Minnesota Physician April 2015 by Minnesota Physician Publishing

Vo l u m e x x I X , N o . 1 A p r i l 2 015

Leveraging information technology A look at EHR data By Bob Johnson, MPP, and Karen Soderberg, MS

lectronic health record (EHR) systems have become commonplace in Minnesota’s health care system, with most clinics and all hospitals transitioning from paper charts to EHRs. Despite this high adoption rate, providers are struggling to optimize the tools and capabilities to support patient care, and to exchange clinical health information with providers outside of their own health system.

Forging new

alliances

The benefits of medical/dental collaboration By John E. Gulon, DDS

y colleagues at Park Dental and I see dozens of patients every day. While our focus is on their mouths, we occasionally encounter other health-related issues that require the attention of a physician. Our dentists and hygienists routinely take each patient’s blood pressure, perform oral cancer screenings, and look for any other symptoms that might be indicative of a larger health issue. If we

encounter any concerning medical issues our dentists instruct their patients to visit their physicians. One of our dentists, Joseph F. Rinaldi III, DDS, recently shared a story with me about just such an occurrence. Dr. Rinaldi was scheduled to remove a patient’s molar. Prior to the surgery, the patient’s blood pressure Forging new alliances to page 16

In 2007, the Minnesota Legislature passed the 2015 Interoperable EHR Mandate, which states that all hospitals and health care providers must use an interoperable electronic health record (EHR) system by Jan. 1, 2015 (Minnesota Statute § 62J.495 Electronic Health Record Technology). An important component of this law is that providers not only adopt the technology, but that they use the tools available in their EHRs and securely exchange relevant health inforLeveraging information technology to page 18

rehabilitation services from P ost-acute the Good Samaritan Society. Post-acute care is designed to heal and assist patients with care and support following a hospitalization from serious illness, injury or elective surgical procedure. Multiple in-patient and out-patient post-acute locations are located throughout the Twin Cities metro area and state of Minnesota. To learn more about our post-acute services, call us at 866-GSSCARE 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-G0066

An approach to consider for type 2 diabetes therapy starts here

Trulicityâ&#x201E;˘ is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Select Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, and Brief Summary of Prescribing Information on following pages. Please see Instructions for Use included with the pen. April 2015 Minnesota Physician

Trulicity offers proven A1C reduction* and once-weekly dosing in the Trulicity pen â&#x201E;˘

*In clinical trials, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose.1

Trulicity may be a good option for adult patients with type 2 diabetes who need more control than oral medications are providing.1 To learn more about Trulicity and the savings card for patients, talk to your Lilly sales representative or visit Trulicity.com.

Trulicity is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

DG95134

02/2015 PRINTED IN USA

Minnesota Physician April 2015

Trulicity is contraindicated in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components. Risk of Thyroid C-cell Tumors: Counsel patients regarding the risk of medullary thyroid carcinoma and the symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Patients with elevated serum calcitonin (if measured) and patients with thyroid nodules noted on physical examination or neck imaging should be referred to an endocrinologist for further evaluation. Pancreatitis: Has been reported in clinical trials. Observe patients for signs and symptoms including persistent severe abdominal pain. If pancreatitis is suspected discontinue Trulicity promptly. Do not restart if pancreatitis is confirmed. Consider other antidiabetic therapy in patients with a history of pancreatitis. Please see Important Safety Information continued on following page.

Important Safety Information, continued

Once-weekly Trulicity 1.5 mg showed significant A1C reduction1

Hypoglycemia: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of the sulfonylurea or insulin to reduce the risk of hypoglycemia.

Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg for additional glycemic 1-3 control.

A1C reduction from baseline

8.4

Hypersensitivity Reactions: Systemic reactions were observed in clinical trials in patients receiving Trulicity. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice.

Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients.

8.0

Gastric emptying is slowed by Trulicity, which may impact absorption of concomitantly administered oral medications. Use caution when oral medications are used with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to a clinically relevant degree. Pregnancy: There are no adequate and well-controlled studies of Trulicity in pregnant women. Use only if potential benefit outweighs potential risk to fetus. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. A decision should be made whether to discontinue nursing or to discontinue Trulicity taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established and use is not recommended in patients less than 18 years of age. Please see Brief Summary of Prescribing Information, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages. Please see Instructions for Use included with the pen. DG HCP ISI 12NOV2014 Trulicity™ is a trademark of Eli Lilly and Company and is available by prescription only. Other product/company names mentioned herein are the trademarks of their respective owners.

Byetta® (10 mcg BID) (n=276; Baseline A1C: 8

7.8 7.6

-0.5

7.4

Trulicity™ (0.75 mg) (n=280; Baseline A1C: 8

7.2 7.0

‡

-1.0

6.8

-1.3* † -1.5*

†

6.6 6.4

93% fewer injections3

Trulicity™ (1.5 mg) (n=279; Baseline A1C: 8

6.2 Baseline

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. The most common adverse reactions reported in ≥5% of Trulicity-treated patients in placebo-controlled trials (placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg) were nausea (5.3%, 12.4%, 21.1%), diarrhea (6.7%, 8.9%, 12.6%), vomiting (2.3%, 6.0%, 12.7%), abdominal pain (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), and fatigue (2.6%, 4.2%, 5.6%).

Placebo (n=141; Baseline A1C: 8

8.2

LS mean A1C LS mean A1C(%) (%)

Renal Impairment: In patients treated with GLP-1 RAs there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, sometimes requiring hemodialysis. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. In patients with renal impairment, use caution when initiating or escalating doses of Trulicity and monitor renal function in patients experiencing severe adverse gastrointestinal reactions.

1-3

Week 13

Week 26

Placebo (n=141; Baseline A1C: 8.1%) Byetta® (10 mcg BID) (n=276; Baseline A1C: 8.1%) Trulicity™ (0.75 mg) (n=280; Baseline A1C: 8.1%) Trulicity™ (1.5 mg) (n=279; Baseline A1C: 8.1%) Data represent least-squares mean ± standard error. * Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C. † Multiplicity-adjusted 1-sided P value <.001 for superiority of Trulicity vs placebo for A1C. Mixed model repeated measures analysis. After 26 weeks, placebo-treated patients were switched in a blinded fashion to Trulicity 1.5 mg or Trulicity 0.75 mg. ‡ American Diabetes Association recommended target goal. Treatment should be individualized.4 •

Data represent least-squares mean ± standard error.

52-week, randomized, placebo-controlled phase 3 study

*(open-label assignment to Byetta or blinded assignment to

Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C.

Trulicity or placebo) of adult patients with type 2 diabetes Multiplicity-adjusted 1-sided P value <.001 for(≥1500 superiority of Trulicity vs placebo for A1C. treated with maximally tolerated metformin mg/day) and Actos® to 45 mg/day) Mixed model(up repeated measures analysis. • Primary objective was to demonstrate superiority of Trulicity After 26vsweeks, placebo-treated were switched in a blinded fashion to Trulicity 1.5 mg or Trulicity 0.75 mg. 1.5 mg placebo on change inpatients A1C from baseline at 26 ‡weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% American Diabetes Association recommended target goal. Treatment should be individualized.4 CI [-1.2, -0.9]; multiplicity-adjusted 1-sided P value <.001; analysis of covariance using last observation carried •forward); primary objective met †

52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated 1. Trulicity [Prescribing Information]. tolerated metformin (≥1500 mg/day) and Actos (up to 45 mg/day) Indianapolis, IN: Lilly USA, LLC; 2014. References assignment

2. Data on file, Lilly USA, LLC. TRU20140910A. • Data Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo o 3. on file, Lilly USA, LLC. TRU20140919C. 4. American Diabetes Association. Standards from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [ of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80. adjusted 1-sided P value <.001; analysis of covariance using last observation carr

objective met

References 1. Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC; 2014. 2. Data on file, Lilly USA, LLC. TRU20140910A. 3. Data on file, Lilly USA, LLC. TRU20140919C. 4. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.

April 2015 Minnesota Physician

TrulicityTM

(dulaglutide) Brief Summary: Consult the package insert for complete prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS • In male and female rats, dulaglutide causes a dose-related and treatment-durationdependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. • Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors. INDICATIONS AND USAGE Trulicity™ is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as a first-line therapy for patients who have inadequate glycemic control on diet and exercise. Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. It is not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not recommended in patients with pre-existing severe gastrointestinal disease. The concurrent use of Trulicity and basal insulin has not been studied. CONTRAINDICATIONS Do not use in patients with a personal or family history of MTC or in patients with MEN 2. Do not use in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components. WARNINGS AND PRECAUTIONS Risk of Thyroid C-cell Tumors: In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. Glucagon-like peptide (GLP-1) receptor agonists have induced thyroid C-cell adenomas and carcinomas in mice and rats at clinically relevant exposures. It is unknown whether Trulicity will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of this signal could not be determined from the clinical or nonclinical studies. One case of MTC was reported in a patient treated with Trulicity. This patient had pretreatment calcitonin levels approximately 8 times the upper limit of normal (ULN). Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the risk for MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). The role of serum calcitonin monitoring or thyroid ultrasound monitoring for the purpose of early detection of MTC in patients treated with Trulicity is unknown. Such monitoring may increase the risk of unnecessary procedures, due to the low specificity of serum calcitonin as a screening test for MTC and a high background incidence of thyroid disease. Very elevated serum calcitonin value may indicate MTC and patients with MTC usually have calcitonin values >50 ng/L. If serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Patients with thyroid nodules noted on physical examination or neck imaging should also be referred to an endocrinologist for further evaluation. Pancreatitis: In Phase 2 and Phase 3 clinical studies, 12 (3.4 cases per 1000 patient years) pancreatitisrelated adverse reactions were reported in patients exposed to Trulicity versus 3 in non-incretin comparators (2.7 cases per 1000 patient years). An analysis of adjudicated events revealed 5 cases of confirmed pancreatitis in patients exposed to Trulicity (1.4 cases per 1000 patient years) versus 1 case in non-incretin comparators (0.88 cases per 1000 patient years). After initiation of Trulicity, observe patients carefully for signs and symptoms of pancreatitis, including persistent severe abdominal pain. If pancreatitis is suspected, promptly discontinue Trulicity. If pancreatitis is confirmed, Trulicity should not be restarted. Trulicity has not been evaluated in patients with a prior history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia with Concomitant Use of Insulin Secretagogues or Insulin: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia. Hypersensitivity Reactions: Systemic hypersensitivity reactions were observed in patients receiving Trulicity in clinical trials. If a hypersensitivity reaction occurs, the patient should discontinue Trulicity and promptly seek medical advice. Renal Impairment: In patients treated with GLP-1 receptor agonists, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis. Some of these events were reported in patients without known underlying renal disease. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Because these reactions may worsen renal failure, use caution when initiating or escalating doses of Trulicity in patients with renal impairment. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

Trulicity DG HCP BS 12NOV2014 Brief Summary 7 x 9.75 Minnesota Physician April 2015

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. ADVERSE REACTIONS Clinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Pool of Placebo-controlled Trials: These data reflect exposure of 1670 patients to Trulicity and a mean duration of exposure to Trulicity of 23.8 weeks. Across the treatment arms, the mean age of patients was 56 years, 1% were 75 years or older and 53% were male. The population in these studies was 69% White, 7% Black or African American, 13% Asian; 30% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.0 years and had a mean HbA1c of 8.0%. At baseline, 2.5% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60mL/min/1.73 m2) in 96.0% of the pooled study populations. Adverse Reactions in Placebo-Controlled Trials Reported in ≥5% of Trulicity-Treated Patients: Placebo (N=568), Trulicity 0.75mg (N=836), Trulicity 1.5 mg (N=834) (listed as placebo, 0.75 mg, 1.5 mg) nausea (5.3%, 12.4%, 21.1%), diarrheaa (6.7%, 8.9%, 12.6%), vomitingb (2.3%, 6.0%, 12.7%), abdominal painc (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), fatigued (2.6%, 4.2%, 5.6%). (a Includes diarrhea, fecal volume increased, frequent bowel movements. b Includes retching, vomiting, vomiting projectile. c Includes abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, abdominal tenderness, gastrointestinal pain. d Includes fatigue, asthenia, malaise.) Note: Percentages reflect the number of patients that reported at least 1 treatment-emergent occurrence of the adverse reaction. Gastrointestinal Adverse Reactions : In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving Trulicity than placebo (placebo 21.3%, 0.75 mg 31.6%, 1.5 mg 41.0%). More patients receiving Trulicity 0.75 mg (1.3%) and Trulicity 1.5 mg (3.5%) discontinued treatment due to gastrointestinal adverse reactions than patients receiving placebo (0.2%). Investigators graded the severity of gastrointestinal adverse reactions occurring on 0.75 mg and 1.5 mg of Trulicity as “mild” in 58% and 48% of cases, respectively, “moderate” in 35% and 43% of cases, respectively, or “severe” in 7% and 11% of cases, respectively. In addition to the adverse reactions ≥5% listed above, the following adverse reactions were reported more frequently in Trulicity-treated patients than placebo (frequencies listed, respectively, as: placebo; 0.75 mg; 1.5 mg): constipation (0.7%; 3.9%; 3.7%), flatulence (1.4%; 1.4%; 3.4%), abdominal distension (0.7%; 2.9%; 2.3%), gastroesophageal reflux disease (0.5%; 1.7%; 2.0%), and eructation (0.2%; 0.6%; 1.6%). Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse reactions was also evaluated in a larger pool of patients with type 2 diabetes participating in 6 placebo- and active-controlled trials evaluating the use of Trulicity as monotherapy and add-on therapy to oral medications or insulin. In this pool, a total of 3342 patients with type 2 diabetes were treated with Trulicity for a mean duration 52 weeks. The mean age of patients was 56 years, 2% were 75 years or older and 51% were male. The population in these studies was 71% White, 7% Black or African American, 11% Asian; 32% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.2 years and had a mean HbA1c of 7.6-8.5%. At baseline, 5.2% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60 ml/min/1.73 m2) in 95.7% of the Trulicity population. In the pool of placebo- and activecontrolled trials, the types and frequency of common adverse reactions, excluding hypoglycemia, were similar to those listed as ≥5% above. Other Adverse Reactions: Hypoglycemia : Incidence (%) of Documented Symptomatic (≤70 mg/dL Glucose Threshold) and Severe Hypoglycemia in Placebo-Controlled Trials: Add-on to Metformin at 26 weeks, Placebo (N=177), Trulicity 0.75 mg (N=302), Trulicity 1.5 mg (N=304), Documented symptomatic: Placebo: 1.1%, 0.75 mg: 2.6%, 1.5 mg: 5.6%; Severe: all 0. Add-on to Metformin + Pioglitazone at 26 weeks, Placebo (N=141), TRULICITY 0.75 mg (N=280), Trulicity 1.5 mg (N=279), Documented symptomatic: Placebo: 1.4%, 0.75 mg: 4.6%, 1.5 mg: 5.0%; Severe: all 0. Hypoglycemia was more frequent when Trulicity was used in combination with a sulfonylurea or insulin. Documented symptomatic hypoglycemia occurred in 39% and 40% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Severe hypoglycemia occurred in 0% and 0.7% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Documented symptomatic hypoglycemia occurred in 85% and 80% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with prandial insulin. Severe hypoglycemia occurred in 2.4% and 3.4% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with prandial insulin. Heart Rate Increase and Tachycardia Related Adverse Reactions : Trulicity 0.75 mg and 1.5 mg resulted in a mean increase in heart rate (HR) of 2-4 beats per minute (bpm). The long-term clinical effects of the increase in HR have not been established. Adverse reactions of sinus tachycardia were reported more frequently in patients exposed to Trulicity. Sinus tachycardia was reported in 3.0%, 2.8%, and 5.6% of patient treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Persistence of sinus tachycardia (reported at more than 2 visits) was reported in 0.2%, 0.4% and 1.6% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Episodes of sinus tachycardia, associated with a concomitant increase from baseline in heart rate of ≥15 beats per minute, were reported in 0.7%, 1.3% and 2.2% of patient treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Immunogenicity : Across four Phase 2 and five Phase 3 clinical studies, 64 (1.6%) TRULICITY-treated patients developed anti-drug antibodies (ADAs) to the active ingredient in Trulicity (ie, dulaglutide). Of the 64 dulaglutide-treated patients that developed dulaglutide ADAs, 34 patients (0.9% of the overall population) had dulaglutideneutralizing antibodies, and 36 patients (0.9% of the overall population) developed antibodies TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

PRINTER VERSION 1 OF 2

against native GLP-1. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, the incidence of antibodies to dulaglutide cannot be directly compared with the incidence of antibodies of other products. Hypersensitivity: Systemic hypersensitivity adverse reactions sometimes severe (eg, severe urticaria, systemic rash, facial edema, lip swelling) occurred in 0.5% of patients on Trulicity in the four Phase 2 and Phase 3 studies. Injection-site Reactions : In the placebo-controlled studies, injection-site reactions (eg, injection-site rash, erythema) were reported in 0.5% of Trulicity-treated patients and in 0.0% of placebo-treated patients. PR Interval Prolongation and Adverse Reactions of First Degree Atrioventricular (AV) Block : A mean increase from baseline in PR interval of 2-3 milliseconds was observed in Trulicity-treated patients in contrast to a mean decrease of 0.9 millisecond in placebo-treated patients. The adverse reaction of first degree AV block occurred more frequently in patients treated with Trulicity than placebo (0.9%, 1.7% and 2.3% for placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively). On electrocardiograms, a PR interval increase to at least 220 milliseconds was observed in 0.7%, 2.5% and 3.2% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Amylase and Lipase Increase: Patients exposed to Trulicity had mean increases from baseline in lipase and/or pancreatic amylase of 14% to 20%, while placebo-treated patients had mean increases of up to 3%. DRUG INTERACTIONS Trulicity slows gastric emptying and thus has the potential to reduce the rate of absorption of concomitantly administered oral medications. Caution should be exercised when oral medications are concomitantly administered with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to any clinically relevant degree. USE IN SPECIFIC POPULATIONS Pregnancy - Pregnancy Category C: There are no adequate and well-controlled studies of Trulicity in pregnant women. The risk of birth defects, loss, or other adverse outcomes is increased in pregnancies complicated by hyperglycemia and may be decreased with good metabolic control. It is essential for patients with diabetes to maintain good metabolic control before conception and throughout pregnancy. Trulicity should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In rats and rabbits, dulaglutide administered during the major period of organogenesis produced fetal growth reductions and/or skeletal anomalies and ossification deficits in association with decreased maternal weight and food consumption attributed to the pharmacology of dulaglutide. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for clinical adverse reactions from Trulicity in nursing infants, a decision should be made whether to discontinue nursing or to discontinue Trulicity, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established in pediatric patients. Trulicity is not recommended for use in pediatric patients younger than 18 years. Geriatric Use: In the pool of placebo- and active-controlled trials, 620 (18.6%) Trulicity-treated patients were 65 years of age and over and 65 Trulicity-treated patients (1.9%) were 75 years of age and over. No overall differences in safety or efficacy were detected between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Hepatic Impairment: There is limited clinical experience in patients with mild, moderate, or severe hepatic impairment. Therefore, Trulicity should be used with caution in these patient populations. In a clinical pharmacology study in subjects with varying degrees of hepatic impairment, no clinically relevant change in dulaglutide pharmacokinetics (PK) was observed. Renal Impairment: In the four Phase 2 and five Phase 3 randomized clinical studies, at baseline, 50 (1.2%) Trulicity-treated patients had mild renal impairment (eGFR ≥60 but <90 mL/min/1.73 m2), 171 (4.3%) Trulicity-treated patients had moderate renal impairment (eGFR ≥30 but <60 mL/min/1.73 m2) and no Trulicity-treated patients had severe renal impairment (eGFR <30 mL/min/1.73 m2). No overall differences in safety or effectiveness were observed relative to patients with normal renal function, though conclusions are limited due to small numbers. In a clinical pharmacology study in subjects with renal impairment including end-stage renal disease (ESRD), no clinically relevant change in dulaglutide PK was observed. There is limited clinical experience in patients with severe renal impairment or ESRD. Trulicity should be used with caution, and if these patients experience adverse gastrointestinal side effects, renal function should be closely monitored. Gastroparesis: Dulaglutide slows gastric emptying. Trulicity has not been studied in patients with pre-existing gastroparesis. OVERDOSAGE Overdoses have been reported in clinical studies. Effects associated with these overdoses were primarily mild or moderate gastrointestinal events (eg, nausea, vomiting) and non-severe hypoglycemia. In the event of overdose, appropriate supportive care (including frequent plasma glucose monitoring) should be initiated according to the patient’s clinical signs and symptoms. PATIENT COUNSELING INFORMATION See FDA-approved Medication Guide • Inform patients that Trulicity causes benign and malignant thyroid C-cell tumors in rats and that the human relevance of this finding is unknown. Counsel patients to report symptoms of thyroid tumors (eg, a lump in the neck, persistent hoarseness, dysphagia, or dyspnea) to their physician. • Inform patients that persistent severe abdominal pain, that may radiate to the back and which may (or may not) be accompanied by vomiting, is the hallmark symptom of acute pancreatitis. Instruct patients to discontinue Trulicity promptly, and to contact their physician, if persistent severe abdominal pain occurs. • The risk of hypoglycemia may be increased when Trulicity is TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

Trulicity DG HCP BS 12NOV2014 Brief Summary 7 x 9.75

used in combination with a medicine that can cause hypoglycemia, such as a sulfonylurea or insulin. Review and reinforce instructions for hypoglycemia management when initiating Trulicity therapy, particularly when concomitantly administered with a sulfonylurea or insulin. • Patients treated with Trulicity should be advised of the potential risk of dehydration due to gastrointestinal adverse reactions and take precautions to avoid fluid depletion. Inform patients treated with Trulicity of the potential risk for worsening renal function and explain the associated signs and symptoms of renal impairment, as well as the possibility of dialysis as a medical intervention if renal failure occurs. • Inform patients that serious hypersensitivity reactions have been reported during postmarketing use of GLP-1 receptor agonists. If symptoms of hypersensitivity reactions occur, patients must stop taking Trulicity and seek medical advice promptly. • Advise patients to inform their healthcare provider if they are pregnant or intend to become pregnant. • Prior to initiation of Trulicity, train patients on proper injection technique to ensure a full dose is delivered. Refer to the accompanying Instructions for Use for complete administration instructions with illustrations. • Inform patients of the potential risks and benefits of Trulicity and of alternative modes of therapy. Inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1c testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications. During periods of stress such as fever, trauma, infection, or surgery, medication requirements may change and advise patients to seek medical advice promptly. • Each weekly dose of Trulicity can be administered at any time of day, with or without food. The day of once weekly administration can be changed if necessary, as long as the last dose was administered 3 or more days before. If a dose is missed and there are at least 3 days (72 hours) until the next scheduled dose, it should be administered as soon as possible. Thereafter, patients can resume their usual once weekly dosing schedule. If a dose is missed and the next regularly scheduled dose is due in 1 or 2 days, the patient should not administer the missed dose and instead resume Trulicity with the next regularly scheduled dose. • Advise patients treated with Trulicity of the potential risk of gastrointestinal side effects. • Instruct patients to read the Medication Guide and the Instructions for Use before starting Trulicity therapy and review them each time the prescription is refilled. • Instruct patients to inform their doctor or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens. • Inform patients that response to all diabetic therapies should be monitored by periodic measurements of blood glucose and HbA1c levels, with a goal of decreasing these levels towards the normal range. HbA1c is especially useful for evaluating long-term glycemic control.

Eli Lilly and Company, Indianapolis, IN 46285, USA US License Number 1891 Copyright © 2014, Eli Lilly and Company. All rights reserved. Additional information can be found at www.trulicity.com DG HCP BS 12NOV2014 TrulicityTM (dulaglutide)

DG HCP BS 12NOV2014

PRINTER VERSION 2 OF 2 April 2015 Minnesota Physician

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Minnesota Physician April 2015

REAL HOPE with April 2015 • Volume XXIX, No. 1

Features Forging new alliances The benefits of medical/dental collaboration By John E. Gulon, DDS

REAL HOPE with REAL HOPE Treatmen with

Leveraging information technology A look at EHR data

By B ob Johnson, MPP, and Karen Soderberg, MS

DEPARTMENTS CAPSULES

MEDICUS

Endometriosis By Matthew Palmer, DO

INTERVIEW

Allied professions 26

Multicare Associates

Wilderness Health By Cassandra Beardsley

Unionizing home health care By Sumer Spika

Matt Brandt

Practice Management

Women’s Health

Neurology

Vision and mild traumatic brain injury By Jessica Schara, OD

REALHOPE HOPEwith with REAL

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capsules

Shared Decision Making Studied in Cancer Screening Allina Health, Virginia Commonwealth University, and the communities of Buffalo and Hastings have concluded a threeyear study on colorectal cancer screening called Colorectal Cancer Screening With Improved Shared Decision Making (CRCSWISDM). The partnership’s goal was to determine whether using educational materials to address patients’ concerns, questions, and preferences about screening options would improve adherence to colorectal cancer screening guidelines. Through the Blue Cross and Blue Shield of Minnesota-funded study, known as the “Don’t Fear the Rear” project, researchers offered patients information about two colorectal cancer screening methods—fecal occult blood test and colonoscopy. Allina Health patients aged 50

to 75 years who were at average risk for colorectal cancer were eligible to participate. Researchers also worked to engage the general public through informational campaigns at community events. They developed an award-winning website with general screening information and updates to help engage and educate the public. More than 3,500 patients who were not up to date with their screening were eligible for the study. Of those, more than 2,500 had colorectal cancer screening tests ordered and more than 100 engaged in shared decisionmaking sessions with a nurse. According to Allina Health, one study participant said, “The WISDM project prompted me to get a screening and a precancerous polyp was removed. So I’m very grateful to the people who put this project together.” Researchers plan to continue analyzing data and will release findings over the coming months. However, they say that

Minnesota Physician April 2015

preliminary results from a community-wide questionnaire show that most people prefer making decisions about their health care with their provider, versus making decisions on their own or leaving decisions solely up to their doctor. “We know that offering choices to our patients can be a powerful strategy to engage in patient-centered care,” said Timothy Sielaff, MD, chief medical officer at Allina Health. “Allina is committed to this strategy and to empowering patients to make informed health care decisions.”

Workplace Solutions For Physician Burnout Studied Addressing communication and workflow issues at hospitals may help reduce rates of physician burnout and dissatisfaction and improve retention rates, according to a national study led

by Hennepin County Medical Center (HCMC). “With more new patients accessing health care systems, we need every clinician possible to be motivated, connected, and functioning at their best,” said Mark Linzer, MD, director of HCMC’s Division of General Internal Medicine. “The loss of clinicians to organizations at this point in time can indeed be a disaster.” Primary care clinicians at 34 clinics in the upper Midwest and New York City participated in the study. Half the clinics were randomized to work-life interventions and half received no interventions. Researchers then measured work conditions, including time pressure, workplace chaos, and work control, as well as clinician outcomes, at a baseline and at 12 to 18 months. Of 166 clinicians, 135 completed the study. The results show that at the clinics with interventions, physician burnout or satisfaction

was 3.5 to 5.9 times more likely to improve than those where no changes took place. Specifically, those with interventions saw a 21.8 percent reduction in burnout rates, compared to a 7.1 percent reduction among the group with no interventions, and a 23.1 percent increase in satisfaction rates, compared to a 10 percent increase among the group with no interventions. The study identified three types of interventional programs that were most effective—workflow redesign, communication improvements (particularly between provider groups), and quality improvement projects targeted to clinician concerns. Specifically, the communications and workflow interventions showed a trend toward greater improvements in clinician satisfaction and retention rates. “These are people who chose medicine because they wanted to help others, and now they are the ones who need support,” said Linzer. “Given that need, we focused on interventions that might improve clinicians’ worklife balance or their experiences at work. This study shows that interventions can have a positive effect on clinicians; and the next step in the analyses will determine how much of this impact is transmitted to patients.” Linzer and his team are now taking these data and interventions to hospitals across the U.S. through collaborations with the American Medical Association.

State Hospitals Report Adverse Health Events The number of deaths due to hospital errors decreased last year, according to the Minnesota Department of Health’s (MDH) 11th annual Adverse Health Events report. The report includes data from 69 Minnesota hospitals and surgical centers from October 2013 to October 2014. In that time period, they reported 2 million visits in which there were 308 adverse health events, including 98 serious injuries and 13 deaths. In the previous report,

which tallied data from October 2012 to October 2013, there were 258 adverse health events, 84 serious injuries, and 15 deaths recorded. The authors point out that four new reportable event categories were added this year and those additions contributed to the rise in reportable errors. The new categories were death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results (in which five events were reported); irretrievable loss of an irreplaceable biological specimen (in which 20 events were reported); neonatal death or serious injury associated with labor and delivery in a low-risk pregnancy (in which six events were reported); and death or serious injury of a patient associated with the introduction of a metallic object into the MRI area (in which no events were reported). “The adverse events reporting system provides a strong system for learning and improvement,” said Lawrence Massa, president and CEO of the Minnesota Hospital Association. “In the 15 years that Minnesota’s hospitals have been spearheading patient safety efforts, they have shown a remarkable commitment to improving patient safety and the addition of these new events demonstrates that commitment to continuous improvement.” The top reported events included 107 pressure ulcers, 79 falls associated with serious injury or death, and 33 events in which foreign objects were left in patients after surgery. MDH’s goals for improvement in 2015 include testing developing strategies to reduce lost specimens; improving communications regarding patients’ test results; more effectively identifying fragments or lost instruments to ensure they are not left in patients during surgery or invasive procedures; improving perinatal safety; and partnering with surgeons and interventional radiologists to improve correct spine level surgery and spinal injections. According to MDH, Minnesota is one of 28 states that tracks adverse events and only Capsules to page 12

THE 5 BROWNS

ANDRÉ WATTS

GARRICK OHLSSON

LIVE AT ORCHESTRA HALL

The 5 Browns

Fri May 15 8pm When The 5 Browns sit at their 5 Steinways and play arrangements from Gershwin to Rachmaninoff, you won’t believe your ears. No wonder the famed Juilliard School admitted them all—simultaneously. Please note: The Minnesota Orchestra does not perform on this program.

Garrick Ohlsson Plays Brahms

Thu May 21 11am / Fri May 22 & Sat May 23 8pm Stanislaw Skrowaczewski, conductor / Garrick Ohlsson, piano The extraordinary Garrick Ohlsson plays the youthful and vigorous Piano Concerto No. 1 by Brahms; this exhilarating program concludes with Beethoven’s dance-infused Symphony No. 7.

André Watts with Osmo Vänskä

Thu May 28 11am / Fri May 29 & Sat May 30 8pm Osmo Vänskä, conductor / André Watts, piano Brahms called his Piano Concerto No. 2, “a tiny, tiny, pianoforte concerto" but it is anything but that, especially when played by the legendary André Watts. Then Osmo Vänskä brings his inimitable touch to Sibelius Symphony No. 3.

Singin’ in the Rain*

Film with the Minnesota Orchestra Thu Jul 9 11am / Fri Jul 10 8pm Sarah Hicks, conductor Short of dancing down a rain-splattered street, there’s no better way to recapture the magic of this classic MGM musical than to see it on a big screen with a live orchestra performing songs from the timeless soundtrack.

minnesotaorchestra.org 612.371.5656 / Orchestra Hall All programs, artists, dates, times and prices subject to change. PHOTOS Watts: Steve J. Sherman, The 5 Browns: Bryan Hernandez-Luch, Ohlsson: Paul Body

Media Partner:

April 2015 Minnesota Physician

Capsules from page 11

two others report the results publicly—New Hampshire and Colorado.

Home Visit Program To Reduce Hospital Readmissions Regions Hospital and the St. Paul Fire Department have teamed up to help reduce emergency calls and unnecessary hospital readmissions in the East Metro through a pilot program where specially trained paramedics will visit patients in their homes within 48 hours after they are discharged from the hospital. Readmissions usually happen within the first 72 hours of being released. The program will focus on patients with congestive heart failure, which has one of the highest hospital readmission rates. Patients will be referred to the St. Paul Fire Department for a free commun-

ity paramedic home visit as part of the discharge process when they leave the hospital. Paramedics will provide education on medications, perform a clinical assessment, help patients understand symptoms to watch for, make sure they are connected to resources within the community for food and transportation, and perform a home safety check. “So much of what keeps people healthy happens outside of the doctor’s office,” said R.J. Frascone, MD, medical director of Regions Hospital Emergency Medical Services. “Innovative programs and partnerships, such as this, help us as a community find new ways to improve health. Our colleagues at Methodist Hospital have seen great results with this program, and we are excited to expand it to the East Metro.” Methodist Hospital launched the program in May 2014. Paramedics have visited almost 200 patients and found 20 cases that

needed additional medical care. They also referred 10 patients to social and community services, seven patients to food shelves, and replaced smoke detectors or batteries in 52 homes.

Patient Safety Bill Introduced in Minnesota House Rep. Joe Atkins (DFL-Inver Grove Heights) has authored a bill related to patient safety that was introduced in the Minnesota House of Representatives on March 9. The Safe Patient Standard bill would establish a workgroup to determine minimum staffing for nurses for various hospital units and sizes in Minnesota. The Minnesota Nurses Association (MNA) is a strong proponent of the bill. “Frontline nurses are worried about their patients,” said Linda Hamilton, RN, president of the Minnesota Nurses Association. “They

know patients are ringing their call lights. They know patients are waiting or they’re not being assessed properly. We’re not delivering the safe, quality care that Minnesotans expect and deserve.” The Minnesota Hospital Association (MHA) opposes the bill, saying that legislation should not determine levels of hospital staffing. “The condition of the patient, the experience of the care team, and the mix of the care team has as much to do with patient outcomes—if not more—as the number of nurses,” said Wendy Burt, spokesperson for MHA. “Staffing should be based on the patient, the severity of the patient’s illness, the whole care team required to care for that patient, and the experience and education of the care team members. Staffing should be flexible. Health care professionals closest to the patient should determine appropriate levels of staffing, not the government.”

Tell them there’s a better way! Get your patients screened for colorectal cancer.

Minnesota Physician April 2015

Medicus Mothilal Sonia Jain, MD, board-certified in cardiovascular disease and internal medicine, has joined the cardiology team at Olmsted Medical Center, Rochester. Jain earned her medical degree at Kasturba Medical College, India, and completed a residency in internal medicine as well as a fellowship in advanced echocardiography and cardiovascular diseases at Mayo Clinic, Rochester. Previously, Jain was a clinical and research fellow in cardiology and earned her residency in internal medicine at University Hospitals, Coventry and Warwickshire NHS Trust, U.K. Ezgi Tiryaki, MD, medical director of the ALS Center for Excellence at Hennepin County Medical Center and associate chief of staff for education for the Minneapolis VA Health Care System, has received the University of Minnesota’s Graduate and Professional Distinguished Teaching Award for being the top instructor at the medical school. The award recognizes excellence in instruction, program development, advising, and Ezgi Tiryaki, MD mentoring, as well as involvement in students’ research, scholarship, and professional development. Tiryaki also serves as an associate professor in the department of neurology at the University of Minnesota and is one of 11 faculty advisors for medical school students. She earned her medical degree from Hannover Medical School, Germany. John Ryden, MD, board certified by the American Board of Family Medicine, has joined Duluth-based St. Luke’s Laurentian Medical Clinic in Mountain Iron. Ryden earned his medical degree at Mayo Medical School, Rochester; completed a residency in family medicine at David Grant USAF Medical Center, Fairfield, Calif., and was previously named Physician of the Year by Lake Superior Medical Society. Ryden John Ryden, MD has over 20 years’ experience as a family practitioner. Most recently, he served as a family practitioner at Essentia Health–Lakeside Clinic, Duluth, and as an urgent care physician for Bloomington-based HealthPartners. Mark Hauge, MD, medical oncologist at Coborn Cancer Center in St. Cloud, has received the St. Cloud Hospital Physician of Excellence award. The award recognizes a St. Cloud Hospital medical staff member for exemplary work ethic and dedication to patient care. Winners are nominated by their peers; those who nominated Hauge characterized him as respectful, dedicated, and Mark Hauge, MD always willing to put his patients first. Hauge earned his medical degree from Mayo Medical School, Rochester; completed a fellowship in medical oncology at Mayo Clinic, Rochester; and completed a residency in internal medicine at the University of Minnesota. Virginia Miller, PhD, director of the Women’s Health Research Center at Mayo Clinic and professor of surgery and physiology at the Mayo Clinic College of Medicine, has received the Woman’s Day Red Dress Award for her contributions to fighting heart disease. Miller’s research has focused on how sex hormones affect the blood vessels and heart in women and men, as well as other gender differences in cardiovascuVirginia Miller, lar health. Miller earned her PhD in physiology PhD at the University of Missouri, Columbia, and completed her postdoctoral fellowship at the University of Virginia. She also serves as the principal investigator for Mayo Clinic’s Specialized Center of Research on Sex Differences and the research director for Mayo Clinic’s Building Interdisciplinary Research Careers in Women’s Health training program. She was the principal investigator for the Mayo site of the multicenter clinical trial, Kronos Early Estrogen Prevention Study (KEEPS).

MINNESOTA HEALTH CARE ROUNDTABLE

The New Face of Health Care

Expanding medical professional relationships Thursday April 23, 2015, 1:00-4:00 PM Downtown Minneapolis Hilton and Towers

Background and Focus: With dramatic population growth, and as baby boomers become senior citizens, the demand for health care is exceeding the supply. Addressing the shortage of medical doctors involves creating new relationships between medical professionals. Training and licensure for Physician Assistants, Advanced Nurse Practitioners, Chiropractors, Respiratory Therapists, Physical Therapists, Home Care Providers, Dentists, and many other health care professions have become increasingly rigorous and provide expanded support to our health-care delivery system. Greater integration of these professions allows medical doctors to work to the top of their license but requires new pathways for communication and care coordination. Objectives: We will examine many of the new partnerships that are emerging between medical doctors and other medical professionals. We will look at the ways leveraging these new relationships can improve access to care while reducing costs and improving outcomes. We will consider points of resistance to forming these kinds of health care teams and what should be avoided in creating them. We will discuss what the proper oversight for these relationships should entail and how to maximize the coordination of care that they require.

Panelists Include: • Mehul Desai, MD, Minneapolis Advanced Pain Specialists • Michael Hu, MD, Vascular Surgeon, Hennepin County Medical Center • Derek Hustvet, RRT-NPS, LRT, Director of Respiratory Service, Pediatric Home Service • John Gulon, DDS, President of Park Dental • Craig Johnson, PT, MBA, President MNPTA, Director of Clinical Integration Therapy Partners • Chuck Sawyer, DC, Senior Vice President, Northwestern Health Sciences University • Gary Wingrove, Paramedic (ret), The Paramedic Foundation Sponsors Include: Minneapolis Advanced Pain Specialists, Park Dental, and Pediatric Home Service Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub.com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAX Card #  Check enclosed  Bill me

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Please mail, call in, or fax your registration by 4/20/2015 April 2015 Minnesota Physician

Interview

PrimaCare Direct: A health care cooperative

Matt Brandt Multicare Associates Mr. Brandt is CEO of Multicare Associates in the Twin Cities, a primary care physician group that has been piloting a direct pay primary care model since 2008. In 2013, he founded a health care cooperative, PrimaCare Direct, which includes over 200 doctors and offers direct pay health care services to employers and patients in the Twin Cities. Mr. Brandt is also CEO of PrimaCare Direct and a board member for the Minnesota Healthcare Network. In 2013, he received the Emerging Leader in Healthcare Award from Minnesota Business.

 Please tell us about PrimaCare Direct. months) spent annually on services at Multicare by Technically, PrimaCare Direct is a health care age, gender, and insurance class. We also compared cooperative made up of health care providers who data from different health plans to determine what work together to market medical services directly their per member, per month spend was on primary to patients and employers. I prefer to think of care. Then we looked at our primary care spendPrimaCare Direct as a group of physician practices ing and researched what other direct primary care that understands how to practices were charging. The make positive changes in end result was $75 per memhealth care by thinking outber per month. The good The goal should really be side of the current system. news is that this price point Today’s system is domiis working well, patients and for health care providers to nated by integrated delivery employers seem to find it keep patients healthy. systems that are primarily reasonable, and clinics are governed by hospitals. happy with the reimbursePrimary and specialty proment. We have only a few inviders who are employed by hospitals are often “ob- stances where the costs to care for a specific patient ligated” to refer patients to the hospital. The goal significantly exceeded the monthly fee. should really be for health care providers to keep patients healthy and out of the hospital. Providers  How does your approach to providing should be free to make decisions with their patients access to health care translate into lower without any outside influence. Cooperative pracoverall cost of care? tices that work directly with health care purchasers When discussing cost of care, we often look at (patients, employers, and government agencies) can chronic disease as being one of the key drivers to be creative in how they finance and deliver health cost. Currently, the big trend for employers is to care. offer a high deductible health plan, but the problem with this is that it discourages patients from visiting PrimaCare Direct’s care delivery model is based their doctor, especially those suffering from chronic on a model called direct primary care (DPC) or diseases such as asthma and diabetes. Instead of direct pay medical home. The defining elements of managing their care with their primary care proDPC is to create improved access to primary care vider they wind up in the emergency room, which and to ensure that patients have an enduring and drives up the cost of care. One ER visit can pay for trusting relationship with their primary care providers. Fee-for-service incentives are replaced with a eight primary care visits. PrimaCare Direct eliminates the barrier for patients to see their primary simple flat monthly fee. This empowers the doctor/ patient relationship and is how we achieve superior care doctor. It encourages good utilization (teaching a patient to use their inhaler properly) versus health outcomes, a better patient experience, and bad utilization (a patient ending up in the ER with lower costs. PrimaCare Direct has also started to an asthma attack). Independent physician groups include specialty services. Specialty practices can join the cooperative and provide procedures or care have typically been very good at developing outpatient capabilities, imaging centers, surgery centers, packages for one bundled fee instead of having diagnostic labs, etc., and these services cost less multiple charges from facilities, physicians, and than hospital-based services. ancillary care providers. Often, specialty physician groups can deliver the same high-quality services in an outpatient setting for 20 percent to 50 percent less than at a hospital. W ould you explain consumer costs and how you figured them? The flat monthly fee for a patient to enroll in PrimaCare Direct is $75 a month. The monthly fee is capped at four family members, so additional family members are free. To come up with the $75 fee we analyzed Multicare Associates claims data and examined what an active patient (defined as a patient who had at least two visits in the past 18

Minnesota Physician April 2015

W hat kind of results have you had with PrimaCare Direct so far? Early results have been promising. Multicare Associates has been using this model with its employees for some time and has kept its health plan costs under control for the past seven years. Over that time, the average cost has declined slightly, which is incredible considering that the industry average has increased in cost somewhere between 8 percent to 10 percent a year depending on which source you quote. The current PrimaCare membership is showing a dramatic decrease in ER visits with the

they work for. This sets up a weird incentive where their commission increases when a premium goes up, yet, they claim to be working on an employer’s behalf. A lot of these brokers don’t really have a solid grasp of how health insurance works and even less  What have been the biggest knowledge about how health care is delivchallenges? ered. So trying to find brokers to work with The two biggest and unexpected challenges have been, 1) the number of patients on gov- who understand the PrimaCare Direct model ernment programs or receiving benefits from and are not afraid to make changes has been difficult. a government entity, and 2) dealing with insurance brokers. When we first started  How can physicians become involved? marketing PrimaCare Direct to our patient PrimaCare Direct is open to both primary base it was shocking to realize how many and specialty practices in Minnesota and patients were receiving insurance through western Wisconsin. We are looking for a government agency. We knew how many physicians who want to help us continue to patients were on Medicare or Medicaid but develop our business model of keeping the we didn’t realize the number of government focus on patient-centered care, where the employees who received benefits such as postal workers, state workers, MnDOT work- patient is the client and a true physician/ patient relationship is the key to success. ers, county workers, etc. This is a barrier for PrimaCare because it is rare for government employees to have a high deductible  PrimaCare Direct does not cover or any deductible at all unlike private sector major medical events. How do employees where a $5,000 deductible is the you advise patients to obtain this norm. This just means that the PrimaCare coverage? model does not currently apply to these We advise patients to obtain a high deductworkers, but that may change over time. ible health plan to insure against catastrophic events (such as cancer or traumatic The other barrier is dealing with ininjury). PrimaCare Direct is currently worksurance brokers who are generally paid in ing to develop and sell its own high deductcommission from the insurance company rate being 112 visits per 1,000 patients versus the norm of 298 visits per 1,000. Groups running the DPC model of care around the country are seeing similar results.

ible health plan that pairs with our direct primary care plan.  How can employers become involved? If an employer is searching for a way to lower their health care costs without sacrificing access, coverage, or quality then PrimaCare Direct is a potential solution. Our care model, coupled with our thirdparty administrator and stop-loss partners, can customize a solution for a company’s employees.  I n an ideal world, what does the future hold for PrimaCare Direct? Ideally, I would love to see PrimaCare Direct grow to cover over 10,000 people here in the Twin Cities within the next year. At that scale it would be hard to refute our results and it would be easier to more aggressively market the concept. This is a stretch goal, but I think it is very doable at our current pace as we have more than 200 doctors currently on board who care for over 300,000 patients. If we can convert over 3 percent of those to the new model we can achieve this goal. From there, I would like to see us grow the model to include a large enough portion of any doctor’s panel that they can change the way they deliver care for all patients, not just those enrolled in our program.

University of Minnesota - Continuing Professional Development Education is essential to achieving and sustaining quality healthcare. Through partnership with healthcare leaders, our educational activities help advance quality improvement and patient care initiatives.

2015 CPD Activities

(All courses in the Twin Cities unless noted)

LIVE ACTIVITIES Maintenance of Certification in Anesthesiology (MOCA) Training April 18, 2015 Live Global Health Training (weekly modules) May 4-29, 2015 Midwest Cardiovascular Forum Controversies in Cardiovascular Disease May 16-17, 2015 Bariatric Education Days: Advances in Bariatric Care May 27-28, 2015 Workshops in Clinical Hypnosis June 4-6, 2015 Topics & Advances in Pediatrics June 4-6, 2015

Pediatric Orthopaedic Trauma Summit 2015 September 24-25, 2015 Twin Cities Sports Medicine Conference 2015 October 2-3, 2015 Psychiatry Review 2015 October 5-6, 2015 NPHTI Pediatric Clinical Hypnosis Workshops October 15-17, 2015

www.cmecourses.umn.edu ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Adolescent Vaccination • Nitrous Oxide for Pediatric Procedural Sedation • Preventing Chronic Pain - A Human Systems Approach • Global Health - To include Travel Medicine & Refugee Health - Family Medicine Specialty - Pediatric Specialty For a full activity listing, go to www.cmecourses.umn.edu

Practical Dermatology 2015 October 16-17, 2015 Donald Gleason Conference on Prostate and Urologic Cancers October 23, 2015

Office of Continuing Professional Development 612-626-7600 or 1-800-776-8636 • email: cme@umn.edu

Promoting a lifetime of outstanding professional practice

April 2015 Minnesota Physician

Forging new alliances from cover

screening revealed his was in the vicinity of 190/100—alarming and far too high to undergo the dental procedure. Dr. Rinaldi shared his concerns and told the patient that he needed to get a medical clearance letter from his physician before he would perform the procedure. The patient visited his family physician and eventually received clearance after his doctor prescribed medications to treat his condition. Dr. Rinaldi later learned that the patient underwent further diagnostic testing, and his physician discovered an adrenal gland tumor that he surgically removed. When Dr. Rinaldi saw this patient a few months later, he discovered the patient had undergone an amazing trans-

formation. To his surprise, the patient had lost a dramatic amount of weight. He told Dr. Rinaldi he hadn’t felt that good in years and expressed how grateful he was that his den-

Integrating oral health and overall health In most people’s minds, dentistry has historically been about teeth. While that is still largely true, a growing number

Physicians do not have access to the data that dentists collect.

tist actually took his condition seriously and prompted him to see his doctor. Dr. Rinaldi said this experience was a sobering reminder of the importance of the screenings we perform in our dental practices and the implications it can have on our patients’ health.

of today’s dentists are more focused on the comprehensive health of the oral cavity, as well as maintaining an astute awareness of its association with the overall health of the body. Dr. Rinaldi’s patient is a great example of the need for a broader focus on overall health

and how dentists and physicians must make an effort to work jointly on behalf of their patients. There is ample opportunity for dentistry and medicine to integrate the oral health dimension into a model of total patient-centered, overall health. Medical/dental collaboration could take place in five key areas: 1) education and training; 2) emergency room oral health services; 3) chronic disease management; 4) in-hospital oral health consultations; and 5) dental office health screenings. Education and training With regards to education and training, the mouth has traditionally been the dentist’s territory. As a result, many physicians have little more than a basic understanding of many oral health issues. Physicians would benefit from training opportunities—most likely in the form of continuing education or specialized training sessions— provided by practicing dentists

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Minnesota Physician April 2015

or dental school instructors. Physicians could even perform some simple oral procedures. For example, it would be beneficial to their patients if pediatricians offered fluoride treatments, especially if their practice works with children who have limited access to a dentist. Emergency room oral health services It’s becoming more common for patients with dental conditions to show up in the emergency room for treatment. This typically isn’t ideal for the patient or the hospital and it’s very expensive. A recent Minnesota Department of Health report indicated that approximately $148 million has been spent over the last three years in Minnesota on dental conditions that are taken care of in hospital emergency rooms. There is a better solution. Patients presenting with dental issues in an emergency room is another area where dentists and physicians could coordinate efforts. One opportunity would be to divert or transfer the patient—barring the absence of other significant injuries—to a dental office to receive the appropriate care. If a patient needs to remain within the emergency room, the opportunity still exists for a dentist to provide clinical care. That care could be in the form of a 24/7 hotline in which a dentist is on call to help treat the injury or provide a phone consultation. Chronic disease management As a physician, you see the prevalence of chronic medical conditions such as diabetes, heart disease, cerebrovascular disease, and rheumatoid arthritis, to name just a few. With our country’s aging population, these conditions will continue to be a challenge for our health care system. Many of these patients with chronic conditions suffer from

poor oral health. A more aggressive collaboration between physicians and dentists to address this issue would create a number of benefits. A collab-

sions when in-patients require a dental/oral consultation. It is difficult for physicians to set up dental consultations and any recommended treatment in a

The ultimate goal is to advance the overall health and quality of life of our patients.

oration, where oral and medical-related issues are addressed in tandem, could improve a patient’s overall health and quality of life. This approach may also reduce the patient’s out-ofpocket medical expenses, as well as medical costs incurred by their employer or medical assistance program. With this collaborative approach, our health care organizations may also realize long-term savings as a result of a patient’s better overall health. A recent study by United Concordia Dental supports this theory. United Concordia Dental found that people who were pregnant or had chronic conditions and received and maintained treatment for periodontal disease saw dramatic drops in hospitalization and physician visits, saving thousands of dollars a year in medical costs. A program designed to address oral health and chronic disease management should be part of most large health care systems. The objective of this program would be to identify patients with chronic health issues and assess their oral health status. This program could then work with their health insurance or medical assistance plans to ensure that their oral health needs are appropriately addressed. In-hospital oral health consultations Throughout Minnesota, there aren’t many dentists on hospital staffs. There are, however, occa-

timely manner when a patient is in the hospital. This is clearly an opportunity for health care organizations that do not have dentists on their staff to establish relationships with dentists in their communities. Once again, with the right working relationship, it could truly enhance the care provided to the patient.

Dental office health screenings Many dental teams already regularly perform basic medical screenings, including those for hypertension, oral cancer, and TMJ facial pain issues. Park Dental is piloting a screening program for sleep apnea and looking at other opportunities, such as inquiring about a patient’s immunization history, screening their glucose levels, or offering smoking cessation education. For some patients, their semiannual dental visit might be the only time they see a health care professional during any given year and health-related issues can certainly surface in that timeframe, especially as Forging new alliances to page 38

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April 2015 Minnesota Physician

Leveraging information technology from cover

EHR requirements and guidance To meet the requirements of the statute, providers must use an EHR that is certified by the Office of the National Coordinator (ONC) pursuant to the Federal Health Information Technology for Economic and Clinical Health (HITECH) Act. Sample EHR certification criteria: • Provides clinical decision support • Supports physician order entry • Captures relevant health care quality information (e.g., patient safety, care coordination, clinical processes/effectiveness, and population and public health) • Exchanges electronic health information with, and integrates such information from, other sources More information, including a comprehensive list of ONCcertified EHRs, is available at www.healthit.gov/policy-researchersimplementers/certified-health-it-product-list-chpl If a certified EHR is not available for a particular specialty or setting, MDH provides guidance on the recommended capabilities. MDH’s Guidance for Understanding the Minnesota 2015 Interoperable EHR Mandate is available at www.health.state.mn.us/e-health/hitimp/

mation with other providers to optimize patient care (see the sidebar about EHR requirements above). Across the nation, this concept of “e-health” has become a powerful strat-

egy to transform access, care delivery, patient experiences, and health outcomes. E-health is also essential in supporting the exchange of information necessary for care coordination

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Minnesota Physician April 2015

and health reform initiatives such as accountable care. Since 2004, members of Minnesota’s health care community have convened regularly as part of the Minnesota e-Health Initiative to develop a statewide plan to meet the goals for statewide adoption and use of EHRs. This plan includes establishing uniform health data standards for securely sharing data across systems. The e-Health Initiative continues to monitor state and national activities and guides Minnesota providers on how they can leverage EHRs to achieve the promised benefits of the Triple Aim: improved patient experience of care, reduced health care costs, and improved public health. This article presents the latest data available on e-health among Minnesota’s ambulatory clinics.

and effective clinical decisions; in participating in voluntary and required quality reporting initiatives; and in contributing to the improved health of individuals and populations. Effective use of EHRs means that the EHR includes tools and processes such as e-prescribing, clinical decision support tools (see Table 2 on page 19), and that staff are adequately trained to use the technology. EHRs are most effective when using nationally recognized standards that enable interoperability with other EHR systems.

Interoperability and health information exchange The goal of health information exchange (HIE) is to make health information available, when and where it is needed, and to improve the quality and safety of health and health care. Currently, most of the HIE Based on data collected occurring in Minnesota is prieach year by the Minnesota marily between Department hospitals and of Health clinics in the using an anHealth care same system nual survey or with affiliproviders are of the state’s ated partners. 1,400 ambuembracing About one-third latory clinics, e-health. of Minnesota Minnesota clinics are exis a leading changing with e-health unaffiliated state. Nine in 10 clinics (93 hospitals or clinics, although percent) and all Minnesota their need to exchange inforhospitals have adopted an EHR. mation is much higher (see Adoption rates vary among Table 3 on page 19). Electronic other settings of care, ranging exchange with unaffiliated labs, from 97 percent among the behavioral health providers, state’s local health departand nursing homes is much ments, to 69 percent of nursing lower. Common challenges for homes (as of 2011), and even exchange include the limited lower rates for settings that capacity of others to exchange, have not had access to Centers lack of technical support or for Medicare & Medicaid Serexpertise, competing priorities, vices (CMS) incentive funding. cost and return on investment, Table 1 on page 19 shows trends and managing privacy issues. in clinic EHR adoption over HIE is happening through a time. variety of mechanisms (see the sidebar about HIE transactions Why Is the mandate on page 36). The most common important? mechanism for health inforEffective use of EHRs The value from investing in and mation exchange is through a common EHR, for example, implementing an EHR system Epic. HIE is also happening comes from using it effectively between organizations that to support efficient workflows

Source for Tables 1, 2, and 3: Minnesota Department of Health, Office of Health Information Technology

Table 1. T rends in the adoption of electronic health record systems among Minnesota clinics, 2005–2014

Table 2. Clinic trends in the use of clinical decision support tools in Minnesota

Compliance The Minnesota Department of Health (MDH) recognizes that some providers may not have achieved the Interoperable EHR Mandate by Jan. 1, 2015. MDH does not have enforcement authority over Minnesota’s 2015 EHR mandate, and does not issue fines or sanctions against providers that have not met the mandate’s requirements. Instead, MDH provides support to providers to help them achieve the goal of statewide interoperability. The Minnesota e-Health Advisory Committee and MDH recommend that all providers demonstrate progress toward

achieving the EHR and interoperability requirements. Potential benefits of compliance may include: • Increased efficiency and quality outcomes • Improved ability to avoid adverse events • Timely access to information from patients’ other providers Looking to the future There is demand nationwide to improve our country’s health care system. When Minnesota’s EHR Mandate passed, it was groundbreaking and forward-looking in its commitment

Leveraging information technology to page 36

Table 3. M innesota clinics’ electronic health information exchange by type of organization, 2014

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use a different EHR, either as a peer-to-peer connection or through an HIE intermediary. In Minnesota, providers who do not operate through the same HIPAA affiliation are required to exchange health information using a state-certified HIE service provider. Interoperability is the ability of two or more systems or components to exchange information and to use the information

that has been exchanged accurately, securely, and verifiably, when and where needed. In the context of HIE, interoperability is achieved by using standardized terminology and data structure in the various types of clinical data transactions (e.g., clinical summaries, lab results, immunizations, etc.). While most of these standards have been developed, adoption and use of these standards is still limited.

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Practice Management

ilderness Health is a nonprofit regional collaborative, consisting of nine independent hospitals and health systems in northeastern Minnesota. It was officially incorporated in December 2013 as a nonprofit corporation in Minnesota, however, the idea of independent facilities working together was born years earlier. The cost of health care Multiple changes in the health care industry are driving changes in reimbursement as well as patient utilization. Since 2006, the inpatient rate has dropped throughout the U.S. with Minnesota experiencing the greatest rate of reduction at 13 percent. The trend is expected to continue throughout the next decade, even in states with loosely managed utilization trends. Minnesota, considered to be a state with conservative admitting patterns and an overall healthier population,

Wilderness Health Providing care in northeastern Minnesota By Cassandra Beardsley

can expect to see admit rates continue to decline. Another key issue impacting revenue is the shift by payers, starting with Medicare, from quality incentives to penalties. Hospital-acquired infections and readmissions are reducing payment rates for providers. Patients can and should expect high-quality care from providers. The burden for providers is ensuring that there is staff available to interpret the measures, review and report on results, and identify and implement opportunities for improvement. The challenge is in the delay between the

reporting and the impact to reimbursement—sometimes a gap of several years. Out-of-pocket costs for patients have risen dramatically over the past decade as employers have shifted costs to employees in an effort to slow employee benefit costs. A November 2014 study by the Kaiser Family Foundation found that the average worker deductible increased from $584 in 2006 to $1,217 per person in 2014. Deductible costs for individuals not covered by employer-sponsored health insurance are even higher. The average annual medical deductible in 2015 is $2,563 for silver exchange plans with a combined medical/prescription drug deductible; in silver plans with separate medical and drug deductibles, the average annual medical deductible is $3,456. Copays and co-insurance add additional patient costs. Many patients are choosing to delay medical care as a result of their out-of-pocket costs. Regional demographics In addition to reimbursement changes, health systems in northeastern Minnesota are challenged by the demographics in the region. According to the 2013 County Health Rankings study, all counties in Wilderness Health’s service area: • Have more people over age 65 than the state and national averages • Consistently report more poor/fair health days, poor physical health days, and poor mental health days than the state averages • Rank in the bottom 20 percent of health rankings (except for Cook, which has the smallest population)

Minnesota Physician April 2015

Medicare is the largest payer for all Wilderness Health members and many have a significant number of Medicaid patients also, meaning that contracted rates are much lower than other payer types. Forming the collaborative Given these financial challenges, several hospitals in northeastern Minnesota began discussions several years ago to identify how they could work together in a more cost-effective, efficient manner that would maintain their independence yet still provide their patients with quality health care. The governance structure among the participants varied. All are nonprofits, but some are hospital districts with public boards, some owned nursing homes, and most are critical access hospitals. Many do not employ physicians in their facilities and instead have Federally Qualified Health Centers (FQHCs) or independent physicians in their communities. After much discussion, the group agreed to a governance structure that allowed for a variety of provider types to join the collaborative without jeopardizing anyone’s nonprofit status or reimbursement structure. The groups that initially joined the collaborative would be considered charter members, with approval rights reserved on any new groups that wanted to join at a later date. Discussions continue with additional hospitals, clinics, provider groups, and stakeholders (such as local counties) about how we can work together. All members have agreed to resource commitments, including financial and time, in order to be part of the collaborative. Each charter member has a seat on the board of directors, regardless of size. Members delegate a senior executive from their organization (typically their CEO) to serve on the board. Membership agreements and budget allocations were approved for 2014 and 2015 to launch the organization. Because of the large geographical area (and traveling distance)

that Wilderness Health covers, most meetings are held virtually via webinars and conference calls. Charter members The charter members of Wilderness Health are located in some of the most rural areas of Minnesota and patients often must travel many miles for access to services. Seven of the nine charter members are critical access hospitals of 25 beds or less. Six facilities also have long-term care facilities on their campus, many of which are owned by the hospitals themselves. Here are the charter members: Bigfork Valley Hospital (Bigfork, Minn.) • A general medical and surgical hospital with 20 beds • Four specialty clinics, a pharmacy, and senior services (adult daycare, home care, long-term care, and an independent/assisted living facility) • G overnment hospital district Community Memorial Hospital (Cloquet, Minn.) • A critical access, general medical, and surgical hospital with 25 beds, a 44-bed long-term care facility, and two clinics • Non-government, notfor-profit

Fairview Range/Range Regional Health Services (Hibbing, Minn.) • Three primary care clinics; memory care, home care and senior services; an inpatient behavioral health unit; a pharmacy; and a general medical and surgical hospital with 81 beds

Cook Hospital (Cook, Minn.) • A critical access, general medical and surgical hospital with 14 beds and a 28-bed skilled nursing facility • Government hospital district

• The primary care clinics in Minnesota are located in Duluth (seven), Hermantown, Hibbing, Mt. Iron, Silver Bay, and in Wisconsin in Ashland and Superior

• Non-government, notfor-profit Lake View Hospital (Two Harbors, Minn.) • A critical access, general medical and surgical hospital with 17 beds, one primary care clinic, and a pharmacy • Non-government, not-for-profit; part of St. Luke’s health care system Mercy Hospital (Moose Lake, Minn.) • A critical access, general medical and surgical hospital with 25 beds, an adjacent skilled nursing health care center, and an assisted living facility

hospital with 25 beds and one primary care clinic • Non-government, notfor-profit St. Luke’s (Duluth, Minn. and surrounding communities) • A health care system with 267 hospital beds, 13 primary care clinics, 23 specialty clinics, one

ing care, improving health, and lowering costs. There are some initiatives that will be addressed during the first years of the collaborative. • Coordinate and improve patient care using evidence-based medicine • Integrate data between entities to enable better care coordination and care planning for patients • Provide quality, local health care in our communities

Hospital-acquired infections and readmissions are reducing payment rates for providers.

Cook County North Shore • Government hospital Hospital (Grand Marais, Minn.) district • A critical access, general Email – Clinic@whla.net medical and surgical Rainy Lake Medical Center hospital with 16 beds (International Falls, Minn.) Telephone-651-426-6995 and a 37-bed skilled • A critical access, general nursing facility medical and surgical • Government hospital district

pharmacy, six urgent care clinics, and one express care site

• Identify shared service opportunities between participating entities to maximize operating efficiencies and reduce costs • Explore alternative payment opportunities, such as accountable care organizations (ACOs), with payers as the system transitions from fee-for-service to fee-for-value

• Non-government, notfor-profit Meeting the Triple Aim Our members are working together to promote the Triple Aim, which calls for improv-

Wilderness Health to page 34

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Telephone: 651-426-6995 April 2015 Minnesota Physician

Womenâ&#x20AC;&#x2122;s Health

here is good news for health care providers who evaluate and treat women with endometriosis. Emerging evidence in the field of minimally invasive gynecology is helping those who treat endometriosis to better understand the treatment modalities that are effective in managing this enigmatic disease. Endometriosis affects 6 percent to 10 percent of reproductive aged women and is one of the most common sources of chronic pelvic pain. Endometriosis refers to the presence of viable, estrogen-sensitive endometrial glands and stroma with an associated inflammatory response outside of the uterus. Several conditions show greater concordance with endometriosis: 21 percent to 47 percent of women presenting with subfertility; 71 percent to 87 percent of those with chronic pelvic pain; and 69 percent of adoles-

Endometriosis Improved outcomes through new technology By Matthew Palmer, DO

cents with nonresponsive pelvic pain. Endometriosis also has a strong familial component and first-degree relatives of individuals diagnosed with endometriosis are seven to 10 times more likely to have the disease themselves. Economic burden Endometriosis is a public health issue that bears an important economic burden. It not only causes pain and infertility, but also has consequences related to medication, health care consumption, work absenteeism, impaired quality of life, and psychosocial factors. The

estimated annual health care burden in the United States for endometriosis exceeds $20 billion. This annual cost actually supersedes that of Crohnâ&#x20AC;&#x2122;s disease ($865 million) or migraine care ($13â&#x20AC;&#x201C;$17 billion). Most experts agree that the disease is multifactorial in etiology but distinct pathophysiology is not well understood. Factors such as retrograde menstruation, metaplastic changes of pleuripotent mesothelial cells, and implantation of cells through hematogenous or lymphatic embolization may play a role in the development of endometriosis. While most women appear to have some degree of retrograde menstruation, not all women develop endometriosis. Those who have endometriosis may have an inherent immune dysfunction that impairs normal clearance yet promotes disease progression. Treatment Laparoscopy is considered the gold standard for the diagnosis of endometriosis with visual identification of classic endometriosis lesions. Histologic confirmation is helpful because visual identification is associated with a high false positive rate. Many patients may be erroneously diagnosed with or without endometriosis due to the lack of a biopsy of the peritoneum at the time of surgery to provide histologic proof of the existence of endometrial glands and stroma in the sample.

Minnesota Physician April 2015

Medical management of endometriosis involves hormonal suppression of endometriosis with oral contraceptives and GnRH agonist medications. The aim of medical management

is to reduce the pain associated with endometriosis. These therapies can be effective but symptoms usually reoccur shortly after the medication is discontinued. Surgical management of endometriosis has largely focused on the destruction or removal of all visible endometriosis lesions. These lesions can take many forms, with the classic presentation being a powder-burn appearance on the surface of the abdominal peritoneum. Endometriosis lesions can also be red, blue, white, or have a more flattened, scarred appearance. Many providers believe that simple ablation of the superficial endometriosis implants is an adequate surgical treatment for the disease. This is usually accomplished with the use of bipolar or monopolar electrocautery. The lesions are usually burned superficially without exploration and removal of the underlying retroperitoneal tissue. Evidence suggests that this type of therapy is inadequate and that true excisional surgery is much more effective in alleviating pain due to endometriosis and preventing recurrence of the disease. Most patients have their pain return in less than a year after having ablative, non-excisional surgery. More important, these methods do not allow confirmation of visual diagnosis by a pathologist. Safety of their application to endometriosis treatment has been questioned. Emerging evidence A recent randomized, controlled trial by Healy, et al. reports on five-year follow-up data on patients who underwent excisional surgery versus ablation surgery for endometriosis. Published in the December 2014 issue of the Journal of Minimally Invasive Gynecology (JMIG), this study compares the efficacy of these two surgical modalities for a variety of outcomes. Their previously published, one year follow-up

data revealed no difference in pain scores among patients treated with either modality. However, when the same patients were interviewed five years after their surgery some differences emerged. Of those that returned the pain assessment survey after five years, 45 patients had undergone excisional surgery and 42 patients had ablative surgery for endometriosis. Both modalities in surgical management proved effective in reduction of overall pain including menstrual-related pain and pain with voiding or defecation. The statistically significant difference was revealed in that patients who had undergone excisional surgery had less pain related to dyspareunia and less need for medical therapy after surgery. It is possible that if the response rate of the survey had been higher, more differences may have been found. This study does help us to understand that deep infiltrating disease, which is often the cause of dyspareunia, is better treated with excisional surgery. Advanced surgery When considering where to refer a patient for management of endometriosis or chronic pelvic pain it is important to understand what patients can expect from their surgeons. Surgeons performing endometriosis resection surgery must be comfortable with complicated pelvic adhesions and dissection of retroperitoneal anatomy. They must be able to navigate bladder and bowel involvement of endometriosis and resect the diseased tissue from these structures. Endometriosis surgeons should be able to repair any bladder and bowel defects caused during resection surgery and must be able to navigate the challenges of a frozen pelvis. Gynecologists performing endometriosis surgery must have a close working relationship with like-minded colleagues in the fields of urology, colorectal,

and general surgery to ensure effective and complete surgical resection. Surgical resection can be planned and completed for even the most challenging of patients.

unproven in a large multicenter trial, data from Ken Levey, MD, published in April 2014, shows a high rate of detection of endometriosis in specimens resected using Firefly. Endometriosis was detected in 78.8

Endometriosis is a public health issue that bears an important economic burden.

Additional research reveals that endometriosis is being detected and treated more effectively than ever with advanced laparoscopic surgical technology and the da Vinci surgical robot. Robotic surgery allows the surgeon to work comfortably, reducing fatigue from standing and bending in a long surgical case. Advanced optics allow visualization in high definition with 10x magnification and 3D and many surgeons believe they can see more disease than they were able to with a traditional laparoscope. Delumba and colleagues reported a 78.2 percent endometriosis detection rate in patients who underwent robotic excisional surgery for supected or known endometriosis. Additionally, advanced robotic technology such as Firefly uses integrated fluorescence imaging capability, which provides real-time, image-guided identification of key anatomical landmarks using near-infrared technology. This technology, which has been used since the 1970s for angiography and hemodynamic monitoring, is now finding an application in minimally invasive gynecology. Firefly takes advantage of the highly vascular nature of endometriosis and helps surgeons identify areas of neovascularization, which is common in this disease. Leaders in endometriosis resection feel that this technology may ultimately help surgeons see more endometriosis and obtain better surgical margins for resection. While this technology remains

percent of specimens biopsied during resection surgery, and in many cases, these areas would not have been removed unless shown to be positive via infrared vision. Conclusion Endometriosis is a common disease in women of childbearing age. This disease can be difficult and challenging to manage for health care pro-

viders across all spectrums of womenâ&#x20AC;&#x2122;s health care. With recent advances in minimally invasive surgery and surgical technology, the management of endometriosis is becoming better understood. As minimally invasive surgeons continue to move the management of endometriosis forward, we are hopeful to see a reduction in the long-term consequences of this disease. Referring physicians should seek out those providers who are comfortable with management of all presentations of endometriosis. A collaborative effort is needed to continue to move this effort forward. Matthew Palmer, DO, is board-certified in obstetrics and gynecology, and practices with Oakdale Ob/ Gyn in Maple Grove, Plymouth, and Crystal. He specializes in minimally invasive surgery with a focus on managing uterine fibroids, endometriosis, and pelvic organ prolapse.

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April 2015 Minnesota Physician

professional update : Genetics

resident Obama announced his Precision Medicine Initiative on Jan. 30, 2015 (www.whitehouse. gov/precisionmedicine). Harold Varmus, director of the National Cancer Institute, and Francis Collins, director of the National Institutes of Health, outlined what the initiative could achieve in a recent issue of the New England Journal of Medicine. The initiative involves a $215 million investment that will be launched in 2016. The National Institutes of Health (NIH) and the Food and Drug Administration (FDA) are just two organizations that will work to develop the resources necessary to attain these objectives: 1) more and better treatments for cancer, 2) creation of a voluntary national research cohort, 3) commitment to protecting privacy, 4) regulatory modernization, and 5) public-private partnerships. At the center of precision medicine is pharmacogenetics.

Pharmacogenetics Tailoring drug therapy Ken Dornfeld, MD, PhD, and Catherine A. McCarty, PhD, MPH

What is pharmacogenetics? Different patients can show dramatically different responses to the same medication. Physicians and patients are often left waiting to see if a new medication works and if it is safe. Tests based on an individual’s genetic composition may allow the treating physician to determine if a medication will be safe and effective for an individual patient without the need for several months of clinical observation. For example, patients lacking glucose-6-phosphate dehydrogenase (G6PD) activity are more prone to increased side effects from a number of medications. What other genetic

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Minnesota Physician April 2015

variations can lead to altered response to medications? Pharmacogenetics, sometimes called personalized medicine, is the study of genetic influences on an individual’s response to medications. The ultimate goal is to use genetic information to tailor drug therapy that is safe and effective. It is also being used to discover new targets for drug therapy. Pharmacogenetics generally refers to a relatively small number of genetic markers, while pharmacogenomics usually refers to a set of markers spanning the entire genome. Individual enzyme testing The FDA maintains a list of approved drugs with pharmacogenomic information on their labeling. Labeling does not translate directly to genetic testing, however. As of Aug. 18, 2014, more than 150 drugs had pharmacogenomic labeling. Some of these drugs include the commonly prescribed celecoxib, codeine, glipizide, metoprolol, and warfarin. Classical pharmacokinetics can describe drug absorption or uptake, metabolic activation or deactivation, and elimination. These pharmacokinetic properties are determined by enzymatic activity that itself is determined by genetic sequence. Variation in sequences in genes active in any pharmacokinetic process can alter the activity and side effects of a drug. Predicting how genetic variation will affect pharmacokinetics in any one individual is the promise of pharmacogenomics. Most medications are subjected to a variety of metabolic enzymes that alter the drug. If

a drug is metabolized slowly, it may reach higher or more toxic levels. If a drug is metabolized quickly, it may be eliminated before reaching effective levels. One large family of drug metabolizing enzymes is known as cytochrome P450. Variations in toxicity and activity of a large number of medications are influenced by variations in genes coding for P450 enzymes. Tamoxifen is an example of a commonly used medication that is metabolized by a cytochrome P450 enzyme. One of the P450 enzymes is responsible for converting tamoxifen into a more active form. Genetic polymorphisms (variations that are more common than 5 percent in the general population) within this particular P450 gene can be responsible for less tamoxifen activation. Whether people with the less active P450 enzyme have different breast cancer outcomes is currently under investigation. Warfarin is another drug that is metabolized by P450 enzymes. Clinical genetic tests are available to determine if an individual is likely to inactivate warfarin quickly or slowly, and may aid in initial dosing decisions. Since clotting times are measured so frequently with international normalized ratios (INRs), the genetic test is rarely used clinically and there is no universal agreement as to its cost effectiveness. Genetic variations in genes leading to altered drug metabolism are fairly rare in the general population. Therefore, testing individual enzyme activities would lead to a large number of negative tests. The inefficiency of this approach has limited routine enzymatic testing. Genetic testing An alternative to individual enzyme tests is genetic testing. The gene coding for important enzymes in drug metabolism can be sequenced to determine if a person is likely to have

abnormal drug metabolism. The appeal of this approach is the increasing efficiency in sequencing genes. The human genome consists of 3,000,000,000 base pairs. The first draft of the sequence was deciphered in 2000 at a cost of $3 billion. This large investment initiated a wave of innovation leading to a dramatic drop in the price of DNA sequencing. This technologic revolution makes testing the genes of interest more cost efficient than testing enzyme activity. Some companies have offered DNA sequencing services directly to the public. The genes sequenced include those responsible for some genetic disorders as well as genes involved in drug metabolism. One company that offers these sequencing services, 23andMe, was required to stop in November 2013 by the FDA. The issue that forced the suspension is whether DNA sequencing is a medical test subject to FDA control or simply a source of personal information not subject to FDA regulation. The case with 23andMe is still ongoing and shows how rapidly this technology is changing. This case also highlights the novelty of genetic information and underscores the need for new approaches to manage genetic data. The Genetic Information Nondiscrimination Act (GINA) was passed in 2008. It prohibits health insurance and employment discrimination based on genetic information. However, as the 23andMe case highlights, several aspects of regulation are still evolving. Sequencing the entire genome The efficiency of DNA sequencing continues to accelerate. A significant milestone was reached last year when Illumina announced its ability to sequence the entire genome for $1,000. From a pharmacogenetic standpoint, this is a major development and means that instead of specialized tests

for several different genes or enzyme activities, a single test, sequencing a personâ&#x20AC;&#x2122;s entire genome, can provide information on how an individual is likely to respond to a variety

The normal DNA sequence and cancer DNA sequence from the same individual can be compared to find unique genetic changes in the cancer. These genetic differences may serve as

Different patients can show dramatically different responses to the same medication.

of drugs. The hope of personalized medicine is to use this personal sequence information to increase the specificity and effectiveness of disease prevention and treatment. Pleitropy Pleiotropy is another challenge for clinical translation of genetic discoveries. Pleiotropy is the influence of a gene on more than one outcome. For example, complement factor H, which is thought to be responsible for 70 percent of age-related macular degeneration (AMD), may also be related to Parkinsonâ&#x20AC;&#x2122;s disease. There is a commercially available genetic test for AMD that includes complement factor H results, but does not provide information about Parkinsonâ&#x20AC;&#x2122;s disease.

targets for therapy. The genetic changes seen in cancer are very diverse and incompletely understood. However, some genetic changes are seen frequently and have been used to develop specific therapies. One example is Herceptin, also known as trastuzumab. Approximately 20 percent of breast cancers contain an overabundance of the growth factor gene Her2. Excess Her2 leads to excess cell growth. Herceptin

can block the growth-promoting action of Her2 and improve control of these cancers. Every patient diagnosed with breast cancer is now tested for the Her2 genetic abnormality and Herceptin is offered only to patients with tumors containing this abnormality. Her2 amplification is also seen in a minority of esophageal cancers. The benefit of Herceptin for these patients is under investigation. Therapy targeted against the epidermal growth factor receptor (EGFR) improves the outcome for colorectal cancer patients but only those that do not have mutations in genes acting downstream of EGFR. Testing cancers for mutations in one downstream gene, KRAS, is now standard for patients with colorectal cancer. Several other cancer treatPharmacogenetics to page 32

Another example is CYP2C9, one of the genes that explains warfarin metabolism. If a clinician orders a CYP2C9 genetic test that is commercially available, they will likely not be told that there are available guidelines for dosing tolbutamide, phenytoin, and a number of other medications based on CYP2C9 genotype. The genetic sequence of cancers There are even greater genetic variations between cancers than genetic differences between individuals. The same revolution in technology that allows rapid DNA sequencing of normal genomes has allowed investigators to determine the genetic sequence of cancers. April 2015 Minnesota Physician

Allied Professions

his past August, I was one of thousands of home care workers who voted in the largest union election in Minnesota history to form our union with SEIU Healthcare Minnesota. This vote was a historic moment in the fight that we are still waging to improve the home care field for both workers and the seniors and people with disabilities that we serve.

My story I had over 10 years of experience working in health care when a family I knew experienced a tragic loss. As a result, I ended up becoming a home care worker for the first time for a young girl named Jayla. Jayla’s dad was the main caregiver for her until he passed away in December 2008. Jayla’s mom, my friend Sarah, was left caring for a special-needs child on her own, and desperately needed help. I saw a little girl who deserved to be able to spend her time at home, not

Unionizing home health care How both providers and patients benefit By Sumer Spika in an institution. I knew that if I cared for Jayla she could remain at home. I had no idea what challenges awaited me as a home care worker though! Jayla was born with pulmonary hypertension and a genetic disorder called Opitz syndrome. She is also deaf. She requires breathing treatments and thickened liquids, and needs help eating, toileting, and performing many other basic activities that require support every single day. I have a strong desire to care for others, and I know that it is beneficial for people to be able to stay in their homes while

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When I first started caring for Jayla, I was offered benefits such as health insurance and vacation time. But over the past few years, my pay has been cut, my vacation time taken away entirely, and the health insurance offered is impossibly expensive and only covers catastrophes. I no longer have the option of taking a day off because I can’t afford to lose the pay. When I gave birth to my daughter last year, I had to return to work the day after I got out of the hospital, even though I’d had a C-section. Forming a union My story is all too familiar to the tens of thousands of home care workers in Minnesota, and it is why we fought for and won the right to vote on forming a union in 2013. A resounding majority of workers voted to form a union in August 2014.

Wherever you are!

receiving the care they need. It gives the person being cared for a sense of dignity and independence. In the home care workers’ campaign that I have come to lead over the last couple of years, we want both home care consumers and the workers who serve them to be able to live the lives they choose.

We have reached a tentative agreement with the state. The contract, which was ratified by members and now needs to be ratified by the Minnesota Legislature, makes many important gains for home care workers. We will go from zero to five days of paid time off, have a dedicated training fund, have the pay floor raised to $11 per hour, and finally have a voice on the job. In other states with established home care unions, increases in pay, benefits, and training have led to less turnover, more stability, a better

prepared workforce, and higher quality care. Everyone who has looked into our growing long-term care system understands that home care offers not just independence and quality of life, but huge taxpayer savings, compared to nursing homes or other institutional care. And in Illinois alone, Attorney General Lisa Madigan has reported that the reduction in turnover that occurred when home care workers won better pay and benefits through their union has saved the state over $600 million. How the union affects home care consumers Home care consumers (people with disabilities and seniors who receive in-home support services through Minnesota’s Medical Assistance program) have been an important and leading part of our fight from the very beginning of our campaign to form a union. Their stories have informed our policy and contract demands, and have moved legislators to understand that low pay and no benefits for home care workers creates instability and constant challenges in the lives of home care consumers. The bill we advocated for and passed at the State Capitol in 2013 explicitly maintained consumers’ rights to hire and fire their home care workers. While pay and benefits are set by the state, consumers need control over their own care. We were proud to have home care consumers join us in pushing for our right to organize, and we continue to include consumers in leadership roles as we negotiate our first contract. Many people end up taking care of family members out of necessity. If home care workers miss work because they can’t afford to take the bus or leave for a better paying job, family members may be forced to step into the caregiver role to prevent their loved ones from entering an institution. The same situation occurs if a consumer has only six or eight hours of care available per

day, but needs more than that to live independently. Often, these family caregivers end up working 24 hours a day, leave jobs with benefits, and become underpaid caregivers. If the home care profession was compensated in a way that made sense, given the importance of the services we provide to seniors and people with disabilities, then consumers would have more stability in their care. Families would know that the workers caring for their loved ones will not only be there every day, but will have a deeper knowledge of the care their clients need. What our union means Eight other states have established home care worker unions, and over the years they have seen their pay and working conditions improve. Consumers also have reaped the benefits of having a more stable, professional workforce. When Illinois home care workers first organized in the 1980s, many of the workers made $1 an hour; now the minimum wage for the state’s home care workers is over $13. In the state of Washington, many union workers are now making $15 an hour. And in multiple states, home care workers have won affordable health insurance. We are confident that as workers see the gains we are bargaining for, we will see a decrease in the incredibly high turnover rate that plagues our field here in Minnesota. The recent U.S. Supreme Court ruling in Harris vs. Quinn made home care unions “open shops.” Every one of the home care workers in our bargaining unit will receive the benefits of the contract, but only workers who have signed cards will pay dues and be members. We already have thousands of members who have signed cards to be part of the union, and our support level has remained high from workers and consumers at every step of this campaign. As workers talk to each other and recognize the systemic problems facing our field, they get

fired up about supporting and joining our union. Even before we won the right to vote on forming a union, two extreme anti-worker lobbying groups filed federal lawsuits to stop us. However, we are confident our union will not be weakened by these outlandish attacks. Both in

es will only compound. Many seniors and people with disabilities would already say we have a crisis, but this will only spread in future years if we don’t find a way to respect and invest in home care work. Most people want to stay in their homes, and that saves money for the state compared with

We want to make sure that our work is “invisible no more!”

Minnesota and across the country, anti-union groups recruited a handful of home care workers to use in their attacks on workers’ collective bargaining. But that has not stopped workers and consumers from coming together to improve the conditions in our field. We don’t expect any of the attacks to derail our movement, especially as we are able to see gains made through bargaining our first contract. The future outlook Many of us have been involved in this struggle for more twists and turns than we care to remember, but we have remained unwavering in our belief that we will win this fight to improve our industry. Our goal has remained unchanged from the first days of this campaign over a decade ago: We want to make sure that our work is “invisible no more!” We know from other states that better pay and working conditions leads to more stability, and we fully expect that to happen in Minnesota as well. Especially when we consider the coming age wave, and the fact that home care work is projected to be the second fastest growing job in the country for the next couple of decades, we don’t feel like we have much of a choice but to win this battle. Home care consumers will attest to the challenge of finding stable care, and as baby boomers age and want to stay in their homes, these challeng-

long-term care facilities. It is a win-win situation. For myself and other home care workers, we want to be able to continue to do the work we love, yet it is imperative that we are able to provide for our own families. I’ve seen too many wonderful caregivers leave the field to do other work, not because they were not talented or caring, but because

they couldn’t afford rent or time off when they were sick. It has been a powerful experience for home care workers to come out from the shadows and talk to each other, recognizing that the daily challenges we face are frighteningly common. We know our first contract won’t change the industry overnight, but we know we will be moving in the right direction. We appreciate all of the people who work hard in the medical field, and we simply hope the important role home care workers play in supporting millions of people across the country will finally be recognized and compensated fairly here in Minnesota. When at long last this happens, both home care workers and the people they serve will finally be able to live the lives they choose. Sumer Spika is a home care worker and executive board member for SEIU Healthcare Minnesota.

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April 2015 Minnesota Physician

NEUROLOGY

ision is controlled in over 30 areas of the brain. Vision is different than eyesight. Where eyesight is a measurement of acuity, vision is extremely complex and involves visual processing in the brain. Seventy percent of all sensory processing in the human body is affected by vision. Because the brain is such an integral component of vision, it should come as no surprise that up to 40 percent of patients with mild traumatic brain injury (mTBI) complain of visual symptoms. According to the Centers for Disease Control and Prevention, about 1.7 million people sustain a traumatic brain injury (most of which are mild) in the U.S. every year. This is likely an underestimation because some concussions go undiagnosed or are underreported. Despite the fact that some patients exhibit the signs and symptoms of mTBI and are unable to function at work or school, imaging often shows no structural

Vision and mild traumatic brain injury A look at the consequences By Jessica Schara, OD injury. Yet something is clearly wrong. Current theories support the fact that brain injury symptoms likely arise from diffuse axonal injury, whether it is to the axon itself or from altered cellular transport or metabolism from the injury. Treatment modalities vary but cognitive brain rest allows the altered metabolism in the brain to heal. Any increase in cognitive or physical activity places more demands on the already metabolically altered and energy-lacking brain and will likely worsen symptoms. Recovering

from mTBI may take a few days or a few weeks. If symptoms last longer, patients may develop post-concussion syndrome, which refers to concussion symptoms that linger for weeks or even months after the injury. Visual symptoms Vision can be disrupted via pathway signaling disruption or by direct damage to the structures involved. As an optometrist, I have seen structural issues related to mTBI such as retinal detachment and dry eye syndrome that

are important to address and treat. More often, I encounter patients who have refractive error changes (that may or may not resolve over time) and visual efficiency problems that make functional vision such as reading, using a computer, and driving much more difficult or impossible. If the eyes and the brain are not working together properly (teaming, focusing, and tracking all at the proper time), the concussed brain must expend energy (which it already lacks because of the mTBI) to try and fix the problem. As a result, reading automaticity and comprehension can be laborious. The importance of conducting a comprehensive eye and vision exam on all mTBI patients may play a significant role in recovery. In my practice, the majority of mTBI patients exhibit some visual symptoms. Common symptoms and signs of mTBI include blurred vision at distance, blurred vision at near (more common), fluctuations in vision, pain around the

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Minnesota Physician April 2015

eyes, headaches (usually frontal and severe), words appearing to move when reading, double vision, light sensitivity, the need to close or cover an eye, squinting, losing your place when reading, and rereading for comprehension. Patients often exhibit head tilts or turns and coordination issues, and will bump into objects due to visual field defects or have to hold on to the wall when walking. Dizziness when reading, problems judging size and distance, visual midline shift syndrome, staring behavior, poor balance, and nausea with near work activities are often observed as well. Itâ&#x20AC;&#x2122;s important to remember that every mTBI patient is different. Probably, the most frequent complaint from mTBI patients is that they have blurred near vision. Many patients report that their eyes feel tired, blurry, or hurt when trying to read or view a near object. The near reflex consists of pupils constricting, eyes turning inward

may include orthoptics/vision therapy. Convergence and divergence binocular teaming issues are also prevalent, most commonly, convergence insufficiency. Convergence insufficiency can cause symptoms of diplopia, eye strain, dizziness, headAbout 1.7 million people aches, covering an eye while sustain a traumatic brain reading, and injury in the U.S. every year. poor comprehension. Treatment of this condition includes orthopappropriately either. The ciliary tics or vision therapy, lenses, and muscle controls lens changes prisms in spectacles. that cause our accommodative system to keep vision clear when shifting focus at varying Eye movement distances. It has both sympaThere are two main types of thetic and parasympathetic eye movements that seem to be innervation in which the signal- affected in mTBI patients: puring seems disrupted due to the suit movements and saccades. autonomic dysfunction experiPursuit eye movements are enced by mTBI patients, thus used to track a moving object causing symptoms. Treatment and are not only important in for accommodative dysfunction sports but also in reading. The includes the use of spectacles pathway for pursuits involves for near vision, bifocals, and the frontal eye fields to the

(converging), and the accommodative (focusing) system becoming stimulated. In my experience, because these components are all interrelated, if one part isnâ&#x20AC;&#x2122;t functioning properly, the others may not be functioning

pontine nuclei to the vestibular nuclei and finally ends at the oculomotor nuclei. While testing, if there seems to be a large variation in response in different directions that usually means that the frontal eye field on the ipsilateral (same) side is affected. Saccades are fast, fine eye movements that occur when our eyes look from one place to the next, such as while reading. Saccadic pathways occur from the frontal eye fields to the superior colliculus to the paramedian pontine reticular formation to the oculomotor nuclei. Patients with pursuit and/ or saccadic dysfunction experience frequent loss of place when reading, may need to use their finger as a guide, reread text for comprehension, and skip words or lines. Brain injury patients may exhibit pursuit dysfunction, saccadic dysfunction, and sometimes both. This is an inefficient visual system and can have significant impact on qualVision and mild traumatic brain injury to page 30

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Vision and mild traumatic brain injury from page 29

ripheral vision, which may lead to mobility issues and decreased depth perception. Intractable diplopia patients may benefit from spot patching, which essentially looks like a small piece (less than the size of a dime) of scotch tape that is placed in the center of fixation of the patient’s glasses thereby allowing peripheral vision to remain intact.

ity of life. Treatment options include spectacle correction if necessary and possibly vision therapy. Diplopia Strabismus and decompensated phoria can all lead to diplopia after mTBI. Patients that once had good control of their strabismus prior to mTBI may not have the same ability after the injury. Many times, simple application of a prism can be very successful in eliminating patient symptoms during the healing process. Fresnel prisms are useful in that they can be applied to a patient’s glasses when they are in the office. As the patient heals, if the prism is decreased, a simple replacement with the lesser prism can be applied without having to remake the lenses. If the prism is not an option, patching may be necessary to ease diplopia. Patching limits a patient’s pe-

Photophobia Pupil size can be influenced by the autonomic system and can dilate when in fight or flight mode allowing more light in, thereby making photophobia worse. This may not fully explain light sensitivity after mTBI. Photophobia/light sensitivity usually improves with time, however, patients can be made much more comfortable with tinted lenses for outdoor and indoor use. Specifically, I have found that amber tints and gray or blue tints are successful in relieving patient symptoms.

Visual field defects Visual field defects are a common sequelae of mTBI. This causes peripheral vision issues that may in turn affect mobility and cause patients to bump into objects or fall. In the office, peripheral vision testing plays an important role in managing mTBI patients. Visual field defects can adversely affect reading. For example, a patient with right hemianopsia will be missing part of their field of vision on the right side of each eye and will stop reading a line of text too soon. A patient with left hemianopsia will have difficulty starting a line of text when reading. Boundary marking at the beginning or at the end of a column of text can help patients who lose their place when reading. Working with a therapist who teaches scanning techniques and expanding the field of vision with prisms may also be of benefit.

Conclusion Many patients recover from mTBI with brain rest treatment. For those who take longer to recover or who may have post-concussion syndrome, consider vision issues as a possible culprit in delayed healing. I have had the most success treating patients when physicians and physical or occupational therapists share information. mTBI patients have many issues that can complicate recovery and these issues must be addressed so they can return to work, school, or play. Strong communication between providers gives the patient the best chance for a quick and full recovery. Jessica Schara, OD, is an optometrist at Mead EyeCare & EyeWear in Woodbury. She completed a residency in pediatrics and binocular vision and is a member of the Neuro-Optometric Rehabilitation Association. She currently serves as a trustee on the Minnesota Optometric Association board.

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Minnesota Physician April 2015

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April 2015 Minnesota Physician

Pharmacogenetics from page 25

ments based on the specific genetic changes within a cancer have been developed in recent years. For example, mutations in the BRAF gene are associated with melanoma. Dabrafenib and related drugs are active against melanoma tumors with a specific BRAF mutation. Treatment directed toward mutant or altered gene products are available for disease other than cancer. For example, one drug has been developed to treat a subset of cystic fibrosis in patients with a specific genetic alteration in the gene responsible for this disease. The importance of family history Until genomic-based drug therapy becomes a standard of

care and is readily available, clinicians should continue to use detailed family health histories to personalize health care delivery. A good family health history includes three generations of biological relatives, the age at diagnosis of various conditions, and the age at death for deceased relatives. Patients can be directed to the Surgeon General’s electronic family health

Family Medicine General Surgery Hospitalist Internal Medicine Neurology

history tool to prompt them to collect necessary information. Family history information should be updated regularly. Genetic counselors are a great resource to collect family health history information and to counsel patients.

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Where can I go for more information? There are a number of reputable websites that contain accurate, up-to-date information regarding genomics. This is a rapidly developing field with new results coming out daily.

Minnesota Physician April 2015

is responsible for genomics research. Their site has information for patients as well as for researchers and clinicians. • The Surgeon General’s Family Health History Initiative site (www.hhs.gov/ familyhistory/) contains information about National Family History Day, declared by the Surgeon General as Thanksgiving Day since 2004, and a link to My Family Health Portrait, an online family health history tool. • The Centers for Disease Control and Prevention– Office of Public Health Genomics (OPHG) (www. cdc.gov/genomics/) provides timely and credible information for the effective and responsible translation of genomics research into population health benefits. • The Food and Drug Administration site (www. fda.gov/Drugs/ScienceRe search/ResearchAreas/ Pharmacogenetics/default. htm) has genomics information and includes the table of approved drugs with pharmacogenomic information on their labeling.

• The National Society of Genetic Counselors site (www.nsgc.org) explains how to find a genetic counselor and learn about the services they provide. • The American Cancer Society site (www.cancer. org) has cancer-specific information about genetic causes and gene-based therapies for cancers. • The American Heart Association site (www.heart. org) has information about the genetic basis of heart disease and treatment. • The Genetic Alliance (www.geneticalliance. org) is a nonprofit health advocacy organization and their site has information on a wide range of genetics topics. • Pharmacogenetic Research Network (PGRN) is funded by the National Institutes of Health and is a resource (www.pharmgkb.org) for the latest pharmacogenetics research results and evidence-based guidelines for genetic-based prescribing. • The American Medical Association site has a page (www.ama-assn.org/ama/ pub/physician-resources/ medical-science/genet ics-molecular-medicine/ current-topics/pharmacogenomics.page) that discusses pharmacogenomics. Ken Dornfeld, MD, PhD, is a radiation oncologist at Essentia Health in Duluth. His research interests include laboratory research into interactions between drugs and radiation and clinical research in breast cancer. Catherine A. McCarty, PhD, MPH, is a principal research scientist and director of the Research Division at Essentia Institute of Rural Health. She is currently conducting genomic medicine and family health history studies funded by the National Institutes of Health.

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Emergency Medicine Geriatrician (part-time) Hospitalist (Internal Medicine or Family Practice) Nephrologist Oncologist

Primary Care (Family Practice or Internal Medicine)

Join our team At Allina Health, we’re here to care for the millions of patients we see each year throughout Minnesota and western Wisconsin. From rural to urban settings, you’ll find a practice and community that is right for you, with ideal staff support and the widest range of clinical practice options, physician leadership opportunities and competitive benefits. EOE/AA/Vet/Disabled Employer

Psychiatrist Pulmonologist Urologist (part-time)

(605) 333-6852 www.siouxfalls.va.gov Applicants can apply online at www.USAJOBS.gov

Join the Leader in Correctional Health Care FEDERAL BUREAU OF PRISONS

Full-Time Psychiatrist – FMC Rochester, MN Full Time Clinical Director – FCI Sandstone, MN Learn more at: www.bop.gov

Make a difference. Join our award-winning team.

Sioux Falls VA Health Care System

1-800-248-4921 (toll-free) Katie.Schrum@allina.com

allinahealth.org/careers

Family or Internal Medicine Physician An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites. For more information Call Kirk Stensrud, CEO 320.634.4521 Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334 Email CV to: kirk.stensrud@glacialridge.org

www.glacialridge.org April 2015 Minnesota Physician

Wilderness Health from page 21

• Work with key community stakeholders to improve the continuum of care and identify gaps in care

data from multiple sources to quickly and efficiently identify quality improvements and better manage patient care coordination. This tool will enable the collaborative to: • Monitor quality across the organizations

Data integration A comprehensive needs assessment was done and it was determined that one of the areas of opportunity for health outcome improvement was in data integration. All of the Wilderness members use electronic health records (EHR), but none of the hospitals have a system with the ability to interface with payer data feeds to identify care performed throughout the continuum or analyze total cost of care for patients. Improving data integration for one facility was not feasible due to cost, resource availability, and volume. The collaborative is currently working with a vendor to implement an analytical tool that allows integration of

• Identify opportunities to positively impact patients’

of care and enable participation with Medicare, Medicaid, and commercial payer alternative payment models. Health systems and physicians across the region will work together to develop consistent best medical practices, enabling coordinated, patient-centered, efficient, and high quality care.

Medicare is the largest payer for all Wilderness Health members.

health and enhance care coordination across health systems • Perform predictive modeling to identify patients at risk of chronic conditions The collaborative will be able to monitor the total cost

Wilderness Health received an eHealth Development Grant from the Minnesota Department of Health in October 2014. This grant is being used to fund a project management plan for the data integration project. The planning process is expected to wrap up in June 2015,

with system implementation to occur throughout 2015 and probably 2016. Once implemented, the system will enable the collaborative to meet the additional goal of expanding access to and improving the quality of essential health care services. Monitoring quality requires the ability to measure results and we know that we need better tools to do this. Wilderness Health Medical Director G. David Spoelhof, MD, describes his vision for Wilderness Health as, “We hope to use our shared data to identify opportunities for enhanced care management, resulting in better health outcomes and decreased costs for our patients.” Cassandra Beardsley is executive director of Wilderness Health and serves on the Health Industry Advisory Panel for MNsure.

Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.

Avera Marshall Regional Medical Center 300 S. Bruce St. Marshall, MN 56258

Currently we are seeking to add the following specialists: • Psychiatrist

• Family Medicine

• Psychologist

• Internal Medicine

• Orthopedic Surgeon

• OBGYN

• General Surgeon

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • Dave.Dertien@avera.org

www.averamarshall.org 34

Minnesota Physician April 2015

Olmsted Medical Center, a 220-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: Family Medicine

Pain Medicine

Spring Valley Clinic

Rochester Northwest Clinic

Nursing Home Physician

Psychiatrist – Child & Adolescence

Rochester and Southeast MN

OB/GYN

Rochester Southeast Clinic

• Allergy/ Immunology

• Geriatric Medicine

• Orthopedic Surgery

• Dermatology

• Hospitalist

• Pain Medicine

• Emergency Medicine

• Hospice

• Psychiatry

• Family Medicine

• Med/Peds

• General Surgery

• Internal Medicine • Rheumatology • Sports Medicine

• Ob/Gyn

Hospital – New Women’s Health Pavilion

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

Tell them there’s a better way! Get your patients screened for colorectal cancer.

April 2015 Minnesota Physician

Leveraging information technology from page 19

to leveraging new technology to improve the health of all Minnesotans. E-health is a critical component of advancing the notion of accountable health, in that it supports the safe, accurate, and efficient exchange of information between the care teams. E-health will play a pivotal role in achieving our health system’s transformation to one that utilizes information and collaboration to continually improve population health by providing the tools needed

to gather and use information. Building off of Minnesota’s strong history of collaboration among health care organizations, this “learning health

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

healthpar tners .com

36 Minnesota Physician MN Physician 4" x 5.25" 4-color

April 2015

Health care providers are

Nine in 10 clinics and all Minnesota hospitals have adopted an EHR.

system” will encompass a continuous cycle of learning and improvement that optimizes information for research, public health surveillance, quality improvement, and consumer’s knowledge-driven decision Common HIE transactions making. Achiev• Electronic prescribing ing a learning • Public health transactions health system will enable • Laboratory data transactions health care in • Quality reporting transactions Minnesota to • Transfer of care and referral summaries move beyond

the goals of the Triple Aim to truly transform the health and well-being of our citizens.

EHR systems and workforce HIT skills evolve, health care providers in Minnesota will be positioned to use HIT tools to optimize patient care and outcomes, and to engage patients to be partners in their health care. Resources for achieving the 2015 Interoperable EHR Mandate are available at: www.health.state. mn.us/e-health/

embracing e-health to improve overall population health. Adoption rates are high for clinics and effective use of EHRs for patient care has increased over time. Progress is still underway to achieve the benefits and promise of fully interoperable EHRs in Minnesota. However, the providers in the state are well positioned for success because of their commitment to health IT (HIT) and the collaborative efforts of the health care community. As

Bob Johnson, MPP, is a planner with the Minnesota Department of Health’s Office of Health Information Technology. He supports programs that advance the adoption and effective use of EHRs and other health information technology statewide and coordinates the work of the Minnesota e-Health Advisory Committee and the Privacy and Security Workgroup. Karen Soderberg, MS, is health information technology assessment & evaluation coordinator with the Minnesota Department of Health’s Office of Health Information Technology. She coordinates and directs the statewide informatics profile of adoption, the use of EHRs, and the secure exchange and interoperability of health information.

Family Medicine with Clinic OB Physician-owned Gateway Clinic seeks a family medicine physician to join our new Hinckley clinic. 3 or 4-day week practice with shared hospital call. Full-scope primary care and clinic OB practice (prenatal and postpartum care in clinic, option for colleagues to cover OB call and deliveries). Generous salary with sign-on and retention bonus, outstanding benefit package, 15% retirement contribution. Shareholder opportunities available. Gateway Clinic has locations in Moose Lake, Sandstone and Hinckley. Centrally located between Mpls/St. Paul and Duluth, the area provides an excellent family focused, quality of life opportunity in a rural setting with good public schools and abundant with lakes, rivers, state parks, and ideal hunting - all within an hour to metropolitan conveniences.

For additional information, contact Dr. Kathy Brandli, President, at kbrandli@gatewayclinic.com or Eric Nielsen, Administrator, at enielsen@gatewayclinic.com or 218.485.2000

www.gatewayclinic.com

Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

Opportunities for full-time and part-time staff are available in the following positions:

• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

Please contact or fax CV to:

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

• Associate Chief of Staff • Compensation & Pension Physician

• Medical Director Extended Care & Rehab (Geriatrics) • Ophthalmologist

• Dermatologist

• Physician (Pain Clinic)/ Panel Management • Geriatrician/Hospice & Palliative Care • Psychiatrist • Internal Medicine/ Family Practice Applicants must be BE/BC.

www.NWFPC.com

Family Medicine & Emergency Medicine Physicians

Great Opportunities

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

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. 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 Nola Mattson, STC.HR@VA.GOV

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

Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 April 2015 Minnesota Physician

Forging new alliances from page 17

people age. Dental practices can provide limited health screenings, education, and possibly follow-along services to their patients. As in the case of Dr. Rinaldi’s patient, it makes sense for dentists to be another line of defense for their patients’ overall health and a partner to their primary physician. The flaw in this system is that physicians do not have access to the data that dentists collect. Conversely, unless a patient volunteers health-related information during a dental visit or is asked, dentists are often unaware of any new medical issues they might have. The obvious solution would be for dentists and doctors to be able to share all their patients’ dental and medical records. Such a system does not currently exist. With the advent of electronic medical and dental records, this could one day become a reality. However,

both physicians and dentists need to collaborate in order to build a shared electronic record system. The future of dental/medical collaboration Although there is ample opportunity for the dental and medical professions to collaborate, so far only the surface has been scratched. Awareness is an important first step. While today’s dental instructors at the University of Minnesota and elsewhere now train their students about the oral and overall health connection, Park Dental has taken recent steps to further the dialogue by hosting an annual forum on current strategic health care issues for dental students. February’s event featured speakers from dentistry and medicine and several gave keynote presentations and participated in a panel discussion about the oral/overall-health connection. George J.

have made incredible strides in today’s electronic medical and dental records. With support and guidance from the medical and dental communities, true interoperability between these records will one day be possible.

Isham, MD, MS, senior fellow with HealthPartners Institute for Education and Research, discussed his role in working with his organization’s senior management team to improve patient care. His participation on the panel prompted some great interaction among the other panel members, dentists, and the dental students in attendance. Park Dental recently embarked on a new initiative called Vision 2030. This 15-year effort will help us increase our interaction with our patients’ physicians, as well as increase our focus and ability to measure outcomes of care. Through these efforts, we hope to elevate Minnesota’s oral health to become the best in the nation, a ranking in which the state currently falls short. Technology will certainly play an important role in overcoming the challenges currently faced in medical/dental collaboration. System developers

In his recent essay “Market Trends in Dentistry,” Jeffrey R. Lavers wrote, “The dental care system will evolve more in the next 20 years than in the previous 50.” The same can probably be said for medicine. This evolution should include a much closer working relationship between dentists and physicians. Research has already demonstrated that a medical/ dental collaboration could be an important key in controlling rising health care costs. The ultimate goal, however, is for physicians and dentists to advance the overall health and quality of life of their patients. John E. Gulon, DDS, is president and a board member of Park Dental, where he has been a practicing dentist since 1987.

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Minnesota Physician April 2015

t i y r T r o f E FRE ths n o m 3

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