MED-Midwest Medical Edition-April/May 2016 by MED- (Midwest Medical Edition)

APRIL / MAY

2016

Vol. 7 No. 3

When

Providers arePatients Insights from the other side Outsmarting the CRYPTOKILLER Family Law Q & A for Medical Professionals

Spring Conference

C A L EN DA R THE SOUTH DAKOTA REGION’S PRE M IER PUBLICATION FOR HEALTHCARE PROFESSIONALS

MIDWEST MEDICAL EDITION

Contents VOLUME 7, NO. 3

■

Providers as Patients

A P R I L / M AY 2016

REGULAR FEATURES 4 | From Us to You 2016’s record number of fellowship matches, the emotional benefits of spinal stimulation for pain and other content available exclusively on our website Recognitions, new providers, accreditations, and more

27 | The Nurses' Station

Outsmarting a CryptoKiller ■ By Buzz Hillestad Protection, Detection and Mitigation of this top cybersecurity threat

IN THIS ISSUE 6 | Slip, Trip and Fall Prevention

18 | The CMS “Two Midnight” Rule ■ By Melissa Grant

20 | New Call Center Helps Patients “Navigate” Cancer

Insights from the

other side

Outsmarting the

Personal and Professional Family Law Considerations A Q & A for healthcare professionals ■ By Michele A. Munson and Kristine Kreiter O’Connell

19 | Liquid Biopsy Study Shows Promising Results for Patients with Pancreatic and Bile Duct Tumors

When Providers are Patients CRYPTOKILLER

16 | Wearing the Slipper Socks ■ By Lori Atkinson What we can learn about the patient experience from our own experiences as patients

Vol. 7 No. 3

Nursing News from

around the region

■ By Lori Berdahl Tips for avoiding the second-leading cause of workplace injury and primary cause of lost work days in healthcare facilities

By Peter Carrels 2016

10 | N ews & Notes

APRIL / MAY

ON THE COVER

5 | MED on the Web

INSIGHTS FROM THE OTHER SIDE

35 Learning Opportunities

22 | Petrasko Performs 100th Robotic Angioplasty

Upcoming Spring Conferences, Events, and CME Oportunities

Family Law Q & A

for Medical Profes sionals

Spring Conferen ce

CA LEN DA R

page

THE SOUT H DAKO TA REGI ON’S PRE M IER FOR HEA LTHC ARE PROF ESSIO PUBL ICAT ION NAL S

By Faith A. Coleman

How does the experience of being a patient impact the way medical professionals relate to and care for their patients? In this month’s cover feature, we hear insights from three local providers (and one provider-intraining) who have been there.

23 | New Studies Focus on Head and Neck Cancers 27 | Near Infrared Spectroscopy

Improves Care in Omaha NICU

30 | Staying on Track with Your Retirement Investments ■ By Mark Schlueter

page

From Us to You Staying in Touch with MED

elcome to Spring, a time of new ideas, new pursuits, and new perspectives. This month, we focus on healthcare providers who have gained new perspectives from the experience of being patients. We hope you’ll enjoy reading about how their illnesses have impacted their own caregiving. As always, we have also packed this issue not only with all the medical community news you need to know to be “in the know”, but also practical advice and tips from area experts. You’ll find vital advice on such diverse topics as cybersecurity, fall prevention in the medical workplace, the CMS “Two-Midnight” rule, investing for retirement, and family law. MED is committed to serving as the premium communication tool for the South Dakota region’s medical community. We welcome unsolicited submissions as well as article ideas and feedback. We would love to help promote your business or practice to our readership of 5,000 medical professionals. Reach us any time at Info@MidwestMedicalEdition.com.

PUBLISHER MED Magazine, LLC Sioux Falls, South Dakota VICE PRESIDENT SALES & MARKETING Steffanie

Liston-Holtrop

Steffanie Liston-Holtrop

EDITOR IN CHIEF Alex Strauss

GRAPHIC DESIGN Corbo Design

PHOTOGRAPHER studiofotografie WEB DESIGN Locable

DIGITAL MEDIA DIRECTOR Jillian Lemons CONTRIBUTORS: Lori Atkinson

Alex Strauss

Happy Spring!

Lori Berdahl Melissa Grant Buzz Hillestad Michele A. Munson Kristine Kreiter O’Connell Mark Schlueter

STAFF WRITERS Liz Boyd

Caroline Chenault

—Steff and Alex

John Knies Faith A. Coleman

NEWS & NOTES

EDITOR Réne Anderson

Reproduction or use of the contents of this magazine is prohibited.

MED was proud to once again sponsor the American Heart Association’s annual Go Red for Women event to raise awareness for heart disease in women.

MED’s Staffanie Liston-Holtrop with Sanford cardiologist Kelly Steffen, DO, and Lynn Thomas, Heart and Vascular Development Director, Sanford Health.

Paul Hanson, President, Sanford USD Medical Center, Steff, Sanford cardiologist Tom Stys, MD, and Brad Schipper, Sanford Health Vice President

Midwest Medical Edition (MED Magazine) is committed to bringing our readership of 5000 South Dakota area physicians and healthcare professionals the very latest in regional medical news and information to enhance their lives and practices. MED is published 8 times a year by MED Magazine, LLC and strives to publish only accurate information, however Midwest Medical Edition, LLC cannot be held responsible for consequences resulting from errors or omissions. All material in this magazine is the property of MED Magazine, LLC and cannot be reproduced without permission of the publisher. We welcome article proposals, story suggestions and unsolicited articles and will consider all submissions for publication. Please send your thoughts, ideas and submissions to alex@midwestmedicaledition.com. Magazine feedback and advertising and marketing inquiries, subscription requests and address changes can be sent to steff@midwestmedicaledition.com. MED is produced eight times a year by MED Magazine, LLC which owns the rights to all content.

MED welcomes reader submissions! 2016 Advertising EDITORIAL DEADLINES Jan/Feb Issue December 1 March Issue February 1 April/May Issue March 1 June Issue May 1 July/August Issue June 1 Sep/Oct Issue August 1 November Issue October 1 December Issue November 1

CONTACT INFORMATION Steffanie Liston-Holtrop VP Sales & Marketing 605-366-1479 Steff@MidwestMedicalEdition.com Alex Strauss Editor in Chief 605-759-3295 Alex@MidwestMedicalEdition.com

Stay in the Know Join our mailing list for advance notice of the MED digital issue, up to two weeks ahead of print. (And absolutely no spam)

On the Website this month Hope for the Doctor Shortage? More than 8,000 physicians matched to fellowship positions through the NRMP’s Specialties Matching Service, becoming the highest fellowship match rate on record.

Spinal Stim and the Emotions of Pain A new study finds that spinal cord stimulation can reduce patients’ emotional response to chronic pain.

100th Stem Cell Operation for Orthopedics Orthopedic Institute’s Walter Carson, MD, of Sioux Falls recently performed his 100th spinal surgery incorporating stem cell therapy.

MORE THAN A MAGAZINE, A Medical Community Hub

Fax 605-231-0432 MAILING ADDRESS PO Box 90646 Sioux Falls, SD 57109 WEBSITE MidwestMedicalEdition.com

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DOWNLOAD THE DIGITAL ISSUE - Want to read a back issue of MED but don’t have it on hand? Download it onto your computer, tablet or smartphone in seconds. Click the “Archives” link on the right side of the MED homepage.

Slip, Trip and Fall

PREVENTION

By Lori Berdahl

LIPS, TRIPS, AND FALLS ARE NO LAUGHING MATTER. In most healthcare facilities, falls are the second leading cause of workplace injury and the primary cause of lost work days. An average person takes 8,000 steps/day and the hard-working healthcare professional is likely taking many more. Exposure to slips, trips, and falls comes with every step and diligence is needed to stay safe and on our feet.

Inadequate footwear causes 24% of falls (National Floor Safety Institute NFSI)

Walking surface problems cause 55% of falls (NFSI)

■ S mooth, plastic, or leather soles

■ Objects or changes in step height

act like slippery snow skis on wet or slick surfaces. ■ S oft rubber soles indented with deep

treads or channels are best for wicking moisture to the sides and leaving many contact points with the ground – just like your car tires! ■ W earing shoes with good grip is

important both inside and outside, and is critical during winter months. ■ O vershoes with cleats, spikes, or coils

are available at sporting goods stores and increase traction on snow and slush. Wear them in parking lots, but take them off when you reach the door as they are not safe inside. ■ W ipe feet well when coming in from

wet conditions. Wet shoes make flooring very slippery. ■ O pen-toe shoes such as sandals and

flip-flops create a trip hazard as they can catch on stair nosings, cords, mats, or changes in elevation. ■ L oose fitting shoes such as Crocs or

clogs should be avoided by healthcare professionals needing to respond quickly. These shoes slide or fall off of feet too easily when rushing.

as small as a ¼ inch creates a trip hazard per the NFSI. ■ O bjects or changes in step height

of a ½ inch or greater can limit access and mobility per the Americans with Disabilities Act. ■ R eport hazards such as uneven

walkways, buckled carpet, raised thresholds, dented or chipped tiles, curled or lumpy mats, damaged steps, and cracked or chipped concrete. ■ A lso, report slippery surfaces,

pooling water, poor drainage, loose tiles, and inadequate lighting. ■ C lean spills immediately. If you must

leave the area to retrieve cleaning supplies, leave a sign or a buddy near the spill to warn others. ■ B undle cords and Velcro or tape

them to the floor, or suspend them under desks/beds.

Unsafe behavior and inattention is a common contributor to slips, trips, and falls ■ S low down, and “walk like a penguin”

across indoor and outdoor wet or slippery surfaces – take short steps, keep your stance wide, step with flat feet, and keep your hands out of your pockets. ■ W hen entering or exiting a car, use

the door for support until your footing is sure. Keeping a container of sand in your car can also be helpful for sprinkling near the door and in front of you as you walk. ■ U se walkways that have been salted

and shoveled. Avoid taking shortcuts over snow piles or landscaping. ■ D on’t disregard caution and wet floor

signs. ■ A void carrying items in front of you;

don’t block your view of the path. ■ U se handrails on stairways. ■ U se ladders or stepstools properly;

do not stand on chairs/stools. ■ P ay attention to where you are going

– watch for hazards in your path. ■ D on’t text and walk!

Falls can injure multiple body parts at once, and can result in serious injuries including fractures, dislocations, and concussions. Making good footwear choices, using caution near hazards, and simply paying attention can help keep you on your feet! ■

Lori Berdahl is an occupational therapist and holds the Certified Ergonomic Evaluation Specialist designation. She is an Ergonomics and Loss Control Specialist with RAS. National Floor Safety Institute. Causes of Slips, Trips, and Falls. Retrieved from https://nfsi.org/nfsi-research/.

Midwest Medical Edition

Not all colonoscopies are created equal.

Muslim Atiq, MD Gastroenterology

Lee Austin, MD Gastroenterology

Brett Baloun, MD Gastroenterology

Jorge Gilbert, MD Gastroenterology

Heather McDougall, MD

Gastroenterology

Jeffrey Murray, MD Gastroenterology

Robert Meyer, MD Gastroenterology

Bhavesh Patel, MD Gastroenterology

Paul Bjordahl, MD General Surgery

Dennis Glatt, MD General Surgery

Curtis Peery, MD General Surgery

Matthew Sorrell, MD General Surgery

Itâ&#x20AC;&#x2122;s true.

The team you choose for your patientsâ&#x20AC;&#x2122; colonoscopy does matter. Some are better at finding polyps than others during this important screening. When compared with national averages, our team at Sanford Health detects more potential problems. Gain an advantage against colorectal cancer with our experts. Call (855) 726-3329 to schedule your colonoscopy today. sanfordhealth.org, keyword: Colonoscopy Quality Statistics based on data provided by The American Society for Gastrointestinal Endoscopy (ASGE). Visit us online to read full details.

019029-00104 2/16

Gary Timmerman, MD General Surgery

Matthew Tschetter, MD General Surgery

Outsmarting a

CryptoKiller By Buzz Hillestad

ITH THE RECENT incident at Hollywood Presbyterian Medical Center in Los Angeles where medical records were ransomed for $17,000 by hackers, it is easy to see why the most recent variants of CryptoWall are a valid business model for organized crime.

BACKGROUND The original CryptoLocker debuted sometime in 2013. While CryptoLocker is what most people refer to today, it’s the variant CryptoWall that has garnered much of the fearsome reputation that so many of us know today. CryptoWall 3.0 debuted in early 2015. According to Dell SecureWorks, there were 625,000 infections worldwide the first 6 months after its discovery while not long after that, in October, the number spiked to nearly 1 million infections. The truth is that security firms and the authorities have not been able to slow the infection rate because the $325 million dollar extortion total (Cyber Threat Alliance’s calculation) has not drawn the massive attention needed to confront such a threat.

A company called Imperva stated it found Bitcoin Wallets from 670 victims who paid a total of $337,607, which was only a small subset of the actual number. Security Firm PhishMe has found similar results. Based on the fact that 2 security firms have been able to peel back the layers of the financial business of the threat, they suggest that if the proper authorities got involved, they could be successful in hurting the business model extensively. More attention is certainly needed.

HOW IT WORKS The most common vector of infection of this ransomware is through an infected email attachment. In this case, the user has to open the attachment, usually a zip file, and execute the file within. Another common attack vector of this ransomware is through what is called a drive-by-download. That is when a user visits an infected website or web ad and downloads the executable into the browser cache. The executable is then run as the user using the computer. Another attack vector that is used to a lesser extent is the ransomware can be downloaded to the

computer by another piece of malware. In all cases, the ransomware uses what is called a dropper to “unpack” itself and start its nefarious purpose. The dropper has 3 phases in which it decrypts itself using various API calls to memory. It is then injected into the SVCHOST.exe. Once it is in that process, it acquires a lot of system information like computer name, processor speed and type, etc. It uses this information to generate a global MD5 hash, which it uses as the victim’s ID for encrypting the files. Then the ransomware generates its I2P or TOR network proxy and URL list. These networks are used to anonymize the traffic back to the attacker’s command and control servers. They do this so law enforcement can’t trace the attack back to the attacker. At this time, the main CryptoWall thread uses the Windows “Cryptographic Services” service to create the registry keys public encryption key. The same service is then used to crawl the user’s computer and network drives that are connected to that computer. In information security we have several goals. Those include protection, detection, and response.

Midwest Medical Edition

PROTECTION

First let’s look at the attack vectors and how to protect against those. We discussed email attachments and drive-by-downloads. The following protections can decrease the risk of getting infected in the first place. ■ O nly allow email attachments to certain people in the

organization that need them. This decreases the possible attack surface. ■ R estrict the types of attachments that can be downloaded.

Encrypted zip files should be automatically filtered out. If there is a true business need, take it on a case-by-case basis or use an email encryption software that you can upload legitimate attachments to and from email users.

Seek

HELP

Find

HOPE

■ R eputation based web filtering decreases your risk of

drive-by-downloads. It’s not 100% proof positive but gives enough risk mitigation to be a very valuable tool to help prevent the infections from happening in the first place.

Helping Professionals Stay on Track

■ W ebsite whitelisting is very effective in combating

drive-by-downloads but can be an IT nightmare and resource intensive. It can also delay business processes in some cases so the risk mitigation is not always worth the cost of implementing the solution. Smaller organizations with dedicated IT staff usually are the most successful at this type of security control.

Midwest Health Management Services SD Health Professionals Assistance Program

ph | 605-275-4711 fax | 605-275-4715

www.mwhms.com

DETECTION One great ways to detect CryptoWall activity, if you don’t have an anti-malware solution that can detect the activity is to alert on “Cryptographic Services” activity, on your systems. Other great methods for detecting it are: ■ A lert of file system activity on workstations above a certain

benchmark. There may be some false positives but if you have a workstation and several servers screaming alerts at you, this might be a good indicator of the encryption activity. ■ A lert of attempts to access I2P and TOR networks coming

from your network. These applications rarely have a business need and can also key you into to other potentially nefarious activities happening on your network. ■

The hits just keep coming. For sinus sufferers dealing with nasal congestion, pain, pressure and head-aches... the hits just don’t stop. The sinus specialists at Midwest Ear, Nose & Throat take a team approach to finding the right sinus solution for each patient. You can trust your patients will receive the highest quality of care with our highly trained and experienced team of doctors.

Sinuses are our specialty, and we appreciate your referrals.

Buzz Hillestad is Principal Consultant and Partner at Helix Security, LLC in Sioux Falls.

“Feel better.” 2315 W. 57th Street | Sioux Falls, SD 57108 | (888) 336-3503

(605) 336-3503 | www.midwestent.com

For more on how a layered approach to security can protect your organization from CryptoWall and how to mitigate its impact, log on to our website.

April / May 2016

Meet the Midwest Ear, Nose & Throat physicians

Paul Cink, MD, FACS

Greg Danielson, MD

Bethany Helvig, MD, FACS

Peter Kasznica, MD

Kenneth Scott, MD, FACS

Thomas Tamura, MD

Daniel Todd, MD, FACS

Happenings around the region

South Dakota Southwest Minnesota Northwest Iowa Northeast Nebraska

News & Notes BLACK HILLS Regional Health has announced its three caregivers who were recognized during the month of March for the “I Am Regional Health” campaign. The individuals are:

Tammy Burke, Clinical Informatics Lead Coordinator, Rapid City

Douglas Everson, MD, Belle Fourche

Joni Hill, Operations Manager, Medical Imaging, Custer

Regional Health has implemented new visitation guidelines to minimize patient risk from respiratory infections, which are on the rise in the region. Impacted facilities

include Regional Hospitals in Custer, Lead-Deadwood, Rapid City (including the Regional Rehabilitation Institute), Spearfish and Sturgis. Patients with respiratory symptoms and those under 18 are asked not to visit until the restrictions are lifted.

Regional Health Sports Medicine and Physical Medicine and Rehabilitation physician Joshua Sole, MD, FAA, PMR, has relocated to Regional Medical Clinic, 2805 Fifth Street. The new office on

the corner of Fairmont Boulevard and Fifth Street offers more space and resources for patients.

SANFORD Sanford Health has received approval as South Dakota’s first and only Cleft Palate Team for a five-year period.

The clinic was recognized by the Commission on Approval of Teams (CAT) under the American Cleft Palate-Craniofacial Association and Cleft Palate Foundation. The purpose of the CAT is to assure teams demonstrate compliance and adherence to the standards established by the commission. Approval by the commission is considered a marker of team excellence. Sanford’s clinic is led by Patrick Munson, MD, ear, nose and throat specialist. Bethesda Home of Webster, South Dakota, welcomes its new CEO, Isaac Gerdes. Gerdes

joins the team after working as the administrator for the Evangelical Lutheran Good Samaritan Society in Ottumwa, Iowa. Gerdes has a Bachelor of Business degree in health services administration from the University of South Dakota. Bethesda Home is a 50-bed long term care facility affiliated with Sanford Webster Medical Center serving the Day County region.

Ghana Health Services recently transitioned 12 of its facilities in the Central and Western Regions of Ghana to Sanford World Clinics, more than doubling

Sanford’s presence in the region. Sanford World Clinics launched in 2007 as an initiative to develop clinics in the US and around the world in areas that lack adequate primary care services. Domestic sites include Duncan, Oklahoma; Oceanside, California; and Klamath Falls, Oregon. In addition to the 18 Ghana locations, international locations are also in Kunming, China, and Munich, Germany.

SIOUXLAND Mercy Medical Center has received the Get With The Guidelines-Heart Failure Bronze Quality Achievement Award for implementing specific

quality improvement measures. Get With The Guidelines-Heart Failure is a quality improvement program that helps hospital teams provide the most up-to-date, research-based guidelines with the goal of speeding recovery and reducing hospital readmissions for heart failure patients. Mercy Medical Center is home to the only Level II trauma center in Western Iowa.

Mercy Medical Center-Sioux City received the 2016 Iowa Healthcare Collaborative Patient Culture of Safety Award at the Patient Safety

Conference on March 9, 2016 in Altoona, Iowa. This award is presented to healthcare providers and/or healthcare organizations who have demonstrated outstanding leadership and achievement in patient safety. The Patient Safety Award aims to raise the standard of healthcare in Iowa by promoting a culture of continuous improvement in quality, safety, and value. Wellmark Blue Cross and Blue Shield announced that Mercy Medical Center has been designated as one of the first hospitals to receive the Blue Distinction Center for Maternity Care. Hospitals that

receive a Blue Distinction Center for Maternity Care designation agreed to meet requirements that align with principles that support evidence-based practices of care. UnityPoint Health-St Luke’s has also been designated a Blue Distinction Center for Maternity Care. Nearly four

million babies are born in the U.S. annually, making childbirth the most common cause of hospitalization.

Midwest Medical Edition

The Sioux City Police Officers Association has donated $5000 to the Mercy Child Advocacy Center’s endeavor to build a new facility. The Mercy Child

Advocacy Center is a comprehensive, child-friendly program dedicated to serving children who are the victims of abuse. The Mercy Medical Center Foundation launched the campaign for a new facility and to date, over $1 million has been raised for the effort.

Whitney Delforge, CNP, MSN, has also recently joined the Yankton Medical Clinic team. Delforge

grew up in Yankton and graduated from Yankton High School. She earned an MS in Nursing as a primary care nurse practitioner at Indiana State University in Terre Haute. Delforge joins Dr. Mary Lee Villanueva in Oncology. She began seeing patients in February. Gurkirpal Gill, MD, has joined the Sioux Falls VA Health Care System. Dr. Gill is board

L to R–Carla Granstrom and Amy Scarmon with Mercy’s Child

certified in Internal Medicine and Nephrology and came to VA from private practice.

Veterans Health Administration recently acknowledged the Sioux Falls VA Health Care System on achieving the basic level of Facility Simulation Certification, which supports

improved local delivery of simulation-based training, improves access to curricula, enhances the Secretary’s Blueprint for Excellence, and improves Clinical standards. This certification is valid for two years. Anneka Mikel, RN oversees the SimLEARN Program.

Prairie Lakes Healthcare System has also been honored with the Blue Distinction Center for Maternity Care designation. The program

evaluates hospitals on several quality measures, including the percentage of newborns that fall into the category of early elective delivery, an ongoing concern in the medical community.

Advocacy Center, Barb Small, Manager of Mercy’s Child Advocacy Center, Sgt. Ryan Bertrand, Sgt. Jeremy McClure, Karin Ward and Torri Hilton with Mercy’s Child Advocacy Centet

OTHER Yankton Medical Clinic, PC, is pleased to announce that PA Dawn Lauer has joined the Orthopedic Department and will be working with Dr. Brent Adams.

Lauer grew up near Hartington, Nebraska and completed her undergraduate studies at Mount Marty College with a BA in biology and chemistry. She received her MS in Physician Assistant Studies from the University of South Dakota.

April / May 2016

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MidwestMedicalEdition.com

“If you understand any one’s ailments so well as to sit down and tell him exactly how he feels, better than he can tell you; he will be apt to believe all you afterward say and do.” The Physician Himself from Graduation to Old Age by DW Cathell, MD, 1922

T’S ANALOGOUS to becoming a parent. Among people who have children, virtually everyone, even

before conception, thinks, “I got this.” After the birth, shock sets in

along with the thought “What was I thinking? !” The parent realizes that no one can know what it’s really like to be a parent, until they’re a parent. No returns, even with a receipt. Likewise, most healthcare providers think they “get it”. They believe that they truly understand the thoughts, feelings and experiences of their

Providers as Patients INSIGHTS FROM THE OTHER SIDE

By Faith A. Coleman

Midwest Medical Edition

hamburger squad – I took a lot of hits,” he says. Eventually, the

pain

and

disability

progressed to the point where he couldn’t reach for instruments in the operating room. The day he could no longer do a push-up, he knew things had to change. Over the last three years, he had both shoulder joints replaced. “It’s just been a remarkable experience,” says

Steven Meyer, MD

Meyer. “The greatest thing

patients (or want them to think they do.) Then the provider becomes a patient, and realizes just how much they didn’t really “get”. That can be especially true in cases of life-altering medical conditions. Providers who experience these, like their patients, cannot help but be changed by them. If they are humble and courageous enough to examine that experience with their minds and hearts, they may be so fortunate as to become uncommonly great healers.

April / May 2016

BEEN THERE, DONE THAT Orthopedic surgeon Steven Meyer, MD, with the CNOS Clinic in Dakota Dunes, South Dakota, admits that he kept his pain and loss of function a secret until it could no longer be hidden.

about it is that I’m re-enthused about what I do for a living, because it was absolutely lifechanging. There’s nothing worse than chronic pain with

hopefulness, content-

ment, and confidence, alive in a patient is a

great one; and the look with which you meet

them has much to do with this. A bright, fresh, thoughtful

countenance, and an

easy, soothing profes-

sional air and manners are powers that will

impart tranquility and

repose to their minds, and carry many a patient with you

toward recovery.” –DWC, 1922

everything. It makes me feel incredibly blessed to be able to be an orthopedic surgeon – I know the impact I have on people’s lives.”

“I think doctors often try,

And Dr. Meyer says his

intentionally or not, to hide any

experience has been as good

weaknesses we might have,”

for his patients as it has been

says Dr. Meyer. “We want to

for himself. “You always tell

present this kind of ‘got it all

patients ‘your pain is going to

together’ thing, you know?

be like this or that’ and they say

If you went to most doctors

‘you’ve never had it.’ Now, I

and asked them if they had

can look at people and say I

a colonoscopy at age 50, or

know exactly what that’s like.

get their executive physicals

I know the anxiety that you

every year or two, you’ll find

have ahead of time, the concern

out that doctors are often the

about risks and benefits. My

worst patients. We don’t follow

shoulders were affecting every-

our own advice. We don’t eat

thing in my life. I wish I had

right or sleep right or live right.

done mine sooner. That’s why

We think the rules don’t apply

I advise you to get it done.” “It’s given me a greater

to us.”

“ The faculty of keeping

As a case in point, Meyer

sense of empathy, and enhanced

had lived with pain in his

my understanding. It helps

shoulders for more than 10

me relate to patients, and helps

years. He attributed it to wear

my patients relate to me,” says

and tear during his college

Meyer.

football days. “I was on the

MidwestMedicalEdition.com

Stephanie Broderson, MD

TOUGH LOVE Stephanie Broderson, MD, a family doctor with Sanford Family Medicine in Sioux Falls, was 28 weeks pregnant when she learned that her kidneys were failing. When things didn’t return to normal after delivery, a kidney biopsy revealed that she had lupus. So two months after the birth of her son, Broderson began a two-year course of chemotherapy for class IV lupus nephritis.

“Around 2000, Dr. Burris [Larry Burris, DO], who is now my transplant nephrologist, told me that I could expect worsening kidney failure for about a decade and that I would eventually need a transplant,” says Dr. Broderson. That transplant happened on June 27, 2011, when Broderson received a kidney from her 24-year-old stepdaughter, Andrea. “Before the transplant, I was tired all the time and I was chronically anemic. But I was the main breadwinner for our family, so I had to work. I just made modifications. I tried to get more sleep, etc. I just had to do things a little differently.” Five weeks after the transplant operation, Broderson returned to work at Sanford. She says the experience definitely had an impact on her practice. “I feel like I can relate on both ends of the spectrum [as a physician and as a patient],” Broderson says. “I had to do a lot of yucky stuff. I had to do chemo. I had to do a kidney biopsy and a bone marrow biopsy. I was chronically ill and had to take medication. And I underwent a major surgery. So I understand how tough it can be.” Today, the healthy and pragmatic Iowa native says she has little patience for patients who neglect their health and offers tough love, born of experience, for the rest. “My motto is ‘No whining’,” she says. “That’s it. You do what you need to do. It is what it is. Deal with it. I did.” “ Keeping up the patient’s courage is a great thing,

often a large part of the treatment. A few cheering words sometimes relight the lamp of hope and

do the timorous and despondent as much or more good than a prescription.” –DWC, 1922

Dr. Broderson's stepdaughter and kidney donor Andrea, transplant surgeon Thavam Thambi-Pillai, MD, and Dr. Broderson just after surgery.

David Meisinger

PREPARED FOR PRACTICE Sioux Falls native David Meisinger is a first-year medical student at the Sanford School of Medicine. As a 19-year-old college freshman on an athletic scholarship (soccer), he was diagnosed with the rare and obscure neurological disorder, transverse myelitis.

school. He’s leaning toward psychiatr y as a specialty, but is also now considering neurology or physiatry. “I recently had the chance to follow my physical rehab doctor who treated me at Sanford, and it was great to have that connection” says Meisinger. “Once you’ve been a patient, you start to do things differently, even the little things. I appreciate that the way you conduct yourself

“I had had a pretty hard

has a great impact on them

workout a couple of nights

[patients], and the way you

before and I was a little stiff,

deal with their families.”

but that wasn’t too unusual,”

Early in the third and

says Meisinger. “I was in a

fourth clinical years of med-

research class in the library

ical school, research shows a

when my legs began to feel

drastic drop in empathy among

like they were falling asleep

many medical students.

and it just kept getting worse.

“Patients expect you to be

Then, I had a sharp pain in

better than you are,” explains

my lower back. I told my

Meisinger. But, thanks to his

teacher that I thought this was

experience, he is hopeful that

something fairly serious.”

he won’t suffer the same fate.

Meisinger’s plan, even

“I hope my experience

before college, had been to

will increase my empathy. If a

become a physician. His expe-

patient says something that

rience as a patient solidified

stings or offends you, a lot of

his decision to go to medical

the times it’s because they’re

Midwest Medical Edition

scared, not that they’re angry

him for what happened after

with you. I think that under-

he developed a bout of a flu-

standing will be a big benefit

like illness.

to me when I start interacting with patients in a few years.” “ Do not get insulted at the foibles and

infirmities and hasty and angry . . . bear with the rude and discourteous

treatment you will

occasionally receive from the hysterical

and the peevish – with

their patience down to zero, and petulance

and nervous irritability up to a hundred . . . ; never take anything

a sick or silly person says in a paroxysm

of nervous effervescence, or a period

of despondency, or

a spell of bad humor, or in great pain (or for want of sense) as an insult.” – DWC, 1922

GETTING REAL

Sioux Falls Audiologist

“I was left with a mild to moderate hearing loss and a horrible ringing in my left

“ There is an art, a

ear,” Froke recalls. “It was

perfection, in entering

keeping me awake at night

[an encounter] with a

and it started to affect my

thoughtful and

work performance. Not only

dignified, yet gentle,

was I exhausted because of

manner that clearly

the constant ringing in my

evinces interest and a

ears, but I was also missing

determination to

things. A couple of times I

master the case . . .

gave some pretty off-the-wall

with a cheerful,

answers and people would

self-satisfied

say ‘That’s not what we were

demeanor that puts a

talking about.’ Trying to focus

patient at his ease and

was like carrying a 10-pound

inspires confidence.”

weight all day. ”

–DWC, 1922

Like his patients, Froke says he “played the denial game”, telling himself that everyone around him was mumbling. “Then suddenly I caught myself. I thought ‘You hear this all the time from your patients!’ So I decided I had better get real about it.” Although it can take the typical patient seven years to come to terms with hearing loss, Froke took just three months to grieve before taking action. After an MRI ruled out a tumor, his Midwest Ear

Robert Froke, MA, CCC-A,

Nose and Throat colleague

has been around the block–

Kelcey Cushman, AuD, pre-

more than once. He has been

scribed a set of RIC (receiver

a school-based audiologist,

in canal) digital hearing aids

has taught undergraduates at

that Froke can adjust with

Northern State and SDSU,

his iPhone.

patients are going through, even after years of practice, was an unexpected bonus. “This has really helped me help my patients,” says Froke. “Now, I can be one step ahead of people in terms of my counseling and tell them, yeah that’s normal. That is to be expected as far as your adjustment to your hearing aids or to hearing the world again.” “I’m kind of taking this lemon life gave me and

Robert Froke, MA

turning it into lemonade.” These days, he’s serving it to anyone who’s thirsty. ■

and has cared for patients

“It’s an absolute godsend,”

from infants to centenarians

he says of the lack of ringing.

in the clinic setting. But

“I feel like I’m back in the

and community partners in the Upper Midwest to support donor

even his three decades of

ballgame.” Gaining a better

families, facilitate the donation of organs, eyes, and tissue to

experience did not prepare

understanding of what his

transplant recipients, and encourage people to register as donors.

April / May 2016

NOTE: Our thanks to LifeSource for putting MED in touch with Dr. Broderson. LifeSource works with hospital, transplant center,

MidwestMedicalEdition.com

WEARING the SLIPPER SOCKS

What we can learn about the patient experience from our own experiences as patients

By Lori Atkinson

E’VE ALL been patients. And many of us have helped family members navigate today’s complex healthcare system. So we’ve seen firsthand what works and what doesn’t. But how do we translate our good or bad experiences as patients into improving the patient experience in our own organizations?

The challenges of being a patient In today’s healthcare environment, patients face many challenges. They can include: ■ Sifting through massive amounts of

healthcare information on the Internet ■ Choosing a healthcare insurance plan ■ Worrying about privacy

of personal data ■ Comprehending medical terminology ■ Recognizing and scheduling

timely preventive care ■ Understanding test results and

follow-up care recommendations ■ Self-managing multiple chronic

diseases ■ Administering complicated

medication regimes ■ Transitioning care from multiple

providers at multiple facilities

Transitions of care mean high risk for patients Transitions of care, i.e, the transfer of patient care from one healthcare provider or facility to another, can be a confusing and high-risk time for patients. The transition is often complicated by breakdowns in communication

between providers and patients, as well as between providers themselves. These breakdowns can result from a number of factors including: ■ Failure to use standardized

communication tools and processes ■ Failure to include the patient and

family caregivers as part of the healthcare team ■ Failure to consider the health literacy

of the patient and family caregivers ■ Failure to utilize health information

Studying the effects of patient-centered care, researcher Sarah Greene, MPH, and colleagues defined it as “care that honors and responds to individual patient preferences, needs, values and goals.” 3 They identified pertinent attributes in the interpersonal, clinical and structural dimensions of healthcare, and they outlined a framework for a comprehensive approach to making patientcentered care a health system priority.3 For example, attributes in the interpersonal or relationship dimension may include:

technology (IT) to share patient data

■ Communicating empathetically

Any of these mistakes can result in poor outcomes, hospitalizations and serious patient injuries.

■ Finding common ground based

on patient preferences ■ Ensuring responsiveness by the health-

care team to patient and family needs

Understanding what works Nearly half of all Americans live with at least one chronic condition, and of these, 1 out of 4 sees at least three physicians regularly.1 Healthcare providers should consider the patient’s perspective on how confusing it can be to manage appointments, medications and self-care instructions from multiple providers. In order to improve both patient experience and health outcomes, it is important to know what interventions are most beneficial to a patient’s understanding of self-care, followup care and medication management. A patient-centered care approach has the potential to improve patient outcomes and increase patient satisfaction. Studies show that when healthcare providers work with patients and family caregivers as a team, the quality and safety of healthcare rise, costs decrease, and provider and patient satisfaction increase.2

Included in clinical or provision-of-caredimension attributes are: ■ Using shared decision-making

based on the best available evidence and patient preference ■ Coordinating care with

community resources ■ Accommodating virtual visits

as well as in-person visits The researchers suggested these examples of structural or system-dimension attributes: ■ Providing a calm and welcoming space ■ Minimizing clinic wait times ■ Providing self-management tools

Patient care coordinators help patients understand and transition successfully across the continuum of care. Researchers found that patients who had a care coordinator were

Midwest Medical Edition

less likely than patients without one to report 1 that their care was poorly organized and coordinated, 2 that test results or medical records were not available at their scheduled appointments,3 that they received conflicting information from different physicians,4 that they did not receive follow-up instructions and 5 that their regular physicians and specialists were not sharing information about their care.4 In addition, the lack of health literacy tools and a poor understanding of how to use their medications properly were shown to have negative impacts on their overall healthcare experience and their outcomes. â&#x2013; Lori Atkinson, RN, BSN, CPHRM, is a Research, Development & Education Manager with MMIC

REFERENCES 1. Greene J, Hibbard JH. Why does patient activation matter? An examination of the relationships between patient activation and healthrelated outcomes. Journal of General Internal Medicine. 2012;27:520-526. 2. Rathert C, Wyrich MD, Boren SA. Patient-centered care and outcomes: A systematic review of the literature. Med Care Res Rev. 2013;70(4):351-79. 3. Greene S, Tuzzio L, Cherkin D. A framework for making patient-centered care front and center. Perm J. 2012;16(3):49-53. 4. Doty MM, Fryer AK, Audet AM. The role of care coordinators in improving care coordination: The patientâ&#x20AC;&#x2122;s perspective. Arch Intern Med. 2012;172(7):587-588.

For a full list of resources to help patients more successfully navigate their healthcare experience, read the full version of this article on our website.

April / May 2016

MidwestMedicalEdition.com

Ask ur tO Abou dge Lo e! g Packa

“

Although seemingly simple in construction, The Two Midnight Rule has sparked complex debates over the requirements . . .

”

The CMS “Two Midnight” Rule By Melissa Grant

N NOVEMBER 13, 2015, the Centers for Medicare and Medicaid (CMS) published the final rule, “Short Inpatient Hospital Stays,” included in the 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System rule (80 FR 70297), (the “OPPS Final Rule for 2016”). The OPPS Final Rule for 2016 clarified questions and modified the original rule on inpatient stays and subsequent published guidance from CMS. Originally published in the 2013 Federal Register as part of the 2014 Inpatient Prospective Payment System final rule (78 FR 50495) (the “IPPS Final Rule for 2014”), the “Admission and Medical Review Criteria for Hospital Inpatient Services Under Medicare Part A” clarification from CMS became known as “The Two Midnight Rule.” The Two Midnight Rule created a “benchmark” that inpatient hospital stays falling short of the two midnights minimum are generally classified as outpatient services unless an exception was warranted by the (1) total medically necessary services a patient received and (2) clinical documentation supported the physician expected the patient stay required two midnights. Therefore, in addition, the rule created a “presumption” that medically necessary stays spanning two midnights are generally Medicare Part A services. Although seemingly simple in construction, The Two Midnight Rule has sparked complex debates over the requirements as well as the renewed risk of post-payment audits. Reflecting back to 2013, CMS’s intent with The Two Midnight Rule is to proactively

reduce the volume of beneficiary payments improperly paid as higher inpatient rates through the Medicare Part A reimbursement schedule, when the stays should have been paid as an outpatient services at the lower Medicare Part B rates. CMS data studies indicated a significant amount of short term stays, extended outpatient “observation” services, and procedures performed in medically unnecessary inpatient setting were inappropriately being billed to Medicare Part A at higher rates. The result, or consequence as CMS stresses, has been unnecessary higher costs passed on to patients or taxpayers. On the other side of the debate, healthcare professionals generally opposed The Two Midnight Rule as a dramatic change that interferes with a physician’s professional medical judgment. CMS, in response and prior to the 2016 final rule, published numerous guidances such as conceding in 2014 that “rare and unusual” exceptions may exist for appropriate Medicare Part A payments notwithstanding the physician’s medical judgment concludes a hospital stay shorter than the two midnights is appropriate care for the patient. In addition, the following two exceptions were identified: OPPS inpatient-only procedures and some initiated mechanical ventilation. Yet, the healthcare industry overall continued to pressure CMS for additional changes and clarifications. Under the OPPS Final Rule for 2016 update, CMS reaffirmed all healthcare services provided to a patient at a hospital are considered in determining whether the stay was truly an inpatient stay and property payable under Medicare Part A.

The two midnight clock starts when services start, including services a patient received as a regular outpatient in the emergency room, observation time, and all other appropriate “pre” and “post” inpatient care. The OPPS Final Rule for 2016 also reiterates the “benchmark” is to “ensure that all beneficiaries receive consistent application of Medicare Part A benefits to medically necessary services” and firmly states this benchmark “instruction does not override the medical judgment of the physician…” Beginning January 1, 2016, the “presumption” component of the medical review policy as originally provided in the 2014 final rule became effective. The “presumption” was not modified in the 2016 update. Unless other evidence shows indicators of fraud and abuse, reviewers will not subject claims meeting the The Two Midnight Rule benchmark to an audit. The 2016 final rule extended the prohibition on post-payment auditing under the “Probe and Education” time period to admissions from October 2, 2013, through December 31, 2015. The bad news is that CMS’s “Probe and Educate” time period for Medicare Administrative Contractors (MACs) to evaluate understanding of the rule and educate expired on December 31, 2015. ■ Melissa Grant is a Health Law Attorney at Goosmann Law Firm For more on what did change in the updated final rule, see the full version of this article on our website.

Midwest Medical Edition

Being able to isolate shed exosomes in blood, scientists used genetic data generated by the AIHG’s laboratory to obtain tumor profiles for each patient. This data enables clinical oncologists to identify DNA mutations that are specific for a patient, and in turn target these mutations with chemotherapy regimens. “The ultimate goal of this research is to translate these findings to treating patients safely and effectively,” said Erik Ehli, PhD, Research Scientist at the Avera Institute for Human Genetics. Also, RNA sequencing of the samples identified the presence of expressed fusion

genes, representing a potential avenue for elucidation of t umor neoantigens, which could help make personalized immunotherapy treatments a reality. These treatments would be tailored to the specific makeup of the patient’s tumor as it evolves over time to help ensure continued treatment effectiveness. “This is the true essence of precision healthcare. We’re excited to be a part of this groundbreaking research which could represent giant steps forward in cancer care,” said Ryan Hansen, Administrative Director of the Avera Institute for Human Genetics. ■

2016

THE AVERA INSTITUTE for Human Genetics in Sioux Falls is part of a clinical study demonstrating the usefulness of genetic testing of blood samples, serving as “liquid biopsies” to characterize diff icultto-access tissues in the pancreas and biliary system, without an invasive or surgical biopsy. Positive results of the study were recently published in the January 12, 2016 issue of Annals of Oncology. Obtaining a biopsy of tumors in the pancreas or bile duct typically requires surgery along with a stay in the hospital, adding risk, cost and discomfort to the patient.

APR IL / MA Y

Liquid Biopsy Study Shows Promising Results for Patients with Pancreatic and Bile Duct Tumors

Vol. 7 No. 3

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”

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• Just What the Doctor Ordered •

MidwestMedicalEdition.com

When “I” is replaced with “We” even illness becomes wellness. - Malcolm X

Our care is holistic. Our approach is integrative. At The ReBalance Center our mission is to provide a balance of science and nature to improve patient outcomes and quality of life. By fusing traditional and nutritional medicine together, we can truly offer the best in whole person care for everyone we serve. Our desire is to work together with the patient and their care provider to empower people to be active participants in their health and healing. For more information see www.rebalancesf.com or call 605.275.0001 to speak with one of our health care providers.

Healing Happens Here

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New Call Center

Helps Patients

“Navigate”Cancer AVERA CANCER Institute’s new Navigation Center opened in March for patients and families across the health system’s 72,000 mile footprint. Calls are answered around the clock, seven days a week. From 8 am to 8 pm, the Navigation Center is staffed by registered nurses and social workers and overnight calls are answered by Ask-A-Nurse RNs. “Our goals are to overcome barriers to care, reduce burdens of cancer and improve access to quality care as we connect people back to resources that are close to home,” says Jamie Arens, Director of the new Avera Cancer Institute Navigation Center. Reasons for calling the Navigation Center can range from managing symptoms, to finding resources for emotional support, to getting help for the whole family for issues created by the effects of cancer and treatment. Anyone can call the Navigation Center – they do not need to be an Avera patient. “This offers an added layer of support to connect people to the help they need,” Arens says. The community-based model is designed to connect people to resources such as support groups, transportation resources or physician outreach clinics closest to where they live. Although the Navigation Center, located on the first floor of the Prairie Center in Sioux Falls, is primarily a call center, it is also equipped to handle anyone who walks in seeking assistance. Navigation staff reach out the following business morning for further follow-up. Avera has had disease-specific navigators for cancer patients for several years. This new service expands navigation, making it available across the entire Avera service area. ■

Midwest Medical Edition

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PETRASKO PERFORMS 100TH ROBOTIC ANGIOPLASTY

We understand the art

MARIAN PETRASKO, MD, PhD, an inter-

of healing and the

ventional cardiologist with Sanford Heart Hospital in Sioux Falls, recently performed his 100th robotic-assisted angioplasty. San-

science of avoiding risk.

ford Health has one of the country’s leading interventional robotics programs. Petrasko notes that the CorPath System used at Sanford, which is the first FDA cleared robotic-assisted system for Percutaneous Coronary Intervention (PCI), has provided significant benefits to physicians, staff and patients. “For patients, the precision of the robotic system allows for interventional procedures with more accurate measurement of the anatomy of interest,” says Petrasko “That accuracy may improve patient outcomes.” Petrasko adds that he and his colleagues are inspired by utilizing cutting-edge technology. He says other staff members are empowered to work more independently at the patient table while he controls the devices robotically from an interventional cockpit. “Robotic-assisted technologies have defined a clear role in the future of healthcare, and Sanford is a key player in the evolution of healthcare,” says Petrasko. ■

DID YOU KNOW ?

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Then and Now

For Drs. Richard

and Tom

Howard, Plastic Surgery is a Family Affair

Father and son in the “T-Ball” days

By Alex Strauss

Dr. Tom

Howa

rd IOUX FALLS PLASTIC Dr. Richa and his fathe r, rd Howa surgeon But things changed rd Richard Howard, for Dr. Tom Howard MD, says it was and the opportunity when he realized T-Ball that originally how the cardiovascu to get to know patients prompted lar over time, such as landscape had changed him to establish over the course of in recent years. his practice in a breast reconstruct ion. Sioux Falls in 1992. “Intervent ional As much as he cardiologis ts have Specifically, his knows he son stands to learn from become so proficient Tommy’s T-Ball. his dad, he’s also that the surgeons hoping tend to be able to teach to get the very sickest “We were living some, too. in Kansas City at patients. That means the more challenges, time and we had one “I am hoping that longer recovery, son. It was T-Ball he will show me season some more of the old tried-and-tr problems,” says and, if I wanted the younger Dr. to catch a game, ue things that always Howard, it was a work and I’ll be able who completed his 45 minute drive there and then another to show him some Plastic & Reconstruc things 45 that are on the forefront tive Surgery residency minutes back to the office to finish up,” at the University of the specialty,” says of says Tom, who will Oklahoma in June. Dr. Howard. “An be studying for his hour and a half to “With plastics, everyone board watch exam in the fall. seemed really happy one game. Living in the big city had and excited to go pros to work. Their patients and cons but, at For his part, Dr. Richard that point, the cons tend to be happier, Howard, whose were too. Sioux Falls Center It all seemed much outweighing the pros by a long shot.” more attractive.” for Plastic and Reconstructive Surgery After discussions Leaning on advice has been primarily with his dad and evalufrom his father that a solo practice, is glad ation of the local “a man who fails medical landscape, to be gaining not his family fails his the idea only a life”, partner he likes and of coming home to Dr. Howard moved Sioux Falls with his trusts, but also a his family and surgical closer wife relationship with Katie (also a Sioux practice to Sioux his three-and-a-half Falls, enjoyed as Falls native) and young much year old grandson, Benjamin. son seemed more T-Ball as he could, attractive, too. and never looked back. “He’s my only grandson “My dad and I Twenty-three years get along great,” later, that emphasis and now I am says going to get to go Tom. “He’s a wonderful on family appears to to be paying off in his T-Ball teacher, games,” a talented spades. says Dr. Howard. ■ surgeon, and great Not only did Thomas with people. I would Howard, MD, decide be missing a great opportunity to follow his father into medicine, but if I went anyhe has NOTE: Dr. Tom where else.” recently decided – after some considerabl will join Dr. Richard in e practice at the debate – to follow “I’m confident knowing Sioux him into his Sioux Falls Center for Plastic Tom’s personalFalls and Reconstruct ity, his high standards, practice. ive Surgery in August. and how he approaches taking “Tom told me years care of people, that ago that he was absohe will do very well lutely not going to here,” says Dr. Richard, go into plastic surgery,” who is hoping to recalls Dr. Howard cut back his own with a laugh. “He workload got by 25 to 30 percent. into medical school “I think it will be at USD and arranged a lot of fun. And the most of his rotations timing for me right outside of Sioux Falls. now couldn’t be better.” He decided that he wanted to do cardiovascular surgery.” Like his father, Dr. Tom Howard says he enjoys the personal nature of plastic surgery

Contact informat

ion: 6301 S. Minnesota

Ave. Suite 300 Sioux Falls, SD 57108

605-334-1930

Midwest Medical Edition

New Studies Focus on Head and Neck Cancers Two new clinical trials at Sanford are focused on patients with head and neck cancers ONCOLOGIST and researcher Steven Powell, MD, is heading up a new trial of the investigational immune checkpoint inhibitor pembrolizumab to evaluate its ability to activate the immune system and boost the effectiveness of chemotherapy and radiation. Participants in this study will receive standard of care chemotherapy and radiation in addition to pembrolizumab. The goal of the study is to evaluate the safety and efficacy of adding this immunotherapy to standard therapy to improve long-term outcomes. After 18 months from initial treatment, annual

evaluations will be conducted to monitor each patient’s cancer status or recurrence. Pembrolizumab was developed by Merck and is FDAapproved for melanoma and certain types of lung cancer.Participants for this study must be at least 18 years old and have advanced stages of squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx or larynx. The pembrolizumab trial is the product of laboratory research performed at Sanford by Powell and the head and neck cancer research team led by John Lee, MD, and W. Chad Spanos, MD.

At the same time, Dr. Spanos is leading a separate trial of the PD-1 inhibitor nivolumab for not only head and neck cancers but also Merkel cell, gynecological and gastric cancers. Spanos practices at the Sanford Ear, Nose and Throat Clinic in Sioux Falls and runs a cancer biology lab that focuses on head and neck cancers caused by the human papilloma virus (HPV). “When used with other treatment methods, nivolumab has shown promise in managing other types of cancers.” says Spanos. Participants in the nivolumab trial must be at least 18 years old and have confirmed carcinoma of specific solid tumor types or progressive metastatic or recurrent cancer that has been treated with no more than two prior therapies or regimens. ■

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CASE STUDY:

Mercy Medical Center Combats

Food-related Costs by Outsourcing Food Services

“

atients don’t always know P how good their medical care was, but they know how good their food was.

”

— Ron Muecke, Vice President Facilities & Support Service, at Mercy Medical Center–Des Moines.

Like many healthcare facilities, Mercy Medical Center was facing challenges when it came to its food service department. Food and labor costs, waste, and inventory were high, while quality and customer satisfaction were low. Retail areas were underutilized; a newly implemented room service program was significantly over budget; and the department director resigned. In addition, Mercy had accepted the Partnership for a Healthier America (PHA) challenge – part of Michelle Obama’s initiative to combat obesity – and committed to providing healthier food and beverage choices throughout the medical center. Although they embraced the initiative, they didn’t realize the associated costs and issues involved in complying with the strict criteria.

generate some additional goodwill in the community by delivering more than 500 mobile meals at Christmas.

RESULTS

■ Reduced food waste by 50% ■ Increased revenue from $2.65M to $2.9M ■ Improved Catholic Health Initiatives

purchasing compliance to 93%, increasing discounts and rebates

The changes Mercy implemented with the help of their outsource partner produced a range of benefits for the medical center which

■ Enhanced Partnership for a Healthier

■ Decreased FTEs by 25%

■ Improved Solucient performance

■ Reduced inventory by almost half

America compliance to 85% to the 8th percentile

SOLUTION Mercy’s solution was to outsource their food services. With the help of ABM Healthcare Support Services, the medical center implemented a number of changes including establishing new best practicing and running customer service training for their staff. They put a recycling program in place, and instituted some new menu offerings. Signage and promotions got a makeover, too. The medical center was even able to Go online read more about the partnership and the solutions that turned things around for Mercy’s food service.

Midwest Medical Edition

step up. extends beyond your medical practice,

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Midwest Medical Edition

Near-Infrared Spectroscopy Improving Care in Omaha NICU Neonatologists have begun using Near-

no way to detect the significant drops in oxygen

Infrared Spectroscopy to measure oxygen

delivery that were occurring,” he says.

delivery and consumption in the brain and tis-

In the future, measuring these changes in

sues of the babies in the Newborn Intensive

oxygen delivery may help improve the neuro-

Care Unit at Children’s Hospital & Medical

logical outcomes of the most fragile NICU

Center in Omaha.

patients, Dr. Gollehon says. “We can also detect

Near-Infrared Spectroscopy (NIRS) “enables

sepsis and shock earlier with this technology,

us to measure the oxygen supply to the brain

which may allow us to take proactive steps to

and kidneys in some of the most vulnerable

prevent damage, as opposed to waiting for other

babies we treat,” says neonatologist Nathan

signs of illness to appear as the child gets sicker.”

Gollehon, MD, Children’s Specialty Physicians, Neonatology..

Midwest Medical Edition

NIRS has previously been used in the Pediatric Intensive Care Unit at Children’s. “We are taking

“NIRS allows us to detect changes that we

what the intensivists have learned from it there

might not otherwise be able to see or measure,”

and are bringing that knowledge into the NICU,”

Dr. Gollehon says. “Detecting these changes

Dr. Gollehon says.

early means we can prevent sick infants from getting sicker.”

Another advancement making its way into neonatology includes personalized medicine.

The technology is particularly useful in treat-

One example of this is genetic testing for cystic

ing babies with congenital heart disease. For

fibrosis and the disease mutations associated

example, one NICU baby was experiencing

with it.

recurrent bradycardia. Dr. Gollehon says

“We are starting to see therapeutics designed

Children’s neonatologists used NIRS to measure

for specific mutations,” Dr. Gollehon says. “I

the impact of the bradycardia on the baby’s

think it is very likely in the next few years we

perfusion and supply of oxygen to the tissues.

will see a specific medication targeting specific

“Without NIRS technology, there would be

changes in the genetic code.” ■

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April / May 2016

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2016 E OURS

20 Y A Y, M GOLF C A D I R F EN

SD GRE , E S I L R L I PRA X FA U O I S

Personal and Professional

Family Law Considerations By Michele A. Munson and Kristine Kreiter O’Connell

ANY FAMILIES are impacted by divorce, child custody, and related issues. Dealing with these legal issues personally can be difficult and emotional. It is also difficult on a professional level for physicians, nurses and other staff who work with families going through divorce. Because having accurate information about the legal process is important in both instances, below are answers to five frequently asked questions.

Q1: How will the judge decide who gets custody of the children? Custody decisions are based on the best interest of the child. To determine this, a judge looks at a number of factors, including: (1) which parent is better equipped to provide for the child’s temporal, mental, and moral welfare; (2) who can provide a stable and consistent home environment; (3) who is more committed and involved in parenting the child; and (4) has there been any parental misconduct that has had a harmful effect on the child. If the child is of a sufficient age to form an intelligent preference, the court may also consider that preference in determining custody.

April / May 2016

Q2: What is the difference between legal and physical custody?

assets. Depending on your case, you may also argue that certain property should be awarded to you alone and excluded from the property division.

Legal custody is the right to determine the child’s upbringing, including education, healthcare and religious training. Generally, both parents are entitled to legal custody. Physical custody is the routine and daily care of the minor child. As a general rule, access to medical records pertaining to a minor child shall be made equally available to both parents having legal custody, with both parents having involvement in the child’s healthcare decisions. As such, parents must make reasonable efforts to ensure that the name and address of the other parent is listed on all records.

Q5: Will the court award alimony?

Q3: How is child support determined? Both parents are obligated to support their child(ren) in accordance with their respective incomes. While it is based on a formula, there are deviations and abatements that may apply to the situation, and it is important that the Court calculate parents’ income accurately.

Q4: How will property be divided? The judge will make an equitable division of marital property by considering factors such as the length of marriage, value of property, age of parties, health of parties, parties’ competency to earn a living, contribution of each party to the accumulation of property, and the income-producing capacity of the

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The judge will decide whether alimony is appropriate and, if so, the amount and duration of alimony order, by considering the length of the marriage, earning capacity of the parties, financial condition after the property division, age, health and physical condition of the parties, the parties’ station in life or social standing, and fault for the divorce. It is important that you advise the Court of monthly expenses so it can determine if you have the ability to pay alimony or there is a need for alimony support. Alimony is not intended to allow the other spouse not to work, nor is it meant to equalize incomes. ■

This article contains general information and addresses only a few of the issues involved in family law. It does not represent a legal opinion or advice regarding any particular case or issue.

Michele A. Munson and Kristine Kreiter O’Connell are attorneys with Woods Fuller Shultz and Smith, PC, in Sioux Falls.

Staying on Track

with Your Retirement Investments By Mark Schlueter

NVESTING FOR RETIREMENT often takes patience, prudence and a long-term approach. The below information from Broadridge Investor Communications Solutions Inc. and Thrivent Financial detail some easy steps you can take. Investing for your retirement isn’t about getting rich quick. More often, it’s about having a game plan that you can live with over a long time. You wouldn’t expect to be able to play the piano without learning the basics and practicing. Investing for your retirement over the long term also takes a little knowledge and discipline. Though there can be no guarantee that any investment strategy will be successful and all investing involves risk, including the possible loss of principal, there are ways to help yourself build your retirement nest egg.

Compounding is your best friend It’s the “rolling snowball” effect. Put simply, compounding pays you earnings on your reinvested earnings. Here’s how it works: Let’s say you invest $100, and that money earns a 7% annual return. At the end of a year, the $7 you earned is added to your $100; that would give you $107 in your account. If you earn 7% again the next year, you’re earning 7% of $107 rather than $100, as you did in the first year. That adds $7.49 to your account instead of $7. In the third year with a 7% return, you’d earn $8 and have a total of $122. Like a snowball rolling downhill, the value of compounding grows the longer you leave your money in the account. In effect, compounding can do some of the work of building a nest egg for you. The longer you leave your money at work for you, the more exciting the numbers get. If your retirement savings plan contributions are made pretax, as most peoples are, compounding really becomes a powerful force. Not having to pay taxes from year to year on either your contributions or the compounded earnings helps your savings grow even faster. The value of compounded

tax-deferred dollars is the main reason you may want to fully fund all tax-advantaged retirement accounts and plans available to you, and start as early as you can.

Diversify your investments Asset allocation is the process of deciding how to spread your dollars over several categories of investments, usually referred to as asset classes. A basic asset allocation would likely include at least stocks, bonds, and cash or cash alternatives such as a money market fund. The term “asset classes” also may refer to subcategories, such as particular types of stocks or bonds. Asset allocation is important for two reasons. First, the mix of asset classes you own is a large factor in determining your overall investment portfolio performance. How you divide your money between stocks, bonds, and cash can be more important than your choice of specific investments. Second, by dividing your portfolio among asset classes that don’t respond to market forces in the same way at the same time, you can help minimize the effects of market volatility while maximizing your chances of long-term return.

Take advantage of dollar cost averaging One of the benefits of investing into a retirement savings plan is that you’re automatically using an investment strategy called dollar cost averaging. With dollar cost averaging, you acquire shares of an investment by investing a fixed dollar amount at regularly scheduled intervals over time. When the price is high, your investment buys less; when prices are low, the same dollar investment will buy more shares. A regular, fixed-dollar investment should result in a lower average price per share than you would get buying a fixed number of shares at each investment interval. In addition to potentially lowering the average cost per share, investing the same amount regularly automates your decisionmaking, and can help take emotion out of investment decisions.

Stick to your strategy Try to resist the impulse to change your investment strategy with every news headline or investing tip from a relative or coworker. Timing the market correctly is very difficult; even professionals find it a challenge. Most people fare better by having an investment game plan that can weather good times and bad, and then sticking to it. That doesn’t mean you should simply forget about your investments altogether. At least once a year, you should review your portfolio with your financial professional to see if your choices are still appropriate. ■ Mark Schlueter, CFP, FIC, CLTC, has been a financial consultant with Thrivent Financial since 2006.

Midwest Medical Edition

April / May 2016

MidwestMedicalEdition.com

The Nurses’ Station Nursing News from Around the Region

Awards & Honors for VA Nurses Holly Lunde, RN, Clifford-Chapin, LPN,

Sioux Falls VA nurses and Marie

were recently recognized as DAISY Award recipients for exceptional nurses. DAISY recipients are nominated by a peer or patient’s family for Lyn Haug

Steve Linman

Sheila Johnson

Recent DAISIES at RCRH

making a difference in Veterans’ and families’ experiences.

Claire Forster, RN,

on the Community

Registered Nurses Lyn Haug, Steve Linman and Sheila Johnson are the

Living Center was also honored as the 2015

latest recipients of Rapid City Regional Hospital’s DAISY Awards for Nurses.

Employee of the Year for the Sioux Falls VA Health

Haug provides patient care in Labor and Delivery and has worked at the hospital for more than 22 years. She was nominated for the DAISY Award by a recent patient who praised her no-nonsense approach and competence. “Lyn expertly and efficiently spent hours assisting me through labor and helping our son move along in the process after 33 hours of labor. She is an amazing nurse,” the patient wrote.

Linman has worked as a Hospice nurse for more than 25 years and was nominated for a DAISY for caring for a husband and wife who entered the Hospice House at the same time. “Steve comforts patients and families by his quiet, calm manner,”

Care System. Claire was originally nominated as wrote the couple’s daughter in her nomination. “He has a special gift of singing which he shares beautifully with his patients and families.” Finally, Johnson, a one-year member of the Emergency Department, was nominated by the sister of a recent cancer patient. According to the nomination, “Sheila’s level of compassion and concern for my sister made my Mom and I feel like we were the only people in the ER and it was a madhouse. She thoroughly explained everything, continually checked on my sister, and helped alleviate our anxiety.”

one of the 2015 Employees of the Month by a Veteran’s family.

Susan Leitheiser, MS, RN, NP-BC, has been selected as the Mental Health Service Line Director at the Sioux Falls VA. Loretta (Lori) Thomas, MSN, CNP, NE-BC is the new Extended Care and Rehabilitation Service Line Director.

Holly Lunde

Marie Clifford-Chapin

Midwest Medical Edition

Sanford Nurses Go

Above & Beyond Mila Pugach of Sanford Health recently received a DAISY Award for her quick problem solving

Keeping the game fair...

when she noticed that a patient had an outdated car seat. Pugach quickly called a family member and procured a car seat for the family, who then passed the car seat challenge.

Megan Vanliere of Sanford Heart Hospital received two separate DAISY nominations, one for her Mila Pugach

kindness and thoroughness in explaining to a patient and another for handling a patient with chest pains.

“ She dropped everything to help us,” wrote the patient. “I feel so much better with all of her care.”

Miranda Pate, RN,

a clinical

...so you’re not fair game.

care coordinator in the critical care

Megan Vanliere

unit at Sanford Aberdeen Medical

Your South Dakota medicine

Center, was nominated for a DAISY

is getting hit from all angles.

Award for her “exemplary compassion” and ability to establish special connections with patients and their

You need to stay focused and on point—

families. Miranda has been employed

confident in your coverage.

with Sanford Aberdeen for four years.

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Miranda (center, in blue) with her family and SAMC staff.

April / May 2016

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Nationally Recognized

The University of South Dakota School of Health Sciences

South Dakotaâ&#x20AC;&#x2122;s only comprehensive health sciences school is a recognized, national leader in interprofessional education. We help advance and define healthcare in our state and nation.

Our

exceptional faculty excels at teaching, researching, mentoring.

Ten standout programs benefit our students and our communities. Addiction Studies Dental Hygiene Health Sciences Medical Laboratory Sciences Nursing Occupational Therapy Physical Therapy Physician Assistant Studies Public Health Social Work

We develop scholars, practitioners and leaders in health and human services to serve South Dakota and beyond.

w w w. u s d. e d u / h e a l t h

Midwest Medical Edition

Learning Opportunities Spring 2016 April 8 8:00 am - 4:00 pm

15th Annual Avera Pediatric Symposium Location: Prairie Center, Avera McKennan

Information: Avera Education Events, 605-322-7879 Registration: Avera.org/conferences

April 13 7:30 am – 4:00 pm

24th Annual Avera Trauma Symposium

Information & Registration: Avera.org/conferences

April 14 9:00 am – 12:00 pm

The Longest Loss: Alzheimer’s Webinar

Registration & Information: HospiceofSiouxland.com

April 15 8:30 am – 4:30 pm

Avera McKennan Diabetes Conference

Location: Sioux Falls Convention Center

Location: Hospice of Siouxland, Sioux City

Location: Hilton Garden Inn Downtown, SIoux Falls

Information: 605-322-7879, AveraEducationEvents@avera.org Registration: Avera.org/conferences

April 29 - 30 8:00 am – 6:00 pm

10th Annual Sanford Sports Medicine Symposium Location: Ramkota Hotel & Conference Center, Sioux Falls

Information: 605-312-7808

April 29 8:00 am – 4:30 pm

Edith Sanford Breast Center Symposium Location: Sanford Center, Sioux Falls

Information: Jessica.Aguilar@sanfordhealth.org

May 5 8:30 am – 3:30 pm

Avera Caring Professionals Conference: Nurturing the Caregiver

Information: 605-322-7879, AveraEducationEvents@avera.org

Registration: Avera.org/conferences

May 6 8:00 am – 4:30 pm

North Central Heart Vascular Symposium

Registration & Information: Marilyn.paddock@avera.org, 605-977-5122

May 11 8:30 am – 4:00 pm

UnityPoint Health-St. Luke’s 42nd Annual Perinatal Conference

Registration & Information:

unitypoint.org/siouxcity/services-professional-eduction.aspx

June 9 4:00 pm – 7:00 pm

Avera Sports Medicine Symposium

Information: 605-322-7879, AveraEducationEvents@avera.org

Registration: Avera.org/conferences

Location: Holiday Inn City Centre, Sioux Falls

Location: Sioux Falls Convention Center

Location: UnityPoint Health-St. Luke’s Auditorium, Sioux City

Location: Holiday Inn City Centre, Sioux Falls

SAVE THE DATE: JUNE 24 - 25 38th Annual Sanford Black Hills Pediatric Symposium

MED reaches more than 5000 doctors and other healthcare professionals across our region 8 times a year. If you know of an upcoming class, seminar, webinar, or other educational event in the region in which these clinicians may want to participate, help us share it in MED. Send your submissions for the Learning Opportunities calendar to the editor at Alex@MidwestMedicalEdition.com.

FRIDAY

APRIL 29

2016 Edith Sanford Breast Center Symposium Symposium Agenda: 7:15 a.m.

Continental Breakfast and Registration

12:15 p.m. Lunch

8 a.m.

Welcome and Opening Remarks

1 p.m.

8:15 a.m.

Keynote: BRCA1 and 53BP1: Regulating DNA Repair Choice and Chemosensitivity Shridar Ganesan, MD, PhD

Less is More: Current Trends in Breast Surgery Michael Bouton, MD

1:45 p.m.

9:15 a.m.

The Role of Physical Activity and Energy Balance in Breast Cancer Prevention and Survivorship Lisa Cadmus-Bertram, PhD

State of the Art in Breast Surgery: Breast Reconstruction After Cancer Heather Karu, MD & Jesse Dirksen, MD

2:30 p.m.

Break

2:45 p.m.

Breast Cancer Imaging Equipment and Why It Matters Thomas Cink, MD

3:30 p.m.

Hereditary Breast Cancer: What do I need to know? Lauryn LaPoint, MS, CGC

10:15 a.m. Break 10:30 a.m. Addressing the Needs of Patients with Metastatic Breast Cancer Lillie Shockney, RN, BS, MAS 11:30 a.m. Case Studies in Breast Cancer Survivorship: Making the “new normal” better Shelby Terstreip, MD

EXIT 399 EXIT 400

Go to sanfordhealth.org and search keyword: Edith Symposium 2016.

South Lot

Hainjes Ave

E. 54th St. N.

Main Entrance

Sanford Center 2301 East 60th Street, Sioux Falls, SD 57104

E. 52nd St. N

tsda mA ve

For more information, please email Jessica Aguilar at jessica.aguilar@sanfordhealth.org.

E. 57th St N. N. Lewis Ave

General Registration $50.00 Sanford Employees/Physicians, Students $25.00

N. Cliff Ave

Cost:

E. 60th St. N

E. Benson Rd

N. P o

Pre-registration is required:

EXIT 9

Sanford Center

011004-00275 2/16

2301 E. 60th Street North Sioux Falls, SD 57104 CME: Sanford Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Sanford Health designates this live activity for a maximum of 6.75 AMA PRA Category I Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ANCC: Sanford Health Center for Learning is an approved provider of continuing nursing education by the Washington State Nurses Association Continuing Education Approval & Recognition Program (CEARP), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. 7.0 ANCC Contact Hours Genetic Counselor CEUs: This event has been submitted to the National Society of Genetic Counselors (NSGC) for approval of Category 1 CEUs. The American Board of Genetic Counseling (ABGC) accepts CEUs approved by NSGC for purposes of recertification. Approval for the requested CEUs and Contact Hours is currently pending. AAFP: Application for CME credit has been filed with the American Academy of Family Physicians. Determination of credit is pending.