laparotomy was routine. The surgical landscape has altered radically, but although the specific treatments we learned have become outmoded, I do not believe that those (many) years were wasted. Much of the purpose of medical training is to equip physicians to anticipate such change and manage its consequences, and I believe our training has prepared us well to embrace advances in disease management. It is not only the treatment of disease that is changing; the medical profession itself is undergoing radical change. Much of this is cause for anxiety among the members of the profession, and the conversation in the doctors’ lounges suggests a profession under siege. Shrinking reimbursement, increased bureaucratic regulation, corporate agendas and third-party payer obstacles to care increase the “hassle factor” and cause a sense of malaise, if not despondency. At the same time, patients are more demanding and less forgiving, fueled by sensationalist news media and by Internet sources of varying accuracy. As Ambrose Bierce put it, a physician has become “one upon whom we set our hopes when ill, and our dogs when well.” Despite these difficulties, I truly believe that ours is still “The Noble Profes-

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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 Christina J. Templeton, M.D., Specialty Director, Psychiatry Scott A. Uttley, M.D., Director Marie L. Witte, M.D., Director

THIS YEAR, RAMSEY Medical Society changed

EMMS UPDATE

2008 EMMS Annual Meeting was Magical

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he Town & Country Club in St. Paul provided a beautiful venue for the 2008 EMMS Winter Gala and Annual Meeting. The highlights of the evening were the installation of Peter B. Wilton, M.D., St. Paul Surgeons, P.A,. as the 138th president of EMMS by outgoing president, Dr. V. Stuart Cox and the presentation of the 2007 Community Service Award to Walter Bailey, M. D., retired neurosurgeon from Neurosurgery Associates in St. Paul. Some of the business partners through EMMS’ for-profit subsidiary, Minnesota Phy-

Walter Bailey, M.D. was the recipient of the 2007 RMS Community Service Award.

sician Services, Inc., attended the meeting and displayed their materials for attendees to peruse. We would like to say a special thank you to AmeriPride Services and Stanton Group for their Gold sponsorship, and Berry Coffee V. Stuart Cox, M.D. and SafeAssure Con- displays his outgoing sultants, Inc. for their president’s plaque. Bronze sponsorship. Everyone in attendance enjoyed the excellent dinner and the evening concluded with the audience being wowed by the comedy magic show presented by Mr. Gary Tyson.

Business Partners and Gold Sponsors (from left): Jerry Fleischhacker, AmeriPride Services; Jim Fries, Stanton Group; and Steve Severson, AmeriPride Services.

Legislative Updates Presented at Council Meeting

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March/April 2008

Dr. Peter Wilton with his family (from left): Ashley, Madee, David and Rebecca. Not pictured is daughter Kristyn.

Dr. Peter Wilton is pictured with his partners from St. Paul Surgeons, P.A. (from left): Drs. Peter Kelly, Peter Wilton, Kyle Wahlstrom, Diane Ogren and James McGreevey. Not pictured: Dr. William Rupp.

Rep. Mindy Greiling Meets with Hamm Clinic Physicians

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epresentative Erin Murphy (DFL) 64A and Representative Jim Abeler (R) 48B were the guest speakers at the Council on Professionalism and Ethics on January 17, 2008 at Bethesda Hospital in St. Paul. Representatives Murphy and Abeler addressed the group of about 25 and discussed the work they did as co-chairs of work groups for the Legislature’s Health Care Access Commission. There was also a fair amount of discussion related to the recently released Governor’s Transformation Task Force Report. Also in attendance were Senator Sandy Rummel (DFL) 53 and Representative Paul Gardner (DFL) 53A.

Dr. Peter Wilton (left) is installed as the 138th president of East Metro Medical Society by outgoing president V. Stuart Cox, M.D.

J From left: Senator Sandy Rummel; Representative Jim Abeler; Representative Erin Murphy; Dr. Bob Geist, chair of the Council on Professionalism and Ethics; and Representative Paul Gardner.

MetroDoctors

im Jordan, M.D. and Robert Nesheim, M.D. hosted Representative Mindy Greiling (DFL) 54A, on Friday, November 30 at the Hamm Clinic in St. Paul. Representative Greiling received a tour and spent some time talking with Drs. Jordan and Nesheim about the issues surrounding mental health. Among other things, Representative Greiling co-chairs the bipartisan House and Senate Mental Health Caucus.

The Journal of the East and West Metro Medical Societies

President’s Message (Continued from page 25)

Drs. Jane Pederson and Jacques Stassart’s terms expired on the EMMS board of directors at the end of 2007. We wish to thank them for their dedication and service to the East Metro Medical Society. MetroDoctors

Care System. He is also the chairman of Infection Control at HealthEast. He served for seven years as a board member and medical director of Amigos de las Americas, which is an international non-profit public health and community development agency based in Houston. He has been a member of the East Metro Medical Society since 1993 serving most recently as the chairman of the EMMS for-profit subsidiary, Minnesota Physician Services, Inc.

Paul Verret Addresses Foundation Board Mr. Paul Verret was the speaker at the East Metro Medical Society Foundation Board of Directors meeting on January 23, 2008 at Regions Hospital in St. Paul. Mr. Verret is very well known in the foundation world having served as president of the St. Paul Foundation for 28 years. Under his leadership, the St. Paul Foundation has grown to be one of the top 10 most successful community foundations in the country. Mr. Verret addressed the Foundation Board and provided some insight

into the opportunities that face the foundation as they continually strive to fulfill their mission to improve the health of residents in the communities that we serve. Former president of the St. Paul Foundation, Mr. Paul Verret, addresses the EMMS Foundation.

Call for Resolutions: Due Date: Friday, May 9, 2008 Do you have an issue that you’d like to bring forward for debate and discussion by your colleagues? The issue could be regulatory, clinical, related to public health or anything in between. If you’re not sure how to get started with the resolution process, please consider calling the staff at EMMS to ask for assistance. We’re here to help you. A resolution identifies and directs a specific issue for the Minnesota Medical Association to focus their attention on in the coming year(s). When appropriate, resolutions are forwarded to the AMA for national consideration. Nick Meyer, M.D. is an orthopedic surgeon with St. Croix Orthopedics in Stillwater. Last year, he had an idea that asked physicians to be welcoming of TRICARE insurance for the veterans who are coming home from the war. This resolution went through the EMMS caucus process, then on to the Minnesota Medical Association, and then on to the American Medical Association where it has the strong possibility of affecting change at the national level for our military members and their families. Please help us to ensure that your interests are accurately conveyed by contacting EMMS staff to submit resolutions: phone (612) 362-3704; fax (612) 623-2888; or e-mail: sschettle@ metrodoctors.com.

EMMS Caucus

MMA Annual Meeting

(NOTE: There will be only one caucus this year.)

September 17-19, 2008

Wednesday, May 21, 2008

Crowne Plaza Hotel-Riverfront, St. Paul

6 p.m. Miller Room—John Nasseff Medical Center (formerely known as the Heart & Lung Center) 255 N. Smith Ave., St. Paul

If you are interested in serving as an Alternate Delegate, please contact EMMS.

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Metro Medical Society

Thanks to Outgoing Board Members

Dr. Peter Bornstein is an infectious disease physician practicing at St. Paul Infectious Disease Associates, Ltd. He received his medical degree from Rush Medical College of Rush University Medical Center in Chicago, Illinois. He completed his internal medicine and pediatric residency at Henry Ford Hospital in Detroit, Michigan and his fellowship in infectious diseases at Northwestern University in Evanston, Illinois. Dr. Bornstein is the chairman of the Antibiotic Subcommittee of the Pharmacy and Therapeutic Committee for the HealthEast

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doctor-patient relationship and to maintain the integrity of medical practice. It is our mission to advocate for the health of our patients and the well-being of our community — in which role we are possibly at our best; and we are the voice of the East Metro medical profession in the chambers of policy. A recent example illustrates our effectiveness. As a founding member of the Smoke Free Coalition, we have played a longstanding leadership role in the hard work associated with comprehensive tobacco control policies in Minnesota. We have taken on this work because studies suggest that secondhand smoke adds more than $215 million a year to health care costs in Minnesota alone, sickens more than 66,000 Minnesotans and kills more than 580 each year. We advocated at the local level through grassroots activities, held meetings with local elected officials and legislators and the members of the press and participated with partners in vigorous lobbying efforts at the Capitol. As a result of these efforts, local smoke-free ordinances were passed in the East Metro, which served as momentum for the state to eventually act and put forward a comprehensive statewide smoke-free law in 2007 known as the Freedom to Breathe Act. We can be justly proud that our efforts will result in better health for our community. In this changing environment, more than ever, the voice of our medical community needs to be heard — in the public media, at the legislature, and at the patient’s bedside. I encourage all members to let the society know your concerns, and to participate in the many activities of East Metro Medical Society. I also encourage you to take pride in the society, now enjoying its 138th year, and to recruit your friends to join us. Together, we can make sure that changes in health care are positive, and ensure the future of our profession.

Meet New EMMS Board Member Dr. Peter Bornstein

Wisconsin Governor Meets With Smoke-Free Staff from EMMS

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n January 9, 2008, Sue Schettle, CEO of EMMS, attended a press conference with Cynthia Piette, Smoke-Free Washington County project coordinator, where Wisconsin’s Governor Jim Doyle (DFL) discussed his desire to have Wisconsin become the 23rd state to go smokefree following the lead of Minnesota. Washington County is on the border with Wisconsin and border issues are often cited as an issue when proponents discuss the problems associated with enacting smoke-free policies and laws. The Governor was able to spend some time talking with Sue and Cynthia about the importance of

Smoke-Free Dakota Celebrates

grassroots efforts associated with enacting comprehensive smoke-free legislation.

Tales of a Smoke-Free County

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ince the implementation of the Freedom to Breathe Act October 1, Smoke-Free Washington County has been collecting smoke-free stories about why people are enjoying the new “Fresh Air.” When we started asking for stories we thought we would get just a few, but as it turns out it has been a huge success with 61 stories and more coming in! These stories have been collected a couple of different ways. First, we sent out an e-mail to our 500 supporters with e-mail addresses. Second, we distributed boxes to our supportive organizations to collect stories in waiting rooms and at front desks. Third, we sent out a mailing to the 1,700 supporters we have addresses for asking them to share a story through calling, mailing or going online. Lastly, we have collected stories at our events. The goal of sharing the stories is to remind Washington County residents the reason this law was passed—protecting our health from the dangers of secondhand smoke. So far, all of the stories are posted on our Web site at www.smoke freewashingtoncounty.org. We are also hanging posters in Washington County communities. The Stillwater Gazette has been highlighting stories in

a “Tales of a Smoke-Free County” Friday feature story. So far eight have been published. As physicians your stories can be very powerful. You see the harmful effects of secondhand smoke in clinics every day. Everyone has a story to share, please share yours by e-mailing Cynthia at cpiette@metrodoctors.com. Here is an example: “I remember when my son’s asthma would flare up and I would have to figure out what restaurants had no smoking or limited smoking. It is great to know that now restaurants are smokefree and I don’t have to worry about my son’s asthma when taking him out to eat. I also really appreciate that I don’t smell like a cigarette when I come home. I also work on an asthma coalition and am coming to understand more about the need to be sensitive to other’s allergies with their asthma. Smoke-free public places really help!” — Julie — Stillwater

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moke-Free Dakota celebrated “The Gift of Fresh Air” at a holiday party at the Mediterranean Cruise Café on Thursday, December 13, 2007. Over 40 attendees came out to dine on delicious Greek and Middle Eastern cuisine, get to know their fellow Dakota County neighbors, and watch traditional belly-dancing entertainment onstage. Dr. Ron Hansen represented the East Metro Medical Society as a physician living and working in Dakota County and presented certificates thanking legislators supportive of the Freedom to Breathe Act and clean air in Minnesota. Honorees included Representative Karla Bigham (D-57A), Senator Jim Carlson (D-38), Representative Shelley Madore (D-37A), and Representative Sandy Masin (D-38A). Dr. Joel Arney also attended and supported the event, as did MN Medical Association’s MN Voices for Public Health staff, Rebecca Thoman, M.D. and Eric Myers. As of early December, Dakota County has received no reports of violation of the smoke-free law and the state’s two largest health plans have indicated an increase in the number of people using nicotine replacement products and smoking cessation counseling programs since the statewide law was enacted October 1.

From left: Dr. Ron Hansen; Mediterranean Cruise Café Owner, Jamal Ansari; Representative Karla Bigham (D-57A); Representative Shelley Madore (D-37A); Representative Sandy Masin (D-38A); Senator Jim Carlson (D-38); and Diane Tran, Smoke-Free Dakota Project Coordinator.

The East Metro Medical Society Wants Your E-mail Address! In the modern world of fast paced actions we need to have a fast paced network system to send and receive information. We have the capability to send mass e-mails about: s ,EGISLATIVE .EWS s -EETINGS s #ONFERENCES s 2EQUESTS FOR )NFORMATION Send your EMMS e-mail address to: dhines@metrodoctors.com, or call (612) 362-3705.

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The Journal of the East and West Metro Medical Societies

CHAIR’S REPORT ANNE M. MURRAY, M.D.

Transformation of Health Care in Minnesota: What do the Governor’s Task Force Recommendations Really Mean? WMMS Officers

WMMS Board Members

Alan L. Beal, 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.D. J. Riley McCarten, M.D. Frank S. Rhame, M.D. Thomas C. Tunberg, M.D. David J. Walcher, M.D. David A. Willey, M.D. WMMS Ex-Officio Board Members

Michael B. Ainslie, M.D., MMA Trustee Martha Arneson, Co-Presiding Chair, HMS Alliance Beth A. Baker, M.D., MMA Trustee Christian L. Ball, M.D., Resident Representative David L. Estrin, M.D., AMA Alternate Delegate Melanie Fearing, Medical Student Representative Donald M. Jacobs, M.D., MMA Trustee Roger G. Kathol, M.D., MMA Trustee Candace S. Simerson, MMGMA Representative Richard E. Burman, M.D., Sr. Physicians Association Representative Karin M. Tansek, M.D., MMA Trustee Trish Vaurio, Co-Presiding Chair, HMS Alliance 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

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THE GOVERNOR’S TASK Force recommendations include many needed and thoughtful goals to improve health care efficiency, access, quality of care, and outcomes in Minnesota. Less realistic is the goal of reducing total health care costs by 20 percent by 2013, given an obesity epidemic that will take far more than five years to contain and the burgeoning geriatric population. Even more unrealistic and unfair is that the largely non-physician Task Force will hold the physicians, or “providers” responsible for effecting these cost reductions. The recommendations clearly state that it is the providers who will be held accountable for reducing total health care costs by 10 percent in 2011, and 20 percent in 2013. Buried deep within the nebulously-defined three-tiered payment system is also the stipulation that if total costs are not reduced by 10 percent by 2011, there will be a 1 percent hike in the already-regressive provider tax. In contrast, there is less call for accountability of the “non- profit” insurers and HMOs. The actual percentage of the average Minnesotan’s health care premium donated to the administrative cost of their HMOs or Blue Cross is very difficult to document, because these costs are not revealed to the providers or the public. The administrative cost estimates vary from 10-30 percent, depending on the source, in contrast to the administrative costs of Medicare, at less than 5 percent. The HMO and insurance administrative costs should be required to be just as transparent as the physicians’ costs per service will be. Thus, as outlined in the implementation steps, if by June 2008, health care providers must show consumers the full price of each health care service they use, HMO and insurance companies must reveal their administrative charges for each service. Logistically, in most cases it will be the primary care physician who will be held responsible as the driver of health care costs, quality and outcomes, and for creating the patient’s medical home. What is poorly defined is exactly how physicians are to carry this out within the three-tiered system, for those who are not already a part of a Mayo or other already-streamlined large health care system with an intact infrastructure.

The Journal of the East and West Metro Medical Societies

What additional resources will be allotted to pay for additional office staff FTEs to coordinate efficient care, encourage patient compliance with such goals as the proposed aggressive reduction in obesity, tobacco and alcohol use, and physician compliance with quality and pay-forperformance measures? There is a suggestion of improved reimbursement for primary care physicians, but how will this be implemented? More importantly, who will pay for the time-intensive outpatient management of chronic, often progressive diseases, and specifically geriatric disease management? There is also no mention of managing the rapidly growing and costly dementia population. How Medicare will fit is poorly defined; there is mention of efforts to work with Medicare on future demonstration projects. Since a growing proportion of the population will be covered by Medicare, this needs to be addressed early in the reform process. An increase in reimbursement for Medicaid and MinnesotaCare physician services is long past due and is also not addressed. Physicians providing these services at the current rates can no longer afford to do so. In the end, the devil will be in the details of the health care transformation Payment System. This will be designed by the Transformation Coordination Organization, whose members are yet to be defined, other than “individuals who do not have direct financial interest in health care services, equipment, or facilities.” It is difficult to imagine who would fit this role that would bring knowledge and experience to the table (Mother Teresa, Wellstone, God?). It will be critical for practicing physicians to be invited and to participate as members of this committee, to be true partners in the long-awaited health care transformation in Minnesota. We are grateful for the substantial effort and time contributed by the Task Force to this first version of a transformation plan. As physicians, we need to become more closely involved in its continued evolution.

March/April 2008

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

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 NEWS

John A. Reichert, M.D., Receives the Charles Bolles Bolles-Rogers Award

J

ohn A. Reichert, M.D. was presented with the 2007 Charles Bolles Bolles-Rogers award at the Park Nicollet Methodist Hospital Medical Staff meeting on Monday, December 27, 2007. In presenting the award, Jan Strathy, M.D. noted that Dr. Reichert received his medical degree from the University of Minnesota in 1964; completing his residency in Obstetrics and Gynecology at the University of Minnesota Hospitals. Dr. Reichert’s career spans 35 years as an OB/GYN with Park Nicollet delivering babies, providing surgical treatment for reproductive conditions and providing primary preventative health care for generations of women. He shared this knowledge with OB/GYN residents and family medicine residents via the U of M’s OB/GYN Program and the Creekside Family Medicine Program based at Methodist Hospital. In the 1990s, Dr. Reichert was an integral member of a team of physicians who went to Nicaragua to provide gynecological procedures to women where access to such care was otherwise impossible. For many, the need was sterilization. Poverty was rampant and there were too many children to care for with the resources available. Dr. Reichert and team provided safe sterilizations and women walked for miles to obtain this procedure. This was provided under local anesthesia, using different gases and blocks to minimize postoperative pain. It was via this work that Dr. Reichert became familiar with the work of Dr. Henrik Kehlet of Denmark, who specialized in multimodal approaches to peri-operative care of colectomy patients that speeded recovery and decreased morbidity. Called the “Rapid Recovery Protocol,” he showed, via clinical research, that women recover faster with fewer complications if hysterectomies are done under spinal rather than general anesthesia. Beyond the mode of anesthesia, the protocol involves setting appropriate expectations for activity post-op, pre- and post-op dietary recommendations, and intraoperative use of local anesthetics to decrease post-op pain. He helped institute this protocol at Park Nicollet Methodist Hospital, now used in gynecology, general surgery, urology and orthopedics and plans for publication of this experience is underway. 30

March/April 2008

On behalf of his colleagues at Park Nicollet Methodist Hospital and the 4,400 members of the West Metro Medical Society, James A. Rhode, M.D., past chair, (right) and Jan Strathy, M.D. (left) congratulate John A. Reichert, M.D., recipient of the 2007 Charles Bolles Bolles-Rogers Award.

Dr. Reichert always puts patients first and his knowledge, together with his humor, will be missed by his colleagues and patients as he deservedly retires from active practice. Originally called the St. Barnabas Bowl,

the award was established in 1951 by the late Mr. Charles Bolles Bolles-Rogers, who served on the St. Barnabas Hospital Board of Trustees and was President of that Board for many years. Mr. Bolles-Rogers died in 1975 at the age of 91 but prior to his death, he made provisions for this award to be continued and is currently funded by the West Metro Medical Society. The award is an engraved sterling silver Revere Bowl. The award is given to a physician who, in the opinion of the members of the selection committee and by reason of his or her professional contribution on the basis of medical research, achievement or leadership, has become the outstanding physician of this and other years. The nomination and selection of the recipient of this honor is made annually by nomination submitted by hospital medical staffs in Hennepin, Anoka, Carver, Scott and Western Dakota counties.

American Legion Fundraiser a Smokin’ Success

W

ith the sponsorship of the Partnership for a Smoke-Free Scott County, the Savage American Legion held a successful silent auction on Saturday, January 26. All proceeds from the event are going toward interior improvements such as new, white ceiling tiles and replacement of the carpet throughout the building. The silent auction brought in roughly 250 people from the community who value the importance of the Dan Patch American Legion and want to make sure the institution stays put in downtown Savage. The Legion is open to the public and has begun to see more families coming in for dinner, as well as a larger lunch crowd since Freedom to Breathe was implemented on October 1, 2007. This unlikely collaboration began after the Savage Pacer printed an article about some of the financial struggles the club was having, naming Freedom to Breathe as another hit on their finances. After an initial meeting in early November 2007, a collaborative effort began to put in motion a plan to raise money for the Legion that would take some of the heat off and MetroDoctors

allow the club to move forward while keeping its doors open. The silent auction brought in just under $3,000 and the Legion management has several more upcoming events that aim to raise money so they can stay firmly planted in downtown Savage. Their Web site is www.savageamericanlegion.org. For more information, contact Jennifer Anderson at janderson@metrodoctors.com or at (612) 578-0981.

Jennifer J. Anderson, project coordinator, Partnership for a Smoke-Free Scott County (left) with Bernadette Chlebeck, Anoka County Smoke-Free Partnership, and a commander at the Coon Rapids Legion.

The Journal of the East and West Metro Medical Societies

In Memoriam

ANDRIONICO FERIA CULLADO, M.D., F.A.A.F.P. died December 31, 2007. He was 77. He was born in the Philippines and spent several years of his childhood in WWII occupied Philippines, awaiting liberation by American troops. He became a U.S. citizen in 1963. Dr. Cullado moved to Minneapolis after graduating from medical school at the Faculty of Medicine and Surgery, University of Santo Tomas, Manila in 1955. He completed his medical residency at The Swedish Hospital. He was a Fellow of the American Academy of Family Practice and a former chief of staff at North Memorial Medical Center. Dr. Cullado practiced family medicine/general surgery in Minneapolis for 38 years until he was diagnosed with colon cancer. He retired in 1995 and moved to Wichita, Kansas to be near family. Dr. Cullado survived two more cancer diagnoses before passing away in California while vacationing with his wife and daughter. Dr. Cullado joined WMMS in 1965. LAURENCE F. ERICKSON, M.D., died January 11, 2008. He was 87. He graduated from the University of Minnesota in 1944 and completed a residency in pediatrics. He practiced pediatrics in the metropolitan area for 42 years, with some time away for service in the U.S. Navy during WWII and the Korean War. Dr. Erickson joined WMMS in 1949. JAMES ROGERS FOX, M.D., died in 2007 at the age of 85. He graduated from the University of Minnesota Medical School. He was in private practice in internal medicine, and MetroDoctors

THEODOR B. GRAGE, M.D., Ph.D., died after a long illness on December 11, 2007. He was 80. He was born in Münster, Germany and immigrated to the United States at the age of 24 after attending the University of Münster Medical School in Germany. He graduated from Creighton Medical School in Omaha, Nebraska. Dr. Grage did his surgical training and also earned Masters and Ph.D. degrees from the University of Minnesota. He spent 35 years at the U of M before retiring in 1992. Dr. Grage did pioneering work in head, neck and esophageal surgeries. After retirement he was a volunteer professor and surgeon in Pretoria, South Africa and St. Lucia, the Grenadines. Dr. Grage joined WMMS in 1971. JACK A. VENNES, M.D., died on January 8 at the age of 84. He graduated from the University of Minnesota Medical School in 1951. He specialized in internal medicine/ gastroenterology. Following a residency at the VA Medical Center in Minneapolis MN, he accepted a staff position there, which he enjoyed till 1990. He spent six years in private practice at the original St. Louis Park Medical Center from 1957-1963, and then committed the remainder of his career to teaching and research. He was a professor emeritus at the University of Minnesota. He began teaching medicine at the Navy University of Minnesota in 1955 and retired in 1993. Along with his colleague Dr. Steven Silvis, he introduced the technique of ERCP to the United States. He dedicated much of his career to its development and training the first generations of physicians in the procedure. In WW II he served as a Naval Pilot from 1942-1945 in the Pacific, piloting “Avenger” Torpedo Bombers. He ended his active duty service in December 1945 at the rank of Ensign. In 1951 he enlisted in the United States Army Reserve Medical Corps. He was discharged in 1954 as a First Lieutenant. Dr. Vennes joined WMMS in 1989.

The Journal of the East and West Metro Medical Societies

WALTER LLEWELLYN WILDER, M.D., died November 30, 2007 in his sleep. He was 81. He embarked on his medical career by enlisting in the U.S. Navy as a 17-yearold in 1944. He earned his B.A. and a B.S. in Medicine at the University of Minnesota, before transferring to Harvard Medical School where he graduated with an M.D. in 1950. He served as a Navy pediatrician at the Cherry Point Marine Corps Air Station in NC during the Korean War. A pediatrician and allergist, Dr. Wilder retired at the age of 78. He was the last partner in the firm of Arey, Erickson, Mulholland and Wilder to retire. Dr. Wilder joined WMMS in 1957.

SAVE THE DATES: West Metro Medical Society Caucus

Wednesday, May 21, 2008 7:00 – 8:30 a.m. Broadway Ridge Building 3001 Broadway Street NE – Lower Level Conference Room D Minneapolis, MN 55413 Minnesota Medical Association Annual Meeting

Crowne Plaza, St. Paul Riverfront Wednesday, September 17 late afternoon/early evening*

Thursday, September 18 WMMS Caucus – 7:00 a.m.*

Friday, September 19 Joint WMMS and EMMS Caucus – 8:30 a.m.* *Times are Tentative

Call for Resolutions

Resolutions should be submitted no later than Friday, May 9. If you would like “A Guide to Developing Resolutions,” please request a copy from Kathy Dittmer at (612) 623-2885 or visit our Web site at www.metrodoctors.com. Click on West Metro Medical Society; open topic folder, Caucus and MMA Meeting Information.

March/April 2008

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

M. ELIZABETH (PEGGY) CRAIG, M.D., died January 13 at the age of 86. In 1945 she was one of three women in a class with about 200 men at the University of Minnesota School of Medicine. Dr. Craig opened a pediatric office in St. Louis Park in 1949. She later added an office in Eden Prairie. She practiced until 1986. Dr. Craig was the first woman to be president of the medical staff at St. Louis Park’s Methodist Hospital, in the late 1970s; president of the Minnesota Medical Association, in 1986-87, and CEO of the university’s Alumni Association, in 1977. She served as a University of Minnesota regent from 1987 to 1993. In 1989, the university gave her its Distinguished Service Award. Dr. Craig joined WMMS in 1949.

served as medical director of Control Data and United Capital Life Insurance. Dr. Fox was best known for “Doctor’s House Call” on KSTP television and WCCO radio from the 1960s to early 1970s, as well as Dr. Fox’s Family Health Guide, published in 1965. He was the founder of the Academy of Occupational Medicine and the International Institute for Effective Communications. Dr. Fox joined WMMS in 1947.

HMS ALLIANCE NEWS

Leadership Development Conference

T

he AMA Alliance Leadership Development Conference (LDC) was held September 29-October 2 at the Drake Hotel in Chicago. I had the great pleasure to attend and was joined by Candy Adams, MMAA President, and Linda Wigg, MMAA President-Elect. The AMA Alliance did an outstanding job with the planning and presentations for 170 Alliance members representing 29 states and 75 counties. There were dinners with program speakers, general sessions, and small discussion groups. I chose to attend the meetings on screen out, health promotion, membership marketing, advocacy, public speaking, and alliance planning. At the county track session on revitalizing your Alliance, I heard many distressed members share a common concern: declining membership and the inability to recruit new board members and leaders. This problem seems to be one now

Martha Arneson, Co-Presiding Chair

experienced by a large majority of county Alliances. A panel of presenters challenged us with ideas to revitalize the Alliance, and encouraged us to think big and make changes that will produce positive results. While busy learning and networking, I did have time to participate in social events, such as the reception with hostess Dianne Fenyk for

Alliance Members Enjoy Holiday Celebration

Update from AMA Alliance President

I

t has been a busy fall with travels, meetings and Alliance work. Most of it has been fun, rewarding and meaningful — not a day goes by that I don’t learn something new. I must admit, however, that disastrous events like the fires in California have been difficult for me to deal with — I wanted to reach out to all California Alliance members on behalf of the AMAA, but all I could really do was send a generic message of concern and support. Frustrating! I was pleased by our successful Leadership Development Conference in Chicago and am very grateful to our own Martha Arneson, and MMAA leaders Candy Adams and Linda Wiig who served as hostesses during the Presidents’ Reception in my suite. (By-the-way, my suite was the Princess Diana suite at the Drake! Wow — what a room!). The SCHIP issue has kept me on my toes — with members on both sides of the issue filling my mailbox with their thoughts. In addition to this issue, I’ve had to stay informed about several others — including the 20/200 rule that was eliminated by the government (this one means students and residents have to begin paying student loans immediately). 32

March/April 2008

the state presidents, president-elects and special guests. Our AMAA President held this in her luxurious Presidential Suite. The next evening Candy, Linda and I had dinner with Dianne in her suite. That was very special to have some relaxing, quiet time together. I was very happy to participate in LDC this year, because of our own HMSA and MMAA member presiding as President of the AMA Alliance. Dianne Fenyk makes us all proud with her demonstration of grace and poise, talent, knowledge, leadership skills, and likeability. The LDC is well worth anyone’s participation. It is packed with educational and networking opportunities and you can have fun in the process. Individual state Alliance displays present you with ideas for projects and programs. If you have never attended LDC, I encourage you to consider participating once. I don’t think you would regret it.

One of the biggest stretches for me was leading the Board in the yearly evaluation of the AMAA’s Executive Director, Jo Posselt. Because this is a new process for the Alliance, it required I Dianne Fenyk, AMA Alliance President do hours of research to develop an evaluation that is both fair to Jo, the AMAA Board and the Alliance itself. I learned a tremendous amount about employment in nonprofits, the many facets of being an Executive Director and the value of having an Executive Committee to bounce ideas off. As I write this, I’m preparing for a trip to Hawaii and the AMA Interim meeting. John and I will spend some vacation time while we are there, but I’ll also be working very hard. I am scheduled to address the entire AMA House of Delegates, seven sections of the AMA, meet with representatives of other organizations, and will be attending many meals and receptions. Wherever I am, I carry you in my heart and look forward to next year when I can come home and play with my HMSA friends! MetroDoctors

Emily Wagner, hostess and Martha Arneson, HMSA Co-Presiding Chair.

HMSA members enjoyed the Holiday Tea. $1,236 was raised at the HMSA silent auction for the HMSA STI/HIV/AIDS Education Folder.

The Journal of the East and West Metro Medical Societies

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