Minnesota Physician March 2014 by Minnesota Physician Publishing

Vo l u m e x x v i i , N o . 12 M a r c h 2 014

Catch and release Undercurrents of healing By Charles Bransford, MD

Editor’s note: This essay was written for the Kelly Culhane Writing Prize on the topic, “How nature eased my pain and helped me heal.” The contest was sponsored by Savage Press, Inc., Superior, Wisc.

stand in the shallow water, comfortable in my trusty waders, fly rod in hand, looking patiently for clues. Rising haughtily out of the mist enshrouding the bulrushes to my left, a great blue heron flaps his antediluvian wings and disappears, but not before he tips his head, wink-like, towards the half-submerged tree near the water’s edge.

Ready or not … ICD-10 is coming By Katie Kerr, MA, RHIA, and Brooke Palkie, EdD, RHIA

here’s no turning back now: Big changes in medical diagnosis and inpatient procedure codes are coming for “HIPAA-covered entities”—and if you’re reading this publication, that almost certainly means you. Specifically, as of Oct. 1, 2014, ICD-9-CM (the U.S. version of the World Health Organization’s International Classification of Diseases, Ninth Revision, Clinical Modification), will be replaced by ICD-10-CM/PCS. In this tenth version of the ICD:

inpatient hospital and physician practices alike.

• ICD-10-PCS procedure codes will be used for inpatient hospital procedures only.

The transition is occurring because the ICD-9 codes provide limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9-CM, which was developed more than 30 years ago, uses outdated and obsolete terms, and is inconsistent with current medical practice. According to CMS.gov (the website of the Centers for Medicare & Medicaid Services), ICD-10-CM/PCS is more robust and descriptive. In “one-to-many” matches, for example, one ICD-9 procedure code may translate to hundreds of anatomi-

• ICD-10-CM will be used by

Ready or not ... to page 10

Now I know she is really there—the magical fish I’ve been seeking all my life: the one all fishermen imagine every time they have a big fish on the line just before they can actually see it. The fins appear, then shadows of the towering giant, and finally the real thing. Today, the calls of red-winged blackbirds, blue jays, wrens, and chickadees blend with the soft hum of cicadas and crickets. Bullfrogs provide the percussion. However, it’s the silence between the sounds that calls to my soul and settles me into the Catch and release to page 12

Join an Established Medical Community

High Pointe Health Campus 8650 Hudson Boulevard | Lake Elmo, MN > Class A medical building > Independent multi-specialty surgery center > Urgent care and extended clinic hours > Easy access to I-94, I-494, and I-694 Meet our new management team:

TENANTS: > High Pointe Surgery Center > St. Croix Orthopaedics > Orthopaedic Sports Inc > Park Dental > Pediatric & Young Adult Medicine Scan the QR code to view our e-brochure or visit colliersmsp.com/highpointe

Dawn Grant

Karleene Knight

This property is just a sample of our extensive medical portfolio. For more information on this or any of our other her listings, contact the Healthcare Services Group today. Healthcare Services Group Direct 952 837 3061 healthcare@welshco.com www.colliers-healthcareservicesmn.com

March 2014 • Volume XXVII, No. 12

Features Ready or not … ICD-10 is coming

MINNESOTA HEALTH CARE ROUNDTABLE

By Katie Kerr, MA, RHIA and Brooke Palkie, EdD, RHIA

Catch and release Undercurrents of healing

By Charles Bransford, MD

DEPARTMENTS CAPSULES 4 MEDICUS 7 INTERVIEW 8 Kathy Sheran

Gastroenterology 16 Gastroesophageal reflux disease By Rafael S. Andrade, MD

Urology 18

Chair, Minnesota Senate Health, Human Services and Housing Committee

Erectile dysfunction By Matthew Braasch, MD

Post-acute care Fixing cracks in the system

Telehealth potential By Cathy Brady, RN, WCC

SPECIAL FOCUS: Pharmacy

Practice-Based Research Networks By Jon C. Schommer, PhD

Objectives: We will discuss the evolution of post-acute care and illustrate the 1:00–4:00 PM, Symphony Ballroom dynamic potential it holds. From the Downtown Minneapolis Hilton and Towers hospital to the physician to skilled nursing, rehab, and home care, we will present perspectives from across the care continuum. We will investigate communication problems between care team members and present potential solutions. We will examine how elements of health care reform like ACOs and insurance exchanges can drive both improvement in and higher utilization of post-acute care. We will discuss the tools that are necessary for post-acute care to reach its full potential. Thursday, April 17, 2014

PROFESSIONAL UPDATE: Home Care

Compounding pharmacies 26 By Geoffrey Emerson, MD, PhD

Background and focus: Post-acute care is becoming an increasingly important component of health care delivery. It is also becoming increasingly community-based. Medical advances are dramatically expanding the range of access to these services and, at the same time, creating a larger number of problems providing them. Choppy access to electronic medical records and ensuing medication management complications, as well as problems with care team coordination, can impede the goal of improving outcomes while lowering costs.

Recently approved by the FDA 30 By Jean Moon, PharmD, BCACP

• Krista Boston, JD, Director, Minnesota Board on Aging • John Frederick, MD, Medical Director, PreferredOne • Sharon Klefsaas, Vice President, Operations, Presbyterian Homes and Services

Feature: Community Caregivers Community caregivers 2014 By Minnesota Physician Publishing staff

Panelists include:

• Rahul Koranne, MD, MBA, FACP, Executive Medical Director, Bethesda Hospital • Dawn Simonson, MPA, Executive Director, Metro Area Agency on Aging, Inc. • Kari Thurlow, JD, Senior Vice President, Advocacy, Aging Services of Minnesota

Sponsors include:

• Aging Services of Minnesota • HealthEast Care System • MN Association of Area Agencies on Aging • Presbyterian Homes and Services • Senior LinkAge Line

www.mppub.com Publisher Mike Starnes mstarnes@mppub.com Senior Editor Janet Cass jcass@mppub.com

Please send me ____ tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone 612.728.8600 or fax 612.728.8601. Name Company Address

Editor Stacey Bush sbush@mppub.com

City, State, ZIP

Art Director Alice Savitski asavitski@mppub.com

Telephone/FAX

Office Administrator Amanda Marlow amarlow@mppub.com Account Executive Iain Kane ikane@mppub.com

Card #  Check enclosed

Exp. Date  Bill me

 Credit car (Visa, Mastercard, American Express or Discover)

Signature Email

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email mpp@ mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

Please mail, call in, or fax your registration by 4/7/2014

March 2014 Minnesota Physician

Capsules

Optum Labs Partners With U of M School of Nursing The University of Minnesota (U of M) School of Nursing is one of seven new partner organizations named by Massachusetts-based Optum Labs. “Cross-industry collaboration is vital to the success of our collective research agenda, and these leaders bring important perspectives that will advance our current efforts, and help us embark on new adventures,” said Paul Bleicher, MD, PhD, CEO of Optum Labs. Optum Labs, founded in a collaborative effort between Optum and Mayo Clinic in 2013, offers participants access to information resources, proprietary analytical tools, and scientific expertise to support the discovery of new applications, testing of new care pathways, and other innovations. “The University of Minnesota School of Nursing is at the forefront of advancing the use of data and analytics to improve patient care. With access to

the electronic health data from Optum Labs representing more than 140 million lives, we look forward to collaborating with our national and university partners to identify, explore, and answer research questions that will lead to better and more consistent evidence-based care,” said Connie White Delaney, PhD, RN, dean of the U of M School of Nursing. The U of M program will utilize the new partnership to conduct research to identify which nursing interventions may be most effective in reducing hospital readmissions for elderly patients. Long-term interventions for diabetes, reducing infections, and other topics will be researched as well. Other new partners that were announced are American Medical Group Association, Alexandria, Va.; Boston University School of Public Health, Boston; Lehigh Valley Health Network, Allentown, Pa.; Pfizer, Inc., New York City; Rensselaer Polytechnic Institute, Troy, N.Y.; and Tufts Medical Center, Boston.

UCare Hires New Vice President/CIO Minnesota’s nonprofit health plan, UCare, has hired Daniel Abdul as its new vice president and chief information officer. Previously, Abdul served as chief information officer at the Minnesota Department of Veteran Affairs. He earned a Master of Business Administration degree in business strategy from the Carlson School of Management and has nearly 13 years of experience in the field of information technology. “Dan Abdul is an experienced information technology leader with extensive data management knowledge. He has a strong record of enterprising technology solutions for claims, data security, compliance, and other areas critical to the efficient delivery of quality health care today,” said Hilary Marden-Resnik, senior vice president and chief administrative officer at UCare.

State, Businesses Partner to Promote Worksite Wellness Several business executives joined Gov. Dayton in the Capitol rotunda in early February to promote workplace wellness as part of an effort to improve workers’ health and productivity, and decrease health care costs and absenteeism. Minnesota spends almost $6 billion in excess health care costs each year due to obesity and tobacco, according to Minnesota Department of Health officials. Nationally, employers spend $93 billion in health insurance claims and $1.3 trillion due to lost productivity and absenteeism each year. “We look forward to helping more businesses create healthy worksites … good for employees, communities, and the bottom line,” said Ed Ehlinger, MD, Minnesota commissioner of health. As part of the event, Dayton proclaimed 2014 the “Year of Worksite Wellness.” A CEO pledge effort was also introduced. The

Orthopaedic

Radio Drive

7 DAYS A WEEK

o ds Hu

Urgent Care

High Pointe

Providing walk-in care for: • Fractures • Joint Pain • Dislocations • Sports Injuries • Sprains and Strains • Concussions • Muscle Pain

High Pointe Health Campus Off I94 and Radio Drive 651.439.8807 or 800.423.1088 www.stcroixortho.com

Monday - Friday 1:00 p.m. to 8:00 p.m. Saturday & Sunday 8:00 a.m. to noon • No appointment is necessary • All patients are seen by a physician 4

Minnesota Physician March 2014

URGENT CARE

pledge asks businesses to incorporate strategies to promote a culture of physical activity in the workplace. “Healthier workers—and healthier bosses—will lead to improved company morale, lower health care costs, and increased productivity,” said Anytime Fitness CEO Chuck Runyon, who is spearheading the effort. A 2012 survey found that 87 percent of Minnesota workplaces are interested in improving wellness, while only 23 percent currently offer workplace wellness efforts. Poor employee health is correlated with a more than 50 percent decrease in overall productivity, which costs U.S. companies an estimated $225.8 billion annually, or $1,685 per employee each year. Minnesota businesses that already support the effort include Schwan Food Co., Blue Cross and Blue Shield of Minnesota, Anytime Fitness, Dakota County Regional Chamber of Commerce, Connolly Kuhl Group, Lakewood Health Center, Lifetime Fitness, St. Paul Area Chamber of Commerce, Staywell Health Management, Taher Inc., and TEAM Industries. Members of Minnesota’s Legislative Wellness Caucus also support the initiative, including Sen. Sandy Pappas, Sen. Dave Senjem, Rep. Leon Lillie, Rep. Matt Dean, and Rep. Erin Murphy.

New Executives at Sanford Health Sanford Health of Northern Minnesota (SHNM) has named David Wilcox, MD, its new chief medical officer (CMO) and Vicky Korynta, BSN, MSN, its new chief nursing officer. Wilcox earned his medical degree at the Medical College of Wisconsin and is certified by the American Board of Family Medicine. He has served as a family medicine physician with Sanford since 1988, and has been part-time chief medical informatics officer (CMIO). Sanford officials say Wilcox will continue his regular clinical practice while serving part time as both CMO and CMIO. He will also oversee quality at Sanford Health Bemidji. Korynta has been on staff with

SHNM since November. She has a bachelor’s degree in nursing from the University of North Dakota and a master’s degree in nursing leadership from Grand Canyon University in Phoenix, Ariz. Previously, Korynta served as senior vice president and chief operating officer at Fairview Range Medical Center in Hibbing.

RARE Campaign Receives Award The Reducing Avoidable Readmissions Effectively (RARE) campaign has received the 2013 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality. The annual award is presented by The Joint Commission and the National Quality Forum. RARE was launched in 2011 by the Institute for Clinical Systems Improvement (ICSI), the Minnesota Hospital Association, and Stratis Health. According to officials, the 82 hospitals and 100 community partners that participate in the initiative prevented more than 6,200 readmissions between Jan. 1, 2011 and June 30, 2013. Kathy Cummins, RN, MA, ICSI project manager, said the campaign’s partner organizations aren’t given specific instructions, but RARE encourages focused efforts to address comprehensive discharge planning, medication management, patient and family engagement, transition care support, and transition communications. RARE provides guidance and technical support, and each hospital and community partner determines its own specific strategies to reduce readmissions. “Hospitalists don’t want to see their patients readmitted to the hospital,” said Howard Epstein, MD, FHM, chief health systems officer at ICSI. “It doesn’t look good on their part, and it’s not the best thing for their patients. The RARE campaign galvanized the system to support what hospitalists have been demanding for many years.”

New Medical Director At Honoring Choices Honoring Choices Minnesota, a project of the Twin Cities MediCapsules to page 6

Physician Driven. Patient Inspired.

“The time“The theytime save they me meeting save me meeting reporting requirements allows ACO reporting requirements allows meNtoowspend c me to spend moremore time time with patients.”er tified with patients.” — Christopher Wenner, MD, Clinic Owner Integrity Health Network member, Cold Spring – Christopher Wenner, MD, Clinic Owner Integrity Health Network member, Cold Spring

Helping Independent Hospitals and Clinics compete: Helping Independent Hospitals • Referral network of 215 primaryand and Clinics specialtycompete: physicians • Network of over 200 physicians and providers • QI/P4P Measurement development & reporting

• •QCompetitive 1/P4P Measurement development & reporting group purchasing contracts to control costs • Cyour ompetitive group purchasing contracts to control •your Latest in EHR & Web Portal technology costs • Partnering with health plans on new models of care

• •APartnering ssistance in finding an EHR to meet your needs with hospitals, clinics and employers to

work on clinical integration and delivery • Partnering with select health plans on new models •ofData careWarehouse under development. Information is key to competing and improving quality

• •Partnering hospitals, clinics and employers Marketing,with risk management, clinic staff training to work on clinical integration and delivery • Developing strategies to leverage exciting new opportunities: Accountable Care Organizations,

• Data analytics. Information is key to competing and Medical Home, Baskets of Care improving quality Our independent physicians keep

• Marketing, risk management, clinic staff training hometown healthcare where it belongs. • Developing strategies to leverage exciting new opportunities: Accountable Jeff Tucker,Care CEOOrganizations, Medical Home, Episodes of Care (jtucker@ihnhealth.com) Rachael Nyenhuis, COO

(rnyenhuis@ihnhealth.com) Our Independent physicians keep hometown healthcare where it belongs.

888.722.8802

Jeffrey L. Tucker, CEO jtucker@ihnhealth.com 218.722.8802.112 IntegrityHealthNetwork.com Delivering a network of solutions

Melissa Larson, COO mlarson@ihnhealth.com 218.722.8802.115

888.722.8802 Delivering a network of solutions IntegrityHealthNetwork.com

March 2014 Minnesota Physician

Capsules from page 5

cal Society, has announced that Kenneth Kephart, MD, will serve as its new medical director. Kephart, the medical director of senior services at Fairview Health Services and an adjunct professor in the University of Minnesota Department of Family Medicine, is board-certified in family, geriatric, hospice, and palliative medicine. Previously, Kephart served on the Honoring Choices advisory committee. Kephart will replace Kent Wilson, MD, who has served as the Honoring Choices medical director for five years.

MHA, DHS Work Toward Presumptive Eligibility

the Affordable Care Act. The Minnesota Hospital Association (MHA) says PE helps uninsured patients receive initial care, often in an emergency room setting, and follow-up care while their applications are processing. MHA is working with the Minnesota Department of Human Services (DHS) to explore solutions that would let hospitals in the state determine PE as quickly as possible. However, none of the solutions have been approved by DHS and currently, no plan is in place to implement the change. “It isn’t about a lack of commitment from DHS. It’s about a lack of capacity. Resources are being diverted to address issues with MNsure. We believe, when they are able, DHS will have a PE process in place,” said Matt Anderson, MHA vice president of regulatory and strategic affairs.

As of Jan. 1, hospitals have the authority to make a presumptive eligibility (PE) determination for low-income, uninsured patients, temporarily enrolling them in Medicaid until an actual determination is made by the state, under

Minnesota Physician March 2014

Adverse Health Events Show Improvement Results from the Minnesota Department of Health’s (MDH) tenth annual report on adverse events in hospitals and ambulatory surgery centers are encouraging, according to Minnesota Alliance for Patient Safety (MAPS), a statewide patient safety coalition. In 2013, 258 events were reported, a decline of 18 percent from 2012. According to MAPS officials, this indicates an overall downward trend in deaths and disabilities in Minnesota. MDH noted that the report showed improvements in specific areas. The number of pressure ulcers declined for the second consecutive year, and decreased by 33 percent since 2012. The number of retained foreign objects also declined for the second consecutive year, and decreased by 29 percent since 2012. Wrong body part surgical/invasive procedures decreased by 36 percent, the largest decline in that category in 10 years and the lowest number

since ambulatory surgical centers began reporting. “This trend and the infrequency with which these events occur is a step in the right direction,” said Marie Dotseth, MAPS executive director. “Even more encouraging is the progress that has been made that is not reflected in the numbers. I’m referring to the increased transparency, a willingness to share prevention strategies and implement them, improved reporting and monitoring processes, and a culture shift that prioritizes the work needed to prevent errors and harm.” Minnesota was the first state to enact a law to enforce the reporting of adverse health events and subsequent in-depth analyses to determine the cause of each event. According to officials, there was no way to track these types of preventable events before the law was passed in 2003. The overall purpose of the system is to use the data that is collected to identify the issues that led to the adverse events and utilize that information to determine prevention strategies.

Medicus David Dries, MD, an assistant medical director for surgery at HealthPartners Medical Group and a professor of surgery, a professor of anesthesiology, a clinical adjunct professor of emergency medicine, and the John F. Perry, Jr. endowed Chair of trauma surgery at the University of Minnesota, has received the highest honor bestowed by the world’s leading organization of critical care physicians. Dries has been designated a Master David Dries, MD of Critical Care Medicine (MCCM) by the Society of Critical Care Medicine. Since its founding in 1970, the Society has conferred this designation on only 53 individuals. MCCM is awarded to an individual who has been a Fellow of the American College of Critical Care Medicine for at least five years and has achieved national and international professional prominence through personal character, leadership, eminence in clinical practice, and outstanding contributions to research and education in critical care medicine. Dries developed the complex abdomen program at Regions Hospital and serves on multiple editorial boards. Louis Kazaglis, MD, has joined the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center (HCMC), Minneapolis. He completed medical school at the University of Illinois, Chicago; internal medicine residency at the University of Minnesota Medical School; and a sleep medicine fellowship at HCMC. Also joining HCMC is Nathaniel Scott, MD. Scott graduated from the Louis Kazaglis, University of Minnesota Medical MD School and completed a combined residency in emergency medicine and internal medicine at HCMC. He is Nathaniel Scott, a staff member of both the internal medicine and MD emergency medicine departments. Andres Wiernik, MD, has joined HCMC’s hematology/ oncology department and its Comprehensive Cancer Center. He earned a medical degree from Universidad de Ciencias Medicas, San Jose, Costa Rica; completed his internal medicine residency at HCMC; and completed a fellowship in hematology, oncology, and transplantation at the University of Minnesota. All three physicians are Andres Wiernik, board-certified in internal medicine. MD

Lindsey Klocke, MD, board-eligible in otolaryngology, has joined Lakeview Health System’s Stillwater Medical Group. She earned a medical degree at the University of Iowa Carver College of Medicine, Iowa City, and completed an otolaryngology residency at the University of Nebraska, Omaha. Terry Pladson, MD, will retire as president and CEO of CentraCare Health on Dec. 31, 2014. Pladson graduated from the University of Minnesota Medical School and joined Internal Medicine Associates of St. Cloud as a pulmonologist in 1978. That clinic later merged with St. Cloud Internists Clinic to form St. Cloud Clinic of Internal Medicine (SCCIM). Pladson became SCCIM’s president in 1990. Five years later, SCCIM and St. Cloud Hospital merged to form CentraCare Health Terry Pladson, System. Pladson and hospital president John MD Frobenius were CentraCare co-presidents until Frobenius retired in 2002. Since then, Pladson has been sole CentraCare president. CentraCare Health is conducting a nationwide search for Pladson’s replacement.

R e q u e s t f o R n o m i n at i o n s

2014 HealtH care arcHitecture & Design

Seeking Exceptionally Designed Health Facilities in Minnesota Nomination Closing: Friday, May 9, 2014 Publication Date: June 2014

Minnesota Physician announces our annual health Care architecture & Design honor roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. the nominees selected for the honor roll will be featured in the June 2014 edition of Minnesota Physician, the region’s most widely read medical publication. eligible facilities include any construction designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. interiors, exteriors, expansions, renovations and new structures are all eligible. in order to qualify for the nomination, the facility must have been designed, built or renovated since January 1, 2013. it also must be located within Minnesota (or near the state border within Wisconsin, north Dakota, south Dakota or iowa). color photographs are required. if you would like to nominate a facility, please fill out the nomination form below and submit the form, three to eight 300 DPi resolution color digital photographs, and a brief project description (150-250 words) by Friday, May 9, 2014. For more information, call (612) 728-8600. 2014 health caRe aRchitectuRe & design honoR Roll nomination foRm FaCility NaMe tyPe oF FaCility loCatioN owNershiP orgaNizatioN owNer CoNtaCt NaMe and PhoNe owNer aDDress City, state, ziP arChiteCt/iNterior DesigN FirM arChiteCt CoNtaCt NaMe and PhoNe arChiteCt aDDress City, state, ziP eNgiNeer CoNtraCtor CoMPletioN Date total Cost square Feet NuMber oF Color PhotograPhs eNCloseD (Note: please include a caption for each photo) NoMiNatioNs ProCeDure: submit the information on this form, along with a project description (150-250 words), and 300 dpi resolution color 8" x 10" digital photographs (no more than eight) to amarlow@mppub.com For further information, please phone (612) 728-8600, fax (612) 728-8601 or e-mail comments@mppub.com

March 2014 Minnesota Physician

Interview

Health care and the 2014 Legislature

H ow does health care legislation come into and out of your committee?

Sen. Kathy Sheran DFL-Mankato Sen. Sheran is chair of the Minnesota Senate Health, Human Services and Housing committee. Before being elected to the Minnesota State Senate in 2006, Sheran worked in the nursing field for more 30 years, including spending several years as an assistant professor of nursing at Minnesota State University–Mankato.

the language and still meet the objective of the bill, taking out anything that creates a negative for a stakeholder. Hopefully, by the time the bill Legislation can originate with a legislator or is brought to my committee, most of the issues an interest group. There are many channels have been resolved and we’ve settled the issues through which probetween the stakeposals for legislaholders. Sometimes, tion come. Putting I would love to have physicians there is a basic disthose proposals talk to me directly, rather than agreement about the into legislative course or direction of always talking through a lobbyist. language and into public policy and then bill form requires it’s a vote, but lots of an author. That times, it’s sort of nursing the language in a way means the people who support it have to find a that people can come together. I oversee that. I legislator to affirm that he or she will “carry” try to encourage the authors of bills to get work that legislation and get it written in the format like that done outside of the hearing, before they that’s needed for it to move through the combring it into the session. mittee process. Then it goes to the office of the President of the Legislature in the House and the Senate, and is assigned—based on the content—  Do the bills coming up include one to a committee. Obviously, anything that relates about advanced practice registered to health policy would come to my committee. nurses and their ability to assume adMy committee administrator keeps a list of all ditional duties in terms of prescribing the referred bills, and we establish blocks of legmedications working in free-standing islation that are related to each other and try to independent clinics? create an agenda for the committee during our That is a bill I will author, which will be heard hearing time. in this legislative session. When it is presented, the legislature will learn how other states handle this issue—that they remove language  What kind of influence can you bring from the scope-of-practice bill that requires to bear on proposed health care written agreements with physicians. It’s not a legislation? scope-of-practice expansion. What changes in As the committee chair, I decide what gets heard the language of the bill is the written agreement and what does not get heard. We don’t have an with the practicing physician. There will be a endless amount of time, and we have deadlines, presentation about demonstrated outcomes and which help us move through a session. Any the occurrence of positive outcomes. We’ll also bill has to get through the committee process address concerns about the safety and the wellby what’s called the first deadline in either the being of patients who are served by advanced House or the Senate. That deadline is set in the practice nurses in various fields. That’s a perfect beginning of the year by the leadership. It can example of a bill that has been worked on for be three or four weeks into the session. With at least two, maybe three years, trying to work this year’s short session, the deadlines are through language with various stakeholders, really tight. including the Minnesota Medical Association. I can say to the authors of a bill that there’s too much controversy and suggest that they pull  What can you tell us about the interinterested parties together and try to work out actions you have with the health insurthe language. Often language has implications ance lobby? that the author is not aware of. You can change There is constant interaction. Last year, there

Minnesota Physician March 2014

monitoring. How do you gradually finance something in a way that’s fair—and what is a fair distribution of the cost of doing what we need to do? On the front end, we want to try to get control or containment over prescription drug abuse so that we can save money on the back end, where the criminal issues, the health care problems, and chemical dependency problems come into play.

was a significant discussion with the insurance lobbist because we decided that it would be good public policy to develop our own insurance exchange, as opposed to just participating in a mass federal exchange. We brought in insurance companies to discuss how an exchange should be formulated. This is another example of interactions with insurance companies as ways to find best practices for sustainability, to offer coverages at an affordable price.

W hat can you tell us about MNsure?

W hat’s being done to slow prescription drug abuse through improvements in Minnesota’s prescription monitoring program?

The glitches that are occurring in being able to access MNsure are creating a great deal of discouragement, frustration, and confusion in the public marketplace between what is really about the Affordable Care Act and what is about the technology of trying to get the thing implemented so people can access it online. When the mechanisms to help you learn what the insurance policy differences are do not operate properly, it adds to the frustrations. I think that the transition time for a change of this magnitude is longer than people expect. We’re immediate gratification-type folks, and this is a reform. This is a first step in a series of reforms that have to oc-

We have a constant process where people are trying to improve prescription monitoring programs, and the pharmacists and their organization engage in these efforts. The conflict occurs between privacy rights—people who are concerned about us being able to accumulate and gather data that tells us the course of the direction in which a client’s or physician’s practice is going—against the patient’s right to privacy. We have an interest in trying to figure out how to curb prescription drug abuse. The next question is, who’s going to pay for

cur in how we deal with health care.

W hat advice do you have for physicians who are interested in participating in the legislative process? Talk to your district’s legislator and get on a group mailing list for physicians. Ask that legislator to communicate with you about what is emerging on health care issues. I would love to have physicians talk to me directly, rather than always talking through a lobbyist. The psychiatric arm of the Mankato Clinic invited me to a meeting during this interim. It was a fabulous opportunity to talk more directly about what is happening. That connection with a legislator taking at least one time during the interim to have a general meeting can’t be emphasized enough. If, for example, the pediatric community needs something specific, they should say that at a meeting. If the orthopods need something specific, they should say that. If the independent practitioner wants to say something, I’d like to know what that is directly from my constituency.

University of Minnesota Continuing Professional Development 2014 CME Activities

(All courses in the Twin Cities unless noted)

Fundamentals of Critical Care Support March 17-18, 2014

Maintenance of Certification in Anesthesiology (MOCA) Training Course May 3, 2014

Advanced Critical Care for Hospitalists March 17-20, 2014

Live Global Health Training (weekly modules) May 5-30, 2014

Spring Psychiatry Update: Pursuing Wellness Across the Lifespan April 3-4, 2014

Global Health - Honoring Choices Across Cultures May 7, 2014

Cardiac Arrhythmias: Interactive Update for Internal Medicine, Family Practice & Pediatrics April 4, 2014

Midwest Cardiovascular Forum May 17-18, 2014

Integrated Behavioral Healthcare Conference: Building a Framework So You Can Grow April 25, 2014 Pediatric Dermatology Progress & Practices April 25, 2014 Annual Surgery Course: Vascular Surgery May 1-2, 2014

Bariatric Education Days: Decade of Bariatric Education May 21-22, 2014 Topics & Advances in Pediatrics May 29-30, 2014 Workshops in Clinical Hypnosis June 5-7, 2014 NPHTI Pediatric Clinical Hypnosis September 11-13, 2014

ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health - NEW! Family Medicine Specialty • Nitrous Oxide for Pediatric Procedural Sedation

For a full activity listing, go to www.cmecourses.umn.edu

Psychiatry Review September 29-30, 2014

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

Promoting a lifetime of outstanding professional practice

March 2014 Minnesota Physician

Ready or not ... from cover

cally specific ICD-10 procedure codes: ICD-9-CM code 92.27, implantation or insertion of radioactive element, has 263 possible alternative anatomic sites in ICD-10 (www.hfma.org).

10 allows for the description of comorbidities, manifestation, complications, detailed anatomic location, degree of functional impairment, biologic and chemical agents, phases and stages, lymph node involvement, lateralization and localization, and age-related and joint your involvement.

Ideally, organization has already initiated an ICD-10 transition plan.

The expansion of the number of codes allows greater specificity and exactness in describing a patient’s diagnosis. ICD-10 will accommodate newly developed diagnoses, advances in technology and treatment, performance-based payment systems, and more accurate billing. ICD-

A successful transition to ICD-10-CM will be vital to transforming our nation’s health care system and ensuring uninterrupted coding operations. But the transition to ICD-10-CM/PCS will be a major undertaking for providers, payers, and vendors. It will drive business and systems changes throughout the health care industry, from solo physician practices to large health care

When you need it.

Medical professional liability insurance specialists providing a single-source solution

ProAssurance.com

Minnesota Physician March 2014

and hospital systems. Developing plans well in advance for staff time and financial resources will help the transition go much more smoothly. The following discussion details steps that physician practices should be taking to prepare for the transition to ICD-10. Planning Ideally, your organization has already initiated an ICD-10 transition plan. If it hasn’t, you want to be sure to develop an implementation timeline as soon as possible. The plan should take into consideration training related to the fundamentals of using and applying ICD-10, documentation training due to the specificity of ICD-10, software changes that come with ICD-10 upgrades, and billing changes related to payer variations. According to ImplementHIT, a company that offers EHR training and education services, identifying the top 10 primary and top 10 secondary diagnoses by specialty is a good place to start. Remember, success with ICD-10 begins with physician and provider documentation and specificity. Practices are most likely to be successful in a phased roll-out approach to the transition. CMS provides implementation guidance for large practices and small and medium practices. The steps included in a phased roll-out are shown in Figure 1 (page 11). Education/training The practice should identify all the roles within the organization that use coded data and will be affected by the transition to ICD-10. Staff training should start with organization-wide education on what ICD-10 is and the impact it will have on the practice. Intense training should then be provided to coders, billers, clinical documentation improvement specialists, and health care professionals in the practice. According to ImplementHIT President and COO Michael Clark, “ICD-10 is about … documenting with a greater level

Resources

• C MS, General information about ICD-10 and links to implementation, education, and training resources for providers, payers, vendors, and non-covered entities: www.cms.hhs.gov/ICD10 orld Health Organization ICD10 • W training tool: http://apps.who.int/classifica tions/apps/icd/icd10training/ • W EDI (Workgroup for Electronic Data Interchange): www.wedi.org • A HIIMA (American Health Information Management Association): www.ahima.org/icd10/ APC (American Association of • A Professional Coders): www.aapc.com/icd-10/ • H IMSS (Health Information and Management Systems Society) www.himss.org/library/ icd10-transition?&navItem Number=17736 • I CD10 Watch: www.icd10watch.com/ • I CD10 Monitor – Talk 10 Tuesday Webinars and resources: www.icd10monitor.com MGMA (Minnesota Medical • M Group Management Association) education and training resources on ICD-10: www.mmgma.org/ • M N ICD-10 Collaborative – Co-chair, Tim Nix: tnix@ucare.org; webinars and educational offerings can be found at www.health.state.mn.us/auc/

The MN ICD-10 Collaborative Medical groups in Minnesota are fortunate to have one of the leading ICD-10 collaboratives in the nation. The MN ICD-10 Collaborative is a consortium of providers and payers brought together to identify and evaluate opportunities to minimize the disruption in health care billing, reporting, and related processes for a variety of stakeholders in the health care industry in connection with the ICD-10 conversion. Founded in 2010, the MN ICD-10 Collaborative works to improve communication between providers and payers, share lessons learned, provide validation and feedback on plans and progress, share testing scenarios and approaches, and provide educational opportunities. Joining a collaborative like this can help you in your transition to ICD-10 by conserving your resources.

of specificity the practice of medicine/treatment the physician is already providing, but documenting that diagnosis and treatment to a more complete degree of specificity.” To this

Figure 1. Steps in a phased roll-out of ICD-10 (Source: www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10_Small-MedPractice_Handbook_060413%5B1%5D.pdf) Planning • Establish project management structure • Establish governance • Plan to communicate with external partners • Establish risk management

Communication & Awareness

Assessment

Operational Implementation

Testing

• Create a communication plan

• Assess business and policy impacts

• Identify system migration strategies

• Complete level 1 internal testing

• Assess training needs and develop a training plan

• Assess technological impacts

• Implement business and technical modifications

• Complete level 2 external testing

• Meet with staff to discuss effect of ICD-10 and identify responsibilities

end, the company’s approach to teaching providers includes short (3- to 5-minute), self-paced modules that target specific specialties (Primary Care: Internal Medicine, Family Practice, Pediatrics; Specialty: Cardiology, Endocrinology, Gastroenterology, etc.; and Surgical Specialty: Cardiothoracic, OBGYN, Orthopedic, etc.). Specialty-specific key concepts, principles, and key learning points are applied across anatomical systems. Since physicians have a finite amount of time, the training for the ImplementHIT curriculum is accessible online, offering flexibility in learning times and topics. Other training tools and resources are available from professional organizations such as AHIMA (American Health Information Management Association) and AAPC (American Association of Professional Coders), as well as from the World Health Organization and the CMS. See the Resources sidebar on page 10 for their websites. In addition to web- and computer-based training tools, some practices use internal staff (e.g., a coder or physician) who have been trained on the ICD-10 transition to train other staff. Practices should begin educating their staff members now in order to minimize loss of productivity and query overload when ICD-10 is implemented. Finally, access to training content needs to be available beyond the October 2014 deadline, meaning post-implementation education needs to be part of your planning process.

• Prepare and deliver training

Assessing the impact of ICD10 on documentation ICD-9-CM has a limited data set with approximately 14,000 codes containing between three and five numeric digits. In comparison, ICD-10-CM has an expanded data set, providing for increased specificity and consistency, with 68,000 codes that contain between three and seven alphanumeric characters. It is imperative to understand the impact of this increase in specificity and level of detail in the ICD-10 codes on documentation. Providers must assess their current documentation practices in light of ICD-10 code expansion. Compare, for example, ICD-9-CM code 813.15, Open fracture of head of radius, with ICD-10-CM code S52122C, Displaced fracture of head of left radius, initial encounter for open fracture type IIIA, IIIB, or IIIC (CMS, https://impl ementicd10.noblis.org/). In ICD-10-CM, much more detail is required to establish the correct code. The physician will need to address the documentation elements listed in Figure 2 (page 38) in order to arrive at the proper ICD-10-CM code. This may seem like a daunting task, but starting this assessment now will help the process go more smoothly for your organization. Focus on your historical top 10 primary diagnoses and learn what’s different/needed for ICD-10. This approach will (1) get you significantly down the road on a large percentage of the volume of patients you currently see and (2) help to identify lessons learned in each of those diagnoses. This

Transition • Prepare and establish the production and go live environments • Deliver ongoing support

• Prepare and deliver training

approach also can be used with a multitude of other diagnoses that your practice sees less frequently, so you will be able to apply the same knowledge more broadly. Using general equivalence mappings (GEMs) is one way to help your organization assess the differences between ICD-9CM and ICD-10-CM. CMS and the National Center for Health Statistics (NCHS) developed the ICD-10-CM GEMS as a cross-

walk between ICD-9-CM and ICD-10-CM codes. The GEMs should not be used as a “conversion” tool, but rather to assess coded data and implement ICD10. For example, applying the GEM principle of “one-to-many” (e.g., documenting exposure to smoke for ALL respiratory conditions), or of “many-toone” (e.g., tuberculosis of the lung in various stages) across conditions to define ICD-9/ICD10 relationships, will make the

Ready or not ... to page 38

The Lawyers and Lobbyists that Doctors Trust Medicine is complicated. So are the laws that doctors, hospitals and insurance companies have to manage. Lockridge Grindal Nauen is one of Minnesota’s leading health care law firms. Our health care clients are so satisfied they’ll write us a referral.

Contact Eric Tostrud

612-339-6900 ectostrud@locklaw.com

From the Courtroom to the Capitol.® March 2014 Minnesota Physician

Catch and release from cover

magic of this place. I sip my second cup of coffee, watching the water bugs jet back and forth, creating a kaleidoscope of ripples on the clear lake surface. I carefully choose the fly that mimics these bugs and tie it easily onto my line—I’ve tied so many of these, I know the knot will hold. I begin my meditation. I lay out several feet of line in front of me, and then with a smooth, even intake of breath, I draw my fly rod back until the line is fully extended behind me. Next, I slowly breathe out as I thrust the line forward, in a gentle whipping motion. As the fly line loops forward and back, always tied closely to the breath, the fly rod becomes an extension of me. The reel sings as it releases the line. This rod was handed down lovingly from my grandfather to my father, and then, suddenly, to me after my father’s untimely death. Someday I hope to hand it down to my grandson, the

one who spotted a heron— “Grandpa, look!”—outside his bedroom window at the cabin when he was little more than a year old, chomping on his bottle and clinging tightly to his blanket.

stunned and it takes my breath away. The reel shrieks with the speed of its release, and I feel the fish’s wild power and instinctual drive toward freedom. She is not one bit afraid but rather is filled with the univer-

It’s the silence between the sounds that calls to my soul and settles me into the magic of this place. I send my fly to imaginary points along the water, slapping the water, waking up the fish. When I loop the fly back and forth, glistening drops of water cling to the line, reflecting the early morning sunlight. I feel like a great artist, or a magician waving his wand. Eventually, when I am good and ready, I launch a perfect cast to the base of the log my heron friend pointed to, and then: Wham! She takes the fly the moment it hits the surface. She takes off with such power that I am temporarily

Minnesota Physician March 2014

sal desire to wriggle free that all sentient beings carry deep within their soul. She transmits this intention through the fly line to my very soul. We are connected, this fish and I, as she zooms back and forth across the bay. Suddenly, she changes direction and dives for the bottom. To stop her from wrapping around a rock or a log, I gently pull up on my rod; then she turns abruptly and heads for the surface. She jumps completely out of the water, her body bends in an undulating S curve, flailing back and forth, using her

every muscle to dislodge the fly. I begin to feel her tiring. She has no less will, but simply is running out of energy. Just before reaching my hand, she makes one more gallant run for freedom, but I am lucky enough to raise my rod tip at just the right moment and this time she comes in with her head bowed. I catch her, raise her gently out of the water, and remove the hook from the corner of her mouth. I can’t resist giving her one small loving caress from the tip of her mouth, across her back to her tail; and then, after offering a prayer for her safety and a thanksgiving for her appearance, I release her into the shimmering, violet-blue water. For a moment she sits, stunned by this unexpected turn. Then, with a flick of her tail, she is gone.

*** The IV line clings tightly to my arm. No matter which way I pull or dive, I can’t get away. The chemotherapy invades my every thought and feeling. If

only I could be as fearless as that fish, but I’m afraid. I have no instincts to fall back on. Senseless thoughts and continuous worry are my constant companions. I dive to the metaphorical bottom, hoping to wrap the line around some rock or log in the form of a person. But they all treat me the same; they’re afraid they might say the wrong thing, or maybe that what I have is somehow catching. They push me away with their fear-filled platitudes. I try to hide the line, the disease, but everyone knows. It’s written on my face, and the pity reflected in their faces doubles the pull of the cancer line. I leap out of the water, looking in every direction for help, but flop helplessly back into the water. I haven’t lost my will, but I am getting tired, and I feel the pull of the line getting stronger. The harder I resist, the deeper the hook sets into my tender skin. I give one more desperate lunge, hoping to cure

everything. After that I come in with my head bowed, utterly defeated. And then it happens. I am completely pulled out of the water, but instead of being

teaches that healing comes from accepting our place within the firmament. Life and death flow together within the natural order. Each is dependent on the other and has its own time and

The chemotherapy invades my every thought and feeling. thrown into the frying pan, I’m taken off my hook and placed gently back into the water. I could swear I’ve been lovingly caressed by some unknown being. I go into remission. I can feel the prayers that have been lifted up in my name, and all I can do is offer my unending thanks. I can’t believe it—I am free. There are so many undercurrents of healing in this moment: the waves of hard-won science, water from the unending fountain of the human spirit. Healing is a wondrous mystery. Cures are frequent, but healing is rare. Nature

place—one moment the roaring lion, the next moment the mourning dove. For me, the heron has always been nature’s healing symbol. When I see a great blue heron in silhouette standing perfectly still in the shallows of a misty bay it never fails to transport me to the mysteries of the infinite. The physical and metaphorical heron merges into one and produces awe. I think healing is like that. It reminds me we need to be connected to both the physical and metaphorical heart: We need the literal heart to help us

ground our metaphorical heart. This can lead to quite a fulfilling life adventure.

*** I glide through the water of my life, slowly gaining my strength. I swim joyously back and forth across the bay and dive to the bottom, then turn straight up and jump completely out of the water, my body undulating in a giant S curve using every muscle. The hook that was embedded in me was more than chemo. I feel the endless web of hungry ghosts, desires, wants, fears, worries, the future, and the past all dissolving in this remarkable moment. This is true freedom. I stare at the horizon and life beyond, seeing the day-blind stars described by Wendell Berry. I jump one more time, and this time I see the real sky. Charles Bransford, MD, is director of hospice and palliative care services for Lakeview Health System in Stillwater.

March 2014 Minnesota Physician

Professional update: Home Care

mid the changing landscape of health care reform, health care organizations are focused on achieving the industry’s identified “Triple Aim” goals of improving patient care and population health while reducing overall health care costs. While experts in the field maintain these objectives aren’t mutually exclusive, they also suggest that success will require the U.S. health care system to change from the current fee-forservice model—which revolves around individual patient treatments—to a more all-inclusive approach that measures patients’ overall health, wellness, and quality of care. This shift in health care delivery will require better cohesion and coordination among providers, insurers, and government agencies, as well as increased levels of accountability among all parties in the care continuum—drivers for the current development of integrated health delivery networks and accountable care organization (ACO) models.

Telehealth potential Reducing readmissions in an integrated health delivery system By Cathy Brady, RN, WCC

Providers are looking at health care delivery to see where new quality measures can be implemented across the care con-

care model in the U.S. yields readmission statistics with which most industry practitioners are familiar:

Telehealth technology is the perfect companion to integrated health care delivery networks and ACOs. tinuum, to actualize the ultimate realization of improved quality of care and financial benefits. An environment ripe for telehealth adoption A brief look at the current health

I made the move to Minnesota Bank & Trust to offer my clients an exceptional banking experience. Call me for information on an opportunity to earn more interest while we earn your business.

Get more interest from your bank and your banker.

Jennifer Resner vICe presIdenT, CoMMerCIal BankIng

952-841-9313

• Readmissions cost the U.S. approximately $600 billion—or 30 percent of the $2 trillion spent on health care each year. • Approximately 20 percent of Medicare admissions are readmitted to the hospital within 30 days of discharge. • More than 75 percent of 30-day readmissions are due to avoidable circumstances, including poor communication across the patient care continuum, poor planning prior to patient discharge from the hospital, and/or a lack of understanding on the part of the patient or family members involved in patient discharge. In conjunction with increasing health care costs, patients have clearly articulated the desire to incorporate technology into their overall care management. In fact, a recent survey by Accenture, a leading technology consulting firm, found that 90 percent of patients want online access to health information and education to help them manage conditions. The study also found that of the patients surveyed: • 83 percent want to access personal medical information online.

• 72 percent want to book, change, or cancel appointMinnesota Physician March 2014

ments online. • 72 percent want to request prescription refills online. • 88 percent want to receive email reminders about preventive or follow-up care. In an environment where both patients and health care providers desire end results of continued medical oversight after a hospital discharge and increased communication, one key element of the solution is telehealth. With the availability of complete turn-key telehealth-based technology and the unaddressed cost-saving potential within current patient discharge models, it is no wonder the Centers for Medicare & Medicaid Services (CMS) has encouraged ACOs to utilize telehealth. Telehealth technology is the perfect companion to integrated health-care delivery networks and ACOs because these models of care have the same overarching goal: making health care delivery more efficient (bringing the right level of care at the right time) to reduce readmissions, while simultaneously increasing the quality of care. This is not a new notion in Minnesota, where more than 24 hospitals and other health care providers use Honeywell HomMed’s telehealth resources, which are similar to those used in the following case study. Case study Florida-based Lee Memorial Health System is a public health care system that includes four acute-care hospital locations as well as other health care facilities and services, including Lee Memorial Home Health agency, a nursing home, outpatient treatment and diagnostic centers, physician offices, a children’s hospital, and a rehabilitation hospital. In mid-2010, and in preparation for CMS penalties around readmission rates, Lee Memorial Health System committed to the goal of reducing readmissions by 1 percent to 2 percent annually. Recognizing the newly initiated telehealth program could help achieve this system-wide

goal, the home health team obtained broad support for remote patient monitoring through facilitating collaboration among hospitals, physicians, and other care practitioners.

• Calculate readmissions rates on a monthly basis, and track results against previous months.

The home health group used Honeywell’s LifeStream Solutions, a combination of remote patient-monitoring devices and back-end support software, which offered analytical tools to help health care staff track patient outcomes and patient case load, as well as preparing standard reports that measure operational and clinical staff efficiency.

This strategic approach gave the Lee Memorial Home Health group the ability to develop and implement techniques for improving overall communication across the care continuum. For example, protocols were created to alert physicians based on the level of patient urgency/emergency, to address common patient symptoms that present in remote monitoring data.

The effort to reduce readmissions at Lee Memorial Health System centered on improving patient care transitions with telehealth. Since patient biometrics could be regularly monitored with a remote device after hospital discharge, any changes in the patient’s condition could be quickly detected and medical interventions could be initiated to prevent potential complications and a hospital readmission.

To capture program success in addressing the principal goal, Lee Memorial telehealth staff documented interventions that prevented patient readmission, which were recognized as a “save” for the system.

For patients and their families, the telehealth experience laid the foundation for ownership of care, resulting in increased patient compliance and engagement, and improved clinical outcomes. The nuts and bolts of achieving success The Lee Memorial Health System telehealth program began with 50 remote patient monitors. In the program’s first 32 months, it has grown to more than 250, with more than 6,700 patients monitored. To ensure success, data was compared to other programs using the same technology. Plus, the health system collaborated with a team that included physicians, discharge planners, case managers, and clinicians and the patients they serve. As a result, the program was launched with a strategic plan and triple-pronged approach to continual improvement: • Collect data from the inception of the program—and report the metrics within the system. • Analyze data for trends to improve the program and

its methodology.

leadership. Return on investment In its first 32 months of operation, the telehealth program has allowed the system to avoid 950 readmissions to the hospital, resulting in an estimated savings of more than $5.3 million, based on average Lee Memorial Health System hospital costs. The missing link Through examining the rate of success in reducing readmissions in one health care system, telehealth can clearly impact the efficacy of health care delivery at every point in the care continu-

um, providing the opportunity to reduce readmissions and improve the quality of patient care coordination. As health care organizations work to form integrated delivery networks or become ACOs in order to leverage a more streamlined health care model, the system-wide embrace of telehealth solutions as a communication bridge for the patient discharge process can be, quite literally, the missing link. Cathy Brady, RN, WCC, is Lifeline and Telehealth program manager for Lee Memorial Health System Home Health, which provides health care services throughout southwest Florida.

A typical save might include notifying a physician that a patient’s vital signs had fallen out of the established telehealth parameters, for which the physician might provide additional orders. Such an immediate intervention could result in a positive outcome for the patient, who could remain at home, avoiding a trip to the emergency room or a hospital admission. The Lee Memorial Home Health staff is also committed to ongoing improvement of the program through the collection and analysis of a series of metrics designed to not only measure initial results, but also to provide a deeper insight into potential areas of improvement. Current standard metrics include: • Readmission rates • Discharges from acute care for resumption of care by the agency • The total number of patient home visits per episode • Feedback from the Lee Memorial Health System readmission group Clinical outcome data are shared with all applicable practitioners across the full care continuum at readmission team meetings. Additionally, the same outcome metrics are analyzed along with the financial data to validate system cost savings, and are reported regularly to the physician group and senior

With infusions at home, Peter stays in the game. INDIVIDUALIZED HOMECARE IS ALL WE DO.

So, along with comprehensive infusion nursing and pharmacy services, we provide 24/7 support for health care professionals and integrated care for patients where they thrive - at home.

To learn why more doctors trust PHS, call 651-642-1825 or visit:

ChoosePHS.com

March 2014 Minnesota Physician

Gastroenterology

Gastroesophageal reflux disease

astroesophageal reflux disease (GERD) is defined by abnormal esophageal exposure to gastric acid. However, this definition over-simplifies a complex disease that can pose significant diagnostic and therapeutic challenges.

A practical clinical approach By Rafael S. Andrade, MD

The objective of this review is to provide useful advice on how to approach patients with a clinical picture consistent with symptomatic GERD. The recommendations provided in this article are based on the new 2013 American College of Gastroenterology (ACG) guidelines for the diagnosis and treatment of GERD (Katz P. et al., Am J Gastroenterol, 2013) and on the author’s clinical perspective. Symptoms Typical GERD symptoms are heartburn, regurgitation, and dysphagia. Heartburn is considered to be caused by mucosal irritation from refluxate and is a function of the chemical composition of refluxate (acid,

non-acid, bile). Regurgitation refers to the sensation of gastric contents refluxing into the esophagus and is a function of refluxate volume. Dysphagia is often the result of complicated GERD (hiatal hernia, motility disorder, stricture) but may be present in uncomplicated GERD.

ry tract infections, and dental erosions.

Atypical GERD and extraesophageal manifestations of GERD vary widely and include atypical chest pain, cough, hoarseness, bronchospasm, laryngitis, frequent respiratory tract infections, globus, throat clearing, recurrent respirato-

Diagnostic tests. The most common diagnostic test in clinical practice is empiric PPI therapy. The majority of patients with heartburn and regurgitation respond to PPI therapy with complete or near-complete resolution of symptoms and will not require additional diagnostic evaluation.

Diagnosis Diagnostic accuracy of symptoms alone is about 65 percent, and typical symptoms are sufficient diagnostic information to start proton-pump inhibitor (PPI) therapy.

Indications for further diagnostic testing include: • Partial or no response after eight weeks of medical therapy (see “Medical therapy,” page 17) • Dysphagia

driven by your

vision

• Atypical symptoms and extraesophageal manifestations of GERD • P reoperative evaluation for antireflux surgery The diagnostic goal determines the most adequate diagnostic test, as follows:

At RJM Construction, we use insightful planning, a collaborative spirit and

• Establish the diagnosis of GERD: ambulatory pH testing

ﬁnancial responsibility to help bring your vision to life.

• Evaluation of dysphagia: endoscopy • A ssessment of complicated GERD (hiatal hernia, mucosal changes): endoscopy GENERAL CONTRACTING CONSTRUCTION MANAGEMENT DESIGN/BUILD PRE-CONSTRUCTION

Minnesota Physician March 2014

952-837-8600 RJMConstruction.com

Conventional ambulatory 24hour pH testing measures the number and duration of reflux events that lead to a drop in distal esophageal pH to <4. There are well-established guidelines to distinguish physiologic from pathologic acid reflux to confirm the diagnosis. Ambulatory pH testing also provides information on the correlation of reflux episodes with symptoms, but clinical applicability of this correlation is still unclear. In the last decade, the addition of impedance measurements to 24-hour pH testing has facilitated the evaluation of non-acid reflux in patients who are taking PPI or are suspected of nonacid reflux. Endoscopy is the initial test of choice in two patient groups: • Patients with dysphagia, to search for complications of GERD. • Patients at high risk for GERD-related adenocarcinoma of the gastroesophageal junction: white males, >50 years of age, overweight, and with chronic GERD symptoms (>5–10 years). As a general rule, any mucosal abnormality should be biopsied at the initial endoscopy. Repeat endoscopy depends on initial findings: • Normal endoscopy: no repeat endoscopy required. • Esophagitis: repeat endoscopy is recommended in patients with severe esophagitis (LA classification C or D) after eight weeks of PPI therapy, but can be considered in patients with milder esophagitis (LA classification grade A or B). • Peptic stricture: repeat therapeutic endoscopy as needed to treat recurrent symptoms.

• Differential diagnosis from other esophageal disorders: esophageal function testing (manometry, impedance)

• Barrett’s esophagus (BE): repeat endoscopy guided by pathology findings, but all patients should be enrolled in a surveillance program (see “Barrett’s esophagus,” page 34).

Ambulataory pH testing.

Esophageal function tests

(EFT) include esophageal manometry to evaluate esophageal motility alone and esophageal impedance manometry to assess motility and bolus transit. The value of EFT in GERD is to assess any candidate for antireflux surgery, to help with the differential diagnosis of other esophageal disorders that may mimic GERD (e.g., achalasia), or to identify severe esophageal motility disorders that may coexist with GERD (e.g., scleroderma and other connective tissue diseases). However, EFT are of little value in routine evaluation.

H2 blockers at bedtime can be used by patients with nighttime symptoms despite optimal PPI therapy, but tachyphylaxis occurs with continuous use. Sucralfate is of little value in the standard treatment of GERD.

Other tests. Imaging tests such as upper gastrointestinal series, gastric emptying study, and CT scan of the abdomen are of limited value in the routine evaluation of GERD.

is to be considered a surgical candidate must have objective evidence of GERD in addition to symptoms: a positive 24-hour pH study or endoscopic abnormalities that are unequivocally indicative of GERD.

Treatment Lifestyle changes include weight loss; avoidance or limitation of food and beverages that trigger symptoms; and, for patients with nocturnal symptoms, elevation of the head of the bed and allowing two to three hours to pass before lying down after eating.

The most important facts about surgical therapy are:

Medical therapy. Proton-pump inhibitors are the current mainstay of medical therapy for GERD and have proven superior to H2 blockers and sucralfate. Approximately 70 percent to 80 percent of patients will have good symptom control with PPI, and esophagitis resolves in 85 percent of patients on PPI therapy. Risk factors for failure to respond to PPI include long duration of symptoms, hiatal hernia, extraesophageal symptoms, and poor compliance or improper use of medication. No single PPI is superior to other drugs in the PPI group, there is no evidence to support switching of PPI in partial responders, and dose escalation does not tend to make a difference in partial responders. Maintenance PPI therapy is recommended in patients who have recurrent symptoms after discontinuation of an eightweek course of treatment, in all patients with esophagitis (100 percent recurrence rate after discontinuation of PPI), and in patients with BE.

Surgical therapy is a treatment option for patients with chronic GERD. Any patient who

can be a challenging subgroup of GERD. These patients may fail medical therapy despite good acid suppression, since the volume of refluxate is still large and they often complain of spontaneous regurgitation with Valsalva maneuvers or positional changes. Patients with persistent symptoms respond very well to antireflux surgery.

The majority of patients respond to proton-pump inhibitor therapy with complete or near-complete resolution of symptoms.

• Surgical therapy is a longterm treatment option. • Surgical therapy is as effective as medical therapy for properly selected patients with chronic GERD, when performed by an experienced surgeon. • Surgical therapy is generally not recommended in patients who do not respond to medical therapy, with the exception of patients with hiatal hernia and persistent regurgitation or dysphagia. • Surgical therapy in obese patients with a BMI >35 should include bariatric surgery, specifically, Rouxen-Y gastric bypass. • Nissen fundoplication (360° wrap) and Rouxen-Y gastric bypass are the most consistently successful surgical therapies for chronic GERD. No other surgical or endoscopic procedure has proven therapeutic equivalence to Nissen fundoplication and Roux-en-Y gastric bypass. Surgical therapy: special considerations Hiatal hernia. Patients with large hiatal hernias (>3 cm)

A small percentage of patients with hiatal hernia meet criteria for giant hiatal hernia (>50 percent of the stomach is herniated into the chest). Giant hiatal hernias present with progressive symptoms over decades and these patients often underreport their symptoms. Patients may present for surgical therapy at very advanced ages. Minimally invasive antireflux surgery for giant

hiatal hernia can be performed safely even in octagenarians, but requires unique surgical expertise. The notion that patients with large paraesophageal hernias are at high risk for strangulation and gastric necrosis is unsubstantiated. Incarcerated hiatal hernias are rare, and gastric necrosis from strangulation is extraordinarily uncommon. As a norm, patients with large paraesophageal hernias have crescendo symptoms for days or even weeks before they present with an incarcerated hernia. In our experience, patients with incarcerated hernias can initially be managed conservatively with a nasogastric tube and, if necessary, endoscopic decompression, TPN, close observation, and eventual semi-elective repair during the index hospitalization. The presence of a large paraesophageal hernia per se is not an indication for surgery, but symptoms and complications of GERD tend to be the indication to proceed

Gastroesophageal reflux disease to page 34

Cutting edge expertise makes Episcopal Church Home your TCU of choice for patients requiring

Complex Wound Care

Introducing the newest member of our TCU team: Cristina Presbitero, BSN, RN, WCC

Cristina Presbitero is a Med-Surg and Wound Care Certified RN with over eight years of experience in complex wound care and enterostomal nursing and consulting. This means: • More wounds managed in house versus out patient, reducing total care cost and rehospitalization. • Wound vac management. • Track healing rates on hospital and house-acquired wounds, incident bases on diagnosis and risk factors, reducing hospitalization. Questions? Please contact our Admissions Coordinator Kelly Emerson at 651-632-8842

March 2014 Minnesota Physician

Urology

rectile dysfunction (ED) is described by the National Institutes of Health as a consistent inability to maintain an erection sufficient for satisfactory intercourse. This is a common condition that affects up to 9 percent of men under age 40, 11 to 30 percent of men 50–59 years old, and around 35 percent of men over age 60. This article is adapted from the American Urological Association (AUA) Guidelines on the Management of Erectile Dysfunction and tailored to guide the primary practitioner in a step-by-step fashion through the evaluation and treatment of ED.

Telephone Equipment Distribution (TED) Program

Causes and diagnosis Generally, ED must exist for at least three months in order to make a formal diagnosis. Causes of ED fall into two basic categories: organic and psychogenic. Organic ED originates from specific neurologic and vascular impairments. Psycho-

Erectile dysfunction Evaluation and management By Matthew Braasch, MD

genic stems from factors including lack of physical attraction or arousal in a relationship, partner conflict, stress, lack of motivation or performance anxiety. Many cases of ED are

Many cases of ED are a combination of organic and psychogenic causes. a combination of organic and psychogenic causes. The following are important elements of the medical interview with the patient and his partner:

orders, stroke, tumors, mental illness, and dementia can affect brain centers for sexual drive and erection. Relevant surgical history would include radical prostatectomy, cystectomy, abdominoperineal resection or significant pelvic trauma. Sexual history. It is essential to differentiate ED from other related sexual disorders such as anejaculation, premature ejaculation, poor libido, genital pain, and Peyronie’s disease.

Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services

Organic Medical and surgical history. Diabetes, hypertension, hyperlipidemia, cardiovascular disease, alcoholism, and cigarette smoking are common and modifiable causes of ED. Movement dis-

Minnesota Physician March 2014

Pharmacologic. Most common causative medications include antipsychotics, selective serotonin reuptake inhibitors, thiazide diuretics, propranalol, cimetidine, and opioids. Psychogenic Psychogenic ED is typically characterized by sudden onset, situational problems, absence of risk factors, anorgasmia, and the presence of erections upon waking in the morning. Examination Essential elements of the physical exam include abdominal and genital exam and peripheral pulses. Special attention should be directed at blood pressure, waist circumference, BMI, testis size, evidence of gynecomastia, abnormal genital sensation or bulbocavernosus reflex, and penile curvature or fibrous plaques to indicate Peyronie’s disease.

Laboratory exam and specialized testing Many experts recommend complete blood count, serum chemistries, fasting glucose, and lipid panel to screen for medical conditions associated with ED. Morning serum total testosterone should be ordered in men with signs of hypogonadism or symptoms of low libido. Serum free testosterone, lutenizing hormone, and prolactin levels can be considered in men with low morning total testosterone. Nocturnal penile tumescence (NPT) testing can be helpful to differentiate organic from psychogenic ED. Treatment Participation of both partners in decision-making is critical. The type of therapy prescribed depends on such factors as invasiveness, cost, motivation, expectations, and coexisting medical conditions. The general treatment algorithm for ED is as follows: Inform, support, and assess risk. Brief education about the causes and incidence of ED, or simple reassurance, may be all that is needed to improve function or confidence for a patient. Practitioners with experience in sexual and couples counseling should intervene for psychogenic ED, and those without should refer for specialized counseling. Medications known to cause ED should be recognized and substituted or reduced if possible. Endocrinology referral is appropriate for patients with significant endocrinopathies. Patients with histories of unstable or refractory angina, severe CHF (New York Heart Association class III-IV), recent CVA, highrisk arrhythmias, significant cardiomyopathy, and moderate-to-severe valvular disease would be considered high risk for a cardiac event and should not receive treatment for ED. Lifestyle modification. Multiple studies have shown that quitting smoking, weight loss, regular exercise, and improving diabetes control can improve erectile function. Optimal control of blood pressure and cardiac risk factors would also

serve to prevent progression of ED. Oral pharmacologic therapy. Phosphodiesterase Type 5 (PDE5) inhibitors are the most popular agents because of their convenience and should be considered first-line therapy for men with organic ED. PDE5 inhibitors lead to successful intercourse for about 50 to 70 percent of the men with ED. Sildenafil and vardenafil reach a maximum serum concentration at about one hour after administration and have a halflife of four to five hours, versus about two hours and 18 hours respectively for tadalafil. There is no data to support success with a different PDE5 inhibitor in a patient who fails a sufficient trial of one drug. Patients should be counseled about common side effects: headache, stomach upset, facial flushing, and nasal congestion. Sildenafil and vardenafil can affect PDE6 receptors and cause vision changes. Vardenafil may cause QT prolongation and caution is advised in patients with a history of this condition. Caution is also advised for all three medications in men using alpha-blocker therapy because of risk for hypotension. The risk for potentiating hypotension is much higher with oral nitrate therapy and is contraindicated for these patients. It has been suggested that the safe interval for administering emergency nitroglycerin for presumed ischemia is 48 hours after last tadalafil dose and 24 hours after vardenafil or sildenafil. Alternative pharmacologic and nonpharmacologic options. If an adequate trial of PDE5 inhibitor and lifestyle modification has failed, patients should be counseled on remaining options including vacuum erection devices (VED), intraurethral suppositories, intracavernous drug injection, and penile prosthesis. The choice of therapy is determined by the patient and partnerâ&#x20AC;&#x2122;s expectations and desire for invasive versus non-invasive treatment. VED is a cylinder placed around the penis to cause penile

engorgement through negative pressure, which is maintained by placing a restrictive ring at the base of the penis. VEDs can be used in combination with pharmacologic treatments. They are a good option in patients for whom PDE5 inhibitors are contraindicated and poor surgical candidates. VEDs are produced by multiple reputable companies and are totally or partially covered by many insurance plans and by Medicare. Many companies offer full refunds for unsatisfied patients. Intraurethral alprostadil suppositories are not a popular option but may fulfill a niche of patients. There is a risk of hypotension and syncope and should be first administered under medical supervision. The most common side effect is penile pain in about one-third of men, and likewise, only about one-third of men experience effective treatment for their ED. However, intraurethral alprostadil may also be combined with VED for better efficacy. Self-injected vasoactive drugs for ED are most commonly alprostadil, papaverine, and phentolamine. These are available as single agents or specialized combinations from compounding pharmacies (bi-mix, tri-mix). Injections are performed with a small insulin-type needle placed into the base of the corpus cavernosum. Initial treatment is most appropriate under the supervision of a urologist. Injections are the most effective non-surgical treatment for ED (approximately 80 percent), but potential drawbacks include penile pain, hematomas, fibrosis, and the highest risk of priapism of any therapy. Patients must be educated on seeking prompt treatment for erections lasting longer than four hours. Treatment algorithm for priapism is beyond the scope of this article, but physicians treating ED should familiarize themselves with this condition. Self-injections should be avoided in men on chronic anticoagulation, but aspirin is generally safe. Dosage should be titrated up very slowly to an effective dose, and injec-

tions should not be performed more than once every 24 hours. Surgical implantation of a penile prosthesis is the gold standard in men who fail conservative options, choose not to use other treatment options, or for patients with Peyronieâ&#x20AC;&#x2122;s disease and ED. Both malleable and inflatable devices exist, with inflatable prostheses being much more popular. The prosthesis is implanted in the operating room and requires minimal hospitalization. The satisfaction rate for this treatment is very high and the complication rate (infection, erosion, mechanical failure), fairly low. This procedure is covered by many insurance plans and by Medicare. Testosterone supplementation to stimulate sexual drive is controversial because of its limited benefit in treating ED and potential for serious risk. It provides marginal or no benefit to men with normal testosterone levels or normal libido. Exoge-

Mayo clinic health SyStem â&#x20AC;&#x201C; Springfield Springfield, Minnesota

nous testosterone is delivered by patches or gels applied to the skin or oral mucosa, injections, or slow-release pellets inserted under the skin. Among other things, the provider must closely monitor for supratherapeutic testosterone levels, polycythemia, prostate cancer, hyperlipidemia, and liver dysfunction. Many options are available Initial evaluation of ED includes proper history taking and examination. Treatments including counseling, lifestyle modification, PDE5 inhibitors, vacuum devices, and intraurethral suppositories can be offered at the primary care level. Referral to a urologist may be necessary for intracavernosal penile injections or penile prosthesis surgery in patients who fail first-line therapies. Matthew Braasch, MD, is a board-certified urologist practicing in the Twin Cities with Urology Associates.

Engan associatEs architects interior designers

shared vision innovative design

800-650-0860 www.engan.com

March 2014 Minnesota Physician

Community Caregivers 2014

Making a difference in Minnesota and the world

Recognizing Minnesota’s volunteer physicians Each year, Minnesota Physician Publishing honors physicians who have volunteered medical services in recent years. Through volunteer medical activities that span the globe, Minnesota’s volunteer physicians have provided medical care and medical education while expanding cross-cultural skills and understanding. Their compassion, commitment, and generosity reflect deeply held values of Minnesota’s medical community.

By Minnesota Physician Publishing staff

Minnesota Physician March 2014

happened onto this way of giving back when a friend in India called for advice on her mother’s cancer diagnosis. Malisetti was able to review the records via email and offer her perspective. Since then she has been able to help several others in the same way.

Rajini Katipamula-Malisetti, MD Minnesota Oncology

Translating Telugu

ne night a few years ago, Rajini Katipamula-Malisetti received a phone call that a man had been found unresponsive in a swimming pool. She met his family and friends at the hospital and spent two hours helping them understand why they should have life support removed. The family was very grateful to her for explaining this difficult decision in their own language.

Growing up in the Telugu culture and also knowing Western medicine, Malisetti tries to give advice that honors the beliefs of Telugu patients here and in India. “I spend time explaining in the most basic terms what they are up against,” explains Malisetti. “I try to foster the idea that they need to ask questions to understand what they have and how to better manage their symptoms.” The biggest challenge for Malisetti is the gap in cultural beliefs. “In American medicine, people believe that only the patient has the right to choose or refuse treatment,” she observes. “This is different in our culture, where patients are often told what to do. It is very confusing for them when they are given choices.”

Malisetti volunteers out of humility, obligation, and gratitude. “Having grown up in the Indian medical sys“I try to foster the idea that That language is tem, I am reminded of Telugu, spoken by they need to ask questions.” how highly physicians people from Andhra are regarded. This Pradesh, a state in reminds me that I have southeastern India. It is also Malisetti’s first to keep doing the best I can,” she acknowledges. language. “Becoming a doctor was my greatest dream as a child,” recalls Malisetti. “And, with a lot of hard work, I was able to secure admission into a medical college in India.”

Malisetti’s contributions to the health and well-being of the Telugu people in Minnesota and India have not gone unnoticed. Last year she was honored with an award of excellence Malisetti arrived in the U.S. in 1999 for her residency in Massachusetts and then completed at the annual convention of the Telugu Associaa three-year fellowship in medical oncology and tion of North America (TANA). hematology at the Mayo Clinic in Rochester. “My goal is to be able to do more of this,” She now practices at Minnesota Oncology. shares Malisetti. “I have three daughters under While Malisetti is able to offer the occasion- the age of 10 so I am not able to spend more time volunteering. But as the kids get older, I al translation for Telugu patients, most of her would like to become more involved in providvolunteer work consists of reviewing medical ing free care to those in need back home.” records for patients back home in India. She

Thomas Haus, MD

Glacial Ridge Health System

family traveled to Guatemala several years ago. “I observed the profound need there for the most basic health care,” Haus remembers. Several of Haus’ coworkers at Glacial Ridge Health System and fellow residents from Glenwood had been traveling to Honduras on medical mission trips for the last 15 years. “I was gently encouraged to give it a try,” Haus recalls.

Providing care in Honduras

om Haus had always wanted to do a medical mission, but family obligations and other “excuses,” as he calls them, seemed more important. That changed when the family practice doctor from Glenwood, Minn., and his

lieves that “you have to cultivate the idea of good will in your children.” He continues, “I would want someone to help me if I were in need. We are only as well, as a society, as our least well.” The experience in Honduras opened Haus’ eyes to the fact that most U.S. citizens take for granted their easy access to quality and safe medical care. He says, “People would go for months without any medication or even the opportunity to see a care provider. Simple life-saving procedures are often not an option because of cost and travel barriers.”

Haus’ daughter, Katie, a high school junior at the time, had expressed some interest in medicine as a career and Haus remembers a 9-year-old boy who was also profishowed signs of heart cient in Spanfailure. There were no ish. She was “I would want someone to help options for the family immediately by itself to get him to a me if I were in need.” taken with the larger city about three idea of a trip to Central hours away. The loAmerica. “At that point I cal community leadhad no further excuses not to go,” concedes Haus. ers found a way to fund his trip to see a heart specialist affiliated with IHS, who was able to Haus traveled to Honduras with International arrange more treatment. Health Service (IHS, www.ihsmn.org), based in the Twin Cities. He spent two weeks there in several rural villages working in medical and dental clinics along the coast. The trip made such an impression on Haus that he became convinced it was an opportunity every person should have. He will return to Honduras with his second daughter in 2015. Haus be-

“Many people there have so little but seemed to be willing to give as much as they could,” reflects Haus. “They are very generous and thankful. I look forward to returning to this beautiful country with its kind people and playful children.” Community Caregivers to page 22

Mozart’s fanciful masterpiece comes to life in this eye-popping new staging.

APR 12 – 27 TICKETS START AT JUST

$20 EACH!

mnopera.org 612-333-6669

March 2014 Minnesota Physician

Richard Sveum, MD Park Nicollet Health System

obligation is to give back to the community.”

thought this incident Sveum gives back by directing Camp Suwould shut perkids, the summer camp for children with the camp asthma held at Camp Ihduhapi, the YMCA down for camp on Lake Independence near Loretto, good, but it Minn. Camp Superkids is sponsored by the didn’t. They talked American Lung Association in Minnesota, about the incident and with additional support from Children’s Hospital. Sveum inherited the position from decided to create the Consortium on Children’s Asthma Camps, now a national orgaRichard Cushing, nization. The result is better MD, the Park monitoring and care of chilNicollet allergist “The obligation is to give dren at camp. who founded the camp in 1967.

Serving children with asthma

“I

t’s a privilege to be a doctor,” says Dick Sveum, an allergist in the Department of Asthma and Allergic Diseases, Park Nicollet Health System, and an adjunct professor of medicine and pediatrics at the University of Minnesota School of Medicine. “With privilege comes obligation. The

back to the community.”

“We try to see the camp as community education,” explains Sveum. “We have a nurse for every cabin, along with pharmacists and respiratory therapists on site. We incorporate asthma education into daily activities and have a program for the parents, too, when they come to pick up their children from camp.” Most of the campers come from the inner city and receive scholarships, including some from health plans. Data have shown there are better outcomes for children with asthma if they go to camp and learn about the disease. One of the benefits of Camp Superkids arose out of tragedy. In 1987 a child collapsed at camp, was evacuated and resuscitated, but later died at North Memorial Hospital. Sveum and others

Spending time at the camp has directly affected Sveum’s clinical practice. “There is nothing like getting to know my patients outside the clinic by living with them at camp. I can see firsthand how asthma affects their lives,” explains Sveum. “When I see patients back in the clinic, we talk about their camp experience.” The time at Camp Superkids makes an impression— former campers will come up to him and talk about it years later. Sveum received the Lifetime Achievement Award from the American Lung Association in Minnesota, but stresses, “It’s not so much about me. It’s that there’s this thing—Camp Superkids—that doctors do that’s rewarding for children. I want more people to be aware of it.”

Are you satisfied with your claims processing? You will be with ClaimLynx! Every medical practice depends on cash flow. Very few people understand the required processes between when a doctor sees a patient and how/when insurance reimbursement is disbursed. We make these steps simple for you. Among the services we offer: • Direct, real time verification of eligibility • Secure online access to claims tracking • Secure online access to claims correction • Never miss a payment due to late filing • We handle every kind of insurance and every medical specialty • Less time on paperwork, more time with patients

ClaimLynx is used by many national clearinghouses. You may already be using our services and not know it. Shorten your submission route and remittance time—go straight to the payer using ClaimLynx. Every practice is unique and whether a solo practitioner or large multi-specialty group (and everything in between) we can tailor a solution to your claims processing needs that will maximize your benefits.

Claims processing is an art. Let us show you the difference we can make

For more information please contact: Russel Campbell info@claimlynx.com 10700 Old County Road 15 Suite 200, Plymouth, MN 55441

www.claimlynx.com

952-593-5969

Minnesota Physician March 2014

Jim Standefer, MD University of Minnesota

Improving vision worldwide

arly in his second career as a volunteer, Jim Standefer visited Mongolia to perform cataract surgeries with two other ophthalmologists. The chief ophthalmologist at the hospital said, “You need to come back next summer—we don’t know anything about glaucoma.”

Standefer returned for four weeks, and thoroughly enjoyed it.

two weeks with the understanding they will leave to teach others what I taught them.”

Standefer has always been interested in volunteer work, but wasn’t able to make good on that intention until 20 years ago. His ophthalmology practice in Stillwater had grown to include multiple offices and doctors, and he felt the time was finally right to embark on a new course.

Standefer has also brought ophthalmologists to the University of Minnesota for three-month observerships. “I usually teach about the eye bank. One resident from Lithuania went home and started the first eye bank in Lithuania,” Standefer recalls. He is clearly pleased that this ophthalmologist took his instruction to heart.

Standefer’s gift and passion is teaching and Cataracts are easy to see, treating glaucoma. Currentdiagnose, and treat. Surgery “Teaching is key. One ly an adjunct professor of restores vision overnight, lecture can do so much.” clinical ophthalmology at so patients in developing the University of Minnesota, countries are thrilled with Standefer has taken his mesthe “miracle.” “But not so sage throughout the developing world, including with glaucoma,” remarks Standefer. “We can only Nigeria, Siberia, Yemen, Africa, and Vietnam. reduce the pressure in the eyes.” Most glaucoma Pakistan, Iran, Oman, and Jordan are on the patients in these countries go untreated, and thus itinerary in the next few years. This April he will slowly go blind. Although there is no cure for speak in Tokyo at the World Ophthalmology Conglaucoma, at least the surgeons can be trained to ference. “I’m kept busy,” chuckles Standefer. perform the pressure-reducing surgeries. By the numbers, Standefer has taught more than 42 workshops in more than 30 countries. “The variety of countries I’ve been to—that wasn’t by purpose,” Standefer explains. “People would ask me, ‘Come teach,’ and I would go.”

“For me, the best method is still teaching ophthalmologists in these developing countries, using the ‘trainer of trainers’ approach,” maintains Standefer. “They should go and teach others in their institutions as much as they can.

“I use the public health model of ‘teacher of teachers,’” explains Standefer. “I will ask for five ophthalmology residents from different training centers in the host country. They come to me for

“Teaching is key,” he emphasizes. “That is the core of my message—my mission and my passion. One lecture can do so much.” Community Caregivers to page 24

March 2014 Minnesota Physician

Brad Linzie, MD

Hennepin County Medical Center

Linzie, medical director of the surgical pathology department at Hennepin County Medical Center. The women explained to Linzie how they had a huge amount of pent-up anxiety because they had never had a Pap test before. “I have been very much changed by that sentiment,” Linzie reflects humbly.

tance of getting appropriate screening tests.” Linzie marvels at the contrast between his day job and his work at NorthPoint. “Normally when I am working, I am sitting in a quiet room alone or with students while reading slide after slide for abnormal findings,” he explains. “I don’t get to see what impact this will have on a person. At the See, Test & Treat health fairs, I am in the middle of a crowded clinic where I get to bring the patient to the microscope and see her face when I explain her finding.”

Linzie gained this insight at NorthPoint Health and Wellness Center in Minneapolis through the See, Test & Treat program sponsored by the College of American Pathologists. “We physicians have an ethical This national program provides cervical and obligation to get appropriate breast cancer screening medical information and care to aimed at underserved populations, at health groups that need it.” fairs.

Cancer screening for underserved

“I

remember several occasions when I showed women that their Pap test was completely normal and they immediately burst into tears. This was not the reaction I had anticipated,” recalls Brad

Women are seen by a primary care provi-der, get a Pap test and results, and a screening mammogram and results, all on same day. Any follow-up care needed, based on an abnormal result, can be scheduled for that day or whenever it is convenient for the patient. Participants also can view their own Pap test slide with a pathologist and see how HPV is detected and how cells are viewed through the microscope. “This educational opportunity is not available anywhere else,” explains Linzie. “It is a positive reminder for these women of the impor-

Linzie has received the CAP Foundation’s newly created Gene and Jean Herbeck Humanitarian Award, for his leadership in providing outstanding direct patient services to individuals in underserved communities through the See, Test & Treat program.

Linzie has this advice for fellow physicians: “We physicians have an ethical obligation to get appropriate medical information and care to groups that need it. Keep your eyes and ears open for opportunities to join a community outreach effort that appeals to you or needs your unique talent.” He concludes, “Your soul will be rewarded in ways that help you feel creative and better able to deal with the stress and burnout of your regular job.”

Computer Problems? Quality Transcription, Inc. Setting the standards for excellence

Quality Transcription (located in Minnesota) maintains a professional office environment, thus the confidentiality of your work is strictly maintained. We provide medical transcription services on a contract or overload basis. Our equipment is state of the art with 24 hour dictation lines and nationwide accessibility. We are experts in our field. We deliver on time. We have experienced staff. We monitor the quality of our work. We provide services tailored to your needs and will do whatever it takes to get the job done.

We are specialists in Apple devices (including iPads and iPhones) and software. We also support Windows and Windows to Apple integration. We are certified through the Apple Consultants Network serving individuals and businesses inquiring about moving to Apple, or how to improve existing systems.

Services include:

• On-site training – in your clinic, hospital or at home

• Group Workshops • Expedited Computer Repairs • Data Recovery • System upgrades • Network connectivity issues

Rapid service and reasonable rates Quality Transcription, Inc. 8960 Springbrook Drive, Suite 110 Coon Rapids, MN 55433 Telephone 763-785-1115 Toll Free 800-785-1387 Fax 763-785-1179 e-mail info@qualitytranscription.com Website www.qualitytranscription.com

Minnesota Physician March 2014

Providing service throughout the metro area and remote service connection throughout Minnesota

612-643-0643

www.perfecteden.com

Bill Nersesian, MD

Fairview Physician Associates

explains. Minnesota Adult and Teen Challenge has a choir that sings at churches around Minnesota. The singers give testimonies about how they have come back from the depths of despair and drug abuse. The choir had been to Nersesian’s church several times before, and returned at the time he was considering volunteer work.

“Blue collar workers, forklift operators, also stock brokers, pastors, physicians—I’ve come across almost every level of society,” Nersesian marvels. “It’s an eye-opener to see how pervasive drug and alcohol problems are. No one is immune. My experiences at Teen Challenge have made me more aware of the signs and not to take anything for granted.”

Nersesian decided to give Teen Challenge a call. They needed someone to give physicals to the incoming clients. That was the last thing Nersesian thought he wanted to do—more of the same thing he did every day at his job—but he “I feel called to do this—it’s agreed to it anyway. He discovered surprising almost like I couldn’t not do personal rewards as a result.

Changing lives of challenged teens

s his youngest child was finishing high school, Bill Nersesian realized he had extra time on his hands. He started looking for the right outlet for giving back or, “what God would direct me to do,” he

Minnesota state law requires every inpatient who receives drug or alcohol addiction treatment to have a physical exam and blood testing. At least 80 percent of the clients are men. “I’ve been doing this for 11 years now, so I’ve helped about 1,500 men,” estimates Nersesian. Nersesian finished his pediatric practice a few years ago and now serves as the chief medical officer for Fairview Physician Associates. A departure from his day job, Nersesian’s work at Teen Challenge has given him a greater awareness of the drug and alcohol problems in society.

In addition to providing physicals, Nersesian also mentors many of the young men in the program. His greatest enjoyment comes from encouraging them. “I like to point out to them some of the things I see that are good—their personality, their potential, their skills,” he shares. “If they can stay in the program a year, 87 percent will not go back to drug or alcohol addiction. “I feel called to do this—it’s almost like I couldn’t not do it,” explains Nersesian. “I find myself energized and rejuvenated. Even when I’m tired, or the weather’s bad, once I get down there, I’m glad I went.” He continues, “I get rewarded by visiting with these young men. When I leave, I feel like I’ve done what I should be doing. It’s a calling from God.”

Building a Healthy Medical Practice

How to Thrive, Not Just Survive AAPS National Spring Meeting

Friday, May 9, 2014: 12:30 to 6 PM: Dinner program follows Physicians, Surgeons, Nurses, Chiropractors, Medical Professionals, Employers, Individuals, Agents

Sponsored by the Association of American Physicians and Surgeons (AAPS) and the Minnesota Physician-Patient Alliance. Speakers from across the country assessing the future of your medical practice. • Empowering patients and MDs, innovations, legal issues, nuts and bolts on how to change your practice. • Presenting real-life stories of practicing physicians and surgeons who have transitioned from third-party paid practices to a direct-pay model. • $99 for Physicians and Health Care Professionals and $49 for Professional Staff. Scholarships for interns and residents.

Session Speakers: Robert Sewall, MD - TX Susan Wasson, MD - MN Donald Gehrig, MD - MN Doug Nunamaker, MD - KS Kathy Brown, MD - OR Mitchell Brooks, MD - TX Lee Beecher, MD - MN Jane Orient, MD - AZ Lawrence Huntoon, MD - NY Andrew Schlafly, JD Twila Brase, RN - MN Peter Nelson, JD - MN Dave Racer, MLitt - MN Sean Parnell - VA

Marriott, Minneapolis Airport 2020 American Boulevard E - Bloomington MN 55425 Details at http://tinyurl.com/aapsmtg or call 651.705.8583

Keynote Speakers: Richard L. Reece, MD Merrill Matthews, PhD

Up to 6.75 CME Credits Available This activity has been planned and implemented in accordance with the Essential Areas and Policies of the New Mexico Medical Society (NMMS) through the joint sponsorship of Rehoboth McKinley Christian Health Care Services (RMCHCS) and the Association of American Physicians and Surgeons (AAPS). Rehoboth McKinley Christian Health Care Services is accredited by the New Mexico Medical Society to provide continuing medical education for physicians. RMCHCS designates this live activity for a maximum of 6.75 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

March 2014 Minnesota Physician

SPECIAL FOCUS: PHARMACY

n 2012, an epidemic of fungal meningitis hit the United States, killing 64 and sickening 750. The source of the epidemic was found to be contaminated preservative-free methylprednisolone acetate, a steroid compounded by New England Compounding Center (NECC), a mega pharmacy in Massachusetts. It was shipping compounded medication to clinics and hospitals in 20 states, including Minnesota. When the Food and Drug Administration (FDA) investigated, it found substandard conditions at NECC, including tainted medication, contaminated clean rooms, deficient quality control, and disregard for the rules of sterile compounding. Several facilities in Minnesota obtained the preservative-free steroid from NECC. Physicians injected the steroid into their patients’ spines and joints to treat pain—and many patients developed symptoms or disease over the ensuing months. NECC is now closed and bankrupt. Lawsuits are in

Compounding pharmacies New regulations impact medication access By Geoffrey Emerson, MD, PhD

process involving NECC and some of the clinics that administered the tainted product. Lax oversight of the compounding

The requirement impedes physicians from stocking compounded medications that are administered in clinic. pharmacy industry was exposed and became front-page news. The NECC tragedy is one of the worst iatrogenic epi-

Is your jetted tub making you sick? Jetted tubs are full of dangerous biofilm, body waste, mold and bacteria if not cleaned properly. It takes specialized cleaners like Oh Yuk Jetted Tub Cleaner to effectively and safely clean contaminants from the tubs plumbing system. Improperly cleaned tubs may put users at risk of infections and/or respiratory problems. • for your home Jetted tub or hot tub • for your clinics’ rehab therapy whirlpools

• tell your patients!

Order For product information visit: www.scientificbiofilmsolutions.com

demics in recent history for the U.S. health care system. Physicians, pharmacies, and regulators were unprepared

Minnesota Physician March 2014

and had missed warning signs, including NECC’s disregard for the individual prescription requirement for a pharmacy to dispense medicine. By dispensing compounded medicine without an individual prescription as required by Minnesota and 14 other states (Table 1), NECC was illegally operating as a manufacturer (without a manufacturer’s license). Instead, NECC was licensed as a compounding pharmacy by the Massachusetts Board of Pharmacy (BOP). State boards of pharmacy typically oversee pharmacies that are much smaller than NECC, and the Massachusetts BOP may have been ill-prepared to oversee such a large entity. In any event, the Massachusetts BOP failed to inspect NECC and did not discover egregious deficiencies in cleanliness and sterility. Hospitals and clinics across the country were unaware of quality concerns and stocked their clinics with tainted product, even though wholesale supply of medicine to clinics from a pharmacy is illegal in many states, including Minnesota. Furthermore, until the NECC tragedy, many clinics and hospitals in Minnesota were unaware of (or ignored) the individual prescription requirement and commonly ordered supplies of compounded medi-

cation from many pharmacies “for office use.” Nationwide backlash against compounded medicine In late 2012, Congress and the FDA debated whether the FDA had authority to inspect and regulate large compounding pharmacies (previously under state BOP control), which had grown beyond their traditional scope of practice. These large facilities, while pharmacies in name, were making larger batches, shipping across state lines, and wholesaling medicine in bulk, which are activities more typical of manufacturers licensed and regulated by the FDA. Meanwhile, the Minnesota BOP issued an urgent memo alerting pharmacies of established Minnesota statute that all compounding must be done pursuant to an individual prescription. In early 2013, public opinion and legislators called for increased oversight by the FDA of large-scale compounding pharmacies. The FDA conducted surprise inspections, leading to recalls of medication from dozens of pharmacies (Reference 1, page 36). Traditionally, pharmacies that compound sterile medication must follow standards set forth in the United States Pharmacopoeia, chapter 797 (USP 797) and this standard is regulated and enforced by state Boards of Pharmacy. In contrast, manufacturers are under FDA jurisdiction and must follow so-called “Good Manufacturing Practices,” a stricter standard than USP 797 that requires more rigorous documentation. Many of the compounding pharmacies inspected by the FDA met USP 797 standards and did not have any current or prior reports of contamination. However, FDA inspectors concluded that many of these facilities fell short of Good Manufacturing Practices standards, leading to the aforementioned recalls. The impact in Minnesota Pain specialists, ophthalmologists, obstetricians, pediatricians, ENT surgeons, dermatologists, orthopedic surgeons,

Fig 1. Until proposed legislation allows an outsourcing facility to wholesale to a Minnesota clinic, the options for stocking a clinic with compounded medication for office use include, (A) writing an individual prescription for each patient, or (B) compounding the medication in the clinic, using a clean room and USP 797 standards.

Table 1. As of January 2013, 15 states required an individual prescription before medication is dispensed by a pharmacy to a clinic for office use. Colorado

Maine

Minnesota

Pennsylvania

Georgia

Maryland

New Mexico

Rhode Island

Hawaii

Massachusetts

New York

Tennessee

Louisiana

Michigan

Ohio

and interventional radiologists administer compounded medications to patients in their clinics to treat joint pain, macular degeneration or preterm labor, and to diagnose and treat a myriad of other medical conditions (Table 2). Physicians rely on access to these medications to provide timely care to patients. In states that donâ&#x20AC;&#x2122;t require individual prescriptions, clinics may anticipate the needs of their patient population and preorder a stock of compounded medication. Minnesota clinics, however, are required to identify individual patients before ordering individual doses of compounded medicine. The intent of the law was to improve regulation of compounded medication. But an unintended consequence of the law is that access to the medication is delayed, and clinics face increased administrative burden related to writing prescriptions in advance and cataloging medication for individual patients. The individual prescription requirement impedes physicians from stocking their clinics with compounded medications that are administered in clinic. Also, fewer options are

available to patients at the time of their appointments. For some medical conditions, there are serious medical consequences. For example, intraocular infection (endophthalmitis) is treated by injecting the eye with a sterile preservative-free solution of vancomycin or ceftazidime. These ophthalmic preparations are compounded by a pharmacy and are not available from a commercial manufacturer. In endophthalmitis, a delay in treatment means permanent vision loss and risk of losing the eye. For such emergency situations, it is essential to have the medication available in clinic when the patient needs it, rather than ordering it from a nearby pharmacy during the encounter. Furthermore, in nonemergent situations, it is beneficial to have the option of administering the compound during the encounter, in case it is difficult for the patient to return for the injection at a separate encounter after the medication is dispensed. Financial implications When compounded medications are not available in the clinic, physicians turn tmore expensive alternates to treat

their patients in a timely manner. For example, macular degeneration is a condition for which the most common treatment is bevacizumab (Avastin) from a compounding pharmacy, costing about $50 per dose. Ranibizumab (Lucentis) and aflibercept (Eylea) are

alternatives that a clinic can purchase directly from a wholesale distributer without an individual prescription, but the cost of these medications is about $2,000 per dose. The difference in cost is dramatic in light of the CATT trial, a prospective randomized clinical trial that showed no difference in clinical response to these treatment options (Reference 2, page 36). Use of the more expensive medications has increased more than four-fold in Minnesota in the past year, since the individual prescription rule was enforced (Reference 3, page 36). This trend is apparent to health insurance companies, which have responded by increasing patient copays and by increasing prior-authorization requirements for the expensive alternatives. As a case in point, on Jan. 1, 2014, many commercial insurance providers increased the

Compounding pharmacies to page 36

Read us online Wherever you are!

www.mppub.com

March 2014 Minnesota Physician

Special Focus: Pharmacy

Practice-Based Research Networks

ccording to the Agency for Healthcare Research and Quality (AHRQ), a Practice-Based Research Network (PBRN) is “a group of ambulatory practices devoted principally to the primary care of patients, affiliated with each other (and often with an academic or professional organization) in order to investigate questions related to community based practice.” PBRNs were first formed in primary care practices in the late 1970s, and involved community-based clinicians and their staffs in activities designed to help understand and improve primary care. The goal was to link relevant practice questions with rigorous research methods in community settings, to provide information that was reliable, valid, and transferable into everyday practice. Thought leaders within pharmacy have developed PBRNs to take advantage of the locational accessibility of pharmacies and the ubiquitous

Minnesota pharmacies ideal sites to study care By Jon C. Schommer, PhD use of medications. That usage is likely to be the only treatment modality with which people interact on a daily basis. Nearly everyone takes medication Based on publicly available sources, we estimate that more

Pharmacists are the most frequently encountered health professionals for many patients. than 500 million times a day in the United States, individuals

Here to care At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 11 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel. Make a difference. Join our award-winning team. Madalyn Dosch, Physician Recruitment Services Toll-free: 1-800-248-4921 Fax: 612-262-4163 Madalyn.Dosch@allina.com allinahealth.org/careers

3.5x4_AD.indd 1

decide whether or not to take a prescription medication. In addition, there are approximately 6 million pharmacy visits per day. Arguably, these are the most frequently occurring health care events, far outpacing such things as the number of physician office visits (2.6

Minnesota Physician March 2014

million per day), hospital inpatient procedures (123,287 per day), and hospital discharges (108,041 per day). Eighty percent of the way chronic diseases are prevented and managed is with medications. In any given week, 81 percent of U.S. adults take at least one medication, and nearly one-third take five or more different medications. Over a lifetime, it is estimated that a typical person will take 14,000 pills. A person’s regular interaction with medications is not only a frequently and consistently occurring health care event, it also intersects with almost all other aspects of his or her health care. When people have transitions in care, such as hospital discharge, they become especially vulnerable for medical errors as a result of incomplete or inaccurate communication about medication therapies. After hospital and intensive care unit discharges, individuals are at high risk for unintentional discontinuation of medications with proven efficacy for treating chronic diseases. Avoidable hospital readmissions are directly related to medication-related events about one-third of the time.

2/7/13 1:08 PM

Studying medication usage Developing capacity for research in networks of community pharmacies could help fill gaps in our understanding of the medication use process by focusing upon (1) questions encountered by pharmacist practitioners in their practices, (2) issues that are relevant to members of diverse communities served by these practices, and (3) research that can be shared quickly with pharmacy practice and the broader health care community. The advantages of such an approach are clear. In the U.S., there are more than 70,000 pharmacies in all types of health care facilities, including more than 56,000 community pharmacies. The locations of pharmacies are based upon community members’ preferences for convenience and access, making them logical sites through which care can be studied and enhanced. Pharmacists are central to the medication use process and are the most frequently encountered health professionals for many patients. In addition to access and convenience, studies in community pharmacy settings afford the opportunity to observe self-care behaviors that overlay prescribed therapies, including over-the-counter drugs and nutritional supplements. For patients under the care of multiple prescribers, the pharmacy is an ideal place to study and improve the continuity and coordination of care across settings. Since many patients visit pharmacies at frequent and regular intervals, it’s also an ideal place to examine the quality, safety, efficiency, and effectiveness of many prescribed treatments for chronic care. Pharmacy-based PBRNs Such access to patients where they procure most of their medications presents a unique opportunity for pharmacists and pharmacies to help contribute to an understanding of the medication use process. Pharmacy-based PBRNs can focus on collecting information in real-world settings to help address societal, community, or professional questions that relate to medication use. Such a focus would expand upon

existing work and collect information to address societal and community questions related to the medication use process. The Minnesota example The Minnesota Pharmacy Practice-Based Research Network (MPPBRN) was launched in 2008. Its purpose is to collect information, using a network of pharmacies, to address societal and community questions related to the medication use process. The MPPBRN is a collaboration among the Minnesota Pharmacists Association, the University of Minnesota, and pharmacist practitioners, and has been designed to serve as a meeting point for sharing and generating new ideas that are relevant to the interface among the practice of pharmacy, health care, health systems, health technologies, communities, and society overall. To share information with external partners, the MPPBRN was registered with the AHRQ PBRN Registry (http://pbrn. ahrq.gov/pbrn-registry). Information about the PBRN can be found at: (http://pbrn.ahrq.gov/ pbrn-registry/minnesota-phar macy-practice-based-re search-network). As of October 2013, the Minnesota Pharmacy PBRN consisted of 366 geographically dispersed pharmacies and 23 principal investigators from the University of Minnesota. In 2013, we completed the fifth year of our PBRN and conducted a self-assessment of what we have learned and how we can make changes to our network. Projects conducted so far have utilized our PBRN for: • Connecting principal investigators with pharmacists • Providing principal investigators with access to patients • Conducting demonstration projects that involve pharmacist-provided care • Testing tools and measures that can be applied to pharmacy practice • Learning about pharma-

cist workforce and work system designs

Minnesota Pharmacy Practice-Based Research Network at a glance

• Over-the-counter medication use patterns

Who we are: A collaborative among the Minnesota Pharmacists Association, the University of Minnesota, and Pharmacist practitioners (at least 75 percent are pharmacists)

We also learned that our PBRN has encountered limitations due to: • Respect for the proprietary nature of some data in pharmacies • Lack of access to prescription drug claims data, for which data ownership has been transferred to benefit management or claims processing organizations Thus, project ideas that require data extraction or data queries may not always be feasible. We realized that research questions related to over-thecounter medication use might not only be of great interest, but also might be well suited for our PBRN through the use of invoice records (which are under the control of pharmacies). Going forward, we plan to develop some project ideas in this domain. We also realized that our PBRN may be limited because of data access, ownership, and propriety, but we do have expertise in framing research questions and providing stateof-the-art techniques, and can provide credibility for studies. Our plan is to continue to serve as a connector and work in the the same areas of our past projects (listed above). In addition, we believe that areas for growth include: • Involvement with other disciplines, community members, and other stakeholders • Collaboration with PBRNs that are forming in other states • Continued engagement of communities and professional organizations • Management of multiple-site projects • Translating results into practice • Strategic planning as needs/environments change

What we do: MNPBRN is designed to collect information using a network of pharmacies, to help address societal and community questions related to the medication use process Current or past research interests: Arthritis and other non-traumatic joint disease (muscle, bone, joint conditions); cardiovascular disease (including stroke and (HTN); chronic pain; diabetes (type 1 or 2); health literacy; immunizations; pulmonary disease/asthma Website: http://pbrn.ahrq.gov/pbrn-registry/minnesota-pharmacypractice-based-research-network

• Instrument testing and development • Data collection, storage, management, and analysis • Communication over distances and over time Oversight for the MPPBRN is accomplished through a Guidance and Oversight Board. It meets quarterly and includes the PBRN coordinators (Jon Schommer, PhD, Liz Cinqueonce), a practitioner member (Julie Johnson, PharmD), two

scientific members (Ronald Hadsall, PhD, Oscar Garza, PhD), and a public member (Valorie Cremin). If you are interested in serving on the Guidance and Oversight Board, please contact me (schom010@umn.edu) or Liz Cinqueonce (lizc@mpha. org). Jon C. Schommer, PhD, is a professor in the College of Pharmacy, University of Minnesota, Twin Cities.

Medical Director Minnesota Veterans Home – Minneapolis Salary Range: $153,948 - $230,432 annually JOIN OUR TEAM – PROUDLY SERVING THOSE WHO HAVE SERVED The Minnesota Veterans Home - Minneapolis recognizes the great courage of the individuals who fought for our freedom. Our facility has been providing care to Veterans since 1887. Our beautiful and historic campus is located on 51 wooded acres overlooking the Mississippi River. We provide skilled care and boarding for veterans. Free parking is available and we're easily accessible by bus, car or light rail transit. The incumbent will provide direction to the MDVA Medical Staff Quality Program to identify and implement quality initiatives and best practices within MVH Homes. Serve as the medical expert on CMS certification and reimbursement. Serve as the Medical Director for the Minneapolis Adult Day Care Center and Domiciliary and manage the start-up and strategic development of the Primary Care Clinic located on the campus of the Minneapolis Home. Plan, develop and manage Medical services for an assigned portion of the residents at the Minneapolis Veterans Home. Provide timely response for staff when on-call, per the on-call schedule. Provide training and education as requested for all clinical staff. Qualifications: State of MN medical doctor license (unrestricted/unconditional); Board certified preferably in family practice, internal medicine or geriatrics; Two years of medical practice experience in geriatric care (continuum of care) chemical dependency/PTSD/mental health/dual diagnoses or other related areas; Must be able to pass MN Background study. Experience with CMS/Medicare requirements for standards of care and reimbursement preferred. GREAT BENEFITS PACKAGE! The State of Minnesota offers a comprehensive benefits package including low cost medical and dental insurance, employer paid life insurance, short and long term disability, pre-tax flexible spending accounts, retirement plan, tax-deferred compensation, generous vacation and sick leave, and 11 paid holidays each year. Please submit your resume online at the state careers www.state.careers.mn.us and refer to job posting 14MDVA000038.

website

For more information, please contact Barb Zilmer in Human Resources by email at: barb.zilmer@state.mn.us, or by phone at: 651/757-1576. An Equal Opportunity Employer

March 2014 Minnesota Physician

SPECIAL FOCUS: PHARMACY

Recently approved by the FDA

n 2013, the U.S. Food and Drug Administration (FDA) approved 27 novel medications (known as New Molecular Entities, or NMEs), just above its average of 26 NMEs per year. The FDA also issued 32 drug safety communications providing information about contamination, investigations, potential side effects, and labeling changes last year. Considering that prescription drug spending in the United States is projected to increase in 2014 by 8.8 percent, as newly insured consumers enter the health care system (according to the Centers for Disease Control and Prevention national health projections), practitioners will be expected to manage an enormous amount of information about medications. The role of clinical pharmacists is to help practitioners use all of this drug information. This article reviews recently approved medications for diabetes, congestive obstructive pulmonary disease (COPD),

A look at new medications for common ailments By Jean Moon, PharmD, BCACP weight loss, and pain. Diabetes One of the most noteworthy of the novel medications released in 2013 is canagliflozin (Invoka-

Prescription drug spending in the U.S. is projected to increase in 2014 by 8.8 percent. na). In January 2014, a similar drug, dapagliflozin, was approved. This new class of type 2 diabetes medication works by targeting sodium glucose transporter 2 (SGLT2). By inhibiting SGLT2, where most

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • General Surgery • Geriatrician • Outpatient Internal Medicine

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Rheumatology

F o r m o r e i n F o r m aT i o n :

Kari Bredberg, Physician Recruitment | karib@acmc.com | (320) 231-6366

www.acmc.com |

of the filtered glucose from the tubular lumen is reabsorbed, these medications reduce the reabsorption of filtered glucose and lower the renal threshold for glucose. The overall result is

MINNESOTA PHYSICIAN MARCH 2014

increased glucose excretion in the urine. As a class, SGLT2 inhibitors have many advantages. Due to their mechanism of action, they do not carry a major risk of hypoglycemia, and there is evidence that they may reverse beta-cell dysfunction and insulin resistance. Evidence has also shown favorable effects on reducing body weight and blood pressure. SGLT2 inhibitors can be used with other antidiabetic medications. They were not included in the recently released 2014 American Diabetes Association Standards of Care. COPD In recent Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, phosphodiesterase-inhibitors (PDE-4 inhibitors) are recommended as an alternative in patients with high risk (i.e., patient groups C or D), typically classified as GOLD 3 or 4. Approved in 2011 for COPD, roflumilast (Daliresp) is a once-daily oral medication that increases the cAMP (cyclic-3,5-adenosine monophosphate) metabolizing enzyme found primarily in lung tissue. This medication is recommended only in combination with a long-acting anticholinergic or beta 2-agonist, and may take several weeks to achieve full effect. Approximately 25 percent

of patients taking roflumilast experienced fewer COPD exacerbations, and slight increases in FEV1 have been shown. The most common side effects to roflumilast include diarrhea (including severe diarrhea), weight loss (2–5 kg), and nausea, all of which may improve over time. Weight loss also can be severe in some patients, usually those with the most severe COPD (greater than 10 percent of body weight in one year for 7 percent of cases). Providers should take care to monitor for increased suicidal ideation, acute pancreatitis, and urinary tract infections. The incidence of cancer is also a concern; the FDA report showed significantly more prostate, lung, and colorectal cancer in the roflumilast group than in those taking placebo. Side effects alone may keep PDE-4 inhibitors in an alternate treatment category for COPD, but it will be interesting to watch this drug class. Other medications in this class are being studied—and sometimes used—in other countries for asthma, stroke, multiple sclerosis, and a variety of other central nervous system disorders and inflammatory conditions. Weight loss According to the Centers for Disease Control and Prevention, nearly 36 percent of adults in the U.S. are obese; in Minnesota, the prevalence in 2012 was 25.7 percent. New weightloss medications have come to market in recent years, including some familiar drugs that have a new indication for weight loss. One such drug is Qysmia (phentermine/topiramate ER). Topiramate has long been used for seizure disorders or migraines, and clinically has been used off-label to reduce weight gain in those needing to be on topiramate for other medical reasons. In combination with the stimulant phentermine, Qysmia has been approved for obesity in adults with a body mass index greater than 30kg/ m² or greater than 27 kg/m² Recently approved by the FDA to page 32

Psychiatrist Cross-Cultural Medicine HealthPartners Medical Group in St. Paul, Minnesota, seeks a BC/BE licensed psychiatrist to practice cross-cultural medicine with our experienced Behavioral Health team at the Center for International Health (CIH), an internationally recognized refugee/immigrant medicine clinic which has helped define best practices in refugee and immigrant healthcare for 30+ years. U.S. and international experience providing psychiatric care to refugees and globally mobile populations is strongly preferred. Qualified bilingual psychiatrists (especially those fluent in Somali, Khmer, Oromo, Karen, Vietnamese, Hmong, Nepali or Russian) are encouraged to apply. This part-time (0.5 FTE) position will provide outpatient psychiatric care closely integrated with primary care in a holistic care model, while partnering with community organizations and the MN Department of Health’s Refugee Health Program. There is also opportunity for an academic faculty appointment at the University of MN and teaching involvement in the Global Health Pathway (www.globalhealth.umn.edu). HealthPartners offers a rewarding practice with a competitive salary and benefits package. Forward your CV and cover letter, specifying your language fluency and global health/refugee medicine experience, to lori.m.fake@healthpartners.com or apply online at healthpartners.com/ careers. For more details, call 800-472-4695 x1. EOE

Minnesota Physician 4" x 5.25" Join the top B&W

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:

• 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

www.NWFPC.com March 2014 Minnesota Physician

Recently approved by the FDA from page 30

Information about newly approved pharmaceutical products • D rug information for health care professionals: www.fda.gov/Drugs/ResourcesForYou/HealthProfessionals/ • D rug approvals and databases: www.fda.gov/Drugs/InformationOnDrugs/ • Drug safety: www.fda.gov/Drugs/DrugSafety/

with at least one weight-related comorbidity (hypertension, type 2 diabetes, or dyslipidemia). This treatment is an adjunct to a reduced-calorie diet and increased physical activity. The exact mechanisms of action for both phentermine and topiramate are unknown. We do know that phentermine increases catecholamines, leading to reduced appetite and decreased food consumption. We also know that topiramate appears to suppress appetite as well, and enhances satiety through a variety of proposed mechanisms. Clinical trials with thousands of patients have shown the

Unlike fenfluramine/phentermine (fen-phen), lorcaserin has low-to-no activity on serotonin 2B at therapeutic concentrations. Serotonin 2B receptor medications, which activate cardiac interstitial cells, are believed to cause valvular heart disease, while 2C receptor agonists do not.

Due to pregnancy-associated concerns in the first trimester with this medication, the FDA requires a Risk Evaluation Mitigation Strategy (REMS) for Qysmia. Patients should be tested for pregnancy every month on treatment. Also, those select patients on the highest

Due to the FDA’s heightened concerns, lorcaserin was denied approval in 2010 and the manufacturer was required to provide more evidence of safety. It was approved by the FDA in 2013, but the manufacturer is required to conduct six post-marketing studies to measure cardiovascular risks such as heart attack and stroke. So far, three clinical trials have shown a pooled incidence of valvulopathy as 2.4 percent for Belviq vs. 2 percent for placebo, which is not statistically significant.

St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

healthpartners.com 32 Minnesota Physician MN Physician 4" x 5.25" 4-color

With similar indication, lorcaserin (Belviq) is a new selective serotonin 2C agonist that promotes satiety and reduces hunger. One study showed an average weight loss of 5.8 kg on lorcaserin vs. 2.2 kg with placebo after two years.

combination to improve weight and adiposopathy-associated metabolic diseases. Compared to placebo, patients on phentermine/topiramate lost significantly more weight than the placebo group after 108 weeks, and experienced an average 8.9 percent weight loss in the SEQUEL trial.

Family Medicine

doses should be tapered off the medication to minimize risk of seizure.

March 2014

Pain In 2009, the U.S. Drug Enforcement Agency asked U.S. Health and Human Services for a recommendation regarding the scheduling of hydrocodone combination products. Since hydrocodone is the most prescribed prescription drug in the U.S., many groups have been calling for reclassification of its drug schedule status due to concerns about abuse and misuse of the drug. In October 2013, the FDA released a statement recommending that hydrocodone combination products be scheduled at the more restrictive status of CII, rather than CIII. One day after the statement was released, the FDA approved a new extended-release formulation of hydrocodone bitartrate (Zohydro). Zohydro is the first hydrocodone product to be released without acetaminophen.

When prescribed for chronic pain, at twice-daily dosage, this medication would provide an acetaminophen-free option for patients with liver disease or risk factors. Six strengths, from 10 to 50 mg, will be available. The FDA approval of Zohydro requires a standard REMS for opioid medications (i.e., providing patients with medication guides and information about safety issues) and a post-marketing study to evaluate its serious risks. The timing of approval of Zohydro, which has no abuse-deterrent features, was ironic, as it came just months after the FDA’s own advisory committee recommended supporting opioids with abusedeterrent properties (e.g., addition of substances that cause adverse effects when the drug is injected or snorted). Further confusing the issue, the FDA approved labeling changes for the reformulation of OxyContin with abuse-deterrent technology (on the day the patent expired) and rescinded the original patent of OxyContin. This led to a subsequent legal dispute over the manufacture of generic non-abuse-deterrent drugs. The FDA has since clarified that technology for most extended-release formulations is in the early stages and is not available, and this requirement would not be feasible for all oral opioids. Zohydro’s manufacturer, Zogenix, has reported it is working on a formulation with abuse-deterrent technology, as are other manufacturers. This review has touched on just a few of the issues of patient safety and clinical evidence for some medications recently approved for common medical conditions. The sidebar lists several FDA Web resources for information about newly approved pharmaceutical products. Jean Moon, PharmD, BCACP, is a faculty pharmacist and clinical preceptor at the University of Minnesota North Memorial Hospital Family Medicine Residency and an assistant professor in the University of Minnesota College of Pharmacy.

DON’T MISS THE SPCO THIS SPRING! SPCO WITH THE MIRÓ QUARTET

Thursday, Apr 3, 7:30pm Friday, Apr 4, 10:30am Saturday, Apr 5, 8pm Ordway, Saint Paul

COPLAND’S APPALACHIAN SPRING

HAYDN, STRAVINSKY AND KERNIS Thursday, Apr 24, 7:30pm Friday, Apr 25, 10:30am Saturday, Apr 26, 8pm Ordway, Saint Paul

Friday, Apr 11, 10:30am Friday, Apr 11, 8pm Wooddale Church, Eden Prairie

Subject to availability. All artists and programs subject to change.

Photography @Matt Dine

March 2014 Minnesota Physician

Gastroesophageal reflux disease from page 17

with surgical repair. Morbid obesity. Although comparative data between Nissen fundoplication and Roux-en-Y gastric bypass are limited, symptomatic GERD is just one of multiple comorbidities in these patients. Surgical treatment of GERD alone with a Nissen fundoplication ignores the complexities of morbid obesity and eventually complicates conversion to Roux-en-Y gastric bypass if it fails or if the patient elects to undergo bariatric surgery in the future. Barrett’s esophagus Intestinal metaplasia of the distal esophageal mucosa, or Barrett’s esophagus (BE), is a reflection of chronic GERD and does not relate to symptomatology. BE has gained public notoriety and is frequently interpreted by patients as an immediate precursor of esophageal cancer. The annual risk of devel-

oping esophageal adenocarcinoma in BE without dysplasia is 0.25 percent; a 40-year-old patient with nondysplastic BE who will presumably live another 40 years has a lifetime risk of developing esophageal cancer of about 10 percent. On the other end of the spectrum, patients with BE and high-grade dyspla-

Optimal management of GERD is the mainstay of

Barrett’s esophagus poses a significant public health problem. sia have an annual cancer risk of 6 percent; their chance of developing esophageal cancer is >10 percent in just two years and 60 percent in 10 years. The complexities surrounding the diagnosis of BE mandate that patients with intestinal metaplasia be evaluated and treated by expert endoscopists, preferably in a multidisciplinary setting. As a general rule, nondysplastic BE requires surveillance endoscopy every three to five years, while BE with low-grade

THE PATIENT ABOVE ALL ELSE. ®

Current Duluth Opportunities: St. Luke’s Family Practice, Duluth, MN (OB optional) Internal Medicine, Duluth, MN OB/GYN: Duluth, MN Practice Specifics:

    

dysplasia mandates repeat endoscopy in six to 12 months. High-grade dysplasia must be followed at three-month intervals in the absence of eradication therapy (Spechler S.J., JAMA, 2013).

Salary: MGMA Market Competitive & Generous Signing Bonus St. Luke’s-employed position Clinic Hours: M-F 8:00-5:00 40 patient care hours/26 as scheduled clinic hours Benefits for .6 FTE or higher -Minimum 6 weeks Paid Time Off -Flexible Benefits Plan -Medical, Dental & Life -Relocation -Pension & 401(k) -Physician’s Supplemental Retirement Plan -Sick Leave & Personal Days -Short & Long Term Disability -Flexible Spending Account -Malpractice & Tail Coverage

Physician Recruiters

Meghan Anderson & April Knapp Email: mdrecruit@slhduluth.com 1.800.321.3790 ext. 5721 & ext. 5027

St. Luke’s Hospital 915 E 1st Street Duluth, MN 55805 www.SLHDuluth.com

therapy for BE with or without dysplasia. Long-segment (>3 cm) nondysplastic BE and lowgrade dysplasia can be treated easily with endoscopic radiofrequency ablation. High-grade dysplasia requires ablative therapy or, in select cases, esophagectomy to minimize the risk of esophageal cancer. Barrett’s esophagus poses a significant public health problem and guidelines for surveillance and treatment are in evolution. To date, all evidence suggests that antireflux surgery

Minnesota Physician March 2014

Research at the University of Minnesota At the Esophageal Center at the University of Minnesota, we are evaluating the specific role of impedance manometry in patients with GERD, and we have developed an experimental model for the minimally invasive treatment of Barrett’s esophagus. We aim to translate our technique of mucosal resection of Barrett’s esophagus to a clinical phase in the next one to two years. Rafael S. Andrade, MD, is an associate professor in the Division of Cardiothoracic Surgery at the University of Minnesota Medical School, and is chief of the division’s Section of Thoracic and Foregut Surgery.

Family Medicine Physician with C-section An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage and obstetrics 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

and medical therapy have an equivalent impact on the longterm progression of BE. The eventual development of highgrade dysplasia or cancer is the same regardless of GERD treatment, and is unpredictable. The presence of Barrett’s esophagus by itself is not an indication for surgery.

Urgent Care

Sioux Falls VA Health Care System

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

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.

The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Primary Care (Family Practice or Internal Medicine) Primary Care (Sioux City CBOC, IA) Psychiatrist Endocrinology

Emergency Medicine Pulmonologist Oncologist Cardiologist (part time) Gastroenterologist (part time)

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

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

Emergency Room Physicians Looking for leisure work hours? • Set your own hours • No contract • No obligations

Attention Physicians • Immediate openings • Casual weekend or evening shift coverage

• Choose from 12 or 24 hour shifts • Competitive rates • Paid malpractice

Great Emergency Department in Southern Minnesota

763-682-5906 • 1-800-876-7171 F-763-684-0243 michelle@whitesellmedstaff.com

MN Physician 4" x 5.25" 4-color

Opportunities available in the following specialties:

Dermatology

Rochester Southeast Clinic

Olmsted Medical Center, a 160-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.

Family Medicine

Pine Island Clinic Rochester Southeast Clinic Plainview Clinic

Internal Medicine

Rochester Southeast Clinic Women’s Health Pavilion (Hospital)

Hospitalist

Rochester Hospital

Plastic Surgeon Rochester Hospital

Urologist

Rochester Hospital

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: dcardille@olmmed.org Phone: 507.529.6748 Fax: 507.529.6622

EOE

www.olmstedmedicalcenter.org March 2014 Minnesota Physician

New regulations of compounding pharmacies impacts medication access from page 27

Table 2. Examples of compounded medication administered in the clinic Compounded Medicine

Specialty Clinic

Eye drops, Avastin

Ophthalmology

Preservative-free steroid

Joint, spine, and pain clinics

Oxymetazoline/lidocaine nasal spray

Otolaryngology

Sclerotherapy solution, topical anesthetic

Dermatology

Flavored elixirs

Pediatrics

Blocks

Anesthesia

References 1) www.fda.gov 2) Ranibizumab and Bevacizumab for Neovascular Age-Related Macular Degeneration, The CATT Research Group, N Engl J Med 2011; 364:1897-1908 3) M innesota Academy of Ophthalmology survey of retinal surgeons in Minnesota (2013) patient copay for Eylea to $400 per dose (monthly). New legislation may improve access Minnesota Sen. Al Franken

coauthored the “Pharmaceutical Compounding Quality and Accountability Act” to address safety concerns that were exposed by the NECC tragedy. This law creates a new class of large compounding phar-

macies, called “outsourcing facilities,” under the regulation of the FDA. The standards for sterility and quality of compounding at these facilities will be significantly stricter than previous standards for compounding pharmacies. Participation will be voluntary for compounding facilities, and those who decline will remain under the jurisdiction of the BOP.

The Minnesota BOP is introducing complementary state legislation that will also recognize outsourcing facilities. The proposed legislation will permit outsourcing facilities

licensed by the FDA to apply for a Minnesota state license, which would allow the facility to wholesale directly to a Minnesota clinic or hospital. There will be additional regulatory hurdles for facilities that choose to be outsourcing facilities. But hopefully, they will meet these requirements and provide a wide variety of compounded medication to clinics in Minnesota for wholesale purchase. Compounding of medication that is less common (or less profitable) may not be available through outsourcing facilities, but will still be available from a compounding pharmacy, pursuant to an individual prescription. Geoffrey Emerson, MD, Phd, is an ophthalmologist specializing in macular degeneration at the Retina Center in Minneapolis. He is also chair of the Phillips Eye Institute and a member of the board of directors of the Minnesota Academy of Ophthalmology.

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. Currently we are seeking to add the following specialists: • General Surgery

• Obstetrics/Gynecology

• Radiation Oncology

• Family Practice

• Internal Medicine

• Ophthalmology

• Pediatrics 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

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

www.averamarshall.org 36

Minnesota Physician March 2014

ExpEriEncE tHe

north MEMorial

DiffErEncE If you are looking for an alternative to practicing in a big system and want to help lead innovation, change and quality, consider North Memorial Health Care. We are a physician-lead organization with opportunities in primary and specialty care. Practice options include positions with North Memorial, as well as our closely aligned, physician owned practices. We work closely with our physicians to individually tailor practice models that work for our patients and physicians. For more information contact Mark Peterson at (763) 581-2986, mark.peterson@northmemorial.com or visit northmemorial.com.

Opportunities for full-time and part-time staff are available in the following positions: • Dermatologist • Geriatrician/ Hospice/ Palliative Care • Internal Medicine/ Family Practice

• Medical DirectorExtended Care & Rehab (Geriatrics) • Psychiatrist • Urgent Care Physician (IM/ FP/ ER)

Applicants must be BE/BC.

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

AIRFORCE.COM/HEALTHCARE

March 2014 Minnesota Physician

Ready or not ... from page 11

transition far more effective and easier. Another resource is the MN ICD-10 Collaborative (see Resources sidebar on page 10), which brings together providers and payers to assist health care organizations in Minnesota with the ICD-10 transition. Go beyond the mandate Good provider training does not try to turn clinicians into coders; instead, the focus should be on the documentation of clear and specific medical concepts. The goal is to improve clinical documentation, since poor-quality documentation is bad for payers, patients, and providers. Ultimately, the goal should be to go beyond the mandate. Organizations need to leverage the ICD-10 transition as an opportunity to seed efficiencies and improvements, particularly when there is an overlap with

other current federal mandates such as “meaningful use.” Focusing on the transition in this way offers the potential to streamline old processes and workflow and to perform better in the areas of patient history, billing accuracy, quality measures, population management, risk management, and health care analytics.

Figure 2. Documentation requirements for ICD-10-CM code S52122C, Displaced fracture of head of left radius, initial encounter for open fracture type IIIA, IIIB, or IIIC (Source: www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10_Small-MedPractice_Handbook_060413%5B1%5D.pdf) Category

Type Katie Kerr, MA, RHIA, and Brooke Palkie, EdD, RHIA, are assistant professors in the Department of Health Informatics and Information Management at the College of St. Scholastica, Duluth. Both Palkie and Kerr are AHIMA-approved ICD-10 CM/PCS trainers. The authors gratefully acknowledge the insights provided by Michael Clark, president and COO of ImplementHIT, and Andres Jimenes, MD, ImplementHIT CEO on the clinical documentation for ICD-10 collaborative training developed with the American Health Information Management Association (AHIMA), and how physicians can best prepare for the transition to ICD-10.

Healing

Localization

Documentation Requirements • Open • Closed • Pathologic • Physeal (Growth Plate) Fracture • Neoplastic Disease • Torus (Buckle Fractures) • Green Stick Fractures • Stress Fractures • Orthopedic Implant (fractures associated with) • Bent Bone • Routine • Delayed • Nonunion • Malunion • Shaft • Lower End • Upper End • Head • Neck • Styloid Process

Encounter

• Initial • Subsequent • Sequelae

Displacement

• Displaced • Nondisplaced

Classification

• Salter Harris I • Salter Harris II • Salter Harris III • Salter Harris IV • Gustilo Type I or II • Gustilo Type IIIA, IIIB, or IIIC • Right • Left

Laterality

The perfect place to unwind. Joint Involvement

Fracture Pattern

Spectacular Fall Getaways. Relaxing, romantic vacations on Lake Superior’s shore. Enjoy fabulous lakeside dining, a great wine list, fall color hikes and guided sea-kayak tours. A great couples getaway.

888.748.5170 • lutsenlodge.com Lakeside Historic Lodge • Log Homes • condos • townHomes

Minnesota Physician March 2014

Named Fractures

• Unspecified Side • Unilateral • Bilateral • Intra-articular • Extra-articular • Transverse • Oblique • Spiral • Comminuted (many pieces) • Segmental • Colles’ • Galleazzi’s • Barton’s • Smith’s • Radial Styloid Fracture

YOU

SHOULD BE HERE REGISTER TODAY Sept. 7-9, 2014 www.mayo.edu/transform

Mayo Clinic’s Transform Symposium addresses tough questions, focuses on results and engages attendees to catalyze practical innovation for health and health care. Join this growing community of thought leaders, innovators and disruptors all focused on transforming the experience and delivery of health care as only as Mayo Clinic can by attending the annual Transform Symposium on Sept. 7-9, 2014. Five Reasons to Attend Transform: • Learn from thought leaders from around the world • Ask tough questions and understand patient perspectives • Build a network of collaborators across multiple industries • Springboard and promote your own innovation efforts • Positively impact the health care delivery system

CMYK_FullPageAd_Transform2014NEW.indd 1

2/14/14 12:58 PM

The more we get together, the happier and healthier we’ll be.

At MMIC, we believe patients get the best care when doctors, staff and administrators are humming the same tune. So we put our energy into creating risk solutions that help everyone feel conﬁdent and supported. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care. To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.