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MINNESOTA

FEBRUARY 2018

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXI, No. 11

Leveling the playing field The promise of parity in mental health care BY SUE ABDERHOLDEN, MPH “We cannot access a psychiatrist in our area—the ones that exist are not taking new patients.” “My daughter had a crisis and visited the ER three times before being able to get an appointment with a clinic.” “The intake session was scheduled quickly, but the follow-up therapy visit was a month out.” “When I am in crisis it is hard to get in quickly so I can talk to someone before things escalate.”

hese are just some of the many comments NAMI Minnesota received last fall in response to a survey assessing access to mental health care. It is no secret that accessing mental health treatment when and where you need it is difficult and sometimes nearly impossible. This is true for care at every level—outpatient, day treatment, in-home, residential, and hospitalization. Lack of access leads to poor outcomes and utilization of

Physician shortages in Minnesota Significant regional variation BY TERI FRITSMA, PHD

innesota produces roughly 500 new physicians each year, but loses an estimated 630, due primarily to retirements (and secondarily to burnout). These counts are based on the total number of Minnesota residencies, on the one hand, and physicians’ own reports on how long they plan to remain in the workforce, on the other. It is not much of a stretch to conclude that if the numbers of physician entries and exits remain constant in Minnesota, the net size of its workforce will shrink appreciably over time. Conversely, the state’s population is aging faster than ever and its health needs Physician shortages in Minnesota to page 104

Leveling the playing field to page 124

STAY FOCUSED AMONG THE DISTRACTIONS.

Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through coverys.com. M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E  A N A LY T I C S  R I S K M A N A G E M E N T  E D U C A T I O N

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FEBRUARY 2018 MINNESOTA PHYSICIAN

TH 49 SESSION FEBRUARY 2018

THE OPIOID EPIDEMIC:

Volume XXXI, Number 11

COVER FEATURES Physician shortages in Minnesota Significant regional variation

Complex problems, complex solutions

Leveling the playing field The promise of parity in mental health care

By Teri Fritsma, PhD

By Sue Abderholden, MPH

Thursday, April 26th, 2018, 1-4 pm The Gallery, Downtown Minneapolis Hilton and Towers

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Helping people live their best life

SURGERY Robotic hernia repair

Medicine is a field that changes slowly, but in the case of prescribing opioid-based pain medications, the speed of change was unprecedented. It has produced tragic outcomes. Two examples are the number of Americans now suffering from opioid-related substance abuse disorder (over 2 million) and the number of opioid-related deaths (over 50,000 annually, and growing). We are facing a complex problem, created by conflicting industry incentives and one that will demand unified stakeholder participation to solve.

A new option By Steven J. Kern, MD, FACS

Jesse Bethke Gomez, MMA Disability Hub MN

BEHAVIORAL HEALTH Sexual health

BACKGROUND AND FOCUS:

OBJECTIVES:

What physicians need to know By June La Valleur, MD, FACOG, Certified Sexual Health Counselor

We will examine how the opioid epidemic began. We will discuss the elements of mistrust, blame, and miscommunication within the health care delivery system that were responsible for the staggering levels of destruction we face today. Meeting every definition of an epidemic, we will look at how this issue reaches into all parts of society. We will lay out a strategy that can address the central problems in bringing the opioid epidemic under control.

SPECIAL FOCUS: ELECTRONIC HEALTH RECORDS Sharable and comparable nursing data

The challenges and benefits By Bonnie L. Westra, PhD, RN, FAAN, FACMI

Panelists include: Karina A. Forrest-Perkins, MHR, LADC, Chief Executive Officer, Wayside Recovery Center Todd Ginkel, DC, Director of Clinical Affairs, Physicians’ Diagnostics & Rehabilitation Clinics

Medical speech recognition technology

Improving clinical documentation By Wayne Kaniewski, MD

Beth Gomez, RN, BSN, JD, Manager, Risk Management, Coverys Larry Lee, MD, Chief Medical Officer, UCare Laura Palombi, PharmD, MPH, Assistant Professor, U of M College of Pharmacy

MINNESOTA HEALTH CARE ROUNDTABLE

Jeff Schiff, MD, MBA, Medical Director, Minnesota Health Care Programs, DHS

Sponsors include:

Regenerative Medicine Efficacy, Economics, and Evolution

Coverys

UCare

Minnesota Department of Human Services

U of M College of Pharmacy Wayside Recovery Center

Physicians’ Diagnostics & Rehabilitation Clinics

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CAPSULES

Expansion Completed at Glacial Ridge Health System Glacial Ridge Health System in Glenwood moved patients and staff into its newly expanded, nearly $21.7 million hospital facility on Dec. 12. The new facility includes 22 new hospital rooms in a new wing with a double-corridor layout. They include larger bathrooms with walk-in showers. It also includes a new nurses’ station that is now the central hub for nurses and six additional exam rooms, bringing the total clinic exam rooms to 32. Renovations also included two new rooms in the maternity suite that feature a security system for infants that can also be used for patients with dementia. “This new patient room wing is the result of over a year of planning and design work that involved many of the staff, especially nurses,” said Kirk Stensrud, CEO of Glacial Ridge Health System.

“Now that the 15-month construction process is complete, Glacial Ridge Health System has beautiful and functional rooms that will serve our community and facility for many years to come. A variety of technological advances were added to this area that supports high-quality care and enhances the patients’ experience.” The expansion comes after a long-term planning process that began six years ago when the hospital did not have enough patient rooms. The number of patients using the hospital has more than tripled over the past 10 years, and the number of physicians and advanced care providers has nearly quadrupled in that time.

Physicians Boost State’s Economy A new report from the Minnesota Medical Association (MMA) and American Medical Association (AMA) has shown that physicians add

opportunity, growth, and prosperity to the state’s economy by creating more than 171,000 jobs and generating $30.5 billion in economic activity. The report, called The Economic Impact of Physicians in Minnesota, quantified the economic boost that the 13,401 active patient care physicians provide to the state’s economy. It measures the impact using four key economic indicators—jobs; economic activity; wages and benefits; and state and local tax revenue. The $30.5 billion in economic output generated by physicians comprises 9.3 percent of the Minnesota economy. They also contribute $15.7 billion in total wages and benefits paid to workers across Minnesota and generate $1.3 billion in state and local tax revenue. The report also showed that every dollar applied to physician services in Minnesota supports an additional $2.11 in other business activity. “The positive impact of physicians extends beyond safeguarding the health and welfare of their patients,”

said David Barbe, MD, MHA, president of AMA. “The Economic Impact Study illustrates that physicians are woven into their local communities and have a vital role in fueling state economics by creating jobs, purchasing goods and services, and supporting public services through the tax revenue they generate.” Across the U.S., physicians add $2.3 trillion to the economy; support more than 12.6 million jobs; contribute $1 trillion in total wages and benefits paid to U.S. workers; and generate $92.9 billion in state and local tax revenue.

Health Systems Collaborate to Address Major Health Topics Thirteen Minnesota health care systems have joined forces to form the Minnesota Health Collaborative, which will work to rapidly test best practices and develop new approaches to implement shared standards of care. They will address major health

V PTSD is now an approved condition V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year • Intractable Pain • Post-Traumatic Stress Disorder

• Severe and persistent muscle spasms, including those characteristic of MS

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS

(651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

FEBRUARY 2018 MINNESOTA PHYSICIAN

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

CAPSULES

topics affecting the state, beginning with the opioid epidemic and mental health crisis. The collaborative was convened by the Institute for Clinical Systems Improvement and its participating health systems provide care for 80 percent of patients in Minnesota. The first call to action within the collaborative is to implement shared community standards for first opioid prescriptions related to acute and postoperative pain. Their objective is to decrease the population at risk for developing substance use disorder by assuring the smallest needed quantity of opioid medication is prescribed to manage pain. In addition, they will focus on identifying and improving access to services to improve treatment for patients with chronic pain and those at a high risk of overdose. “As a health care community, we need to attack the opioid epidemic on a number of levels,” said Penny Wheeler, MD, CEO, of Allina Health, one of the participating organizations. “What excites me most about the collaborative approach is being able to learn from others and scale solutions at a much quicker pace. This is about working across systems to prioritize patients above all else.” The collaborative is also working to improve care for patients with mental health needs in emergency departments and primary care settings. They are focusing on how to better initiate care for those who present in acute crisis in emergency departments and may face long delays in accessing care. They are also exploring initiatives in primary care settings to better address a patient’s mental health needs before a crisis occurs. Participating organizations include Allina Health, CentraCare Health, Children’s Minnesota, Essentia Health, Fairview Health Services, HealthPartners, Hennepin County Medical Center, Hutchinson Health, Mayo Clinic, North Memorial Health, Ridgeview Medical Center, UCare, and University of Minnesota Health/University of Minnesota Physicians.

St. Luke’s Offers Baby Boxes to New Parents

REQUEST FOR NOMINATION

St. Luke’s has partnered with the nonprofit Babies Need Boxes Northland to give every mom who delivers at its Birthing Center a baby box, which is a specially made cardboard box intended to be baby’s first bed. The box comes equipped with a mattress and safe bedding, as well as support items such as diapers, wipes, and breastfeeding supplies. It also includes an educational video that helps explain safe sleep practices to new parents. The boxes have been independently tested and meet the safety qualifications of a bassinet. The move was made after seeing the profound impact that baby boxes had on parents in Finland, which has one of the lowest infant mortality rates at 2.3 percent for every 1,000 births. Finland has been giving away these baby boxes for the past 75 years. Meanwhile, the U.S. rate is nearly three times Finland’s.

Publication Date: June 2018

Hospitals Contributed $4.9 Billion Toward Community Health Nonprofit hospitals and health systems in Minnesota contributed almost $4.9 billion in programs and services in 2016 to benefit community health. That’s a 7.8 percent increase from 2015, according to the Minnesota Hospital Association’s (MHA) most recent Community Benefit Report. Together, the hospitals provided $567 million in proactive services such as health screenings, health education, health fairs, immunization clinics, and other community outreach programs. In addition, they provided $580 million in uncompensated care, including charity care for patients from whom there is no expectation of payment and bad debt, where the patient could not or did not pay their bill. Charity care costs increased by just under 19 percent to $205 million in 2016, and bad debt expenses increased by just over 3 percent to $374 million.

NOMINATION CLOSING May 4, 2018

Seeking Exceptionally Designed Health Facilities in Minnesota Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2018 edition of Minnesota Physician, the region’s most widely read medical publication. Eligible facilities include any construction designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. Interiors, exteriors, expansions, renovations, and new structures are all eligible. In order to qualify for the nomination, the facility must have been designed, built, or renovated by January 1, 2018. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota, or Iowa). Color photographs are required at 300 dpi resolution (no more than eight) with a caption for each. If you would like to nominate a facility, please fill out the form below and, a brief project description (150– 250 words) or fill out the form on our website by Friday, May 4, 2018. Online form: www.mppub.com/architecture-and-design-honor-roll.html

Health Care Architecture & Design Honor Roll Nomination Form Facility name Type of facility Location Ownership organization Owner address, phone Architect/interior design firm Architect address, phone Engineer Contractor Completion date Square feet Total cost Brief description

Send to: Minnesota Physician Publishing Honor Roll 2812 East 26th Street, Minneapolis, MN 55406 Fax: 612.728.8601 Email: comments@mppub.com For more information, call 612.728.8600

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MINNESOTA PHYSICIAN FEBRUARY 2018

CAPSULES

The hospitals funded $2.5 billion in government underfunding as a result of treating Medicare and Medicaid patients and receiving government reimbursements that were less than the actual cost of care—this cost accounts for 9.6 percent of hospitals’ operating expenses. They also funded education and workforce development ($452 million) and research to support the development of better treatments and cures ($248 million).

New Strategy Proposed to Address Diagnostic Errors A new paper from the University of Minnesota Medical School proposes a new way to tackle the problem of misdiagnosis in hospitals. More than 12 million adults in the U.S. are misdiagnosed each year. The paper proposes measuring the problem of misdiagnosis in a standardized way and tracking improvements to help address some of the major challenges faced by hospitalists and medical professionals.

“One of the major challenges in improving safety and the diagnostic process is that it is very difficult to measure when a diagnostic error happens, and therefore, difficult to show how you can improve it,” said Andrew Olson, MD, lead author of the paper and assistant professor of medicine and pediatrics at the University of Minnesota Medical School. “While many national organizations and governmental agencies have called for programs and initiatives to reduce harm from diagnostic errors in the past, this paper puts forth a new paradigm for measuring safety and diagnosis.” In the paper, called “Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events,” Olson and his team suggest a new approach for measuring and reporting diagnosis errors by first redefining the measurement, which they call undesirable diagnostic events. Based on the proposal, health care delivery systems and researchers will be able to

identify relevant health conditions prone to error and measure how often undesirable diagnostic events associated with those conditions occur. The goal is to use the new criteria to measure when errors happen in the system and take steps to make improvements over time. “This framework is an important step in allowing health care systems to proactively measure diagnostic safety and share this information effectively,” said Olson. “If we design processes to make diagnosis better but can’t measure their effect, we will never know if we are making a difference.” The full paper is published in the Journal of General Internal Medicine.

YMCA at Gaviidae to Build Well-Being Center

The George Wellbeing Center will connect people with integrative health and healing practices that have been shown to reduce stress, promote healing, and improve health outcomes, including lifestyle and nutritional counseling, massage therapy, aromatherapy, meditation, yoga, and acupuncture. It will also house the Healthy Living Program for holistic well-being, which leverages existing community partnerships to link services for underserved populations. Culturally based healing practices will be integrated into the program, supported by the work of the Catalyst Initiative of The Minneapolis Foundation. The center will be the first of its kind offered at any Y location in the U.S. It will serve as a model and initial testing ground for other Ys in the metro area, as well as nationally.

The YMCA at Gaviidae in downtown Minneapolis plans to build an innovative well-being center with a $2.5 million gift from the Penny and Bill George Family Foundation.

Do you have Patients with questions about Regenerative Medicine? We utilize the most advanced technologies to heal patients in the purest and least invasive ways possible. Dr. Ron Hanson is recognized as a leader internationally. He has been performing autologous biologic injections for nearly 10 years, longer than almost every other center or physician in the nation. Dr Hanson has trained dozens of these physicians and has dedicated his whole career to regenerative medicine.

The range of therapies is extensive and treatable conditions include: • Knee arthritis

• Rotator cuff treatment

• Female Incontinence

• Thumb arthritis

• SVF treatment of arthritis

• and many others

• PRP preparation

• ACL tear treatment

We will conduct a two hour assessment covering 15 elements of regenerative care to see how well your patient will improve through the procedures we offer. If you have patients that are not responding to traditional therapies please call to find out more.

6636 Cedar Ave S Ste 170 • Richfield, MN 55423 • (612) 800-5096 • www.orthocureclinic.com

FEBRUARY 2018 MINNESOTA PHYSICIAN

Charles Lazarus Sharon Bezaly

Susie Park

The King’s Singers

Cameron Carpenter Louis Lortie

Thomas E. Kottke, MD, MSPH, has been appointed as the 2018 president of the Twin Cities Medical Society. He steps into the role previously held by Matthew Hunt, MD. Kottke serves as medical director for well-being at HealthPartners, a clinical cardiologist in HealthPartners Medical Group, an epidemiologist, and a health services researcher at the HealthPartners Institute for Education and Research. He is also a professor of medicine at the University of Minnesota. Kottke has contributed to successful health and well-being programs in Finland and the U.S. for more than 40 years. He earned his medical degree at the University of Minnesota and an MSPH in epidemiology from the School of Public Health, University of North Carolina, Chapel Hill, where he was also a Robert Wood Johnson Clinical Scholar.

Osmo Vänskä

Domenico Calcaterra, MD, PhD, chief of cardiac surgery at Hennepin County Medical Center and researcher at Minneapolis Heart Institute, has been named to the American Health Council’s board of physicians. Calcaterra has 25 years of experience in cardiovascular care and will share his extensive knowledge of adult cardiac surgery in his new role on the board. He specializes in the treatment of aortic aneurysms and aortic dissections and is focused on the introduction of innovations in cardiac surgery, such as minimally invasive valve surgery and transcatheter therapy, and maintaining the primary focus on patient safety. He believes in the practice of blood conservation—minimizing blood loss in the operating room and blood waste with the goal of reducing the practice of blood transfusions. Calcaterra earned his MD and PhD at the University of Rome in Italy.

The Steeles

MEDICUS

Our Love is Here to Stay

Charles Lazarus and The Steeles

Christopher Johnson, MD, emergency medicine physician at Methodist Hospital, has received the First a Physician Award from the Twin Cities Medical Society (TCMS). The award recognizes a physician for effective leadership, involvement in improving the public health, or policy and/or legislative advocacy resulting in a positive impact on the practice of medicine or a healthier community. Johnson recognized that opiate prescribing was leading to addiction and worked within his emergency medicine group practice and throughout the Twin Cities medical community to install changes in prescribing patterns. He then focused on working to change the way the national medical community prescribes opiates. Johnson has spoken about the issue across the U.S., including testifying in front of the Food and Drug Administration (FDA) and educating the medical profession about the history of the opiate epidemic, opiates’ effects on the brain, and the safe prescribing of opiates. Most recently, he developed the opiate prescribing recommendations for the Minnesota Department of Health. Johnson earned his medical degree at Virginia Commonwealth University School of Medicine.

with the Minnesota Orchestra Apr 6

Sarah Hicks, conductor / Charles Lazarus, trumpet / The Steeles, vocalists

Wagner, Liszt and Schumann Apr 13-14

Markus Stenz, conductor / Louis Lortie, piano

The King’s Singers GOLD Apr 15

Please note: The Minnesota Orchestra does not perform on this program.

Cameron Carpenter Plays Rachmaninoff

Apr 20-21

Klaus Mäkelä, conductor / Cameron Carpenter, organ

American Voices

Copland and Bernstein May 3-5

Osmo Vänskä, conductor / Sharon Bezaly, flute / Susie Park, violin

612-371-5656 / Orchestra Hall minnesotaorchestra.org PHOTOS Anders Krison (Bezaly). Additional credits available online.

Media partner:

MINNESOTA PHYSICIAN FEBRUARY 2018

INTERVIEW

Helping people live their best life Jesse Bethke Gomez, MMA, Disability Hub MN

Please tell us how the Disability Linkage Line became Disability Hub MN.

Disability Hub MN is a free statewide resource network that helps people with disabilities solve problems, navigate the system, and plan for their future. When it started in 2006, the focus of the Disability Linkage Line was on providing information and assistance. Through strategic growth, this important service grew to offer more tools and services to make it easier for people with disabilities to live their best life their way—a true “hub” of support. So, the launch of Disability Hub MN is a recognition of the evolution in services provided by the Disability Linkage Line. The name change in 2017 was a result of a two-year planning effort and, as part of this process, we engaged over 150 stakeholders, the majority of whom were customers we serve.

Counselors can be reached by phone, through chat, and by email via our website. The Hub team doesn’t just wait for people to call, they also follow up with people who want our continued support and help those experiencing life transitions map a productive course forward.

MCIL assists more than 2,500 people through direct contact and 22,000 through indirect contact on an annual basis. MCIL’s board members, leadership staff, and volunteers all share a deep commitment to promoting the Independent Living philosophy through responsive services that meet the disability community’s needs.

The Metropolitan Center for Independent Living (MCIL) along with Southeastern Minnesota Center for Independent Living, Inc. (SEMCIL) are operational centers for Disability Hub MN, which is contracted through the Disability Services Division of the Minnesota Department of Human Services.

Our mission is to make it easier to understand options, connect to solutions, and engage in possibilities. This is done through a network of experts, tools, and partnerships that bridge systems and focus on helping people live their best life. Our options counselors not only help people find and assess information, they are also trained to make it easier for people with disabilities, their family members, and the professionals that support them to achieve their goals. With our new name comes a stronger focus on person-centered principles; easier discovery of resources, options, and tools; and more opportunities for communication and engagement. In addition to helping people access information, our team also helps people with disabilities review and understand the scope of their benefits, understand their health insurance options, create a plan to enter the workforce or maintain employment, ensure they’re getting the most out of employment and benefits, as well as strategize ways to live more independently.

FEBRUARY 2018 MINNESOTA PHYSICIAN

Tell us about Minnesota’s Olmstead Plan and its impact on the work that you do.

It is“...” important to always recognize the dignity of each individual person.

“...”

What are some of the services that Disability Hub MN provides?

Minnesota petitioning the Federal government to provide for the formation of a Center for Independent Living to assist individuals with disabilities in the St. Paul-Minneapolis seven county metropolitan area. As a Center for Independent Living, MCIL is guided by the Code of Federal Register (366), and Minnesota State Statute, which formally recognize the Independent Living movement. MCIL is one of 403 Centers for Independent Living nationwide, and one of eight centers in Minnesota. MCIL works in cooperation with the Minnesota Statewide Independent Living Council to collectively advance independent living by and for individuals with disabilities in Minnesota.

What are some of the biggest challenges you face?

As there are changes in services and benefits at local, state, and federal levels, we are committed to continual training and upkeep of information. We believe it is important that we provide the most accurate real-time information possible to help our customers put together options and choices that are right for them according to their expectations.

In 1999, the U.S. Supreme Court held in Olmstead v. L.C. that unjustified segregation of persons with disabilities constitutes discrimination in violation of Title II of the Americans with Disabilities Act. The court held that public entities must provide community-based services to persons with disabilities when 1) such services are appropriate; 2) the affected persons do not oppose community-based treatment; and 3) community-based services can be reasonably accommodated, taking into account the resources available to the public entity and the needs of others who are receiving disability services from the entity. Minnesota’s Olmstead Plan is a broad series of key activities our state must accomplish to ensure people with disabilities are living, learning, working, and enjoying life in the most integrated setting. We are committed to implementing the Olmstead Plan by promoting independent living and community integration for people with disabilities.

In addition to your duties with Disability Hub MN, you are also the executive director of the Metropolitan Center for Independent Living. What can you tell us about this organization?

The term “disabilities” covers a wide range of conditions and severity. Please give us some idea of the number of Minnesotans affected.

MCIL is a statutory nonprofit organization based in St. Paul. It was founded in 1981 by the State of

There are approximately 612,000 people with disabilities in Minnesota, according to recent

statistics by the State of Minnesota. As Disability Hub MN, we seek to help everyone we can through the array of services we offer in Minnesota. One of the guiding principles of your work is to help people with disabilities live to the best of their abilities. Tell us more about this.

The Independent Living philosophy and person-centered models of delivery speak to the hopes and dreams of the individual. The Disability Hub MN seeks to be a lead innovator at bridging systems, technologies, and services to strengthen the self-determination, independence, and quality of life of the people we assist so that each person is able to live their best life. People with disabilities may feel marginalized and/or patronized if a physician directs comments in an exam room to an accompanying care provider rather than to the patient. What advice do you have for physicians on this topic?

It is important to always recognize the dignity of each individual person served by a physician and medical providers. We encourage the medical community to continue to grow its expertise and awareness of how to best serve the

unique needs of each person, notably from a person-centered framework. What we mean by this is that each person is in charge of their own meetings, their own choices, and their own life. Therefore asking a person for their preference is a good place to begin in acknowledging what is important to them.

When people feel well, they can lead meaningful and satisfying lives.

What are the most important things that physicians should be aware of when treating patients with disabilities?

the leadership team for Disability Hub MN and

We hope that in helping your readers become more aware of Disability Hub MN, they will refer their patients to us. We focus on the whole person, their unique needs and aspirations, and we go the distance to continually build trust through our sustained commitment. What are some of the ways that physicians could utilize Disability Hub MN to improve care for their patients with disabilities?

It is important that individuals find information and tools that can help support them in creating their best life. The Hub team will help them understand health coverage options, complete forms and applications, and resolve issues accessing or using health care. Health goes hand-in-hand with our ability to live, learn, work, and play.

Physicians and those who work in the health care sector can refer individuals with disabilities to Disability Hub MN by calling 1-866-333-2466 or going online at www.disabilityhubmn.org. Jesse Bethke Gomez, MMA, is a member of executive director of Metropolitan Center for Independent Living, a provider of comprehensive services assisting people with disabilities in the seven county Minneapolisâ&#x20AC;&#x201C;St. Paul area. He is in his 22nd successive year as a chief executive officer in the non-profit sector. He has worked in leadership roles in behavioral health care at CLUES, human services at both American Red Cross and the United Way, and served as chief strategy officer and vice president for a $66 million institution of higher learning. In 2008, he was selected as one of the 100 Influential Minnesota Health Care Leaders by Minnesota Physician Publishing.

OVER PROCESSING

OVER PRODUCTION

PATIENT MOVEMENT

WORKER MOTION

INVENTORY

8 FORMS OF WASTE IN HEALTHCARE

WAITING

CORRECTION OF DEFECTS

WASTED STAFF SKILLS

ARE YOU READY FOR CHANGE IN YOUR ORGANIZATION? EAPC incorporates LEAN process improvement and evidence-based design principles in the facility planning, design, and project delivery processes to eliminate waste in your current or potential new facilities. Chad Frost, Director of Business Excellence, LEAN Specialist | 701.775.3077 | chad.frost@eapc.net

BUSINESS EXCELLENCE

www.eapc.net MINNESOTA PHYSICIAN FEBRUARY 2018 9

3Physician shortages in Minnesota from cover are becoming more complex. All else being equal, these trends will surely increase pressure on the existing physician workforce and make it harder for some Minnesotans to access appropriate care from a physician. Importantly, the aggregate numbers gloss over significant regional variation. When it comes to health care, there isn’t just one story; there are two: an urban story and a rural one. Rural areas, as defined by the U.S. Department of Agriculture, are very sparsely-populated segments of the state in which residents do not typically commute to other small towns or urban centers for work; rather, they stay in the same region or commute to another rural area. For reference, this definition excludes small town areas, such as Pipestone, Crookston, or Thief River Falls. Large segments of Northwest and Southwest Minnesota, and some spots in Central, Northwest, and Southeast are considered rural under this definition. Rural populations always have greater challenges in accessing both primary and specialty care. To appreciate the urban/rural differences in the per capita distribution of the physician workforce, see Figure 1, which shows the number of people for every one physician (of all specialty types) across four different levels of rurality in Minnesota. While there are about 266 people for every one physician in urban areas, there are nearly eight times that many in rural areas, creating access challenges, such as longer appointment wait times and further driving distances. This article describes the physician workforce in both urban and rural areas of the state, illuminating both geographical and specialty shortages. We rely on 2017 data from the Minnesota Board of Medical Practice and the 2016 licensing workforce questionnaire administered by the Minnesota Department of Health.

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1,922 people to every 1 physician

Rural 642 to 1

Small Town Large Town Urban

480 to 1 266 to 1

Figure 1. Population-to-physician ratios in Minnesota across rural, small town, large town, and urban areas of Minnesota. Source: Minnesota Board of Medical Practice, January 2017. Physicians’ primary employment addresses were geocoded, cleaned, and categorized by the Minnesota Department of Health.

A tale of two regions As of January 2017, Minnesota had 23,032 licensed physicians across all specialty types and areas. Statewide, the most common specialty was general family medicine (3,174 physicians, or about 14 percent of the total); followed by general facility-based specialties (2,708; 12 percent); internal medicine sub-specialties (2,550; 11 percent); and general internal medicine (2,315; 10 percent). As of 2017, there were also just under 4,000 physicians who did not have a board certification. These were primarily young physicians who were licensed and in the process of completing a residency. Very few physicians, less than 2 percent of the total, practice in rural areas of the state. Indeed, covering all of rural Minnesota, there were 150 general family medicine physicians, and only one pediatrician; one ob/gyn; eight surgeons; and one psychiatrist. (These counts are based on physician reported primary employment addresses. Some physicians did not report an address, were working out of state, or provided addresses that could not be mapped. There is some chance that a small number of physicians working in rural areas could not be identified through this process.) This maldistribution has changed the practice of medicine in rural Minnesota. The Minnesota Department of Health workforce questionnaire asks physicians, “How often do you provide care that another specialist might provide if they were available/accessible?” For physicians who report that they fill gaps in care, the questionnaire then asks which types (mental health; oral health; pediatrics; ob/gyn). As shown in Figure 2, physicians working in rural areas are far more likely to report filling gaps “frequently” or “all the time” overall, particularly in mental health and pediatrics.

Further risk: retirements and burnout Rural Minnesota already faces what could arguably be dubbed a severe rural physician shortage, ranging from bad to worse depending on the specialty. The data indicate that without intervention, these shortages will only exacerbate. The median age of physicians is 48 in urban areas and 56 in rural ones (see Figure 3). And, as shown in Figure 4, one-third of rural physicians say they plan to leave the workforce within the next five years, compared to 16 percent in urban areas. Though the rural/urban differences in exit rates are due primarily to older rural physicians retiring, there is also a higher rate of burnout among rural physicians. Among all physicians who said they planned to leave the profession within five years, 9 percent reported that their reason for leaving was burnout or dissatisfaction. Among rural physicians, that share was nearly double—16 percent (not displayed in a chart).

Possible remedies to physician shortages

Supply-side policies and funding

There is no silver bullet solution to the problem of physician shortages. Existing remedies come in three general forms: 1) policies and funding aimed at growing or redistributing the supply of new physicians; 2) efforts to recruit and retain the physician workforce and improve their quality of work life; and 3) emerging models of care that shift some work from physicians to physician assistants (PAs) and nurse practitioners (NPs) to expand their reach effectively. As we will see, each of these remedies is important, but none could solve the problem alone.

The Minnesota Department of Health administers a wide variety of programs aimed at growing the physician workforce and addressing the rural/urban maldistribution. These include, but are not limited to, the Minnesota Health Care Loan Forgiveness Program, the International Medical Graduate Program, and the Primary Care Residency Expansion Grant Program. These are important programs that have lasting benefits for the organizations and communities who take advantage of them, but the numbers of clinicians who benefit are small relative to the size of the overall workforce. In 2017, these programs together were only able to provide funding to 14 physicians.

Non-rural

Rural

70%

63%

58% 43%

33% 24%

35%

20% 9%

Overall

Mental Health

11%

Oral Health

OB/GYN

Pediatrics

Figure 2. “How often do you provide care that a different specialist might provide if they were available/accessible?” (Chart shows the share of physicians who responded “frequently” or “all the time”) Source: Minnesota Department of Health Physician Workforce Questionnaire, 2016 (N=16,986)

Rural 53

Small Town Large Town

Figure 3. Median age of Minnesota physicians, by rurality.

6 to 10 years

More than 10 years

55%

56%

23%

16%

23%

22%

Urban

Large Town

Small Town

20%

At the other end of the spectrum, some hospitals and clinics are working with older and emeritus physicians to retain them for as long as possible, by offering flexible schedules or using LPNs, for example, to take on electronic d

Physician shortages in Minnesota to page 384

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64%

Recruitment and retention. Increasingly, rural and small town communities are getting innovative about addressing workforce shortages. Communities can leverage their unique strengths to “grow their own” physician workforce. In some cases, hospitals or clinics begin reaching out to local students as early as middle or high school, starting with introducing them to health careers and investing in promising students from that point all the way through medical school, with the intent of hiring them upon completion of their training. This might involve offering volunteer positions, summer internships, career laddering opportunities, mentorships, scholarships, or loan forgiveness.

Urban

5 years or less

Existing workforce solutions

44%

23% 33% Rural

Figure 4. “About how many more years do you plan to work in this profession?” Source: Minnesota Department of Health Physician Workforce Questionnaire, 2016 (N=18,189)

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3Leveling the playing field from cover

The lack of providers

In addition to workforce issues, more people are trying to access services from an inadequate pool of providers. More people are seeking care as a result of: Medicaid expansion; mental health treatment being included as an essential benefit under the Affordable Care Act (ACA); passage of MHPAEA and applying it to individual and small group policies under Lack of access the ACA; and greater awareness. The Substance Not being able to schedule a mental health Abuse and Mental Health Services Administration appointment or access treatment can cause people (SAMHSA) estimated that less than half of the Nearly every region of Minnesota to end up in the ED. This leads to higher rates people who needed treatment received it prior to is classified as a shortage area of homelessness, loss of employment, an increase 2008. Now we are treating more individuals in for mental health professionals. in school dropouts, and involvement with the need with an increase estimated at between 5 and criminal justice system. Even for a mental illness 26 percent depending on the state and age of the such as schizophrenia—the most disabling of person. So, even though more people have mental mental illnesses—early and intensive intervention health coverage they still can’t access care in a is rare. People must wait until they have been timely way or find a provider in their network. committed or hospitalized numerous times before becoming eligible for A number of recent reports document issues with access and point to intensive treatment and supports. There is no other area of health care causative factors. A NAMI national report issued in 2016 found that people where we say, “Let’s wait until you’re really sick before we treat you.” had difficulty finding providers who took new patients in their network There are many reasons for lack of access. Workforce availability is a and discovered that directories were out of date. Some providers stopped major concern. Nearly every region of Minnesota is classified as a shortage accepting insurance they had previously accepted, some professionals were area for mental health professionals. Health insurance networks are retired or deceased, and many were not making appointments for weeks or often limited and many of the plans apply for a waiver to meet network months. Time spent finding a mental health professional means delays in adequacy standards. Reimbursement rates are often lower for mental health receiving treatment. professionals, which means that fewer are entering the field and fewer mental There are critical workforce shortages. Nine of the 11 regions in health professionals accept insurance. Minnesota are designated mental health workforce shortage areas by the federal government. In 2012, the Minnesota Department of Health (MDH) reported that there were 658 psychiatrists, only 77 percent of whom were based in Minnesota. There were 3,824 actively licensed psychologists in the MDH 2016 report. One worrisome statistic is that 58 percent of psychiatrists and 58 percent of psychologists are over the age of 55, which means the workforce shortage may get worse as people retire. Even social workers, marriage and family therapists, clinical nurse specialists, and licensed professional clinical counselors are in short supply especially in rural Minnesota. care that is more intensive and costly. The mental health community had hoped that the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) would break down barriers to access and create a level playing field, but those hopes have not been realized.

Disparities in coverage

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Two national reports released by NAMI and Milliman Research in December 2017 validate the existence of mental health disparities. The report by the national NAMI office on health care coverage and access to mental health care examined implementation of aspects of MHPAEA such as quantifiable treatment limitations (out-of-pocket costs, arbitrary treatment limitations) and nonquantifiable treatment limitations (criteria for participation in networks, types of treatment). The report found that people use a much higher rate of out-of-network mental health providers than for primary care or medical specialists: 28 percent for a mental health therapist, 21 percent for a mental health prescriber versus 7 percent for other medical specialists, and 3 percent for primary care. One reason was that people with private insurance found it much more difficult to find a mental health provider who would accept their insurance. More than twice as many people reported that they found it difficult to find a psychiatric hospital that was in-network compared to hospitals for any other health care issue. The impact on people with mental illnesses and their families is that their co-payments are higher for out-of-network providers. It was also found that out-of-pocket costs were generally higher for mental health. Higher costs can lead to people receiving less or no care.

This survey by NAMI national has been conducted three times. There are those who dismiss the findings because it is a survey and not based on actual “data.” However, this year a research report was released at the same time by Milliman Research that analyzed three years of claims data from private insurance. They confirmed that individuals with mental illnesses used more out-of-network providers for mental health. They also found that reimbursement rates for mental health providers were significantly lower. In Minnesota, the out-of-network outpatient rate in 2015 was 1.3 percent for primary care, 2.4 percent for specialty care, and 10.8 percent for behavioral health care. The inpatient out-of-network rate in 2015 was 1.9 percent for medical/surgical care and 11.5 percent for behavioral health care. What is significant is that the rate jumped from 3.8 percent in 2014 for outpatient behavioral health care and 2.8 percent for inpatient care. Nationally the figures for 2015 are high as well with some states reaching 16.7 percent for inpatient care and 32.6 percent for outpatient care. While Minnesota isn’t the worst state, it isn’t the best and that has a negative impact on individuals with mental illnesses and their families.

Reimbursement issues The Milliman report also compared payment rates for the same diagnostic code for primary care, specialists, and psychiatrists and found that 46 states paid psychiatrists less than primary care physicians for the same CPT code. In Minnesota, low complexity care by primary care physicians were paid 179.6 percent of the Medicare rate while psychiatrists were paid 126.4 percent—a more than 40 percent difference. For more complex cases, the difference was even greater with primary care physicians paid 188.8 percent of the Medicare rate and psychiatrists paid 116.5 percent—more than a 60 percent difference.

Health plans, as suggested in the Milliman report, should examine their admission requirements to the network and reimbursement rates as part of the NQTL requirements. Plans use many factors to determine rates, but they are not supposed to use more stringent processes, strategies, and standards for mental health services. Increasing rates could expand the number of providers who would be willing to contract with the health plans thus expanding the number of providers in the network. Another step is to change the standards for network adequacy. Requiring that there be providers within 30 minutes or 30 miles doesn’t ensure that someone can actually see a provider within a reasonable timeframe. In Minnesota, health plans can apply for a waiver of network adequacy standards and in 2018, there were 138 waiver requests for mental health providers, and most of those were in Northern Minnesota. Plans are supposed to provide the Department of Health with the steps that will be taken to expand the number of providers in the network before a waiver can be approved. NAMI believes that plans could increase payment rates, pay for clinical trainees, and increase reimbursement for telemedicine. Last, health plans could do a better job of keeping up-to-date provider directories. They should conduct their own “secret shopper” surveys, making certain the information in their directories is correct, and even highlight mental health professionals who are taking new patients. Several health plans used to pre-pay appointments so that if a member needed to see a mental health professional right away they could be seen within a few days. Leveling the playing field to page 364

Paying psychiatrists significantly less makes it easier to understand why a high percentage of psychiatrists do not accept insurance. According to a 2013 survey published in JAMA, only 55 percent of psychiatrists accepted insurance compared to 89 percent of other medical specialists. It is hard to understand why we would pay psychiatrists so much less when we are facing such a severe shortage in Minnesota.

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Addressing inequities Many factors currently erode the hope of the MHPAEA to provide parity in mental health coverage including: workforce adequacy issues, network adequacy issues, payment inequalities, failure to cover the range of needed services, and additional cost and delay in obtaining coverage due to access issues. It is crucial to the well-being of Minnesotans that adequate mental health services be available to all who need them in a timely fashion. There are steps that can be taken to begin to address the inequities, particularly the difficulty accessing mental health care. The first step is to pass legislation to create greater transparency around and enforcement of MHPAEA. NAMI Minnesota worked with legislators to introduce a bill during the 2017 legislative session that would spell out the non-quantitative treatment limitations (NQTL) requirements in state law such as criteria and parameters for including providers in a health plan network and provider reimbursement rates. It would require plans to submit to the Departments of Health and Commerce an annual report detailing how they are complying with the NQTL requirements of the law. The two departments would ensure compliance, conduct market reviews of the plans, and track complaints. An annual report would be submitted to the Legislature essentially reporting on the implementation and enforcement of MHPAEA.

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Sharable and comparable nursing data The challenges and benefits BY BONNIE L. WESTRA, PHD, RN, FAAN, FACMI

harable and comparable data are needed to support health care system reform, which is moving from a fee-for-service model to payment for value and quality. The entire health care team across the continuum needs to work together, efficiently communicating through connected electronic systems to support coordinated care. Patient care is a “team sport” that needs to focus on patient goals and integration of data into longitudinal care. The American Recovery and Reinvestment Act of 2009 provided incentives to integrate common data elements and standard terminologies for patient demographics, medical diagnoses, procedures, medications, and laboratory data, but the use of standard nursing terminologies (SNTs) for documentation is lacking.

Data sets

Telephone Equipment Distribution (TED) Program

Nursing has a long history of developing minimum data sets and SNTs, and harmonizing these with interprofessional terminologies. Two minimum data sets were developed in the 1980s that describe the minimum, essential, comparable core data with definitions and codes that represent a specific domain (nursing in this case). The Nursing Minimum Data Set

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(NMDS) includes elements of the Hospital Discharge Data Set (patient demographics and service elements) and adds a Unique Number for the following: principle registered nurse provider, nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care. The Nursing Management Minimum Data Set (NMMDS) complements the NMDS with data elements useful to support management and administrative decisions. The NMMDS includes environmental data (i.e., type of nursing unit, method of care delivery, etc.), nursing care resources (i.e., profiles of staff and management, staffing, and staff satisfaction), and financial resources (i.e., payer source, reimbursement, etc). Seven of the SNTs are “interface terminologies” that are readily used by nurses to document care. These include one or more NMDS data elements. Some SNTs were developed for use in specific settings or type of practice, such as the Omaha System, Clinical Care Classification, and the Perioperative Nursing Data Set. Other SNTs address a single NMDS data element— the North American Nursing Diagnosis Association (now called NANDA International) nursing diagnoses, the Nursing Intervention Classification and the Nursing Outcome Classification, and ABC Codes (to bill advanced practice nursing interventions). The International Nursing Classification for Practice, which is part of the World Health Organizations’ family of international standards, includes nursing diagnoses, interventions, and outcomes. Two terminologies that include assessments, interventions, and outcomes are Logical Observation Identifiers Names and Codes (LOINC) and Systematic Nomenclature of Medicine-Clinical Terms (SNOMED CT). These two terminologies are essential to harmonize differences in SNTs and make data consistent for interprofessional communication. While all 12 data sets and terminologies are approved by the American Nurses Association (ANA) since early 2000, implementation has been slow. There are a variety of barriers to implementation and to effectively use SNTs. The most significant barrier is limited resources for integration of SNTs into electronic health records (EHRs) and no regulatory requirements for their implementation. Another barrier is the lack of knowledge about and the value of SNTs by health care leaders and practitioners. While nursing schools teach about standardized nursing data, when students don’t see nursing terminologies used in practice or know how to advocate for their use, then systems continued to be built without integration of data standards.

The issue of SNTs Software vendors seldom include SNTs because of the cost, effort required, and lack of organizations requesting them. Lack of consensus by the profession of nursing for use of a single terminology challenges software vendors to design systems that include SNTs. When EHRs are first implemented, most software vendors have a starter set to help organizations get up and running faster. A major selling point for nursing is the ability to customize the EHR the ways nurses want their data to look, which leads to inconsistent data within and across organizations. There are costs associated with some SNTs that have a licensing fee. The most significant cost, however, is the effort needed to map nursing content and maintain mappings over time.

used and what is needed to make progress. In 2015, the Office of the Slowly, there have been changes to encourage the use of SNTs. Over National Coordinator (ONC) financed an assessment about the current time, we have seen an increased awareness of the importance of SNTs state of development and usage of the 12 ANA recognized nursing data through education, publications, and health care and specialty organizations. sets and terminologies. The conclusion of the report is that there is poor Accreditation standards for nursing education programs now require implementation of standardized nursing terminologies due to the barriers faculty to teach about technology and informatics noted earlier. However, multiple initiatives are concepts such as SNTs at both the undergraduate aligning to encourage the use of SNTs in practice. and graduate levels. This is accomplished by In 2013, the University of Minnesota School integrating SNTs into existing courses or offering of Nursing launched a national initiative, the separate nursing informatics courses. Many Nursing Knowledge: Big Data Science (NKBDS) textbooks demonstrate the use of SNTs, such Patient care is a Initiative, which includes an annual think-tank/ as medical-surgical nursing textbooks that are “team sport.” conference and 10 virtual working groups to designed around nursing diagnoses (problems) and improve patient outcomes through the integration related assessments, interventions, and outcomes. of SNTs in EHRs and other information systems. Nursing informatics textbooks have been published Participants in the NKBDS Initiative represent 160 First Street SE, Suite 5, New Brighton, MN 651-383-1083-Main for years, such as Virginia Saba’s “Essentials ofof Business Communication Solutions – www.laserwave.net Providers clinicians, health care leaders, faculty, researchers, Nursing Informatics,” which is in its sixth edition. and national and international organizations such Each of the terminology developers has published as the Health Information Society, AMIA, the Centers 160 First StreetManagement SE, Suite 5, NewSystem Brighton, MN 651-383-1083-Main 160Suite Firstimplementation, Suite 5,MN New Brighton, MNMN 651-383-1083-Main books about their taxonomy, concepts,160 definitions, codes, 160 FirstStreet Street SE, Suite 5,New New Brighton, MN 651-383-1083-Main First 160 First Street SE, 160 SE, First Suite 5,Street Street 5, SE, Brighton, New SE, Brighton, Suite 5, 651-383-1083-Main New MN 651-383-1083-Main Brighton, 651-383-1083-Main Providers of Business Communication Solutions – www.laserwave.net for Medicare and Medicaid, the National Institutes of Health, the Joint Providers of Business Communication Solutions – www.laserwave.net Providers Business Communication Solutions www.laserwave.net Providers Providers ofofBusiness of Business Communication Providers Communication of Business Solutions Solutions ––www.laserwave.net – www.laserwave.net Solutions – www.laserwave.net and the value that is possible when an SNT is used. Additionally, there areCommunication Commission, and accrediting organizations and specialty societies. Together HelloMakers Technology Decision Makers Hello Technology Decision Hello Technology Decision Makers Hello Hello Technology Technology Hello Technology Decision Decision Makers Decision Makers Makers nursing and interprofessional journals that describe the development, use in We market Digital Copier/Network Printer/Scanner these stakeholders are Systems addressing the many ways in which nurse-sensitive practice, education, and research with SNTs, such as Computer, Informatics, data can be integrated with interprofessional data across the continuum of &American Wide-Format Printers to savvycare. business owners and Nursing or the Journal of the Medical Informatics Association. Workgroups are core to this initiative because they develop annual

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SPECIAL FOCUS: ELECTRONIC HEALTH RECORDS

Medical speech recognition technology Improving clinical documentation BY WAYNE KANIEWSKI, MD

usiness, banking, and other industries have used computers for decades. They appeared on desktops over time, allowing for a gradual conversion from paper to digital records. In 2009, the U.S. government decided to impose EHRs on the medical profession with the HITECH Act, giving us just five years to completely adopt this vast technology. This caused universal disruption of medical workflows, inefficiencies, great expense, high anxiety, and the potential for negative patient care outcomes in the process. Granted, we clinicians had been slow to adopt these electronic technologies, resisting change, so we had some culpability for this unsettling evolution. During this EHR transition, paper records were discontinued, replacing hand-written notes. Younger clinicians had grown up attached to keyboards, so typing was a very natural input method. But, what about the majority of clinicians who were not efficient typists? The keyboard and mouse were the only options to input data into the records. EHR companies assured us that their clinical documentation tools could create high-quality narrative notes by clicking through menus. We were

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told that these tools would 1) increase clinical documentation efficiency; 2) decrease costs, 3) improve documentation; 4) “digitize” care notes for data recording purposes, perhaps even eliminating the narrative note altogether; and 5) allow sharing of clinical data. The high cost of EHRs caused many organizations to constrain or eliminate one of their high-budget medical records costs: medical transcription.

Electronic health records To be clear up front, I wholeheartedly embrace the use of EHRs. There is no doubt that EHRs improve the recording, summarization, searching, reporting, sharing, and quality of patient documentation. In the days of paper records, the narrative note was the medical record. There was no other way to record patient care. Sure, paper problem/medication lists and SOAP notes were a step in the right direction, however, today, the narrative note comprises only one part of the medical record. Discrete data and summaries of the patient’s medical history are much better recorded in other sections of the EHR such as Problem, Medication, and Allergy lists and Past Medical History summary screens. We have learned that the narrative note remains an essential part of every patient care encounter. EHR executives convinced us that we could create narrative notes using click-menus, and that this would allow for digitizing every aspect of a patient’s condition. Through digitization, we could probably eliminate narrative notes altogether! Now for the truth: • The narrative note is the patient story. It is a distinctive description of their particular medical state. • The recording of the patient story is done uniquely by every clinician. If we are going to take responsibility for a patient’s care, we feel strongly that the record should reflect our thoughts.

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• Unlike choosing individual keywords from a menu of choices, narrative speech allows for unlimited flavor, nuance, and subtlety regarding the patient’s story, the clinician’s thought processes, and the care rendered. • The nuance and subtleties of medical jargon cannot be automated or digitized.

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• The narrative note cannot be completely digitized with today’s natural language processing (NLP) capabilities. NLP is a technology that allows for finding key words and phrases and storing them in a database for searching, analysis, and reporting. Multiple companies are attempting to digitize notes, but primarily for gathering ICD-10 diagnostic codes, either with methods that are disruptive to clinician thought processes during note creation, or after the fact by adding another step in an already arduous process. • Physicians often lament, “These click-notes don’t sound like my patient and they don’t sound like me!” Due to these limitations, upon adopting an EHR, clinicians instantly realized that EHR records lack important details about a specific patient

FEBRUARY 2018 MINNESOTA PHYSICIAN

and his/her care. They wanted to add details to an encounter note. Many clinicians were stunned to discover that EHRs fell far short of their promises after investing lots of money. They also had to suddenly become typists, much to their dismay.

is not required and the costs are lower in the long term. The negatives are that the software must be installed on every device (more IT effort), the cost is higher up front, and support costs are extra.

The power of speech recognition

Little or no installation is required and it is available through a monthly subscription. The software is available on any computer that has access to the Internet. Frequent automatic updates mean access to the latest in terminology and functionality, and support is included. The downside is that cloud-based software has fewer features than desktop products because of bandwidth limitations. In addition, the long-term costs for a cloud-based subscription are higher.

Using a keyboard to interface to an EHR is much less natural and efficient than using speech. Speech recognition technology (SRT) originated over 25 years ago for physically impaired people to be able to use computers. Today’s SRT software allows one to control virtually every function of a computer. However, clinicians use medical speech recognition technology (MSRT) primarily for its speech-to-text capabilities. Of the many features of MSRT, clinicians really only care about two: speed and accuracy. Due to the advances in processing power, and the decrease in the cost of computers, MSRT has become a practical reality and offers a number of advantages over manual typing: • It can transcribe speech at three to four times the rate of even the fastest typists. • Corrections can be made more quickly via voice, with the associated improvement in the software’s recognition capabilities. • Voice-executed macros can be used to insert repetitive text, making MSRT infinitely faster than typing. • The note is immediately transcribed, edited, signed, and available for all professionals on the health care team. • If a transcription service is available, MSRT decreases or eliminates the costs of medical transcription and eliminates turnaround time. MSRT also helps organize your thoughts on-screen. • Clinical documentation quality is improved, since manual typing tends to encourage more abbreviated notes, which decreases the recorded nuance of the patient story and the care provided. Higher quality documentation can improve patient care outcomes, increase visit reimbursements, and potentially decrease legal liabilities.

Cloud-based software

Medical speech recognition technology to page 324

STATISTICAL ANALYSIS SURVEY MANAGEMENT MANUSCRIPT SUPPORT

• Clinicians will be more efficient, allowing them to see more patients. This provides for a rapid return-on-investment. • The incidence of repetitive strain injuries from keyboarding (e.g., carpal tunnel) can be decreased. • It decreases the incidence of discord, depression, anxiety, missed dinners, divorce, and suicide in families of clinicians. All MSRT products have roughly the same capabilities: • They can augment the capabilities of your EHR, but not change your EHR workflows or functionality. • They are independent of the EHR and simply type for you.

Types of MSRT software When deciding on a vendor/product, the main distinction in today’s software offerings falls into two categories, 1) traditional desktop installed software and 2) cloud-based software.

Desktop installed software There is a one-time, up-front purchase with optional updates that are periodically offered. The system is fully operational on an independent (nonInternet connected) computer. The positives are that an Internet connection

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Contact us today to get started! Professional Data Analysts | 612-623-9110 | pdastats.com MINNESOTA PHYSICIAN FEBRUARY 2018

BEHAVIORAL HEALTH

Sexual health What physicians need to know BY JUNE LA VALLEUR, MD, FACOG, CERTIFIED SEXUAL HEALTH COUNSELOR

he World Health Organization defines sexual health as more than absence of disease, it is “a state of physical, emotional, mental, and social well-being in relation to sexuality... and requires a positive and respectful approach to sexuality...” Many studies have shown that sexual health is important to the overall quality of life and has many health benefits. It is incumbent on us as physicians to recognize that sexual health is necessary for overall health. In 2012, the Program in Human Sexuality in the Family Medicine Department at the University of Minnesota Medical School held the first of three national meetings to address the crisis of inadequate instruction on the topic of sexual health in U.S. and Canadian Medical Schools. In 2003, a U.S. study showed that many schools had only three to 10 hours of instruction on sexual health in the entire four-year curriculum and the major focus was on disease and dysfunction with little attention to healthy sexuality. Coleman et al. in the Journal of Sexual Medicine (2016) reported that certain topics involving aging, disability, and facilitation of healthy sexuality had very

poor if any coverage. They also reported that nearly 20 percent of physicians are uncomfortable when providing care to GLBTI patients. The frequency of sexual health problems is very common and physicians must be ready to deal with them. It has been shown that 43 to 60 percent of women and 31 to 75 percent of men have sexual dysfunction(s).

Reasons for not addressing sexual health In multiple surveys physicians list the following reasons for not asking about sexual health: • It takes too much time. It doesn’t really take much time to ask if a patient has any sexual difficulties however very few sexual dysfunctions can be solved in a 10 to 15 minute appointment, so you should schedule a return visit. • Reimbursement is poor. If you schedule a visit just to discuss a sexual dysfunction with a patient, be sure to document the time spent counseling and the diagnosis in order to assure reimbursement. • Physician discomfort. If you feel uncomfortable addressing the topic of sex you could get more training. It this isn’t feasible, then refer patients to someone who can help. • Fear of embarrassing the patient • Inadequate skills/lack of knowledge • Not a high priority

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• Limited therapies

Managing male dysfunction There are many therapies for the management of male sexual dysfunction, depending on the dysfunction. In the case of erectile dysfunction (ED), the first PDE5 inhibitor, sildenafil (Viagra) was approved by the FDA in 1998 and tadalafil (Cialis) and vardenafil (Levitra) soon followed in 2003. Finally, in 2013 avanafil (Stendra) was approved. mnpsychconsult.com

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Other therapies for ED such as injections into the cavernosa, urethral suppositories, penile pumps, rings, penile implants, etc., have also been available for decades. While occasional ED is very common and normal, ongoing ED needs to be evaluated medically as it can be from underlying disease or medication side effect. Psychological etiologies such as anxiety and depression should be addressed if present and it is often best to refer this patient to a sexual health counselor or therapist. A patient’s lifestyle is also important to consider. Proper diet, exercise, not smoking or using excess alcohol are all necessary to maintain good sexual health. There are other male sexual dysfunctions that are common such as premature ejaculation and loss of libido. Normal changes in sexual function can come with aging. It takes longer to achieve an erection and direct stimulation is often needed. There are fewer and milder orgasmic contractions. Ejaculation is less forceful and less semen is ejaculated. Finally, there is a longer interval after orgasm before another erection can occur. All of these things don’t mean sex should stop.

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Adjustments can be made and communication between partners is especially important. For many couples, sex can improve greatly with aging and focus more on pleasure rather than the orgasm.

Managing female dysfunction

permanent relief. Also available are vaginal moisturizers available OTC that can provide long-term relief of dryness (but should not be used as a lubricant for intercourse). Patients should be told to avoid perfumes, flavors, and warming lubricants as they can be irritating to the fragile tissues.

The North American Menopause Society recently published, “Fixes for a Stalled Sex Life.” Women are encouraged to think about sex more often (although surprisingly, women who have sexual dysfunction think about sex quite often). Couples should schedule intimate time together, Sexual health is necessary for overall health. when they will not be interrupted. It is often thought that sex should always be spontaneous, but scheduling intimate time can be quite invigorating. They advise not to focus on intercourse and orgasm but instead to focus on touch and the largest sex organ, the skin. The pleasure of the journey is often Prasterone (Intrarosa), a daily vaginal DHEA left behind in pursuit of an orgasm. People should feel comfortable speaking insert was approved by the FDA in 2016 to treat dyspareunia related to up and asking for what they like or letting their partner know if something postmenopausal vulvovaginal atrophy. Ospemifene (Osphena), a SERM, is uncomfortable. They also advise to shop for sex toys such as vibrators, sexy was approved by the FDA in 2013 to treat postmenopausal dyspareunia. It is clothing, etc. And most of all, they recommend not to stop having sex! an oral tablet and carries similar contraindications to estrogens. While it is true that in the past there have been few options for the management of female sexual dysfunctions, this is changing. In 2015, the FDA approved flibanserin (Addyi), a norepinephrinedopamine disinhibitor, for the management of hypoactive sexual desire disorder in premenopausal women. Unfortunately, it is not covered by most insurance and costs several hundred dollars a month. It cannot be used with alcohol, can cause hypotension, and prescribers must go through a certification process.

In literally hundreds of trials, estrogen in various forms such as creams, rings, intravaginal tablets, systemics (oral or transdermal) have been shown to reduce dyspareunia in estrogen deficient women.

Sexual satisfaction

Desire discrepancy Often in relationships one person wants to have sex more often than the other, which is called desire discrepancy. It is not a dysfunction per se, but can cause Sexual health to page 294

As with men, women’s sexual function also changes with aging. In a survey of 127 menopausal women, Woloski-Wrabel in the Journal of Sexual Medicine, showed that sexual satisfaction and life satisfaction are correlated and most were interested in maintaining their sexual life. Their biggest complaint was lack of variety. Nearly all felt they needed to communicate with their partner. The most common sexual dysfunction in women is loss of sexual desire, which can occur in any life phase but can increase after menopause for some women. On the other hand, some women are more satisfied in their sex life after menopause as they no longer have to worry about pregnancy and have relationships that have deepened over time.

Orgasms Some women at any age find it difficult or impossible to have an orgasm. This is almost always multi-factorial and can be caused by medications, poor technique, pain and/or various illnesses.

Menopause When women approach and enter menopause, in the absence of hormone therapy the vulva and vagina can become atrophic where the skin loses its most superficial layer and becomes dry and fragile often leading to dyspareunia. Hormone therapy, either local or systemic, can alleviate these symptoms. Local treatment can include vaginal tablets, rings, or creams, all of which have been thoroughly studied and are FDA approved for management of post-menopausal vaginal atrophy. The chosen method is a matter of personal preference or whichever therapy is covered by insurance. Similiar to local therapy, systemic therapy can be very effective for the management of vulvovaginal atrophy in addition to relieving menopausal symptoms. There are also gel or liquid lubricants (water based are best) that can be purchased OTC to relieve dyspareunia. Lubricants can be used on both female and male genitalia at the time of sexual activity, but do not provide MINNESOTA PHYSICIAN FEBRUARY 2018

MINNESOTA HEALTH CARE ROUNDTABLE

TH 48 SESSION

REGENERATIVE MEDICINE Efficacy, Economics, and Evolution It is fair to say that regenerative medicine is a lot like the Wild West. Things are happening fast, laws are sometimes hard to find, and sometimes things are made up on the fly. It is a field that is evolving so quickly that it is not widely understood, though this is quickly changing. Let’s start by defining regenerative medicine. DAVID BROWN: Rarely do two people agree on what constitutes regenerative

Minnesota Physician Publishing’s 48th Minnesota Health Care Roundtable focused on the topic of Regenerative Medicine: Efficacy, Economics, and Evolution. Seven panelists and our moderator, Minnesota Physician Publisher Mike Starnes, met on December 12, 2017, to discuss this topic.

medicine. Last October, a combined group of the National Academies of Sciences, Engineering, and Medicine got together at a workshop exploring the state and science of regenerative medicine. The workshop introduced it as technology with the potential to create living functional cells and tissues that can be used to repair or replace those that have been irreparably damaged due to specific diseases, age, trauma, genetic, or congenital defects. They then looked at four targeted therapies in the areas of cell therapies, gene therapies, tissue engineering, and non-biologic constructs such as signal models and scaffolding. The operating paradigm for this was identifying the right cell to the right target with the right function to the right patient.

certain connotations—but autologous [patient-derived] biocellular treatment using a pool of regenerative cells contained within the patient’s own body.

BLAKE JOHNSON: We are looking at not just replacement, but also rejuvenation

MERI FIRPO: In the laboratory we can use regenerative medicine to identify

of tissue, restoring tissue and organs to their original function when they have been injured or undergone degeneration. We are simply facilitating the innate ability of the body to do that, rather than using pharmacology or surgery as our primary modalities. Instead, we harness the body’s own ability to perform those functions, concentrating them, and serving as both a catalyst and an accelerator for the body’s natural processes.

drugs, for example. We use stem cells all the time as a model system to understand diseases, and we can make stem cells from people who have diseases and do comparative studies. We can model through these degenerative diseases in the laboratory and even come up with novel drug therapies, and I would still call that regenerative medicine. I think it is the approach of looking at these cellular processes in a way of trying to work within the cellular functions to heal the body.

RON HANSON: It is a little broader than that. It is all of the things that

change the issues within the body and the body’s ability to heal on its own— not just the procedural, not just the cellular aspects, but what is the diet, what is the exercise, what is the sleep, what is the mindset of the individual, and doing this from a very broad approach rather than just what is the cell, what is the area that you are putting it into? ROGER HOGUE: Regenerative medicine has a very large scope. As a physician

that performs regenerative medicine, I view myself as a mere catalyst. I look at being able to take a patient’s regenerative capabilities, whether it comes from their bone marrow, their blood, or their fat, and, as a catalyst, allowing them to be able to repair and rejuvenate and replace what is ailed. If you replete regenerative cells that have been depleted, the body has the capability to heal itself. We don’t call these stem cell treatments—because “stem cell” has

FEBRUARY 2018 MINNESOTA PHYSICIAN

The next roundtable on April 26, 2018, will address The Opioid Epidemic: Complex Problems, Complex Solutions.

Does that touch on the concept of the difference between the structure and function of regenerative medicine? DAVID BROWN: To me, regenerative medicine is enhancing or reintroducing

where a particular biologic expression has been incapacitated. It focuses on the normal mechanisms the body uses, biochemically or genetically, to carry out these functions. Whether it is by drug, whether by cell, or whether by genome editing, we simply facilitate that normal biologic expression. I would look more at the phenotypes that result from those underlying processes in terms of either healing disease or improving the status of the individual as what you referred to as the structural component. I was discussing the functional first, and those phenotypic expressions would be the structural component.

Are there conflicts between different kinds of regenerative medicine? AMY FOWLER: Some key FDA definitions differ from the way a physician

might look at it. The Food and Drug Administration defines many different types of HCT/Ps [Human Cells, Tissues, and Cellular and Tissue-Based Products] that, under the 361 PHS [Public Health Service Act], have been carved out of the regulations. When you get out of the criteria for simple tissue transfer and into regenerative medicine, the FDA views it as a potential drug product or biological product. There are four main criteria within this particular category. First, the tissue is minimally manipulated—basically, the same types of structure and function that the cell or tissue had when it was in the donor, it is still going to be in there when it is put into the recipient. Second, they are looking at homologous use. If you had a strength function or some sort of a membrane function in the donor, they want to see that type of use in the recipient. The third criterion for an HCT/P is that there are only certain additives that can be present—water, some simple preservatives, possibly some sugars. The addition of certain pharmaceuticals, etc., might be considered enough to make it more of a drug product. The fourth criterion is that the HCT/P tissue be not just for a medical effect, but that you have a biological effect or chemical effect with the drug product. FDA also has a very small section where you have HCT/P with tissue that has a biological effect, but involving a very close relationship between the donor and the recipient, probably some sort of family member. You can get away with not having that fall into the more highly regulated drug or biologic category. There is one last definition of regenerative medicine: stem cells. MERI FIRPO: Stem cells are a reservoir of functional tissues that are regenerative

in your body in normal physiological conditions and in degenerative diseases. They typically are very, very rare, in the range of one to 100,000 or one to one million cells in a tissue, and they do not usually have a function. They are there, instead, as a reservoir to make cells that do have functions. The best example is the bone marrow stem cell, which gives rise to blood. Bone marrow stem cells can proliferate and remain stem cells, or they can grow and divide and differentiate into functional cells. Some stem cells can only become one cell type, while others can become any cell type. Stem cells differ in their potential to become different cell types. Liver stem cells have a very limited capacity, whereas bone marrow stem cells have a big variety of cells that they can become. The only totally potent stem cells are the first few cell divisions after fertilization. After that, they lose their differentiation potential. These terms are not always used correctly, and I believe a lot of people confuse regenerative medicine as just working with stem cells. Stem cells are just one arm of this growing umbrella term of therapies. PAUL ORCHARD: Patients do not necessarily appreciate all those nuances. We

need to identify the various populations of cells that we are potentially using or not using. I had a family call me and say, “My son has a neurologic disease. We previously transplanted him, and now we are going outside the country to get stem cells.” They could not tell me what kind of stem cells they meant, or how they were produced. Families latch on to the stem cell moniker, but do not necessary understand the implications. MERI FIRPO: People recognize the term and they think it is good. Whatever

they hear about stem cells, they are good with it. It takes a level of scientific understanding to know what you are dealing with, but I think that is why they are told they are stem cells, because that gives them some sort of credibility with the public, which is potentially very dangerous.

DAVID R. BROWN, MD, FACE, Children’s MN Dr. Brown, a staff physician at Children’s Hospitals and Clinics of Minnesota and in practice at Pediatric Endocrinology and Metabolism, has served as a member of the clinical faculty at the University of Minnesota. He completed a fellowship in Pediatric Endocrinology and a National Institutes of Health post-doctoral research fellowship.

MERI FIRPO, PHD, Stem Cell Institute Ms. Firpo, an assistant professor in the Stem Cell Institute, Diabetes Institute, and the Department of Medicine at the University of Minnesota, focuses her research on stem cell biology and therapies for diabetes. She uses human stem cells as a model of development and disease progression, and differentiating stem cells into functional tissues for transplantation.

AMY FOWLER, RAC, JD, Pathmaker FDA Law Ms. Fowler, the founder of Pathmaker FDA Law, has over 25 years of experience in commercializing medical devices, pharmaceuticals, and combination products. Regenerative medicine law is a recent addition to the firm. While specializing in FDA law, her firm also provides marketing compliance, clinical, reimbursement, and quality systems support.

RON HANSON, MD, OrthoCure Clinic Dr. Hanson, a pioneer and innovator in the field of orthopedic regenerative medicine, is the first sports, orthopedic, and pain care-trained physician to perform platelet-rich plasma and stem cell therapies in the upper Midwest. He started the first regenerative medicine fellowship and training program for a coordinated group of physicians.

ROGER S. HOGUE, MD, MN Regenerative Medicine Dr. Hogue—founder and CEO of Hogue Clinics, along with Hogue Surgical LLC, a Minnesota medical device company— is board-certified by the American Board of Laser Surgery and a Diplomate of the American Board of Venous & Lymphatic Medicine. At Minnesota Regenerative Medicine, he performs autologous biocellular treatments.

BLAKE A. JOHNSON, MD, FACR, CDI Dr. Johnson, a board-certified neuroradiologist, is the Twin Cities medical director and director of neuroimaging at the Center for Diagnostic Imaging (CDI), serving as national section leader for interventional procedures and as national medical lead for regenerative medicine practice. He completed a fellowship at the Barrow Neurological Institute.

PAUL ORCHARD, MD, University of Minnesota Dr. Orchard is the medical director of the Inherited Metabolic and Storage Disease Program and a professor in the University of Minnesota’s Department of Pediatrics, Division of Blood and Marrow Transplantation. He is interested in the use of hematopoietic stem cell transplantation and other cell therapies for inherited metabolic diseases.

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MINNESOTA HEALTH CARE ROUNDTABLE

ROGER HOGUE: I deal with autologous or patient-derived regenerative cell

populations. I specifically do not refer to these as stem cells. I think it is too specific, and may denote false advertising. If you take that soup or bone marrow soup out of somebody and you transplant it into an area of injury, you are transplanting the array of regenerative cell populations into that area. Again, you are the catalyst—the patient does the work, not you. You are not doing anything more than what is allowed for processing, what is allowed for filtration. Sometimes it involves a combination of regenerative, rejuvenation, cosmetic, and aesthetic. We track adverse events, safety, efficacy, and outcomes, but it is still the patients healing themselves, and it does so even if I am not making a drug. I just take fat aspirate concentrate and deploy it somewhere that is injured.

leukemia who is unlikely to be cured by standard chemotherapy. We would do an allogeneic bone marrow transplant. We get marrow from a sibling or from a compatible unrelated donor, for instance, give some chemotherapy to the patient, and reinfuse marrow. It is primarily to allow them to recover their hemopoietic function, but there are some immunologic pieces that might help eradicate leukemia. Now, if we were developing a mesenchymal stromal cell population, for instance, that has the capacity to be immunologically important and we give cells like that to patients that have graft versus host disease to calm down a process that is immunologically active, then maybe that could be termed in a different light. BLAKE JOHNSON: We are using autologous cell products, biocellular products—specifically bone marrow concentrate and PRP [plateletrich plasma] harvested from whole blood—to treat musculoskeletal disorders, soft tissues, tendons, ligament injuries, joints, intravertebral discs, and more.

BLAKE JOHNSON: You are not just transferring

a single cell line in stem cells when you do these regenerative therapy treatments. You are getting a host of proteins, growth factor, cytokines, and some cells that help promote the natural healing process. All of us right now are losing millions of cells per second as we sit here. Why aren’t we falling to the ground? Because our bodies constantly replenish them. All we are doing is catalyzing the body’s ability to restore its innate capabilities, especially in areas where there is not a lot of blood flow to deliver those products in those cells. We are actually harvesting, concentrating, and putting them there. Stem cell therapy is not what we are doing. We are doing regenerative medicine.

Where have you seen the greatest success? BLAKE JOHNSON: Patient reports, discussions

Regenerative medicine is enhancing or reintroducing where a particular biologic expression has been

with practitioners around the country, and the peer-reviewed published literature have all shown restoration of the physiologic tissue function and appearance microscopically and even on imaging and also clinical function for patients.

incapacitated.

MERI FIRPO: My lab works with pluripotent stem cells, primarily taken from a little piece of skin. — David R. Brown, MD, FACE We culture out the missing column of cells, and PAUL ORCHARD: Some groups are very interested reprogram them with either genes or proteins or in specific stem cell therapies. The neural stem other factors into pluripotent stem cells. So they cell groups, for instance, are potentially growing were not stem cells, but we reprogrammed them cells that might be oligodendrocyte precursors and they are going to implant into stem cells in the laboratory. These cells are like embryonic cells, which can them in the brain, where you hope to get myelination in a patient that has give rise to any tissue, and we encourage them to become insulin-producing previously been demyelinated. So that is a much different approach because cells that can be transplanted to replace cells lost in patients who have diabetes. you have a defined population of cells that was created in a very specific We have proof of concept that this works, and we are working out all of the way under an IMD [inherited metabolic disorder], and is likely going to be issues that the FDA would like us to describe: what are the cells, what are the company-sponsored in terms of a clinical trial. So that is still regenerative contaminating cells, what do the cells do in the recipient, and whether there are medicine and using stem cells, but it is not a heterogeneous population of any other types of cells that pose risks to the patient. cells that we are talking about in some of the other contexts. AMY FOWLER: In the past, these types of therapies were very much focused

around individual physicians, and now we are starting to see more and more commercial entities coming into this space, then creating a product that is mass produced. You start getting into new types of FDA regulations, not just the practice of medicine and the physician therapy. It is really a health care product that is on the market. Now that we have those definitions in place, let’s discuss some examples of how regenerative medicine is being used today. PAUL ORCHARD: My practice includes blood stem cell transplantation for

a variety of diseases. I think of it primarily as therapy and not necessarily regenerative therapy, but there are things that we would like to use that would fit more into the latter category. For instance, we have a patient with

FEBRUARY 2018 MINNESOTA PHYSICIAN

Let’s talk about the challenges facing regenerative medicine. We can break them into three large categories: regulatory, reimbursement, and integration. New FDA guidelines came out on November 16, 2017, specifically trying to protect the public from clinics that were offering dangerous or improving versions of stem cell therapies. Let’s talk about these guidelines. ROGER HOGUE: What is most interesting to me is that an adipocyte-derived

stem cell has now been categorized as a drug, which means that the specific regenerative cell population within your body is now under the jurisdiction of the FDA. I find that to be an amazing declaration. I certainly do not agree with it, but it is an FDA guidance. It has not been ratified or passed by Congress yet.

AMY FOWLER: Two of the two new November guidances are out for a 90-day

public comment period. This is everyone’s chance to be on the record and give feedback to FDA and guide FDA in putting out something that is more appropriate. I encourage everyone to look at those. BLAKE JOHNSON: It all falls under the definition of HCT/Ps and what you do

with those harvested tissues. If you do anything beyond some limited organic water, etc., then they are going to classify it as a drug. The FDA is overseeing a physician process, something that should be under the purview of physicians. The FDA claims that it falls under its purview because it is now a drug harvested from that patient because of that manipulation, under the interpretation of that guideline of minimum manipulation.

make them sound like they have credibility, and the public has to be aware of that. That is what should be regulated in those products that are potentially dangerous. Many of these procedures are performed by non-physicians who do not even have specialized training. Is the FDA dictating the practice of medicine? AMY FOWLER: That is where the definition of the HCT/P in the regulations

is key. There are also a number of rulings from the Tissue Reference Group that essentially are guidance for companies and for practitioners. It is very specific. Sometimes we get into a gray area and we produce our best opinion. Sometimes we go to FDA to talk about it.

DAVID BROWN: When I started practice, I specialized in pediatric endocrinology. Almost FDA itself, because its mandate is strictly drug every product we had was a biologic-derived oriented. It’s the same in my field in gene editing. product, from animal-derived insulin to human If you were able to genetically manipulate a cell, growth hormone derived from ground-up the end result, that gene sequence, is considered a pituitary glands. Ninety percent of these were drug if it is inserted into a human. It is obviously basically crude cellular preparations, which, it is ridiculous, because the definitions, regulations, astounding, had FDA approval. When I went to quality control, and everything that goes into work for one of the early biotechnology companies, that is so much more complex than a drug. We we did sophisticated genome editing with are being forced to accept regulations that are Some key FDA definitions differ from isolated individual genes for insulin and growth not compatible with biologic reality and are, in hormone. We produced highly purified products, the way a physician might look at it. essence, very unscientific. Some things in my field and it took us 11 years to get the approval for that involve genome manipulation fall under the —Amy Fowler, RAC, JD growth hormone and seven for insulin. It was the Department of Agriculture’s jurisdiction, which opposite paradigm with the FDA when we had has completely different definitions than the something that was pure biologically, produced FDA. This is just an arbitrary designation as to from a single gene source and pure culture using whom you submit for approval to do the work standardized good manufacturing procedures. I or to get approval to take the work clinically. So think we have the same argument in reverse going the federal government has a major problem. It is on now. Back then, we never had a single meeting during any of our clinical inconsistent with science. trials or introduced any idea without having a representative from the FDA AMY FOWLER: I think one thing that the FDA clearly needs to do is to present. We will have to go through that same process here. distinguish physician practice of medicine from more of a commercial DAVID BROWN: This is a problem with the

practice where something is being manufactured and then sold.

AMY FOWLER: There is a lot of innovation out there, a lot of startup

BLAKE JOHNSON: Any time you can make money, the companies are going

companies that have great ideas and great products. They want to go through a regulated process, but it is not economically feasible for a lot of these companies. There has been a lot of investment in this area recently and there is definitely more to come, but there is a big jump to actually taking a drug or a biologic through the agency.

to get into it. When a physician performs a procedure on a patient with autologous tissue harvested from that same patient, there is no chance of rejection, there is no chance of transmission of another disease. If they have a disease, you are going to give it back to them, but you are not giving it to another person. Harvesting amniotic cellular products and selling them might sound pretty enticing to a 75-year-old guy with osteoarthritis in his knees, who might say, “Those young cells are going to be better than my own cells, so I want that amniotic stuff, Doc.” I’m not making this up, I have heard this from patients. It is a very easy sell to take these products and

DAVID BROWN: It costs about $100 million per year for a company to take

a pharmaceutical product for approval, and the average time is 7–8 years. In today’s dollars, it is pretty close to $1 billion per drug. That is really exceeding the capacity for what even large industry can do. But $1 billion per drug is why you have seen so few drugs come to market and why you have the

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problem with regard to efficacy. Almost none of us respond identically to any of these products. They represent the best decision for the common denominator. It is a statistical, population-based approach, whereas the kinds of therapies we are talking about here are much more individual-based. The FDA has to reeducate itself, or we need to have a new federal agency that understands the science. The FDA clearly does not.

clinic. The other one is the American Association of Orthopaedic Medicine [AAOM]. That was the original regenerative medicine group, that and Hackett Hemwall Patterson Foundation, that essentially started using about seven different agents to cause either irritation or induction of the person’s own healing responses in the body from a variety of mechanisms. Very few individuals now have the AAOM’s IROM [Interventional and Regenerative Orthopaedic Medicine] certification.

Isn’t it a significant challenge to say that the drug we bring for approval is made from one patient’s stem cells, which are different from another patient’s stem cells? How can we apply the same testing mechanisms to stem cells derived from your body to stem cells derived from my body?

Another element of insurance coverage will be FDA approval, and FDA approval isn’t going to come without randomized clinical trials. How do you conduct randomized clinical trials on your own stem cells?

DAVID BROWN: We are in an area of reactive

AMY FOWLER: Clinical trials are FDA’s favorite.

medicine. We react and apply things when a disease circumstance presents itself. What we really have to do is define ourselves biologically. What is wellness? What are the transitions into disease? Under P4, or Precision Medicine, we define each individual in terms of a multiplicity of factors. We literally have to construct data clouds on each of us to define who we are biologically, and then attempt to take those therapies and match them as closely as possible to that information. That is a very expensive thing to do.

Well-controlled, randomized clinical trials are also a favorite of CMS, because they give you such great scientific information. A lot of very cutting-edge drugs and other therapies are able to get on the market with maybe a smaller section of clinical information, under the understanding that there is some sort of phase for commitment for further study. We may be able to use that as a bargaining point in some negotiations with FDA.

Professional athletes are starting to look at regenerative medicine as the

RON HANSON: I’ll give you an example of how difficult this is. A leading physical therapist first line of therapy for injuries. recently asked what I did for Achilles tendinosis. —Blake A. Johnson, MD, FACR There are clear benefits to regenerative I asked if she meant Achilles tendinosis in the medicine procedures that are helping middle part of the tendon, at the insertional patients in many ways, but they are not part, if there were calcifications in the insertion covered by health insurance. What needs or in the midbody, adherence to the sheath, to happen for health plans to pay for hypervascularization, increased neural tissue these procedures? around the sheath, peripheral nerve entrapment, radicular symptoms, or RON HANSON: I don’t know of any individual insurance companies and impingement of the nerve root that were causing this? This is why it would HMOs that are paying for this, other than one in Louisiana. The real answer be extraordinarily difficult for us to randomize multicenter-trailed placebo is, as soon as the AMA makes a CPT [Current Procedural Terminology] code control. No one individual is exactly the same as another individual. As for it, that’s when it is going to get covered. That’s when everybody is going materials, methods, protocols, experience, and understanding of all of the to get trained and become regenerative medicine experts. I’m betting that in different facets end up being somewhat standardized, it will be easier to 2019 some AMA codes will be created. The tracking code for platelet-rich understand what works and what doesn’t work and under what circumstances. plasma was created in 2012, and the average from a tracking code to a new code is five years, so they are already taking longer than usual. What sorts of challenges are there in getting providers to refer PAUL ORCHARD: Is there an accreditation process for a group that would want to do a specific type of delivery of a specific cell population process in a specific way? What kind of guidelines can you use to ensure that one person is doing this in a reasonable way and somebody else is a fly-by-night person doing it in their garage? RON HANSON: I know of two. The International Cellular Medical Society wrote the guidelines for platelet-rich plasma, bone marrow, and adipose: how to prepare a patient, extract and process the tissue, and reintroduce it into the patient, as well as aftercare. These were kind of best practice guidelines, just a bunch of people who have been doing this for a while getting together and saying this is what you should do. I have gone around the country four or five times to testify where there was malpractice involved in a regenerative

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patients to regenerative medicine procedures? BLAKE JOHNSON: Right now, this is primarily patient driven. Some patients

are motivated to get better, and they want to use minimally invasive modalities rather than surgery as their first line for treatment. Professional athletes are starting to look at regenerative medicine as the first line of therapy for injuries, before they start going in and getting steroid injections. The second part is education. You have to educate physicians about what we are doing and make sure that they know that you are using sound medical practice. Like anything in medicine, when something is new, not everybody who has been out in practice and out of training for several years is going to know about it. They need to learn about it, just as practicing radiologists had to learn about MR [magnetic resonance] when that came out in the 1980s.

RON HANSON: I sometimes use the example of carpal tunnel syndrome.

ROGER HOGUE: There need to be standards, but understand that physicians

Eyebrows go up a little when I say that the most common pathology in carpal tunnel syndrome is adhesions at the median nerve, at or just before the carpal tunnel, and those adhesions mean that the nerve can’t move appropriately, so it is getting squished in the tissue. Three-quarters of those individuals also have significant neck neural impingement, brachial plexus neural impingement. It’s so much more complex, with so many more moving parts, to educate an average practitioner on this completely different paradigm. It is completely different than just cutting the flexor retinaculum. I’ve seen hundreds of patients after their flexor retinaculum was cut, and their adhesions are now worse than before, because they didn’t deal with the underlying cause of why that nerve was entrapped and symptomatic in the first place.

who are practicing regenerative medicine are already heavily regulated by the Minnesota Board of Medical Practice—and by malpractice attorneys. If a physician harms someone, does something that transmits disease or causes death, it’s ludicrous to think that isn’t going to be investigated or reviewed. Of course it will be. There are a lot of things that need to be done. One of the things that physicians are not doing appropriately is calling it some type of specific treatment like stem cell treatment. That needs to be abandoned because this is really just autologous biocellular treatment. What should patients ask if they are pursuing regenerative medicinebased treatment?

DAVID BROWN: I think it is cost. I worry about

DAVID BROWN: The patient has to be intimately

the real procedures when we get into things that are going to cost millions of dollars, because the problem is that this is front-loaded, and the insurance industry doesn’t like that. With Parkinson’s disease, there may eventually be some technology to induce dopaminergic neurons and have a legitimate effect in regeneration, and it is going to cost a million and a half dollars. The patient has the procedure done in September, Blue Cross will pay for it, and then they are going to be on Medica in January. Medica is the beneficiary of that and that model is known. Blue Cross and any of the companies are going to say we’re not going to front-load on this. We have to have a model that disseminates these costs.

involved in the process and in the conversation and dialogue. It’s not so much what they should ask, it’s how open they are to understanding and asking the right questions regarding outcomes and implications and being an integral part of the decision to proceed with these procedures and any followup. It’s much more of a science and practice that requires active patient engagement. The more educated and more sophisticated the patient is, the better the outcomes.

A lot of patients are confused when they hear “stem cell.”

What are the biggest misperceptions about regenerative medicine? MERI FIRPO: My perspective is that of the potential patient. A lot of patients

are confused when they hear “stem cell.” One woman called me and said that there is a doctor in the Ukraine who will “cure my son’s dyslexia by injecting stem cells into his brain”—for $45,000. When you are desperate or thinking about a loved one, you want to do whatever you can, and some people are vulnerable to being ripped off. It would be helpful to understand what’s real and what is snake oil. There should be some sort of independent oversight or confirmation. Is this something that I’m not providing to my child that could cure him, or is this something that is potentially incredibly harmful? If some kind of cells from somewhere, somebody, some animal, is going to be injected into my son’s brain, there has to be a way for people to tell the difference between what is potentially helpful, whether the data they see on the website is real, versus something that is completely fabricated, or cells taken from someone who potentially has a communicable disease.

—Meri Firpo, PhD

BLAKE JOHNSON: A lot of these procedures are

now done by non-physicians. Do those boards regulate and oversee the practitioners in their field as much as the medical doctors are overseen? If you’re operating under the oversight of a board that will come down hard on anyone who gets out of line and practices any kind of non-safe medical practice, you have a layer of protection. The second thing is to talk to the physician about their experience with what they’re doing. If somebody is just doing this because they can bill for it and they have zero experience in their procedures, you can find that out. What is your experience? Do you have any patient testimonials? Registries are going to be a very important part of that going forward. Patients really do need to educate themselves on this, because it’s not going through the approval of an insurance company, so they’ve lost that layer of vetting. Doctors are not getting taught regenerative medicine in medical school. How does someone go about learning to become a practitioner of regenerative medicine? PAUL ORCHARD: From the patient’s standpoint, it’s hard to ask what the

rationale is, to try to get a better sense of the purpose of using a specific type

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of cell for a specific indication. Down the road, there is going to be some sort of threshold that people would have to reach in terms of becoming certified or having some sort of shingle to hang out and say, “Yes, I’ve done enough of these that I’ve met the accreditation standards.” Say that the guy down the street who is mixing the cells up in his bathtub hasn’t done this. I don’t know exactly how those things are going to end up getting vetted and regulated, but I can well imagine that those things are going to be important to separate out the wheat from the chaff, especially if you get to a point where insurance starts paying for these things and you just don’t know who is going to start doing it and in what circumstances. RON HANSON: I started the first fellowship in

the country that was all regenerative medicine. For that group, I would only train somebody who had a musculoskeletal background already, and they had to be trained in either ultrasound or fluoroscopic guidance before they came into the fellowship, because I was going to train them in at least two more forms of guidance, and there is no way to do three right from the get-go. The reservoir of information that you have to draw from to do this effectively is tremendous. You need to erase everything that you know, because what we are doing in regenerative medicine is completely different. First, your mindset, is it already in a regenerative medicine standpoint, or can we get it there? I have a bias towards DOs [doctors of osteopathic medicine], who must be trained in prolotherapy. That will probably end up being the reservoir from which most regenerative medicine doctors are going to be cut.

the neutrophil or the monocyte percentage and amount, and so whenever you put white blood cells into PRP, it becomes more inflammatory. The monocytes sometimes differentiate into macrophages, and there is some paracrine immune-mediated potential in an inflamed area. So there is a benefit in being able to optimize either the amount of platelet-rich plasma, the percentage above baseline, the different cell populations, and there is technology out there to be able to do that. Not everybody is going to be able to take a hemocytometer and assess exactly what they have when they’re injecting it. Sometimes I see people just draw a tube of blood, spin it, and then the plasma, which is just plasma, they will say it’s PRP, and then they’ll inject it into the patient and it’s completely bogus. There are going to be folks that will cut corners and maybe sell near beer. It’s not as effective. How do we know if a regenerative medicine procedure is working? How can we tell whether it is creating a therapeutic benefit? ROGER HOGUE: If you’re talking about platelet-

rich plasma, the results will be apparent within a few weeks. If you’re talking about a biocellular treatment using autologous bone marrow or fat There are a number of different types that contains mesenchymal stem cells or a host of regenerative medicine. of regenerative cell populations that have the —Paul Orchard, MD ability to help regenerate and rejuvenate damaged tissue, it’s different. We know that the gestational period for humans is about nine months, and, surprisingly, it does take several months for patients to usually see benefit. I believe the benefits will last 1–2 years out. When someone PAUL ORCHARD: Registries for patients treated does an autologous or a microfollicular grafting, for rare disease tend to be company-sponsored, because the company has a the hair transplant specialists usually evaluate at two years whether this graft stake in a product. If orthopedics or radiology or some governing body, or is successful. There is a lot of regenerative medicine being done out there, and maybe the insurance company, is sufficiently interested in developing this, I think that hair grafts is a good example. If they have to wait two years to see that would mean that we really need this data and we’re going to fund it. the full effect of the graft, it isn’t unreasonable that if we are taking fat or bone It’s much better if you have some sort of mandated system where somebody marrow, then months to a year is not unreasonable. collects the data on every patient at various time points. If it’s left open to people to self-report, then you introduce bias. It’s probably better than no information, but it’s tougher to know what to deal with. What is a therapeutic dose of stem cells? How do we measure how much we give and how often do we give it? PAUL ORCHARD: We can look at all the various cell populations that we

administer to patients and know exactly what the doses are of each different cell population, so that’s very useful information in the big picture. There’s no reason that couldn’t happen here, too. If we think that a lot of nuclear cell population with platelet-rich plasma is important, are there specific cells in there that are more important than others? Is there some mix of cells that ends up being optimal? ROGER HOGUE: There are a lot of different FDA-cleared closed loop systems

for isolating platelet-rich plasma from whole blood. Some of them use lasers to sort cells and other ones have different systems. You can control

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BLAKE JOHNSON: That’s not to say that nothing happens for a year, but

it’s not like putting an anti-inflammatory corticosteroid in, where in a day or two the effect will be perceived by the patient, because you’re rebuilding and repairing. If you sprain an ankle, you don’t expect to be better by this weekend. It takes weeks for that to happen. So we definitely tell patients that for the first eight weeks or so, you may not experience any improvement at all, and then after that it’s a gradual healing and regenerative process, and we track it out a year and even beyond. But that doesn’t mean they’re not going to have any perceived improvement for a full year. ROGER HOGUE: Usually when I do either a bone marrow or fat-derived

autologous treatment for osteoarthritis of the knee or hip or ankle or hand, I will, one month or two months post-procedure, do platelet-rich plasma, which is known to help the regenerative cell population by establishing differentiation, division, angiogenesis, and growth factors so there is a continuum of promotion of wound repair.

Should the Federal Trade Commission regulate what can be called stem cell treatments? RON HANSON: Medical boards and physician societies are the best way to

BLAKE JOHNSON: It’s important to put it in context historically. You heard

earlier how human growth hormone got started by putting cadaver pituitary tissue in a little mortar and pestle environment and making a slurry, then injecting it in kids. Only a minority of orthopedic surgical procedures performed today went through any kind of trial at all. Aspirin today would not make it through the FDA’s approval process. You would not be able to buy an aspirin if it was brought today for a trial, because of the side effects. We are holding this to a standard that most of medicine has never been held to. It’s great to have controlled blind trials, getting people to be the controls who don’t get the actual cellular biologics and then going through the same process as those that did, but those are really tough trials to do.

regulate, and the spectrum of malpractice lawsuits is the best way for physicians to be monitored. It’s more or less what the Practice of Medicine Act wanted, which was for us to be as independent as possible, to be able to provide the care needed at that moment for that person the way it needed to be done. The more that these autonomous agencies get involved in different things, the more difficult it’s going to be for any of us to provide the care that a person sitting right in front of us needs. I was at the clinic that the FDA took on in 2007, and that clinic was using a single-cell source of mesenchymal stromal cells for treatment of arthritis, tendons, and ligaments. The FTC was a secondary, behind the FDA, to get involved in what was actually said on the website, what was being said to people calling in to the clinic. They would have fake patients call in and ask, “What are they telling you?” The more arms of the octopus that get involved in this, the more difficult it’s going to be. I believe that trusting the individuals who have been trained to do this, allowing them to do what they were As a physician…I view myself as a trained to do for the best benefit of the patient, is the way to go. mere catalyst.

Life saving and life enhancing advances related to regenerative medicine stand to drastically change the playing field for several areas of health care. What challenges does this pose? RON HANSON: A paradigm shift is coming.

One study looked at 600 patients with knee OA [osteoarthritis] and were candidates for total knee arthroplasty. Two years after a regenerative medicine procedure, 94 percent of them still had not gone on to total knee. We surmised that Medicare alone would save about $10 billion —Roger S. Hogue, MD per year, just on total knee arthroplasty. Before In terms of the professional liability issues you pull out your horns and start to cheer, ask that regenerative medicine poses, is this whose pockets lost out on that $10 billion? That’s limiting quicker physician buy-in? partly what we’re up against. We’re also partly up PAUL ORCHARD: Anybody can sue anybody against the dogma that tends to stay adhered in for pretty much anything, so a lot of it ends up medicine much longer than changes happen. We being what was said to the patient prior to the have a fantastic opportunity to save time, energy, and resources. These are big procedure. We have patients sign extensive consent forms. Some of these changes, not just in dollars, but also in how all of us look at something. Going are 20 pages long and nobody reads them, which defeats the purpose, but from a reactive to a proactive medical model is going to be transformative. understanding the relative risks and benefits of any procedure still ends up That’s a different paradigm than what allopathic medicine was born on. being key. We have a fair amount of data for a lot of the things that we’ve Likewise, it’s a much more integrated care model. The more articulate, been treating for a long period of time. We can say that the peritransplant careful, and understanding that we can be going forward with these changes, mortality is 10–15 percent in this circumstance, and the chance that your the more successful we will be. leukemia will come back is 20 percent. There is a lot of variation in terms of BLAKE JOHNSON: One of the main reasons we do pain management is to how patients present and the range of regenerative interventions we’re talking reduce the amount of analgesics they take. We want to do anything we can about here. If somebody injures their Achilles tendon, there are 50 different do to decrease their level of pain and decrease the net dose of medications, ways to assess where they are. Can we unify that enough to ask a specific because the cycle is really vicious with opioids and is now being recognized as question in a longitudinal study on specific outcomes? Those studies should a crisis—denied by some, but more and more practitioners are realizing that be feasible, but they probably aren’t going to be easy, and they will be very it really is a crisis. We are trying to not just modulate the pain but the source expensive. I haven’t heard that there is somebody willing to put together a of the pain by canalizing the body’s natural healing process. As you do so, huge study like that.

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those nociceptors that are firing that pain message to the brain start to settle down so that patients can start weaning off the medications. ROGER HOGUE: It’s a little humbling for a physician used to healing

somebody to now be the mere catalyst and having patients do it themselves. The thing that happens is that patients might be on multiple anti-inflammatories, sometimes steroids, sometimes taking one drug to treat the side effect of another drug. When I tell them I want them to get off anti-inflammatories two weeks before their procedure, they ask if they will be all right. When they come back a month later, they say that they never knew what it was like when they were overusing, and that they are now listening to their bodies. Our culture is so used to a knee-jerk response: I’ve got a symptom, so I’ve got to take something. That’s partly what led to the opioid crisis. People don’t know what it’s like to just be healthy and to have general feedback from their bodies. In our haste to make something go away quickly, sometimes it doesn’t work well. It’s hard to argue against regenerative medicine when you see the actual dynamic effects of how it can change lives.

while others are using more exogenous, where it comes from another patient, comes from an animal, or gets doctored in some way. That’s the big distinction. BLAKE JOHNSON: Regenerative medicine encompasses a big arena, a big field, and so what one person does in their practice doesn’t encompass the entire field. There is a lot of exciting research being done in neurologic disease, cardiac disease, and endocrine disease. The term does not refer to just one thing. There are a number of different ways of employing that and you really have to know, if you’re a patient looking at a practice and considering it, what materials they’re using, how they’re harvesting it, how they’re delivering it or employing it. There will be a huge amount of variability in terms of what there is on the landscape. RON HANSON: One of my favorite physical

therapists had a plaque on his wall that said, “efficacy.” From a medical standpoint it is the ability to induce meaningful change in another individual. Long ago, I used to think that my injection was the most important piece of the equation. Over time I’ve found that regenerative medicine is far more than this. It is What is the most important thing to “Feeling better” does not equal all the way from what somebody eats to many understand about regenerative medicine? healing. other practices, including their sleep and their PAUL ORCHARD: There are a number of mindset. I like to tell patients that there are 100 —Ron Hanson, MD different types of regenerative medicine. Some things I could do to make them feel better, but are autologous cells, some are allogeneic cells, “feeling better” does not equal healing. Healing and some are genetically derived cells. If we’re is a very personalized, individualized process for primarily talking about cell products, what the person that is sitting right in front of you. exactly are we talking about using, and for what It’s going to be difficult for that to gain steam indication? What works for one particular type because of the way that we are traditionally of injury may not work for another type of injury, or one location may be taught, in kind of a “lowest common denominator,” “this works for different from another. We’re talking about it in generic terms here, but I everybody” approach, but as we think about healing and efficacy and we think being specific about what we’re doing for what indication ends up go forward to see and work with our patients, it will be obvious what the being fundamentally important in figuring out the best paths forward for best choices are going forward. regenerative medicine. DAVID BROWN: Regenerative medicine has the potential to create living ROGER HOGUE: Endogenous regenerative medicine, which deals with functional cells and tissues that can be used to repair or replace those that autologous, patient-derived biocellular treatments, is under the purview of have been damaged irreparably due to a whole spectrum of causalities. the practitioners and state medical boards, and outside the purview of the It encompasses the vast totality of medicine. They have just begun to FDA, because this is taking parts of the patient at the point of care, same scratch the surface with the things that they’re doing, and it’s only going day surgery, and putting it back in to help them. Exogenous regenerative to be better, it’s only going to be validated and become more credible medicine, which means that you are doing gene splicing, gene editing, and universal. growing an organ somewhere, or you’re taking foreign stuff and you’re putting it back in, is a very, very big difference. On this panel, some of us are doing endogenous regenerative medicine using autologous treatments,

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3Sexual health from page 19

women/men your age start to have sexual difficulties. Has this happened to you?” “Do you have any sexual health concerns? Tell me about them.”

significant problems. The solution is compromise. In the patient with lower desire, they need to learn how to say no or to schedule another time. For the couple, boundaries need to be set. Can there be affection without sex? Can a couple compromise by doing something other than intercourse? Can one partner determine sexual frequency one week and the other partner the next week?

While some dysfunctions are easy to treat and can be dealt with by a primary physician, some are often complex. Acknowledging you don’t have the skills/training to manage a problem that is important to your patient and knowing when to refer is important. Sex counselors work hand-in-hand with the referring physician to assure optimal patient care. What happens after you send a patient to a sexual counselor or therapist? The patient will be encouraged to have an intimate connection to their body. We encourage communication with their partner including initiating and scheduling sex. We usually have homework for the patient including a process called sensate focus, a series of specific sexual exercises for couples or individuals developed by Masters and Johnson to increase personal and interpersonal awareness of your own and other’s needs. Participants are encouraged to focus on their five senses rather than orgasm as the sole goal of sex. We may promote fantasy, erotica, and sex toys. Patients often need to be reassured that sex counselors do not watch them have sex or participate with them in sexual encounters (many old ideas about sex therapy still persist).

The effect of cancer While the scope of this article does not allow the space to discuss all medical issues that affect sexual health, one of the most significant medical/surgical issues to affect sexual health is the diagnosis and treatment of several cancers, particularly but not limited to breast or genital. Reports in the general literature show that women who have been diagnosed with breast cancer have sexual impairment years after treatment in the range of 70 to 77 percent. Clinicians who care for these women should begin to routinely discuss sexual health issues with them as part of their routine post-survivorship care and counseling and refer patients with sexual issues to psychologists and gynecologists who specialize in sexual health.

Conclusion Sexual health is a right and sexual dysfunction is common! Being an approachable physician is a critical skill and if you don’t ask, the odds are they won’t bring it up and opportunities for improving their lives can be lost. You can do this by asking simple questions and normalizing your patients’ experiences. “Are you in a sexual relationship? If so, do you or your partner have any problems?” “Many

If you are interested in becoming AASECT Certified, I encourage you to go to AASECT.org where you will find information to begin the process. June La Valleur, MD, FACOG, is a consulting physician/sexual health counselor at Minnesota Personalized Medicine. She is the only physician in the five-state area who is also certified by the American Association of Sexuality Educators, Counselors and Therapists as a sexual health counselor.

Maureen Nelson Plays The Lark Ascending Friday, April 6, 8:00pm Saturday, April 7, 8:00pm Ordway Concert Hall, Saint Paul Sunday, April 8, 3:00pm St. Andrew’s Lutheran Church, Mahtomedi Thursday, April 12, 6:00pm – HAPPY HOUR CONCERT Ordway Concert Hall, Saint Paul Friday, April 13, 11:00am Wooddale Church, Eden Prairie Friday, April 13, 8:00pm Wayzata Community Church, Wayzata Saturday, April 14, 8:00pm Saint Paul’s United Church of Christ, Saint Paul Sunday, April 15, 2:00pm Benson Great Hall, Arden Hills The Lark

SPCO violinist Maureen Nelson takes center stage for Ralph Vaughan Williams’ iconic Ascending tone poem for violin and orchestra.

MINNESOTA PHYSICIAN FEBRUARY 2018

SURGERY

Robotic hernia repair A new option BY STEVEN J. KERN, MD, FACS

inter in Minnesota gives us many enjoyable outdoor activities, but shoveling snow tends not to be one of them. While heart attacks often get the headlines, you might be surprised at the number of inguinal hernias we see as a result of twisting and torqueing the body in pursuit of a clear driveway. Hernias are a common medical complaint with inguinal hernias representing 73 percent of all cases, according to the National Institutes of Health. More than one in four adult men will present with an inguinal hernia in his lifetime. In the past, open and laparoscopic operations have been the methods of choice for repairing hernias—each effective and appropriate in certain cases. I was a bit of a Luddite with the use of the surgical robot for ventral hernias and began using this technique with hesitation, but experience shows that patients sometimes feel less post-surgical pain, require fewer pain medications, and are less likely to experience infections and longer recoveries with the robotic techniques. After more than 1,000 robotic hernia repairs over the last four years, our surgeons believe many patients

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Figure 1. Dr. Kern using robotic surgery to repair a hernia. Source: Specialists in General Surgery (printed with permission)

with hernias should consider robotic surgery. In fact, the improved outcomes have convinced me to use the surgical robot in all but a few specific cases. In the facilities where my partners and I operate, we use Intuitive’s da Vinci Surgical System (see Figure 1), which was introduced in 1998 and currently is the leading robotic surgery system. There are other similar instruments nearly ready for commercial release including Medtronic’s robotic platform due to be released first in India in about a year. Robotic systems consist of the surgeon’s console, a patient side cart, and a computer connecting the two to translate movements of the surgeon to movements of the instruments and camera inside the patient. Surgeons provide direct input for every surgical maneuver. We truly are living in Star Trek times, but using fabulous new technology is not a good reason to adopt a technique. Here are some of the considerations we keep in mind when discerning whether we should use robotics.

Advantages for patients While the experiences of each patient are unique, robotic surgery provides many patient advantages when compared to open surgery or laparoscopic surgery. • Shorter length of stay. According to the Americas Hernia Society Quality Collaborative, the length of stay for robotic ventral hernia repairs averages 2.1 days vs. 5.1 days for open surgical cases. Many robotic hernia repairs are performed with same-day surgeries. As a result, patients can get back to work sooner—lessening their out-of-work costs. • Fewer complications. Due to the smaller incisions, patients are less likely to experience infections or significant blood loss with robotic hernia repair. • Less pain medication. In our experience, patients undergoing robotic hernia repair require fewer narcotic pain medications. This is particularly pertinent in light of the opioid epidemic.

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• Smaller, less visible scars. Like traditional laparoscopic surgery, robotic surgery uses small incisions. Open surgery may require much larger abdominal incisions leaving the patient more vulnerable to infection and blood loss. Patients with multiple hernias can have all of them fixed at the same time through the same small incisions.

Advantages for surgeons Although these are benefits of robotic surgery for surgeons, each also contributes to better patient outcomes.

Cost issues The cost of a robot and subsequent training can be significant, but while initial resource costs are high, the downstream benefits often balance the costs as noted earlier—length of stay, improved outcomes, and quicker return to work and daily activities. Instruments can be re-used approximately 10 times before replacement. Patients often require less medication for pain control, treatment of infections, and blood loss.

You might be surprised at the number of inguinal hernias we see as a result of twisting and torqueing the body in pursuit of a clear driveway.

• Enhanced visualization. For surgeons, the 3D visualization of a robot offers a better view of the surgical site than they get with a laparoscopic procedure. This is especially important in tight spaces or where there is scar tissue or tortuous blood vessels. If the peritoneum tears, the surgeon using a robotic device can repair the tear more easily than is possible with laparoscopy. Enhanced visualization also makes it easier to work with obese patients.

• Improved dexterity and range of motion. Surgeons using the robot have the ability to “feel” the motion and anatomy. Haptic or kinesthetic communication is part of the da Vinci Surgical System Xi, enabling surgeons to experience the sense of touch by applying forces, vibrations, or motions enhancing the surgeon’s performance. The robotic instruments have more articulation than a human wrist, making the robot especially useful when sewing mesh in place instead of tacking it down. This is a huge benefit for the patient, as it creates a sturdier repair, less pain, and less cost. Tacking devices often cost $500 or more apiece.

Advice for physicians

For primary care physicians thinking of referring patients, look for surgeons who have performed a large number of robotic operations but are trained in all three methods (open, laparoscopic, and robotic) in order to choose which is best for the patient. For surgeons considering robotic surgery for hernia repair, spend time with surgeons who are performing these procedures. Watch the flow of activities and how the team is organized. Robotic surgery for hernia repair rapidly is becoming a preferred surgical option. Many patients with hernias are good candidates for robotic repair. Steven J. Kern, MD, FACS, is a surgeon with Specialists in General Surgery based in Maple Grove. He is the medical director at the North Memorial Ambulatory Surgery Center in Maple Grove and the Maple Grove Hospital Chief of Staff. He sees patients in Maple Grove and at North Memorial Health Clinic–St. Anthony.

• Greater surgical precision. Robots improve patient safety by eliminating surgeons’ tremors. • Improved access. Improved access is especially critical during a procedure like a hiatal hernia repair where surgeons often have to torque their body to get to the affected areas. Abdominal wall reconstruction also benefits from improved access, enabling the surgeon to use component separation procedures to reconstruct the natural abdominal wall anatomy. Robotics often enable surgeons to close a ventral hernia defect primarily and sew a mesh patch in posteriorly—a procedure that mimics the benefits of an open procedure and is nearly impossible to do well with the laparoscope.

Helping Beautiful Things Emerge From Hard Places

• Decreased surgeon fatigue. Because robotic surgery permits the surgeon to remain seated at a console during the procedure instead of standing at the bedside, the ergonomics are better, and fatigue is lessened. Back and neck issues are common among surgeons over long periods of time—something the improved ergonomics with robotics may alleviate. Some surgeons believe this may extend their careers— an added benefit to the U.S. population as even conservative estimates suggest a shortage of more than 25,000 surgeons in the next few years.

A learning curve Although performing hernia surgery using a robotic surgical device presents many advantages for a surgeon, there also is a learning curve. Port placement and instrument exchange require practice to become smooth and proficient. While always critical, communication during robot utilization is even more so as the surgeon is working a few steps away from the operating table.

TWO CENTERS.

The Center for Alcohol and Drug Recovery

ONE PURPOSE.

The Vanguard Center for Gambling Recovery

www.ProjectTurnabout.org MINNESOTA PHYSICIAN FEBRUARY 2018

3Medical speech recognition technology from page 17

Current MSRT Products

What is a Cloud-resident application?

These are the current MSRT products available. All require a computer and will not work on smart phones.

This is an app that is installed and runs on an Internet-connected computer (server) distant from the user, rather than on your local computer. Clouds are not involved. • Similar to the speech recognition available via Siri or Google • Little or no installation is required • Paid by monthly subscription rather than a large up-front cost

Dragon Medical Practice Edition (Nuance Communications): This installs on a local machine and is Windows compatible only. It is the gold standard and has been available for over 20 years. The newest version, Dragon Medical Practice Edition-4 (version 15), was just released on Jan. 22, 2018. Older versions What about the majority (v.11 or older) should be replaced. Discounted of clinicians who were updates from versions 11 and 12.5 are available.

not efficient typists?

• It’s more expensive over time • Much less work for your IT people to install and maintain • Automatic periodic, more-frequent updates and improvements • Patient information is encrypted during all phases of interaction with the cloud server • The software company has free use of your acoustic and language data to further improve its products. (Why do you think that Siri and Google are free?) • You must have a fast and reliable Internet connection at all times. The Internet will go down—sometimes catastrophically and for long periods of time.

Creating rural healthcare leaders Rural Healthcare MBA As a physician working in rural healthcare, complement your role and perfect your leadership skills with the courses offered in our MBA in Rural Healthcare. The curriculum focuses on health care economics, finance, organizational behavior and development and provides the tools to be a successful leader in the rural medical field.

• Online, accelerated eight-week terms • Complete in 2 years

Dragon Medical One (Nuance Communications): This is cloud-based and Windows compatible only. A tiny resident app must be installed on each device, or can be embedded in some EHRs. The software has been available for two years. A two or three year contract is required. Fluency Direct (M*Modal): This is cloud-based and Windows compatible only. The product has been out for about a year, but the company is experienced with previous MSRT software. A multi-year contract is required. SayIt (nVoq): This is cloud-based and compatible with both Windows and the MAC OS. There is no local machine installation; the app is accessed via an Internet browser from any computer. The company has been working with cloud-based MSRT since 2010. SayIt is less expensive than other cloud products and no contract is required other than a month-to-month subscription. All MSRT products should be accompanied by professional clinically focused training. Using MSRT is not like buying TurboTax off the shelf. We have found that 95 percent of experienced MSRT users are just scratching the surface of the software’s capabilities. This software cannot be effectively taught in a classroom setting since every clinician has different computer comfort levels, and documents in their own way. An additional investment in personalized/individualized training will reap rapid rewards in efficiency and satisfaction.

Conclusion With today’s versions of MSRT, you can dictate quite quickly, but you must speak clearly and enunciate. Speaking in complete sentences is also important, as the software not only looks at individual words, but also looks at the context of each sentence. MSRT cannot understand dictation at warp speed like a human transcriptionist may be able to, however the advances in speed and accuracy are quite amazing when compared to products of just 10 years ago. With continual improvements in speed and accuracy, speech recognition technology will become the universal method of communication with computers, making our keyboards curious relics for future generations to scoff at. Whichever product serves your needs the best, there is one fact that applies to all medical professionals: medical speech recognition technology software can help you create better documentation, faster, easier, and with less expense. Wayne Kaniewski, MD, was a family physician for 30 years in a wide variety of settings, including the U.S. Navy, rural solo, group, and large

go.css.edu/rural

corporate practice environments. He has always been a proponent of clinical documentation improvement. He founded Twin Cities EMR Consulting in 2009 to assist clinicians in the transition to electronic medical records.

FEBRUARY 2018 MINNESOTA PHYSICIAN

Family Medicine & Emergency Medicine Physicians • • • • •

Sioux Falls VA

Great Opportunities

HEALTH CARE SYSTEM

Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice

Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package.

The VAHCS is currently recruiting for the following positions:

Cardiologist

Orthopedic Surgeon

Endocrinologist

PACT/ Woman Health Director Urologist (part-time)

Emergency Medicine Psychiatrist Hospitalist

Pulmonologist ENT (part-time)

Psychologist

apply online at www.USAJOBS.gov

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

(605) 333-6852 ·

www.siouxfalls.va.gov

www.acmc.com

The perfect match of career and lifestyle. ACMC Health is a multispecialty health network in west central and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • Dermatology • ENT • Family Medicine • Gastroenterology

• General Surgery • Geriatrician • Hospitalist • Internal Medicine

• Neurology • OB/GYN • Oncology • Ophthalmology

• Orthopedic Surgery • Pediatrics • Psychiatry • Psychology

• Pulmonary/ Critical Care • Rheumatology • Urgent Care • Urology

Loan repayment assistance available.

FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | shanaz@acmc.com | (320) 231-6353 ACMC Health is a part of Carris Health, a new entity created to deliver health care to West Central and Southwest Minnesota. Carris Health is a partnership between CentraCare Health, Rice Memorial Hospital and ACMC Health. MINNESOTA PHYSICIAN FEBRUARY 2018

3Sharable and comparable nursing data from page 15 policy, education, data standards organizations, care coordination, research models, and additional initiatives. The proceedings from 2013 through 2017 are available at http://z.umn.edu/bigdata.

Consistency when using SNTs A position statement that emerged from the NKBDS Initiative says that all health care settings should use one or more of the ANA recognized SNTs. Each type of setting, such as hospitals or public health departments should work together to determine which terminology works best for them. Further, when exchanging data across settings or building a clinical data repository, harmonization of the various SNTs is needed using SNOMED-CT and LOINC. One exception is that if data is exchanged or a repository is built that uses the same terminology, such as the Omaha System, then mapping to SNOMED-CT and LOINC is not required. This position statement has been approved by the Minnesota eHealth Advisory Board in 2014, the ANA in 2015, and included in the 2017 ONC Interoperability Standards Advisory. The approval of this position statement from local to national organizations provides consistent guidelines for use of SNTs and support for interoperability.

The benefits The inclusion of SNTs integrated with interprofessional documentation has benefits. Nurses are the 24 by 7 eyes and ears for monitoring and preventing adverse events such as falls, pressure ulcers, catheter associated urinary tract infections, and sepsis. Use of common data models and terminologies

that include SNTs provides the opportunity to implement reusable clinical decision support algorithms across organizations and vendors. The use of SNTs extends current efforts to capture and reuse clinical and management data to evaluate and improve evidence-based practice. Examples of current efforts that would benefit from SNTs are: American Medical Association’s Integrated Health Model Initiative, National Institutes of Health Common Data Elements, common data models such as the Patient-Centered Outcomes Research Institute (PCORI or the Clinical Translational Science Institute. The capture of quality metrics as a by-product of documentation using standard data elements and models in an automated way would save major effort in chart reviews. Most important, however, is care coordination across the continuum that is patient-focused would improve patient outcomes and reduce costs of care. According to Nelson and Staggers, two prominent nurse informaticians, the ultimate goal is to capture data for quality reporting and research in the context of existing documentation workflows. This requires that standard clinical content is adopted and used in electronic systems; standard taxonomies or vocabularies are used to encode that content; and messaging standards are used to transfer information from one health care organization to another. Bonnie L. Westra, PhD, RN, FAAN, FACMI, is associate professor and director for the Center for Nursing Informatics in the School of Nursing at the University of Minnesota.

With more than 25 specialties, Olmsted Medical Center continues to experience significant growth. We are known for the delivery of exceptional patient care that focuses on caring, quality, safety, and service in a family-oriented atmosphere. Rochester is a fast-growing community and provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: • Dermatology • Division Chair - Hospital & Surgical Services • Division Chair - Primary Care • Division Chair - Specialty Services

• Family Medicine • Gastroenterology • Geriatric Medicine - Nursing Home • Internal Medicine • Neurology

• Ophthalmology Surgeon • Psychiatrist - Child • Urology • Women’s Imager / General Radiologist

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities

Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

email: dcardille@olmmed.org • Phone: 507.529.6748 • Fax: 507.529.6622

www.olmstedmedicalcenter.org 34

FEBRUARY 2018 MINNESOTA PHYSICIAN

A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Opportunities for full-time and part-time staff are available in the following positions: • Physician (Internal Medicine/Family Practice)

• Physician (Geriatric Evaluation & Management) • Physician (Hospice & Palliative Care)

• Physician (Pain Clinic)/Outpatient Primary Care • Psychiatrist (Mental Health)

• Pulmonologist (Primary & Specialty Medicine) Applicants must be BC/BE.

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information:

Visit www.USAJobs.gov or contact Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

Apply online at www.mankatoclinic.com MINNESOTA PHYSICIAN FEBRUARY 2018

3Leveling the playing field from page 13

continuing to expand the rural loan forgiveness programs to mental health professionals; using state funding to expand residency programs for psychiatry, psychology, and other mental health professionals; and to increase mental health training for pediatricians and primary care physicians. Knowing the barriers are even greater in culturally specific communities, there needs to be increased training around cultural competency and recruitment from those communities.

The reports did not venture into other areas of NQTL compliance that hinders people from accessing the care they need. Problems that have been brought to NAMI Minnesota’s attention include the fact that private insurance typically does not cover rehabilitation care in residential treatment or in-home care; does not cover new effective approaches (such as First Episode Programs or Assertive Community As we continue to build our mental health Treatment); does not cover new treatments Time spent finding a mental system, it is critical that private insurance pay for even when approved by the FDA (Repetitive health professional means necessary treatment and provide access in a timely Transcranial Magnetic Stimulation [rTMS] delays in receiving treatment. way. The mental health system cannot depend Systems); requires step therapy or fail first protocols solely on public insurance—such as Medicaid for medications; or, requires different standards for and Medicare—and on grants. With one in five medical necessity. The U.S. Department of Labor’s people affected by mental illness it is obvious that report to Congress in January 2016 identified thousands will rely on private insurance to access NQTLs as the most common violation of parity care—even more so now that young adults can from FY 2010–2015. stay on their parents’ plan until age 26.

Conclusion There is no “quick fix” to the problems but there are steps that can be taken. One is to pass the legislation to enforce parity this session (HF 1974/SF2028) to ensure private insurance is addressing mental health treatment as any other health care concern. Another is to further implement the 24 recommendations of the Mental Health Workforce Plan issued in January 2015 around recruitment, education, and training; placement after program completion; and retention. This includes

FEBRUARY 2018 MINNESOTA PHYSICIAN

The Paul Wellstone/Pete Domenici Mental Health Parity and Addiction Equity Act was passed in 2008. Final regulations were issued in 2013 and became effective for most plans in 2015. It’s now 2018 and time to implement and enforce the provisions and ensure parity and a level playing field once and for all. Sue Abderholden, MPH, is executive director of NAMI Minnesota (National Alliance on Mental Illness).

MINNESOTA PHYSICIAN FEBRUARY 2018

3Physician shortages in Minnesota from page 11

physicians would still provide about three-quarters of all primary care, but the projected shortage of primary care physicians would be cut at least in half.

health records or scribe duties that may be especially onerous to older physicians. These strategies are promising, but such stories are anecdotal and tailored to each community, and there is not yet data to show how widespread such efforts are or to what extent they can correct the problem.

These are national findings, but there are two reasons to believe that shifting care to ancillary providers is likely to be a successful strategy in Minnesota. First, Minnesota has been adopting the Health Care Homes model of care (patient-centered medical homes) widely throughout the state. By the end of last year, just slightly more than half of all clinics were certified health care homes. These facilities deploy proportionately more PAs and NPs and fewer physicians than traditional clinics, and emphasize interdisciplinary team care. Second, Minnesota licensure rules now allow NPs to practice independently (that is, they may prescribe, diagnose, and treat patients without physician supervision), opening up a large new supply of independent providers.

Telemedicine. Another potential remedy is to extend the reach of practicing physicians through the use of telemedicine. The Center for Connected Health Policy (the National Telehealth Policy Resource Center) defines Minnesota telemedicine as “the delivery of health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site,” excluding communication exclusively by email, fax, or telephone. Based on physicians’ responses to the Minnesota Department of Health question, “How often do you diagnose or consult with patients or clients in real-time using dedicated telemedicine equipment or software?” an estimated 28 percent of all physicians reported practicing telemedicine at least occasionally. Among only rural physicians, however, that percentage was 36 percent, suggesting rural physicians and organizations may see telemedicine as part of the solution to shortages.

Shifting care to the ancillary workforce In its 2013 report, “Projecting the Supply and Demand for Primary Care Practitioners through 2020,” the Health Resources & Services Administration (HRSA) estimates the national supply of primary care physicians to be growing at a rate of roughly 8 percent (between 2010 and 2020), while the supply of NPs and PAs is growing by an estimated 30 and 58 percent, respectively. Under a scenario where NPs and PAs are fully utilized, HRSA estimates that

Conclusion The more rural the region of our state, the more likely it is to experience a physician shortage—and the data indicates that without intervention, the situation will only get worse. Rural physicians are older, more likely to retire, and more likely to experience burnout. All of the possible remedies discussed earlier are important and will have a positive impact on access to care, but none can fix the problem alone. Minnesota has not yet engaged in coordinated workforce planning and monitoring that systematically evaluates how the full mix of investments and interventions can even out the distribution of the workforce—and more importantly, improve patient access. A rigorous evidence base is needed to understand these variables to better target future investments. Teri Fritsma, PhD, is the lead health care workforce analyst at the Minnesota Department of Health.

Minneapolis VA Health Care System Opportunities are available in the following specialties:

• Associate Chief of Ambulatory Care • Chief of Internal Medicine • Chief of Nephrology • Director of Primary Care Pain Management • Internal Medicine/Family Practice • Outpatient Clinics: Maplewood, MN (Rover); Chippewa Falls, WI; Superior, WI

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Minneapolis VA Health Care System (MVAHCS)

is a teaching hospital providing a full range of patient care services with state-of-the-art technology, as well as education and research. Comprehensive health care is provided through primary care, tertiary care and longterm care in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics and extended care.

Possible Recruitment Incentive • Competitive Salary Excellent Benefits • Paid Malpractice Insurance

For more information on current opportunities, contact: Nicole Barthelemy: Nicole.Barthelemy@va.gov • 612-467-4304 or Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964

One Veterans Drive, Minneapolis, MN 55417

FEBRUARY 2018 MINNESOTA PHYSICIAN

•

www.minneapolis.va.gov

rehabilitate a body, we start T owith the mind and soul. If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a simple premise for you to consider: To recover physically, you need support mentally and emotionally. How positive and how determined someone is can make all the difference. We believe the most effective therapy treats your body, mind and soul. Thatâ&#x20AC;&#x2122;s our approach. Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area.

To make a referral or for more information, call us at (888) GSS-CARE or visit www.good-sam.com/minnesota.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. ÂŠ 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G1553

MINNESOTA PHYSICIAN FEBRUARY 2018

is for cardiology.

University of Minnesota Health Heart Care As leaders in heart-care interventions for over 60 years, we make innovative care our mission. We’ve transformed lives with major breakthroughs in valve replacements, transplants, cardiac resuscitation and other pioneering techniques to treat heart disease. With multiple centers and clinic locations throughout the region, we’re just a heartbeat away. We see patients six days a week at the Clinics and Surgery Center. Learn more about our expert, innovative care.

Visit

mhealth.org/heartcare

University of Minnesota Health is a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ©2018 University of Minnesota Physicians and University of Minnesota Medical Center