MN Physician May 2016 by Minnesota Physician Publishing

Vo l u m e X X X , N o . 2 M a y 2 016

Prescribing medications Assessing the environmental impact By Lowell J. Anderson, DSc, FAPhA

hat portion of the medicines that are prescribed end up in our water supply? Consider that about 2.5 million pounds of amoxicillin was sold in the U.S. in 2009. Eighty-six percent of amoxicillin is excreted unchanged in urine. Less than 2 percent of amoxicillin is removed by water-treatment facilities. That means that 2,100,000 pounds of amoxicillin enter the environment every year! As health care providers, we bear some responsibility for that.

Diagnostic errors Avoiding negative outcomes By Ann Fiala, RN, BSN, CPHRM, CHC

“The best estimate from autopsy studies is that there are 40,000 to 80,000 deaths a year from diagnostic error.”

Mark L. Graber, MD

n September 2015, the Committee on Diagnostic Error in Health Care released a report, Improving Diagnosis in Healthcare (hereafter known as “the committee’s report”) as a follow up to the Institute of Medicine’s Quality Chasm Series. The report states, “It is likely that most

people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.” A study published in BMJ Quality and Safety in 2013 reviewed 25 years of medical malpractice claims for diagnostic errors and found that, “Diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes.” Another study in Critical Care Medicine in 2012 found, “Significant discrepancies in Diagnostic errors to page 10

Medicines are designed to affect living organisms—they kill unwanted bacteria and viruses, alter metabolism, or change hormonal balances. They can have similar effects on other life forms when they enter our lakes and streams. We know that the presence of five parts per trillion of common contraceptive medications can cause the collapse of fish populations and that low concentrations of antidepressants in water can alter fish reproductive behavior. We can document DEET in 76 percent of sampled Minnesota lakes, amitriptyline in 28 percent of studied lakes, sulfonamides in surface water, and triclosan in treatment plant effluent. Iopamidol, a radiopaque contrast agent, was found in 73 percent of the lakes in the 2013 Prescribing medications to page 12

INDIVIDUALIZING MEDICINE 2016 CONFERENCE ADVANCING CARE THROUGH GENOMICS HOSTED BY MAYO CLINIC CENTER FOR INDIVIDUALIZED MEDICINE SUPPORTED BY THE SATTER FOUNDATION

Oct. 5-6, 2016 / Rochester, MN Genetics and genomics is a fast-moving field. At the IM Conference, medical professionals learn from and network with international researchers and experts at the cutting edge.

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MAY 2016 • VOLUME XXX, NUMBER 2

MINNESOTA HEALTH CARE ROUNDTABLE

FEATURES Diagnostic errors Avoiding negative outcomes

By Ann Fiala, RN, BSN, CPHRM, CHC

FORTY-SIXTH SESSION

Prescribing medications 1 Assessing the environmental impact By Lowell J. Anderson, DSc, FAPhA

Value - Based Purchasing: A new way to pay for health care

DEPARTMENTS CAPSULES 4 INFECTIOUS DISEASES MEDICUS

INTERVIEW

Making MNsure work Allison O’Toole, JD MNsure

Travel-associated mosquitoborne diseases By Franny Dorr, MPH

PHARMACY

Redesigning primary care By Lara Kerwin, PharmD, and Heidi Le, PharmD

Thursday, November 3, 2016 • 1:00-4:00 PM

Symphony Ballroom, Downtown Minneapolis Hilton and Towers

PROFESSIONAL UPDATE: WOMEN’S HEALTH What’s new in osteoporosis? 14 By Yasmin Orandi, MD

Gestational diabetes management By Lori Wilcox, MD, and Kim Plessel, MS, RDN, LD

SPECIAL FOCUS: PRACTICE MANAGEMENT Provider burnout 20 By Sara Poplau; Elizabeth Goelz, MD; and Mark Linzer, MD

Moving at the speed of malpractice By Gregory Alch, MA, EdD

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Background and Focus: As initiatives driven by federal health care reform move forward, the term “Value-Based Purchasing” (VBP) is being applied to a wide spectrum of issues. But what does this mean? CMS is developing measurements, well over 150 to date, to define what “value” means in health care. It is proposed that these metrics will be used to create incentives that pay more for better care in every element of health care delivery. Hospitals, physician practices, home care, and long-term care will all be reimbursed by an emerging new math. Objectives: We will explore the motivations behind this changing approach to purchasing health care. We will examine what is being measured and what value really means. We will discuss the arguments that claim VBP is a bad idea and those that believe it is the best solution. We will discuss how a collaborative, transparent system, that integrates care teams, health information technology and improved reimbursement methods will help achieve increased access to high-quality, cost-effective care for patients. Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub. com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable.

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MAY 2016 MINNESOTA PHYSICIAN

CAPSULES

HCMC to Open New Clinic in North Loop Hennepin County Medical Center (HCMC) has announced plans for a new clinic and pharmacy in the North Loop area of downtown Minneapolis. “North Loop is the fastest growing residential neighborhood in Minneapolis and the people who live there have been asking for a local clinic and pharmacy to serve their health care needs,” said Jon Pryor, MD, MBA, chief executive officer of HCMC. “This new clinic will do that, and serve a broader need for several sought-after specialties for people who live and work in the area.” The new clinic and pharmacy will occupy about 7,660 square feet on the first floor of the TractorWorks office building and is expected to open later this year. It will offer primary care, chiropractic services, and several specialty care services. “This is an active neighborhood and this clinic will provide convenient access to primary care, chiropractic care, and acupuncture services that neighborhood residents told us they want,” said Scott Wordelman, FACHE, senior vice

MINNESOTA PHYSICIAN MAY 2016

president of ambulatory care and support services at HCMC. “We will also offer allergy and dermatology specialty care by board-certified physicians, as well as additional specialties such as women’s health and sports medicine.”

Apple Valley Medical Clinic Adds Direct Primary Care Model Apple Valley Medical Clinic has announced it is now offering PrimaCare Direct, a health membership that allows patients to pay a monthly fee of $75 for unlimited primary care access. “Many individuals are searching for a way to lower their health care costs without sacrificing access or quality,” said Victoria Champeau, chief executive officer of Minnesota Healthcare Network. “This innovative health care model is not based on insurance. There are no copays or deductibles. The result is greater access to health care for patients, especially in areas related to primary and preventive care.” Care covered by PrimaCare Direct includes physician

services, throat cultures, casts and splints, blood pressure checks, cholesterol screenings, well child check-ups, nutritional counseling, Pap smears, lab, and X-ray services. “With PrimaCare Direct’s unlimited access to primary care, individuals with chronic conditions, such as diabetes or asthma, are more likely to see a physician before their situation becomes acute,” said Champeau.

Study to Evaluate Cancer Prevention Tool in Rural Areas HealthPartners Institute and Essentia Health are launching a study to assess whether a clinical decision support tool for electronic medical records can increase preventive care for cancer in rural areas. The tool, called the Cancer Prevention Wizard, identifies all eligible patients ages 11 to 80 who aren’t up to date on recommended cancer prevention services. It then offers the provider recommendations for primary and secondary cancer prevention.

Researchers will conduct the study (Implementing Cancer Prevention Using Patient-Provider Clinical Decision Support) over five years. It will involve more than 150,000 patients who receive care at 30 Essentia Health clinics in northern Minnesota, northwestern Wisconsin, and eastern North Dakota. They will use a clusterrandomized trial design to compare three groups of clinics. In the first group, primary care providers will use the tool to identify and offer prevention services. In the second, certified medical assistants will use the tool and discuss screening and prevention services with patients. In the third, patients will receive usual care with no cancer prevention recommendations from the tool. “Nearly one in four Americans live in rural areas, and this study has the potential to improve their health and quality of life because research clearly shows that in general people in rural areas have higher rates of chronic illnesses than people who live in larger cities,” said Tom Elliot, MD, HealthPartners Institute research fellow and principal investigator of the study.

The team will assess whether use of the tool leads to more patients receiving recommended cancer preventive services; whether certified medical assistants have an effect on patients’ health outcomes; and if the tool results in higher short-term health costs but lower long-term costs compared to clinics that don’t use it. “This tool will create a patient’s risk profile for cancer and display it in one place so that the clinician and the patient can engage in a shared decision-making discussion to create a plan for primary prevention of cancer and cancer screening,” said Joe Bianco, MD, primary care provider at Essentia Health and co-investigator of the study. “The rapid collection of data creates efficiency for a busy clinician and how it displays this data for the patient will lead to better patient engagement.”

Sanford Health Buys Medical Center from City of Tracy Sioux Falls-based Sanford Health has purchased Sanford Tracy Medical Center from the city of Tracy, Minn. Previously, Sanford solely operated the facility while it was owned by the city. Now, under the new agreement that began March 31, the health system owns and will continue to operate the medical center building and grounds. Employees will not be affected, as they were already employees of Sanford Health. The purchase price was not released. “This is a win-win situation for our town,” said Steve Ferrazzano, mayor of Tracy and chairman of the Sanford Tracy Medical Center board. “We’ll retain quality health care close to home, and the city will no longer have the financial responsibilities that come with owning a health care facility. This frees up taxpayer dollars for other projects.”

Improved Survival for Patients with LowGrade Brain Tumor New research has shown that patients with a low-grade brain tumor called glioma who received a combination of radiation therapy and a chemotherapy regimen have better

survival rates than those who only received radiation therapy. “This is the first phase III trial to demonstrate conclusively a treatment related survival benefit for patients with grade 2 glioma,” said Jan Buckner, MD, chair of the department of oncology at Mayo Clinic and lead author of the study. Researchers enrolled 251 patients with low-grade glioma into the trial between October 1998 and June 2002. The enrollees were considered to be at high risk due to being over the age of 40 or having a less-than-complete surgical removal of their tumor. They were randomized to one of two trials—one group received only radiation therapy and the other received radiation therapy and six cycles of procarbazine, lomustine, and vincristine (PCV) chemotherapy. The results show that at a median follow-up time of 11.9 years, 67 percent of the patients had tumor progression and 55 percent had died. Patients who received radiation therapy and PCV chemotherapy had a median survival time of 13.3 years, compared to 7.8 years for those who received only radiation therapy. The median progression-free survival time was longer for the group that received a combination of therapies as well—10.4 years, compared to 4 years. Ten year, progression-free survival rates and overall survival rates were better for the group that received radiation therapy and PCV chemotherapy as well—51 percent compared to 21 percent, and 60 percent compared to 40 percent, respectively. “Our results indicate that initial radiation therapy followed by PCV is necessary to achieve longer survival in patients with grade 2 glioma and that salvage therapy at relapse after radiation therapy alone is less effective,” said Buckner. “It has also been hypothesized that other genetic alterations may be responsible for a small subset of patients whose glial brain tumors are chemotherapy-resistant. However, radiation therapy plus PCV appears to represent the most effective treatment identified to date for the majority of patients with grade 2 glioma.” The clinical trial was conducted by Radiation Therapy Oncology Group 9802. Full results were published in the April 7 issue of the New England Journal of Medicine. Capsules to page 6

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Capsules from page 5

but chose two due to the high qualifications of applicants—Hager Mohammed and Sahar Ahmed. Mohammed and Ahmed both came from Sudan, where they worked as physicians. When they unexpectedly relocated to Minnesota, they discovered major obstacles to becoming a doctor in the U.S. Many residency programs require U.S.-based clinical experience and recent graduation from medical school. These requirements disqualify most immigrant physicians. MDH estimates that there are between 250 and 400 immigrant physicians in Minnesota facing these barriers. MDH notes that studies suggest that increased diversity in the health care workforce will lead to improved clinical outcomes for minorities and immigrant populations. Health disparities in Minnesota are some of the worst in the U.S., with poorer health outcomes and poorer general health for people of color and immigrant populations than white Minnesotans. In addition, MDH projects a shortage of primary care providers in Minnesota in the next decade, as well as a growing population.

U of M Announces First Immigrant Physician Residencies The University of Minnesota Pediatrics Residency Program has selected two immigrant physician candidates for residency positions through a grant from the Minnesota Department of Health (MDH) as part of its International Medical Graduate Assistance Program. The program was established by the Minnesota Legislature in 2015. It was the first state-level effort in the U.S. created to support pathways to licensure for immigrant and refugee physicians to increase access to primary care and help eliminate health disparities. MDH funds the program, which includes career navigation, foundational skill building, clinical preparation, and residency positions for immigrant and refugee physicians. The University of Minnesota Pediatrics Residency Program was awarded a grant through MDH to fund one residency position for an immigrant physician,

Fairview Health Services to Acquire UCare Fairview Health Services and UCare have signed a letter of intent to combine their provider and payer operations. UCare will become a wholly owned subsidiary of Fairview under the agreement and Jim Eppel will remain in his position of president and CEO of the health insurance company. It will combine with PreferredOne, which came under Fairview’s sole ownership in January, to form Fairview’s health insurance division. The two insurers are the fourth and fifth largest in Minnesota. The organizations are finalizing details of the transaction, including the new operational model and relationship between Fairview, UCare, and PreferredOne, and hope to secure regulatory approval by mid-summer. However, they have agreed that Fairview will continue to collaborate with other health plan administrators and UCare will continue to do the same with other health care providers and systems. Workforce

reductions are not anticipated as a result of the change.

Medica and Altru Partner on New ACO Minneapolis-based health insurer Medica has announced it is collaborating on a new accountable care organization (ACO) with Altru Health System, a Grand Forks-based system consisting of an acute care hospital, a specialty hospital, and more than 12 clinics in Grand Forks and the surrounding area. The ACO, called Altru & You with Medica, is expected to be available to group purchasers in northwestern Minnesota and northeastern North Dakota in the third quarter of 2016. The ACO includes access to care in more than 30 communities and includes a network of more than 560 providers as well as access to telemedicine. It also includes access to experts at Mayo Clinic because Altru Health System is a member of the Mayo Clinic Care Network.

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MINNESOTA PHYSICIAN MAY 2016

MEDICUS Scott Jensen, MD, president of Catalyst Medical Clinic, PA, in Watertown, has been named the 2016 Family Physician of the Year by the Minnesota Academy of Family Physicians. Jensen has been a practicing family physician for more than 32 years and opened Catalyst Medical Clinic in 2001. He also teaches one day a month as a clinical associate professor at the University of Scott Jensen, MD Minnesota Family Medicine Residency program in St. Louis Park and serves as medical director of Pro Rehab, Inc., in Watertown. Jensen earned his medical degree at the University of Minnesota Medical School. He completed both his residency and internship at Bethesda Hospital. Jensen has served as president of local Lions and Rotary clubs and multiple chambers of commerce and was elected to the District 110 school board where he served for 10 years, including three years as chairperson. He is now running for a state Senate position in Minnesota District 47. Claudia Lucchinetti, MD, chair of the department of neurology and Eugene and Marcia Applebaum professor of neurosciences at Mayo Clinic, has received the 2016 John Dystel Prize for Multiple Sclerosis Research from the National MS society and the American Academy of Neurology for her contributions to understanding and treating MS. Lucchinetti Claudia is recognized as one of few world authorities Lucchinetti, MD in experimental and applied neuropathology research in the area of demyelinating and inflammatory central nervous diseases, including MS, and has published more than 170 research papers on the topic. She earned her medical degree at Rush Medical College in Chicago, completed an internship at Rush Presbyterian St. Luke’s Medical Center, and completed a neurology residency and neuroimmunity fellowship at Mayo Graduate School of Medicine. Sophia Vinogradov, MD, has been named the new head of the University of Minnesota Department of Psychiatry and will step into the position in August. Vinogradov is a schizophrenia researcher who most recently served as vice chair of the University of California–San Francisco School of Medicine’s psychiatry department, where she was also a professor. Prior to Sophia that, she served as associate chief of staff for Vinogradov, MD mental health at the San Francisco VA Medical Center. Vinogradov earned her medical degree at Wayne State University School of Medicine in Detroit. She completed a psychiatry residency at Stanford University School of Medicine, where she also served as chief resident, and completed a psychiatric neurosciences research fellowship at the Palo Alto VA Medical Center and Stanford University. Glenn Shamdas, MD, oncologist at the Fargo VA Health Care System, has received the 2016 Dr. Byron D. Danielson Clinician of the Year Award. The Fargo VA Health Care System presents the award annually to recognize providers with outstanding clinical dedication that go above the call of duty to serve veterans. Shamdas earned his medical degree at the Malaga School of Glenn Shamdas, Medicine in Spain and completed an internal MD medicine residency at the University of North Dakota affiliated hospitals in Fargo. He also completed a hematology/oncology fellowship at the University of Arizona. Shamdas has been with the health care system since 2003, where he also worked from 1992 to 1997. He is also a traditional guardsman with the U.S. Air Force.

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The Duke Ellington Orchestra and Patti Austin*

Laura Osnes and Santino Fontana, vocals Ted Sperling, music director and pianist

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with the Minnesota Orchestra

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MAY 2016 MINNESOTA PHYSICIAN

5/3/16 3:09 PM

INTERVIEW

Making MNsure work

Allison O’Toole, JD MNsure Ms. O’Toole is CEO of MNsure, overseeing an annual budget of nearly $50 million and more than 150 staff. She previously served as MNsure’s deputy director for external affairs and oversaw MNsure’s public-facing departments including Marketing and Communications, State and Federal Government Affairs, Navigator and Broker Relations, and was MNsure’s staff liaison to the board of directors. She was responsible for the implementation of the second phase of MNsure’s multi-million dollar marketing campaign, developed the strategic overhaul of the MNsure outreach and enrollment grants program, initiated the widely successful broker Lead Agency program, and helped lead MNsure’s efforts for greater public accountability and transparency. Prior to her roles at MNsure, Ms. O’Toole was a director at Himle Rapp, a Minneapolis-based public affairs firm and state director for U.S. Senator Amy Klobuchar. She graduated from Franklin & Marshall College in Lancaster, PA, with a bachelor’s degree in government. She earned her Juris Doctor from William Mitchell College of Law.

MINNESOTA PHYSICIAN MAY 2016

W hat does MNsure do? MNsure is a marketplace where Minnesotans can shop, compare, and choose health insurance coverage that meets their needs. MNsure is the only place where consumers can qualify for financial help, either through federal tax credits or through Minnesota’s two public health insurance programs, MinnesotaCare and Medical Assistance. W hat are the biggest challenges that MNsure has faced? It’s no secret that when MNsure launched in 2013 the result wasn’t pretty, and quite frankly, former leadership set expectations way too high. I’ve spent the past two years working to improve the consumer experience and level set with stakeholders about what MNsure is and what it can do. We’ve had external evaluators come in and show us where improvements are needed. We’ve ramped up relationship building with the broker community and community-based organizations. We’ve also worked to let the public know that MNsure is the place to shop and compare health insurance options. We’ve done a good job turning the corner these past two years and the majority of Minnesotans are now enrolling through MNsure with relative ease, but we cannot hide from our history. The good news is we are improving every day.

percent of MNsure’s current private plan enrollees are new for 2016. That’s the highest percentage of new enrollment nationwide. MNsure also saw the largest percentage of overall private enrollment growth nationwide. These statistics tell us that more Minnesotans are getting the message about the benefits of MNsure, and that’s great news for Minnesota. W hat are the most common misperceptions about MNsure? One of the biggest misperceptions about MNsure is that we’re an insurance company and we set health insurance rates. Both of those things are simply not true. MNsure is the marketplace you go to shop and compare health insurance products sold by private companies. Think of MNsure as a grocery store and the private insurance companies as the aisles. When Minnesotans come to MNsure they can walk up and down the aisles to check out insurance products from different companies, and see if they qualify for financial help while they’re at it. MNsure enrolls consumers into health insurance coverage, but once that transaction is complete, the consumer is left with insurance coverage from a private insurance company.

W hy aren’t the choices available through MNsure increased to include the leading national insurance providers? W hat strategies helped you to exceed In order to sell health insurance products in your enrollment goals for 2016? Minnesota, an insurance company must meet very specific requirements that are regulated MNsure is laser focused on helping consumby the Minnesota Department of Commerce. ers find a health insurance plan that fits their The fact is that MNsure does not limit who can needs at a price they can afford. That means providing increased market transparency. At its participate in the exchange and who cannot. If an insurance company is currently not parcore, MNsure really acts like a consumer proticipating in MNsure and would like to do so, tection agency, making sure Minnesotans are aware of all their health insurance options and they are more than welcome to go through the process of having products on the exchange, as the prices that go along with those options. In long as they follow the state and federal laws 2016, Minnesota saw large health insurance that are required. premium increases. While we still have some of the lowest rates in the Midwest, the in What can you tell us about the way creases were a shock for many Minnesotans. MinnesotaCare affects MNsure? What’s important to remember is that MinnesotaCare is a public program that covers MNsure is the only place Minnesotans can certain individuals who make too much money access federal tax credits that can immediately to qualify for Medical Assistance, but not lower those monthly premiums, or qualify for enough to afford a private health insurance public programs. We do not want Minnesotans plan. Minnesota is one of only two states in the to leave money on the table. We’re encouraged country to offer a program like this on the exthat so many Minnesotans came to MNsure change. MinnesotaCare offers great coverage, during this past open enrollment to comand we are happy that Minnesotans are getting pare plans and get financial help. In fact, 45 coverage they need at a price they can afford.

 What kind of data can you share about the savings MNsure members receive through Affordable Care Act subsidies? Last year, Minnesotans saved nearly $50 million on their private health insurance premiums through tax credits available on MNsure. That’s up from $30 million in 2014. This is real money that Minnesota families can keep in their pockets each month. These tax credits act like instant discounts off monthly health insurance premiums, which means Minnesotans see the benefit immediately and do not have to wait until tax time to collect. U nder what circumstances could someone purchase insurance through MNsure outside of the open enrollment period? Just like when you want to make changes to your health insurance policy through an employer, MNsure allows enrollment changes if qualifying life events occur. These usually involve the loss of a job, marriage, birth of a child, or change in income. We require Minnesotans to verify that they are eligible for a special enrollment period. Minnesotans who are eligible for Medical Assistance or MinnesotaCare can enroll at any time during the year. There is no open enrollment for those two public programs.

W hat would you like patients to know about MNsure? If you purchase health insurance coverage on your own, MNsure is the place to shop, compare, and get financial help like tax credits, low-cost, or no-cost plans. Visit us online, or in person, to find out what you might qualify for. The coverage you get through MNsure is no different than the coverage you purchase directly from an insurance company. In fact, it literally pays to shop on MNsure because you may find a better policy at a better price.

Minnesota’s uninsured rate … is now the lowest it has ever been in state history.

W hat would you like physicians to know about MNsure? For your patients who are uninsured or who are not satisfied with their current health insurance plan, MNsure can offer a real solution for Minnesotans to find a plan that

fits their needs and budgets. We all do better when we have quality access to health care.  What do you see in the future for MNsure? The Affordable Care Act is working in Minnesota. We just successfully completed our third open enrollment period and saw the largest percentage of enrollment growth nationwide. Additionally, a bipartisan task force created by the Minnesota State Legislature has recommended that Minnesota stay the course with a state-based marketplace. The Minnesota Department of Health also recently announced that since 2013, Minnesota’s uninsured rate has been cut in half and is now the lowest it has ever been in state history. People are getting into coverage, they are saving money through MNsure, and they are getting the level of coverage they need. I am encouraged by that news, but know there is still more work to be done. We are currently evaluating many of our operations and business practices, as well as identifying areas for IT improvement. Much progress has been made since the initial rollout and the proof of that is starting to show.

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MAY 2016 MINNESOTA PHYSICIAN

Diagnostic errors from cover

18.5% of patients who underwent autopsy, 7.5% of them were diagnoses with impact on therapy and outcome.” Countless stories of patient harm, delayed treatment, and death are shared on the Internet, in medical journals, and throughout our communities. Diagnostic error is a significant and complex problem facing the health care community. Solving it will require a change in culture and a paradigm shift from the old “physician knows best” model to one that includes a team-focused approach, a mission to eliminate all harm, and humility.

diagnosis is communication among all stakeholders— patients, families, consulting providers, and any other member of the health care team involved in the process. The recommendations encourage organizations to focus on eight goals:

Preventing diagnostic errors Because very little research exists in regard to diagnostic error, the committee’s report applied global principles of patient safety and performance improvement to identify recommendations aimed at error reduction. Central to addressing harm caused by missed

1. Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families. 2. Enhance health care professional education and training in the diagnostic process. 3. Ensure that health information technologies support patients and health care professionals in the diagnostic process.

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MINNESOTA PHYSICIAN MAY 2016

6. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses. 7. Design a payment and care delivery environment that supports the diagnostic process. 8. Provide dedicated funding for research on the diagnostic process and diagnostic errors.

results, patient complaints, etc.) may be reviewed but very little was done to change the systems involved in creating the errors. Those systems are deeply embedded in health care culture and will require significant change. The committee’s report provides a framework to begin transforming current practices. Feedback is central to that framework. Let’s take a look at the report’s goals that specifically focus on feedback. Effective teamwork The first goal to facilitate teamwork among providers,

The responsibility for improving diagnostic error cannot lie solely on the shoulders of physicians.

4. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice.

Rediscover...

5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance.

The importance of feedback Several of the report’s recommendations and goals center on the principle of feedback. In 2008, Eta Berner, EdD (professor at the University of Alabama and director of the UAB Center for Health Informatics for Patient Safety/Quality), and Mark L. Graber, MD (senior fellow at RTI International and professor emeritus of medicine at Stony Brook University), conducted a comprehensive review of the available literature that discussed diagnostic errors and how to reduce them and presented their findings in an article in the American Journal of Medicine. According to Berner and Graber, “Feedback in general can serve to make the diagnostic error visible, and timely feedback can mitigate the harm that the initial misdiagnosis might have caused.” Over the years, health care has utilized feedback in a very linear fashion. Retrospective data (incident reports, autopsy

patients, and family members is key to achieving error reduction. Few would argue about the value of effective teamwork among providers to enhance the diagnostic process. Providers and other members of the health care team rely on one another to navigate the day-today management of caring for patients. But including patients and their family members is also essential to error reduction. The Committee’s report states, “Supportive health care environments are places where patients and families feel comfortable sharing their concerns about diagnostic errors and near misses and providing feedback on their experiences with diagnosis.” Patients are the key stakeholders in physicians arriving at the appropriate diagnosis and then treating it. Involving patients in the process and empowering them to take an active part in managing their own care creates engagement and provides an essential safety net to ensure errors are

identified and addressed quickly. Additionally, when errors do occur, creating an environment where patient voices can be heard adds a human element to a complex system. Some suggestions from the committee’s report to support patient and family feedback include: • Utilize shared decision models: Moving beyond the traditional informed consent process to a model that evaluates patient values and preferences. This creates a partnership between health care providers and patients and enhances engagement. • Make follow-up phone calls: Checking in with patients upon discharge shows a sense of caring, allows them to ask questions while under less stress, and encourages feedback. • Implement teach-back educational methods: Evaluating a patient’s level of comprehension establishes trust and partnership with their care providers. Ensuring that they understand follow-up expectations gives patients a sense of shared accountability. • Provide patient portals for clinical notes and test results: Utilizing technology to create transparency and easy online access to medical records and test results, gives patients more control over their care. Empowered patients are engaged patients. • Establish solid disclosure policy and practices: Recognizing the value of disclosing errors to patients and families, while involving them in activities to prevent future occurrences, offers health care systems the opportunity to learn from mistakes. Patients may have unknown information that offers solutions to complex problems. • Form patient and family member advisory councils: Involving patients and families in the development of new or the evaluation of old services fosters a

patient-centered approach to care and may assist in proactively identifying safety issues. • Develop closed-loop communication systems: Including patients as members of the diagnostic team and establishing foolproof systems that funnel reports from consulting specialists to primary care providers may prevent lost, missed, or delayed diagnoses. Learning from mistakes The fourth goal focuses on identifying, learning from, and reducing diagnostic errors and near misses in clinical practice. It’s important to focus on the changing systems and practices that led to any errors. Berner and Graber have argued that, “Physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors.” By the nature of their training and conditioning over time, physicians have come to rely on memory and intuition to diagnose. While this method produces accurate results much of the time, it is not a reliable system and can lead to diagnostic error. Physicians cannot learn from mistakes without reliable data that has been validated and vetted among peers and provides objective, measurable indicators of quality. Constructive feedback utilizing data helps clinicians assess how well they are performing in the diagnostic process, correct overconfidence, identify when remediation efforts are needed, and reduce the likelihood of repeated mistakes. Here are some important techniques for ensuring constructive feedback: • Utilize decision support tools: Computerized software tools that utilize patient-specific symptoms can assist providers in differential diagnosis and treatment recommendations.

• Encourage consults and/ or second opinions: Culture that supports peer-to-peer consults and case discussion lets providers explore diagnosis and treatment options they may not otherwise have considered. • Initiate morbidity and mortality rounds: Review of all deaths, expected or unexpected, provide forums to discuss and learn from actual patient cases. • Initiate planned follow up and tracking of results: Integration of test tracking and documentation into the electronic health record decreases the number of lost or missed reports. • Perform chart audits by using trigger tools: Pre-specified criteria utilizing electronic medical record flags (e.g., readmission to the emergency department within 72 hours or abnormal results without documented follow up) may identify patients

who have experienced diagnostic miss or error. • Review adverse events/performing root cause analyses (RCAs): Detailed analysis of adverse events can identify system-level issues that require change and ongoing monitoring. • Implement post-event and simulation debriefings: Immediate evaluation after a post adverse event or simulated high-risk process can provide members of the care team actionable corrective measures. • Develop robust, focused, and ongoing professional practice evaluation processes: Incorporating diagnostic error measures into the provider credentialing and privileging process provides medical staff leadership with the information necessary to evaluate quality and ongoing membership. Diagnostic errors to page 38

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Prescribing medications from cover

MPCA lake study, including Lake Kabetogama, which is near Voyageurs National Park. Even though only an estimated 2.4 percent of the U.S. population uses cocaine, it is surprising that it is found in lakes across Minnesota. It is puzzling how some of these products, such as cocaine or iopamidol, get into lakes and streams, while for others it is less so. How contamination occurs Certainly medications that are “thrown out” contribute to these numbers. Those unused prescription medications that are out-of-date and thrown in the trash or flushed down the toilet may eventually end up in surface water or in the preload for water treatment plants. Much of what goes into treatment plants comes out the other side into ground water or as drinking water. We have gotten better about offering public “take-back” programs for

unused medicines in pharmacies, municipal buildings, and through community organization programs. These are cumbersome programs, however, in that they require staffing and reporting. Also, because many of them are episodic, it is difficult for consumers to have a dependable way to dispose of excess medicines, even if they understand the need.

water treatment facilities are not designed to remove these products. The bottom line is that we know these products are there but do not know the full risk to the environment or humans. There are a number of efforts in Minnesota to more fully understand the effect of these products on the Minnesota environment.

Eighty-six percent of amoxicillin is excreted unchanged in urine. The other source of water pollution is by active drug ingredients or metabolites that humans and animals excrete in urine and feces. The majority of all medications that are consumed by consumers are excreted in the urine in unchanged condition or as metabolites. Even topical medications such as DEET can enter sewage through bath water. Most

Defining the risk We do know that certain medicines entering the environment can have serious effects. In Pakistan, 95 percent of the Gyps vulture population died from renal failure after feeding on the carcasses of cattle treated with diclofenac, an anti-inflammatory. This is an extreme example of the potency of some of the medicines that we routinely use, but it points to how dramatic the effect can be. It should be accepted that all medicines are inherently hazardous. Hazard considers these inherent environmentally damaging characteristics in terms of: • Persistence: The ability to resist degradation in the aquatic environment. • Bioaccumulation: The accumulation of these chemicals in adipose tissue of aquatic organisms. • Toxicity: The potential to poison aquatic organisms. The challenge is to understand which products pose an environmental risk. “Risk” is different than “hazard.” Risk considers the degree of hazard of the product and the concentration in the environment. It considers how much of a product is used in a geographic area and how much it is diluted in the geographic water supply. Classifying the risk A program launched in Stockholm, Sweden in 2005 found that 6 percent of pharmaceuti-

MINNESOTA PHYSICIAN MAY 2016

cals tested in its market posed a moderate environmental risk. Examples are medicines such as: benzoyl peroxide, ciprofloxacin, erythromycin, estradiol, ethinyl estradiol, ibuprofen, chlorhexidine, propranolol, mycophenolate mofetil, and terbinafin. The antitubercular product bedakilin (bedaquiline in the U.S.) was found to be “particularly hazardous.” The remaining 94 percent were of insignificant risk. In 2004, the Stockholm County Council, LIF (Swedish Association of the Pharmaceutical Industry), and other Swedish agencies collaborated to produce and support a risk classification of pharmaceuticals in the Swedish market. The results of this collaboration are published each year in a booklet, “Environmentally Classified Pharmaceuticals.” This booklet is intended as a reference for both consumers and practitioners. The 2014–2015 edition can be accessed in an English version (http://www.janusinfo. se/Global/Miljo_och_lakemedel/ Miljobroschyr_2014_engelsk_ webb.pdf). This document organizes medicines into therapeutic categories and lists their risk to the Swedish aquatic environment. The risk is rated as “insignificant,” “low,” “moderate,” or “high.” It also provides hazard values (0 to 3) for persistence, bioaccumulation, and toxicity of each product. The Stockholm County Council also considers environmental factors in its medicines formulary called, “The Wise List.” The Wise List includes medicines recommended for the treatment of common diseases. The recommendations are based on scientific evidence regarding efficacy and safety, pharmaceutical suitability, cost-effectiveness, and environmental aspects. By considering environmental factors in the construction of the formulary they remove the necessity for the prescriber to consult yet another document or dropdown list. The “Wise List” is available in English at: http:// www.janusinfo.se/In-English/ The-Wise-List-2015-in-English/.

What can we do? There are opportunities for all practitioners involved in the medication-use continuum, as well as managed care organizations, to make a difference.

• Prescribe antibiotics and opioids prudently.

Practitioners who prescribe medicines • With each medicine prescribed, there is an opportunity to inform patients about the importance of proper disposal of unused medicines. Refer patients to the Rethink Recycling website, which lists the locations of take-back facilities (www. rethinkrecycling.com).

• Be aware of those medicines that are documented as being potentially harmful to the environment, and consider prescribing alternatives when indicated. A good place to start is with those that the Swedish authorities have designated as “moderate risk” even though their risk assessments are based on Swedish use data.

• Even though many health plans encourage a 90-day supply, restrict new prescriptions to no more than 30 days. Take advantage of starter packs for those plans that allow them.

• Remind patients to buy overthe-counter medicines in quantities that can be used before expiration.

• Absent an insurance benefit that allows starter pack prescriptions, encourage your patients to ask their

pharmacists to allow them to partially fill the Rx for a new medicine to see if it works for them.

Pharmacists who dispense and manage medicines • Include a discussion about the appropriate disposal of unused medicines as part of the OBRA ’90 counseling program.

that automatically send out renewal prescriptions without properly monitoring current orders.

• Encourage starter packs when an insurance plan allows. • Work with your municipality to install an approved patient-accessible medicine disposal unit in the pharmacy.

What is the state doing? In Minnesota there are several agencies that are addressing the issues of pharmaceuticals in the Minnesota environment.

• Refer patients to the Rethink Recycling website, which lists the locations of take-back facilities (www. rethinkrecycling.com). Managed-care organizations • Institute polices that encourage, and do not penalize plan members, for using starter packs. • Incorporate environmental risk considerations into the design of drug formularies and note those medicines with potential for environmental risk in the plan formulary. • Reconsider the incentives for 90-day supplies of medicines and contracts with mail-order distributors

• The Minnesota Board of Pharmacy is proposing legislation that will allow the use of secure collection boxes in health facilities for consumers to dispose of unwanted medicines. • The Minnesota Pollution Control Agency is conducting ongoing studies and in 2013 published findings in a report, “Pharmaceuticals and Endocrine Active Chemicals in Minnesota Lakes” (https:// www.pca.state.mn.us). • The Minnesota Department of Health published the “Pharmaceutical Water-screening Values Prescribing medications to page 36

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PROFESSIONAL UPDATE: WOMEN’S HEALTH

steoporosis is increasing in our population—and so is the discussion about guidelines for prevention and treatment options. According to the National Hospital Discharge Summary, 310,800 total hip replacements were performed among inpatients aged 45 and older in 2010, up from 138,700 in 2000. That’s an increase from 142.2 to 257.0 for every 100,000 persons. One in two women now get osteoporosis, along with one in four men. Risk factors We are learning more about the risk factors associated with osteoporosis, including the following: • Diets low in calcium and vitamin D • Physical inactivity • Tobacco and alcohol use • Being a woman

Prevention and treatment options By Yasmin Orandi, MD • Family history • Too much thyroid hormone in women • Too little estrogen in women • Low testosterone in men • Eating disorders, such as anorexia or bulimia • Secondary causes, including gastrectomy, weight-loss surgery, and conditions such as Crohn’s disease, celiac disease, and Cushing’s disease • Certain medications, including long-term use of corticosteroids, aromatase inhibitors, selective serotonin reuptake inhibitors, methotrexate, some anti-seizure medications, and proton pump inhibitors

• Excessive caffeine use • Osteopenia Screening guidelines The U.S. Preventive Services Task Force recommends dual-energy X-ray absorptiometry (DEXA) scans for women 65 years and older and for younger women with increased fracture risks, as determined by the World Health Organization’s Fracture Risk Assessment Tool (FRAX). FRAX is an algorithm based on probabilities that can help physicians determine the likelihood of someone breaking a bone within the next 10 years. These probabilities are based on a person’s age, weight, height, alcohol consumption,

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and history of osteoporosis, among other factors. There are no guidelines for rescreening women who have a normal DEXA screen. Some suggest intervals of every four years, but insurance generally covers screening every two years, which is what I recommend to my patients. Routine screening for men is not suggested unless they have risk factors. Current recommendations for patients with osteoporosis Encouraging adequate amounts of calcium and vitamin D is still the recommended advice for those with osteoporosis. Most studies suggest 1200 mg of calcium and 800 international units of vitamin D daily for postmenopausal women with osteoporosis. Premenopausal women are encouraged to consume 1000 mg of calcium and 600 international units of vitamin D daily. For men between the ages of 51 and 70, the recommended

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dietary allowance is 1000 mg of calcium daily, but after age 70, they should take in 1200 mg each day. In the past, physicians have recommended that at least half of this intake for both men and women come from dietary sources, such as dairy products, broccoli, kale, canned salmon, sardines, and soy, with the rest from calcium supplements such as calcium carbonate and calcium citrate. Calcium citrate is the recommended choice for patients taking proton pump inhibitors or H2 blockers or who have achlorhydria. Studies now indicate, however, that prescribing calcium supplements should be done with care, as new cardiovascular risks are becoming more prevalent. These risks occur when the total calcium intake exceeds recommended amounts or supplements are given in large doses, bringing the total intake above 2000 mg per day. Some physicians believe it is wise to avoid doses greater than

500 mg of calcium at one time. Personally, I encourage calcium to come from diet unless patients cannot tolerate milk or have a diet very low in calcium.

encourage my patients to make lifestyle changes that can decrease their chances of breaking a bone. This includes: • Increasing the amount of exercise. A good balance of strength and cardiovascular exercise, coupled with weight-bearing exercise, is best. Good weight-bearing exercises are walking, jogging, tennis, and climbing stairs.

additional dietary supplements, such as multivitamins, that might contain vitamin D before I prescribe extra vitamin D. Too much of this vitamin,

There are no guidelines for rescreening women who have a normal DEXA screen.

Our bodies need vitamin D to absorb calcium, but the amount of recommended vitamin D is controversial and under discussion by experts. For adults 19 to 70, the RDA is 600 international units each day, increasing to 800 units after age 71. The Institute of Medicine has defined the safe upper limit for vitamin D as 4000 units per day, although sometimes higher doses are required during initial treatment of vitamin D deficiency or when coexisting conditions require higher doses. I always ask my patients whether they are taking

especially if taken with calcium supplements, can lead to hypercalcemia, hypercalciuria, or kidney stones. The goal is to get a patient’s vitamin D level above 30. In addition to sunlight, good sources of vitamin D include oily fish, such as tuna and sardines, egg yolks, and fortified milk. The two most common forms of vitamin D supplements are ergocalciferol and cholecalciferol. Cholecalciferol works more efficiently. While calcium and vitamin D are critical to preventing and treating osteoporosis, I always

• Decreasing caffeine intake. I tell my patients to restrict their caffeine intake to no more than 2.5 cups of coffee or 5 cups of tea per day. A recent South Korean study reported that drinking coffee within these guidelines can actually reduce a person’s risk of osteoporosis. • Drinking in moderation or not at all. That means fewer than four alcoholic drinks per day for men and fewer than two for women. Alcohol can interfere with the body’s ability to absorb calcium. What’s new in osteoporosis? to page 34

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INFECTIOUS DISEASES

he current Zika disease outbreak affecting many Latin American and Caribbean countries provides a timely opportunity to remind Minnesota medical providers of the many mosquito-borne diseases their patients may be at risk for when traveling (see Table 1). Mosquito-borne disease risk can vary considerably depending on geographic location, local mosquito ecology, time of year, and the patient’s length of stay and previous exposure to mosquito-borne viruses. Adding to these intricacies, worldwide mosquito-borne disease risk is expanding and changing, largely due to the unprecedented scale of international travel and commerce. The changing landscape of risk is evident in the recent introductions of two mosquito-borne viruses to Latin America and the Caribbean islands—chikungunya virus in 2013 and Zika virus in 2015. The introduction of these viruses into regions of the world that were previously free of local transmission have had major

Travel-associated mosquito-borne diseases What medical providers need to know By Franny Dorr, MPH implications on local residents and communities, as well as visitors to the affected countries. With the accessibility and speed of modern travel, it is increasingly important for Minnesota medical providers to become acquainted with international and domestic disease risks for their traveling patients. A medical provider’s general understanding of mosquito-borne disease risk is not only pertinent for patients returning with symptoms; providers should also be prepared to give pre-travel advice to patients about their potential risks, or

MINNESOTA PHYSICIAN MAY 2016

point them to reliable resources for information. This article will provide helpful resources for medical providers to use when caring for a patient who is considering travel or returning with symptoms (see the recommended list of resources). This article will also highlight the mosquito-borne diseases in traveling residents most commonly reported to the Minnesota Department of Health (MDH). Although there are many mosquito-borne diseases worldwide, there are some travel-associated diseases that are reported to MDH more often than others. These commonly reported diseases include the ever-significant parasitic infection malaria, emerging viral diseases such as chikungunya and Zika, and re-emerging diseases such as dengue. Malaria Malaria is the most commonly reported travel-associated mosquito-borne disease in Minnesota, with an average of 54 cases annually from 2010–2014. The vast majority of these cases occurred in foreign-born residents returning to their country of origin to visit friends and relatives. The most frequently reported countries of exposure in Minnesota’s malaria cases are Liberia and Nigeria. Notably, Minnesota has the largest Liberian population in the world outside of the country itself. Globally, malaria remains a tremendous problem with an estimated 198 million clinical cases and 500,000 deaths in 2013 alone. Malaria is caused by several protozoan species in the genus Plasmodium. It is endemic in many tropical and subtropical regions of the world, most notably throughout much of

Africa, India, parts of Southeast Asia, and much of northern South America. Malaria is transmitted to humans through bites of infected Anopheles genus mosquitoes. Incubation periods vary depending on the Plasmodium species, but most people develop symptoms within a month following a bite from an infected mosquito. Malaria is a serious febrile illness with many nonspecific symptoms that may become severe, resulting in organ failure and cerebral malaria. Pre-exposure prophylaxis and post-infection treatment are available for traveling patients. Appropriate prophylaxis and treatment vary depending on location of travel and Plasmodium species circulating in the area. Malaria diagnosis is confirmed by microscopic examination (blood smear, typically available in-house) or PCR testing, which is available at many commercial laboratories or the MDH Public Health Laboratory. Chikungunya Chikungunya virus has recently emerged as a commonly reported disease in Minnesota travelers. Prior to 2013, chikungunya virus transmission was not recognized in the Western Hemisphere. Local virus transmission was first reported on the Caribbean island of St. Martin in December 2013 and very quickly spread throughout the Caribbean islands and Latin America. In 2014, Florida reported 12 locally acquired cases of infection with the virus, but following that small outbreak there has been no further local transmission reported in the United States. In 2014, there were 28 cases of travel-associated chikungunya disease reported to MDH, with the majority of cases reporting travel to the Caribbean islands. Chikungunya virus is transmitted to humans through the bites of infected Aedes aegypti and Aedes albopictus mosquitoes—commonly referred to as the yellow fever and Asian tiger mosquitoes, respectively. In contrast to many other arboviruses, most people who are infected with chikungunya virus will develop symptoms,

usually within three to seven days of infection. The most common symptoms include fever and arthralgia, but may also include headache, joint swelling, rash, and myalgia. Severe illness and death are rare, but symptoms of arthralgia may persist for several months following infection. Treatment for chikungunya disease is limited to supportive care. Chikungunya can be diagnosed using serology or PCR testing, available through many commercial laboratories or at the Centers for Disease Control and Prevention (CDC) after consultation with an MDH epidemiologist. Zika Most recently, Zika virus has made its way into much of Latin America and the Caribbean following its introduction to the region in the spring of 2015. Zika virus is transmitted primarily by Ae. aegypti and possibly by Ae. albopictus mosquitoes. Like chikungunya before it, the rapid spread of

the virus is primarily due to infected individuals traveling to areas with competent mosquito vectors and previously unexposed populations. Local transmission of the virus is not expected to occur in Minnesota due to the lack of appropriate vector populations. Nearly 80 percent of Zika infections are asymptomatic. Symptoms of Zika disease are mild for most people and include fever, arthralgia, rash, and conjunctivitis. These symptoms typi-

is also a possible link between Zika disease and Guillain-Barré syndrome. These reported links are still under investigation. Treatment for Zika disease is supportive, and laboratory testing is available at CDC after consultation with an MDH epidemiologist. Medical providers should note the current CDC recommendation that pregnant women should not travel to countries and territories with active Zika virus transmission.

Local transmission of the virus is not expected to occur in Minnesota due to the lack of appropriate vector populations. cally develop within three to 14 days following infection, and may last up to a week. There is growing evidence that Zika infection in pregnant women may be linked to birth defects such as microcephaly, or spontaneous abortion. There

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Dengue Dengue is one of the most frequently occurring mosquito-borne diseases worldwide. MDH has received an average of 11 case reports annually from 2010–2014, most of which were acquired in Latin

America. Dengue is not considered endemic in the United States; however, outbreaks have occurred in warmer states, such as Texas and Hawaii, where appropriate mosquito vectors are found. Regions of the world with endemic dengue include Africa, India and Southeast Asia, Latin America, and the Caribbean. Dengue virus is transmitted to humans through the bite of infected Ae. aegypti or Ae. albopictus mosquitoes. There are four distinct serotypes of dengue virus, and subsequent infections with different serotypes are possible. Symptoms usually occur within four to seven days of infection and may be mild, including fever (which typically lasts two to seven days), headache, arthralgia, and myalgia. Occasionally, symptoms rapidly progress to a more severe disease, characterized by hemorrhage or shock. Risk for severe dengue is greatest during the post-febrile period of Travel-associated mosquito-borne diseases to page 18

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Reporting mosquito-borne diseases Travel-associated mosquito-borne diseases from page 17

the illness. There is no specific treatment for dengue disease, only supportive care to manage symptoms. Until dengue can be ruled out, use of NSAIDS is not recommended due to increased risk of hemorrhage. Dengue infections can be diagnosed using serology or PCR testing, available at many commercial laboratories or at CDC after consultation with an MDH epidemiologist. Other emerging diseases of interest There are many other mosquito-borne diseases of interest to MDH that are not commonly seen in U.S. travelers. A few to keep in mind include Rift Valley Fever virus (occurs in many African countries and is transmitted by infected Aedes genus mosquitoes); Murray Valley encephalitis virus (a risk for travelers to Australia or Papua New Guinea, transmitted by infected Culex genus mosquitoes); yellow fever (occurs in many subtropical regions of South America and

Africa, primarily transmitted to humans by infected Ae. aegypti mosquitoes); and Japanese encephalitis (occurs in many parts of Asia, transmitted by infected Culex genus mosquitoes). Vaccines are available for both yellow fever and Japanese encephalitis viruses. For further information and assessment of mosquito-borne disease risk for travelers, CDC offers an excellent reference guide on health information and international travel called the Yellow Book, as well as a frequently updated website on current travel health notices (see the recommended list of resources). Local mosquito-borne disease risk When assessing patients with a history of travel during warmer months of the year, medical providers should also keep in mind that Minnesota has several endemic mosquito-borne diseases that should be considered. West Nile virus is endemic throughout Minnesota and the U.S., and is the most frequently reported

All mosquito-borne diseases must be reported to the Minnesota Department of Health. Reports need to include demographic, clinical, and laboratory information. To report cases, please download case report forms at www.health.state.mn.us/divs/ idepc/dtopics/reportable/forms/arboviralform.html or contact the vector-borne disease epidemiology staff at (651) 201-5414.

Recommended resources for mosquito-borne diseases CDC Website (Centers for Disease Control & Prevention): • Malaria — http://www.cdc.gov/malaria/ • Chikungunya — http://www.cdc.gov/chikungunya/index.html • Zika — http://www.cdc.gov/zika/ — http://wwwnc.cdc.gov/travel/page/zika-travel-information • Dengue — http://www.cdc.gov/dengue/ Dengue Clinical Case Management Course — http://www.cdc.gov/dengue/training/cme.html Yellow Book — http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014 Travel Health Notices — http://wwwnc.cdc.gov/travel/notices Minnesota Department of Health: • Mosquito-Transmitted Diseases Website — http://www. health.state.mn.us/divs/idepc/dtopics/mosquitoborne/ Metropolitan Mosquito Control District: http://www.mmcd.org/ mosquito-borne disease in Minnesota with an average of 36 cases annually from 2010–2014. Other endemic mosquito-borne viruses in Minnesota include La

Source: Minnesota Dept. of Health

Crosse encephalitis virus, which can cause neuroinvasive illness in children, and Jamestown Canyon virus. Less common

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but possible mosquito-borne diseases in Minnesota include Western equine encephalitis and Eastern equine encephalitis. The risk for acquiring mosquito-borne diseases in Minnesota is highest during the months of July through September. In general, mosquito-borne disease risk is much lower in the United States compared to abroad. This is true even in the southern states that have established mosquito vector populations for many of the diseases discussed in this article. There are several reasons for this decreased risk, perhaps the most important being that buildings in the U.S. have much better structural integrity compared to most tropical and subtropical countries, including screened-in windows or air conditioning that protect people from mosquitoes. Additionally, widespread access to the Internet, television, video games, etc., may lead to behavioral differences in U.S. residents, keeping them indoors more often than residents of tropical and subtropical countries. Wetland drainage and

Table 1. Quick-reference of common travel-associated mosquito-borne diseases Disease

Malaria

Pathogen Type

parasite, Plasmodium spp.

Mosquito Vector Species

Key Symptoms

Diagnostic Tests

Treatment

Anopheles genus spp.

fever, chills, sweats, headaches, myalgia, nausea, and vomiting

blood smear or PCR

Chikungunya alphavirus

Ae. aegypti, Ae. albopictus

fever, arthralgia, myalgia, rash

serology or supportive PCR

Zika

flavivirus

Primarily Ae. aegypti, fever, arthralgia, rash, serology or supportive likely Ae. albopictus conjunctivitis PCR

Dengue

flavivirus, serotypes 1-4

Ae. aegypti, Ae. albopictus

agricultural land use in the U.S. greatly diminishes the breeding habitat for many mosquitoes. In much of the country, cold winters greatly reduce mosquito activity and subsequent virus amplification and transmission for the majority of the year. Finally, there are hundreds of local mosquito control agencies throughout the country that play a large role in reducing mosquito-borne disease risk for the populations they serve. Locally, Minnesota has the Metropolitan Mosquito Control District (MMCD), which operates within the seven-county

fever, headache, myalgia

metropolitan area. MMCD maintains extensive surveillance and control of exotic mosquito introductions, including the detection and elimination of seasonal introductions of Ae. albopictus. What can medical providers do? MDH encourages medical providers to use the available resources on travel-related risks for not only mosquito-borne diseases, but for other diseases as well, as risks in Minnesota may be very different than in other parts of

Varies depending on Plasmodium spp.

serology or supportive PCR Source: Minnesota Dept. of Health

the world. Finally, reporting laboratory-confirmed or clinically suspected cases of mosquito-borne diseases to MDH is important for continued understanding of trends and changes in both locally endemic and travel-associated mosquito-borne diseases (see the sidebar on reporting mosquito-borne diseases). Franny Dorr, MPH, is an epidemiologist in the Vectorborne Diseases Unit at the Minnesota Department of Health.

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SPECIAL FOCUS: PRACTICE MANAGEMENT

Provider burnout

or many professionals in the health care industry, finding the right balance between work schedules and home life can be challenging. Health care providers such as physicians, physician assistants, and nurse practitioners (commonly referred to as advanced practice providers) are not immune to this issue. In fact, stress and burnout are prevalent in the medical field and if left unaddressed, can affect quality of care. As recent studies have shown (Shanafelt, Mayo Clinic Proceedings, 2015), burnout is on an upward trend and now affects more than 50 percent of all physicians in the U.S. Research on Advanced Practice Providers (APPs) is still being conducted but is expected to show similar results to physicians in terms of stress and burnout. This article will refer to the combination of physicians and APPs as “providers.” Hennepin County Medical Center (HCMC), a safety net health care system, is tackling

Addressing a growing problem By Sara Poplau; Elizabeth Goelz, MD; and Mark Linzer, MD

this serious issue in a variety of ways. For the past 20 years, the authors have studied physician satisfaction, stress, and burnout and for the past six years have worked with HCMC executive leadership to better address the components and predictors of burnout, as well as the implications for providers and patients. As a result, the Office of Professional Worklife (OPW) and the Provider Wellness Committee (PWC) were launched at HCMC. The research base In the early 2000s, a team, including one of the authors, was formed to study physician burnout in a randomized control trial called MEMO (Minimizing Error, Maximizing

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Outcome), which was funded by the Agency for Healthcare Research and Quality (AHRQ). MEMO involved data collection from physicians, clinics, and patients and showed there are relationships between work conditions, physician reactions, and patient care. Per MEMO study results published in 2009, 50 percent of physicians needed more time for visits, 27 percent were burning out or burned out, and 30 percent were likely to leave their job within two years. There were strong relationships between work conditions (specifically time pressure, work control, chaos, and culture) and physician satisfaction, burnout, and turnover, as well as links between work conditions and many patient outcomes in terms of chronic disease management and health maintenance activities. The next step in the research was to see if altering work conditions affected providers and outcomes such as burnout and satisfaction, along with clinical outcomes such as diabetes and blood pressure management. The same team conducted a randomized control trial called Creating Healthy Work Places (HWP), also funded by AHRQ, involving medical providers, patients, and clinics. The hypothesis of the study was that workplace changes, prompted by feedback on clinician perceptions and outcomes, would lead to a decrease in clinician stress and improved care for patients. The study used a survey tool called the Office and Work Life (OWL) measure, which assessed the work environment and care quality at baseline and up to 12 months later. Sites in the study were given worklife and clinical data about their practice and provider survey results that they could use to determine what sorts of interventions

would be best for them as a group. HWP identified interventions that would be able to reduce provider burnout. Establishing a committee After seeing the power that HWP survey data could have on a practice (by leading to meaningful discussions between medical providers including physicians and APPs, staff, and leaders), one of the first steps HCMC undertook in 2013 was to establish the PWC. The PWC is composed of physicians and advanced practice providers, including nurse practitioners, psychologists, and dentists from nine clinical departments and three administration units. It meets once a month, has an approved charter, and reports directly to executive leadership on a quarterly basis. The membership of the PWC is a unique component of our provider wellness initiatives as it allows interaction between departments that may not normally interact with one another. These monthly meetings are a chance to share experiences, discuss how policies impact different work areas, review data, brainstorm solutions, and find ways to make HCMC the best place to work. PWC members are not the only staff engaged in wellness on campus. There are departmental wellness champions — individuals who commit to spending time reviewing burnout survey data and working with department chiefs to implement improvement strategies. Wellness champions also act as the face of wellness in their departments and are often the first ones to hear about frontline challenges. Wellness champions interface with the Provider Wellness Committee when someone raises a wellness issue. The survey Once our leaders understood the root causes of physician and other health care provider stress and burnout, and what national burnout rates were, they wanted to learn what those figures looked like locally at HCMC. Our team developed a

short, 10-item survey tool called the Mini Z (the “Z” stands for Zero Burnout Program). The Mini Z derives its questions from validated tools such as the OWL used in the MEMO and HWP studies. The tool is easy to use and provides enough preliminary data to “take the temperature” of a clinical setting. There are questions that address common burnout factors like: work control, workplace chaos, personal values alignment with leaders’ values, stress, teamwork, and time pressure due to the electronic health record (EHR). The Mini Z survey was distributed in the fall of 2013 and 2014 to all HCMC providers (physicians and APPs) who met certain criteria (0.5 full time equivalent [fte] or higher, and employed for more than six months). The response rate was excellent (60+ percent each year) and our analytics team was able to transfer the data into an easy-to-read format. The data After the first survey was distributed and the data analysis complete, we hosted a half-day retreat with PWC members, leaders, department chiefs, and wellness champions to review the data, discuss possible interventions, and plan for data distribution. The survey data showed trends at HCMC that were similar to colleagues across the country—burnout was present in about one-third of the respondents. Respondents reported too much electronic medical record work, excellent teamwork, but also challenges with chaotic workplaces. Key provider wellness leaders held meetings with department chiefs and wellness champions to review survey data within their departments. These meetings were eye opening in terms of discussing real issues facing providers. They also showed how much chiefs cared about their faculty, through their engagement and concern about the data. As a result of the data meetings, executive leadership supported changes in departments

that were experiencing high rates of stress and/or burnout. These changes (sometimes in the form of standard quality improvement Plan-Do-StudyAct [PDSA] programs) were often small and inexpensive, but the response to them was

The importance of wellness After two years, we took provider wellness to the next level and created the Office of Professional Worklife. The OPW program focuses on offering wellness services that improve the work lives of all 600+

Providers need to know that their workplace is supportive of work/ life balance.

overwhelmingly positive. Survey data the next year showed improvements in scores with burnout dropping from 33 to 27 percent, control over workload improving from 55 to 62 percent, time for documentation increasing from 49 to 59 percent, and six of the departments with the highest burnout rates showing substantive improvement in their burnout scores to some of the lowest reported at HCMC. Noticing the results The work the Provider Wellness Committee is doing is being noticed on campus. “With Dr. Linzer’s guidance, attention to provider wellness is starting to bear fruit. Similar to national trends, providers at HCMC are now employed by the health system. That makes provider wellness a system concern,” said Brad Linzie, chief of pathology at HCMC. “The amazing work our providers do depends on staying in a healthy mental zone of focus. The Wellness Committee has helped teach reactive coping tactics like taking a time out and proactive strategies like changing the end of day schedule, which are now becoming sanctioned and supported.” The authors have noticed an increased awareness of provider wellness, a reduction in burnout, and more personal satisfaction. This is an integral part of the organizational goal of improving patient outcomes and satisfaction.

HCMC providers. The OPW recognizes that providers need to know that their workplace is supportive of work/life balance. This can be accomplished by implementing wellness initiatives that redesign workflow in the clinics and improve communication between provider groups. The OPW includes the authors and other committed leaders and the hope is to create a model of a supportive

organization with a positive work environment that promotes humanism in medicine and the highest quality care for patients. The topic of provider wellness is rapidly gaining traction nationally, and HCMC is thrilled to be involved in the front lines of this research and program development. Dr. John K. Cumming, vice president of Medical Affairs and president of the medical staff at HCMC said, “I am invested in supporting our physicians and advanced practice providers. Provider health and wellness is critical to achieving excellent outcomes and patient experience. Through high-value initiatives such as the Provider Wellness Committee and the Provider Dining and Wellness Center (under construction), the Office of Professional Worklife is producing a strong impact on the health and wellness of our providers.” Provider burnout to page 32

Your Link to Mental Health Resources

MAY 2016 MINNESOTA PHYSICIAN

SPECIAL FOCUS: PRACTICE MANAGEMENT

was privileged to give the keynote speech to the March 2016 Minnesota Medical Group Management Association (MMGMA) conference. The conference included executive directors, human resource directors, administrators, and other health care professionals and I discussed the changing state of health care, the impact it is having on physicians (and other health care professionals), and the subsequent rise in burnout among physicians. Unfortunately, many heads nodded in agreement that this is a growing problem in many organizations. This problem will continue to worsen unless we act now to help those who are dedicated to healing others. The changes The last several years have seen accelerated change in health care. For example: • Rising costs mean that smaller, independent physician groups are being

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bought or merged with larger health care organizations to stay alive and/or relevant. • Decreased reimbursement, particularly from Medicare, is creating a vicious cycle of working harder and longer for the same (or less) pay, even after a buyout or merger with a larger entity. • The enactment of digitized medical records have, however inadvertently, made the doctor/patient interaction less patient centered and less personal, increasing the stress and frustration on both sides.

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• ICD-10 coding, may offer more specificity, but it has turned out to be a lot more costly and time consuming than anticipated. • All of this (and more) results in the increased pressure to do what has become a mantra in many hospitals and clinics, “Do more with less.” These issues are hardly new and, in fact, are becoming the new normal. So, what is the impact of these changes on physicians? Increased expectations In a large, independent, specialty medical group in another state, physicians are very busy and dedicated to providing excellence in health care. Within their specialty, like the rest of health care, if mistakes are made, people can die. Many of the shareholders, who are physicians and partners, offered their opinions on the problems they were facing in their daily practice. Complaints were at an all-time high, backbiting was prevalent, revenue (and thus income) was down for the second consecutive year despite being busier than ever, physicians distrusted administrators, and complaints of burnout were openly discussed. When asked what had the biggest impact on their practice, one of the physicians summed up his experience in a sentence that spoke volumes, “I’m moving at the speed of malpractice.” What does moving at the speed of malpractice look like? • Increased pressure to see more patients, causing physicians to spend less time with each patient in order to maintain their tight schedule.

• With increased pressure to move quickly, physicians become stressed and patients pick up on this, which affects the clinic visit. This negatively impacts the doctor/patient relationship, often culminating in patient complaints. Staff, can also be adversely affected by physician stress leading to hurt feelings and hostility. • When staff are preoccupied with the perception that they are being treated disrespectfully, mistakes are made. Communication between physicians and staff is rushed because of time constraints, often resulting in more misunderstandings or miscommunications. (This can happen with patients too.) The Mayo Clinic study The Mayo Clinic Study (Mayo Foundation for Medical Education and Research; Mayo Clinic Proceedings, December 2015) (http://dx.doi.org/10.1016/j. mayocp.2015.08.023) examined physician burnout and work/ life balance (WLB) comparing the years 2011 and 2014. They found that over half of U.S. physicians experience at least one of the following indicators of professional burnout: 1) emotional exhaustion, 2) loss of meaning in their work, 3) feelings of ineffectiveness, 4) depersonalization (the tendency to view people as objects), and 5) compromised patient safety. As a result of the burnout study, Mayo observed that the quality of care that physicians provide decreases and that physician turnover increases—all of which combines to significantly and negatively impact the quality of the health-care delivery system. Physician burnout increased from 45.5 percent in 2011 to 54.4 percent in 2014. While some specialties suffered more than others, all specialties saw at least a 10 percent increase. Compared to the general population, physicians were at a burnout rate of 48.8 percent vs. 28.4 percent and for work/life balance satisfaction, physicians

were at 36 percent vs. 61.3 percent for the general population. As you can see, physicians (and health care staff) are under a great amount of stress and pressure. Hospital errors are now the third leading cause of death, behind heart disease and cancer, estimated between 220,000–450,000 deaths per year (Journal of Patient Safety, September 2013). While there are many factors contributing to these adverse events, the research specifically identifies the following as contributing factors: 1) increased production demands, 2) decreased staff, and 3) a shortage of physicians, which leads to fatigue and burnout. Not surprisingly, this mirrors much of the Mayo Clinic’s findings. Helping the healers Considering the problems shown in the Mayo study and in points already discussed, there are several recurrent themes. 1. Physicians care, sometimes too much. They practice medicine to help people and make a difference. When they experience a “system” that isn’t working well or effectively they become stressed and frustrated because their work is hampered by forces outside of their control. 2. Physicians are held to the highest standards, by the health care system, patients and their families, and themselves. When those standards are not attainable, stress and frustration rise, and can often affect staff, partners, and patients. 3. Physicians can become desensitized due to the pressure of having less time. This takes a toll on their self-esteem and sense of effectiveness and they become increasingly disengaged. 4. The increased demand and pressure to earn their keep takes a toll on the physician and his or her family. They are absent from home more, miss out on raising their kids, and when they are home they are exhausted or finishing dictation.

When staff is happy and unprofessional behavior, healthy that means that padespite rules that allow tients and their families are them to do just that. Leadhappy too. ership (the Board of Directors, the administration, The individual level or human resources) must In addition to systemic hold physicians accountable. interventions, it is important to When leadership doesn’t do include interventions that hapthis, morale drops and staff pen from an individual level, or members go silent. what executive coaches can do 4. Training. It is important with individuals. Physicians are to train employees—physisent for or seek executive coachThe paths for change cians and staff alike—in key ing for a wide variety of issues workplace beThere are and concerns, but more often haviors, such many things than not, it is because they have as conflict that can be maxed out their coping mechamanagement, Physicians often done to curtail nisms. Here are some examples: professional and minimize have poor stress 1. Define what you can control boundaries, physician and what you can’t. When management skills. and dealing burnout. It is a coach sits down with a with difficult important to physician, the administrasituations/ note, as the tion has already filled the people. Mayo Clinic did in their study, coach in on the problem, but that the most effective process 5. Developing a positive organiit’s important to understand includes interventions that hapzational culture. By engagthe physician’s perspective pen from both a systemic (what ing in steps 1–4, organizaas well. There is overlap the administration can do) and tions can work to positively between the two sides, but individual perspective. shape their culture by showit’s common to hear from ing care and commitment The systemic level and by minimizing disrupMoving at the speed of malpractice 1. Identify systemic concerns/ tive behaviors and attitudes. to page 30 issues sooner. Physician complaints, even if they have merit, are often dismissed by administrators because of how physicians go about voicing their concerns. Their concerns are seen as being “negative,” and physicians are sent for executive coaching sessions without the administration fully reviewing the issue. Relatedly, if a physician is being identified as having issues or concerns, administrators need to act sooner rather than later and address the concerns before they become even more disruptive. 2. Develop an accountability Burnsville Golden Valley process/procedure. Every 952.435.8516 763.588.0661 organization should have Coon Rapids Maple Grove a graduated process for addressing behavior issues 763.427.8320 763.302.4114 in the workplace that apply Edina Outreach Clinics to everyone. This helps with “fairness” concerns and 952.920.7200 throughout MN & western WI decreases the possibility for others to claim discrimination if they believe they are treated differently. For directions or additional information about the 3. Leadership involvement. It Minneapolis Clinic of Neurology is unrealistic to think that staff will report a physiVisit us online at www.minneapolisclinic.com cian, who is often their MAY 2016 MINNESOTA PHYSICIAN 23 boss, for inappropriate or 5. Physicians often have poor stress management skills because this isn’t taught or emphasized in medical school. There is an increased risk for burnout because of many factors. While many factors are out of their immediate control, many are not and can be effectively managed.

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estational diabetes mellitus (GDM) is on the rise worldwide and is now among the most common medical complications of pregnancy (Poomalar, 2015). According to the Centers for Disease Control and Prevention, the prevalence of GDM in pregnant women is estimated as high as 9 percent. Data suggest this rise is linked to the coinciding increase in obesity (DeSisto, Kim, & Sharma, 2014). In response, increased efforts in research and prevention are influencing today’s clinical management of GDM in the primary care setting, including pre-pregnancy counseling, early screening strategies, therapeutic management, and long-term follow up postpartum. What is GDM? Gestational diabetes is defined as any degree of glucose (carbohydrate) intolerance, with onset or first recognition during pregnancy. The American Diabetes Association (ADA) suggests this definition encompasses

Gestational diabetes management A holistic approach By Lori Wilcox, MD, and Kim Plessel, MS, RDN, LD

insulin or diet-only modifications for treatment and whether the condition continues after pregnancy. Among GDM risk factors are a body mass index (BMI) greater than 30, family or previous history of GDM, known impaired glucose metabolism, polycystic ovary syndrome, and previous infant birth weight over 9 pounds. Other factors associated with glucose abnormalities in pregnancy include excessive weight gain prior to pregnancy and excess saturated fat intake. Significant health concerns GDM is associated with

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neonatal and fetal complications. Women with GDM are at higher risk of gestational hypertension, preeclampsia, and cesarean delivery. Infant risks include macrosomia, neonatal hypoglycemia, hyperbilirubinemia, operative delivery, birth trauma, and respiratory distress syndrome. The long-term impact of GDM is significant. The American College of Obstetricians and Gynecologists (ACOG) projects that upwards of 50 percent of women with GDM will develop type 2 diabetes at some point in their lives. Children of women with GDM are at greater risk for diabetes, glucose intolerance, and obesity (Metzger & Coustan, 1998). Early screening strategy, diagnosis ACOG recommends all pregnant women who do not have preexisting diabetes be tested for GDM (see the sidebar). A two-step approach to testing is common in the U.S. The first step is performed by checking capillary or serum glucose one hour after ingesting 50 grams of carbohydrate. Depending on the results, a second diagnostic step includes a three-hour glucose test with ingestion of 100 grams of carbohydrate. • Low-risk patients are screened at 24 to 28 weeks of gestation; if glucose levels meet or exceed screening thresholds greater than 135 or 140 mg/dL (based upon community prevalence rates of GDM), the patient undergoes diagnostic testing. • High-risk women, those with a history of previous gestational diabetes, known impaired glucose metabolism, or obesity, are screened at 10 to 14 weeks. If glucose

levels are normal, she will be rescreened with a onehour glucose test at 24 to 28 weeks. If the glucose is high, the patient will complete an early three-hour glucose tolerance test (GTT). If she passes threshold parameters, she will be rescreened at 24 to 28 weeks. Alternative protocols have been used and promoted by other organizations. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) suggest a one-step approach. At the first prenatal visit, a hemoglobin A1c or a fasting plasma glucose (FPG) test is performed for all or only highrisk women to identify undiagnosed pregestational diabetes. Overt diabetes in pregnancy is indicated with an A1c >6.5 percent or FPG > 126 mg/dL. While the A1c may be a useful marker to help identify pregestational diabetes, ACOG continues to recommend the two-step approach due to lack of evidence that the one-step approach would lead to clinically significant improvements in maternal or newborn outcomes (Feldman, Tieu, & Yasumura, 2016). Medical management during pregnancy It is important to offer nutritional counseling as part of a multidisciplinary approach to medical management of gestational diabetes. Medical nutrition therapy, initiated within one week of diagnosis and with a minimum of three nutrition visits, results in decreased insulin use, improves likelihood of normal fetal and placental growth, and reduces risk of perinatal complications, especially when diagnosed and treated early. Registered dietitians and certified diabetes educators help patients achieve normoglycemia, prevent ketosis, and gain appropriate pregnancy weight. Timely referrals allow women to quickly access resources and provide seamless continuity of care. At our practice, for example, women receive education on gestational diabetes that includes a carb-controlled meal plan, glucometer teaching, and exercise

counseling. They also receive patient navigator services throughout their pregnancy to ensure glycemic control. If a woman experiences persistently elevated glucose at any point of her pregnancy and/or excessive rate of fetal growth, she should be referred to a diabetes specialist for consideration of pharmacological therapy. Women requiring medication can also start weekly biophysical profiles at 32 weeks. In the absence of a dietitian or certified diabetes educator, here are some useful recommendations from ACOG: 1. Practitioners should encourage patients to consume adequate calories to promote appropriate weight gain with guidance from the Dietary Reference Intakes (DRI) for pregnant women, as research indicates that inadequate weight gain during pregnancy is associated with an increased risk of preterm delivery, regardless of pre-pregnancy BMI levels. The USDA has created a useful app, “DRI Calculator for Healthcare Professionals.” In obese women, the Academy of Nutrition and Dietetics Evidence Analysis Library recommends that 70 percent of the DRI calculated energy needs, or at least 1800 calories daily, will help slow weight, prevent ketonemia, and ketonuria. The general caloric needs of pregnant women increase by ~340 calories in the second trimester and another ~110 calories in the third trimester. For obese women, the addition of 150 calories in the second and third trimesters will help meet their pregnancy needs while supporting appropriate weight gain. 2. The DRI recommends that pregnant women consume a minimum of 175 g of carbohydrate daily to provide glucose for the fetal brain and to prevent ketosis. Carbohydrate intake affects post-meal blood glucose levels. Postprandial hyperglycemia is associated with increased incidence

of large-for-gestational age infants and increased rate of cesarean deliveries. Studies show improved outcomes at carbohydrate intake of less than 45 percent of total energy intake.

weight, which limits its usefulness. It has been estimated that up to 588 cesarean deliveries for an EFW of 4,500 gm and up to 962 cesarean deliveries for an EFW of 4,000 gm would be needed to prevent a single case of permanent brachial plexus palsy. It is reasonable to discuss the option of scheduled cesarean delivery when the EFW is 4,500 gm or more.

glycemic control and no other complications can be managed expectantly. Women on medical therapy with good glycemic control do not require delivery before 39 weeks of gestation. Delivery at or after 37 weeks

Children of women with GDM are at greater risk for diabetes, glucose intolerance, and obesity.

3. ACOG recommends that carbohydrates be distributed between three meals and two to three snacks to reduce postprandial glucose fluctuations. Due to pregnancy hormones, women with GDM often find it hardest to control their blood sugar in the morning. Clinicians can consider recommending a general pattern of 15 to 30 grams of carbohydrate at breakfast and snacks with 45 to 60 grams of carbohydrate at lunch and dinner. 4. Useful apps primary care providers can recommend to patients include: Diabetes App by BHI Technologies; Glucose Buddy by Azumio; Diabetes Tracker by MyNetDiary; or Diabetes in Pregnancy by Coheso. Food and glucose diaries, whether electronic or paper, have been shown to be more effective in controlling GDM when practitioners request and review them. Clinicians should also consider recommending a moderate exercise program that consists of physical exercise for 30 minutes per day to improve glycemic control (Blumer et al., 2013). If women are prescribed insulin, they should check their blood glucose prior to exercise. The ADA (2016) recommends consuming carbohydrates before exercise if blood sugar levels are below 100 mg/dL. Considerations for delivery According to ACOG, women with gestational diabetes with good

should be considered for women with poor glycemic control. Macrosomia is more common in women with gestational diabetes, and shoulder dystocia is more likely at a given fetal weight in pregnancies complicated by diabetes. Ultrasound for estimated fetal weight (EFW) may be considered for those women in which macrosomia is expected. The accepted range of error in ultrasound EFW is 10 percent of the actual fetal

Medical management postpartum At a patient’s postpartum appointment at six to 12 weeks, it is recommended that all women with gestational diabetes complete a fasting glucose. They may also be tested with a 75 gm two-hour challenge test. If postpartum testing is normal, repeat testing is conducted at three-year intervals in concordance with ACOG and the ADA. Clinician support of breastfeeding is also notable. Research has indicated Gestational diabetes management to page 29

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PHARMACY

ccording to the Centers for Medicare & Medicaid Services (CMS), the total cost of health care in the United States in 2014 reached $3 trillion, with government programs and private payers spending at rates higher than ever before. Much of this cost is due to an increase in prescription medication utilization. Four out of every five health care visits result in a medication being prescribed. Eighty percent of adults take prescription or over-the-counter medication, or other remedies on a weekly basis, and 30 percent of these adults take at least five medications. Medications are beneficial when appropriately taken as prescribed; however, they can also do significant damage if not used appropriately. The Institute of Medicine (IOM) estimates that hospitalizations caused by adverse drug events costs the health care system $3.5 billion annually. The health care system is undergoing major payment reform in an

Redesigning primary care The role of the pharmacist in value-based care By Lara Kerwin, PharmD, and Heidi Le, PharmD

attempt to address the rising total cost of health care—shifting from an entirely fee-for-service world to a world that rewards high-quality care. Value-based payments are intended to both increase the quality of care provided and minimize the cost of care to whatever extent possible. Minnesota-based health systems and physician groups are responding to this call for change, recognizing the opportunity to revamp a system in need of repair. To begin the renovation, blueprints for the remodeling process have been outlined in the core objectives

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set forth by the Institute for Healthcare Improvement (IHI) Triple Aim: to elevate the patient experience, improve the health of the population, and reduce the per capita cost of health care. Safe and effective medication use should be at the forefront of this charge. Reducing the cost of care In order to achieve these core objectives and sustain the results, health systems and physician groups are redesigning the structure of primary care practice with a collaborative, team-based approach. As medication specialists, pharmacists are becoming an increasingly important member of a patient’s care team. How does the addition of a pharmacist to a care team contribute to value-based care? Pharmacists have effectively managed high-risk patient populations by optimizing medication use to improve clinical outcomes and reduce health care costs. For example, results from a prospective study published in 2008 in the Journal of the American Pharmacists Association showed a statistically significant total decrease in health expenditures over one year (from $11,965 to $8,197 per person) when incorporating clinical pharmacy services to optimize patient care. A 2010 article in the Journal of Managed Care Pharmacy studied cost savings by pharmacists in a health system. The results showcased a total cost savings of $2,913,850 ($86 per encounter), and the total cost of clinical pharmacy services was $2,258,302 ($67 per encounter), for an estimated return on investment of $1.29 per $1 over 10 years.

Improving patient experience through team-based care Minnesota’s three pioneer accountable care organizations (ACOs)—Allina, Fairview, and Park Nicollet/HealthPartners—are paving a new path for payment, from volume to value. These ACOs are gaining headway by enlisting the help of pharmacists to provide direct care for patients through a consistent patient care process known as Comprehensive Medication Management (CMM) or Medication Therapy Management (MTM). CMM is a value-added service delivered by pharmacists in Minnesota health systems to optimize medication use. Through this consistent care process model, pharmacists systematically “...determine that each medication is appropriate and effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.” Pharmacists design and implement patient-driven care plans to achieve therapeutic goals with appropriate follow-up to determine actual patient outcomes. According to Rae Ann Williams, MD, regional medical director at HealthPartners, “[Medical] providers in my internal medicine clinic rely heavily on their pharmacists to help titrate and monitor medications. It is one thing if patients are well controlled, but the literature would suggest that approximately 50 percent of the time patients’ medication doses are not optimized for their chronic conditions for a variety of reasons. While physicians often address multiple health concerns during an office visit, pharmacists can focus on titrating medications and following up on necessary dose adjustments, which allows us to expand our ability to care for more patients.” Effectively, CMM adds value to the care patients receive and also fosters cooperative relationships between pharmacists and providers. Williams puts it this way, “You can care for patients yourself, but once you work

with a pharmacist and appreciate their knowledge base, it is hard not to have them on your team and utilize them. There’s opportunity here. We, as physicians, are very busy and may not have the ability to follow up with patients as quickly as they want, but if they partner with a pharmacist providing comprehensive medication management, they can help optimize their medications and get them to goal.” Each member of the health care team should be leveraged to work to the top of his or her license. Pharmacists delivering comprehensive medication management in ambulatory care settings can address and fulfill this need. Caring for populations While comprehensive medication management has an important role in the value-based care model, generally, it is a resource-intensive process focusing on patients at the highest risk for poor outcomes and does not broadly target a large population of patients. Because

of the improvement to quality and cost-savings seen by having a pharmacist in clinics, many

upon state quality metrics and national quality measures, such as from CMS.

Comprehensive medication management has an important role in the value-based care model. health systems are integrating pharmacists into care teams in non-dispensing roles. Pharmacists are now taking on roles to manage population health. For instance, pharmacists in primary care clinics are leading quality improvement initiatives. One example is a pharmacist evaluating all patients with diabetes within a clinic that are not on statin therapy and working with clinic-based quality improvement teams to resolve this population-based drug therapy problem. In this way, pharmacists are able to facilitate quality improvement

On a larger scale in Minnesota, health systems are joining forces with payers to broadly review medication utilization and identify gaps in care. Pharmacists like Amanda Brummel, PharmD, BCACP, director of Fairview Pharmacy Clinical Ambulatory Services (which employs 25 pharmacists in primary care clinics across the health system), are championing these efforts. When system-payer collaborations come to fruition, it forms a partnership that helps eliminate the issue of each party working parallel to one another instead of in tandem. Brummel

notes, “We need to stop duplicating efforts—it is better for everyone if we can all work together as a team.” The role of community pharmacists With established CMM services happening in primary care clinics and population health management partnerships growing with payers, what is the role of community pharmacists in value-based care of the future? Dan Rehrauer, PharmD, of HealthPartners suggests focusing on an overlooked asset of the pharmacist: accessibility. One of the key barriers to providing high quality population-based care is underutilizing key players on the health care team, such as pharmacists, who have frequent opportunities to impact and monitor the care of patients between primary care visits. In a climate where there is a shortage of primary care providers and access to patients in a clinic setting is Redesigning primary care to page 28

MAY 2016 MINNESOTA PHYSICIAN

Redesigning primary care from page 27

limited, the opposite holds true with pharmacists in a community-based setting. A pharmacist can be found on nearly every street corner and in every hospital, and they have the advanced training necessary to provide direct patient care and to care for Minnesota communities. Rehrauer of HealthPartners discusses implications for community pharmacy involvement in the value-based care model, “Community pharmacy partnerships are still very much in their infancy. We can utilize the community setting to provide better care and decrease overall cost of care by focusing on population health. We just need to figure out how to use and pay for community pharmacies to roll out these services. People aren’t necessarily exploring this opportunity or thinking about it right now. This is beyond comprehensive medication management. Community pharmacies can touch

big populations when CMM doesn’t.” In addition, pharmacists may be able to evaluate and adjust medications for conditions such as high blood pressure and diabetes in-between medical visits to more closely manage follow up and

reducing total cost of care. Although progress is advanced in Minnesota, compared to other states, there is still work to be done to realize the full potential of each team member in value-based care. Rehrauer states, “While pharmacists are

Pharmacists are becoming an increasingly important member of a patient’s care team.

facilitate improved health outcomes. Establishing relationships with untapped resources such as community pharmacies is one such example answering the IHI’s charge of restructuring primary care services. Many health systems and physician groups in Minnesota are using pharmacists to drive progress toward improving the patient experience, managing population health matters, and

MINNESOTA PHYSICIAN MAY 2016

a part of it, it is going to take a system as a whole, not an individual provider, to move forward.” In addition, Brummel stresses, “It will be necessary to take all of these interventions (CMM, population-based efforts, new partnerships, and team-based care) to tackle the health of the population.” Williams concludes, “We are at a pivotal point in which we need to be forward thinking, be more

proactive than reactive, and touch more patients.” Minnesota health systems and physician groups are aligning their mission and visions for the future of value-based health care. At the forefront of achieving this goal is optimizing medication use and preventing adverse drug events, which can be facilitated by leveraging the skills of a pharmacist as an integral member of the care team. Now, it is up to pharmacists and providers to come to the table, to open lines of communication, build collaborative partnerships, and start the conversation. Lara Kerwin, PharmD, is a phar-

maceutical care leadership resident at the University of Minnesota and practices at Smiley’s Family Medicine Clinic. Heidi Le, PharmD, is a pharmaceutical care leadership resident at the University of Minnesota and practices at Broadway Family Medicine Clinic.

Gestational diabetes management from page 25

that breastfeeding results in long-term improvements in glucose metabolism even after adjustment for maternal age, BMI, and use of insulin during pregnancy. Breastfeeding may also reduce the risk of type 2 diabetes in children (Academy of Nutrition and Dietetics Evidence Analysis Library, 2016).

patient-centeredness; diabetes across the life span; and advocacy. Recommending a comprehensive plan with a multi-disciplinary approach will reduce health risks including blood pressure and lipid control, smoking prevention and cessation, weight management, physical activity, and healthy lifestyle choices. Improving coordination between clinical

levels of the health care system will help improve the societal determinants of obesity and diabetes that are at the root of these problems.

Diagnosis of GDM Two out of four glucose values are high on the three-hour glucose test. ABNORMAL VALUES:

Lori Wilcox, MD, is an obstetri-

• Fasting ≥ 95 • 1 hr ≥ 180 • 2 hr ≥ 155 • 3 hr ≥ 140

cian/gynecologist who practices at Oakdale Obstetrics and Gynecology (a division of Premier ObGyn of Minnesota). Kim Plessel, MS, RDN, LD, is a registered dietitian and sees patients at Oakdale Obstetrics and Gynecology.

Source: American College of Obstetrics and Gynecologists, Practice Bulletin No. 137, 2013

The prevalence of GDM in pregnant women is estimated as high as 9 percent.

Conclusion With the increasing incidence of obesity and diabetes in pregnancy, health care providers are uniquely positioned to advocate for holistic approaches to improve patient health. The ADA recommends that clinicians consider three key themes for diabetes care including:

teams will also help patients transition through different stages of their life span. The natural transition from gestational diabetes to postpartum prevention of type 2 diabetes is an opportune time to make long-lasting lifestyle improvements for women and their children. Advocacy at multiple

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Moving at the speed of malpractice from page 23

physicians what it’s like to be in the “trenches” and how difficult it is to meet the needs of the health care system, the parent organization, the clinic, and the patient in a fast-moving system. It’s important for the physician to determine and understand what is within his or her control and what is not. 2. Learn to manage your emotions so your emotions do not manage you. It’s important to talk about stress management; self-management (managing yourself and not outcomes, which have many variables that are often outside of your control); impulse control (just because you think or feel something, does not mean you should verbalize it); and “slowing down” so you can think before you speak. 3. Be in the present (mentally), not in the past or the future.

EQ is a more accurate predictor of success in life (not just work) than IQ. 4. Develop emotional intelligence in a high IQ environment. Physicians are, on the whole, a very bright bunch of people. That said, their intelligence may be more “narrowly” focused, often excluding the skill sets identified as necessary for working well with others. This has been called emotional intelligence (EI or EQ for short). Study after study has found that EQ is a more accurate predictor of

are quietly and constantly running behind the scenes, dictating what you can or can’t do. It’s helpful to explore your beliefs and keep what works for you, discard what doesn’t, and adopt new beliefs that fit who you are and your current situation.

success in life (not just work) than IQ. Learning to read situations, have empathy, be flexible, know how you feel, and how it may impact others are indicators of your emotional intelligence. The BarOn EQ-i is a useful tool

In short, the only time you have control over anything is in the present. Staying in the present enables you to think about what is helpful now. This is highly effective in minimizing stress, pressure, and anxiety.

to evaluate a physician’s emotional intelligence and determine where their skills lie and where they are lacking. Developing these “soft” skills makes you more communicative, a better team member, and a more effective leader. 5. Explore your underlying attitudes and beliefs that give rise to your behavior. A person cannot act against his or her belief system on a regular basis. Belief systems

Conclusion As health care continues to evolve, the constant in all the change is physicians. We need to ensure we are helping our healers (and health care organizations) to stay healthy, so they may continue to heal all of us. Gregory Alch, MA, EdD, is a licensed psychologist and organization consultant in practice for over 28 years. He is the founder and president of Method 44, an organization consulting group. He works extensively with health care organizations providing executive coaching, leadership development, team building, training, and other change initiatives.

You’ll love what you hear!

DID YOU KNOW? X 21% of diabetics have hearing loss – compared to 9% of non-diabetics X Hearing loss is tied to three-fold higher incidence of injury-causing falls, as well as more frequent and longer hospitalizations X Untreated hearing loss can affect cognitive brain function – and is associated with the early onset of dementia

After discovering I needed hearing aids, I wanted the best-trained, most competent and experienced audiologist I could find. I also wanted the widest selection of quality products and finest follow-up services. After information-seeking visits with several recommended audiologists, Dr. Paula Schwartz easily rose to the top of my list. Paula and her excellent group of audiologists, all with doctorates, have given me outstanding care over the past eight years.

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MINNESOTA PHYSICIAN MAY 2016

North Memorial is hiring MDs, NPs and PA-Cs.

He needs you.

We are a fiercely independent, physician-led organization. Our physician leaders, including our CEO, and VPs see patients every week. Healing defines us. Not bureaucracy. We treat our patients and our employees better. We’re committed to ensuring our providers have fulfilling clinical work, competitive salary and benefits, and work-life balance. Interested applicants may contact: Robert McDonald, MD Medical Director, Primary Care Robert.McDonald@NorthMemorial.com Todd Gengerke, MD Medical Director, Urgent Care and Convenient Care Medicine Todd.Gengerke@NorthMemorial.com

FAMILY PRACTICE PHYSICIANS:

What if work was where you went to recharge? Do you know what it feels like to work with a sense of purpose? At Marathon Health, we’re on a mission to put “health” back in healthcare. We have partnered with Cargill’s turkey and cooked meats business in Albert Lea, MN and are looking for a parttime Family Practice Physician to work with employees and their families (newborns +). This is an onsite position, working either four hours per week or two days per month (total:16 hours per month) with a clinical team consisting of a Family Nurse Practitioner and a Medical Assistant. There are no on-call hours. Our intention is to provide the best patient care in a collaborative clinical community, and to give access to the workforce population in and around Albert Lea. Imagine – work could be the highlight of your day. For a more detailed job description and to apply online, please visit www.marathon-health.com. MARATHON HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER

Family Medicine Minnesota and Wisconsin

PRACTICE WHERE BEAUTY SURROUNDS YOU

We are actively recruiting exceptional board-certified family medicine physicians to join our primary care teams in the Twin Cities (Minneapolis-St Paul) and Central Minnesota/Sartell, as well as western Wisconsin: Amery, Osceola and New Richmond. All of these positions are full-time working a 4 or 4.5 day, Monday – Friday clinic schedule. Our Minnesota opportunities are family medicine, no OB, outpatient and based in a large metropolitan area and surrounding suburbs. Our Wisconsin opportunities offer with or without obstetrics options, and include hospital call and rounding responsibilities. These positions are based in beautiful growing rural communities offering you a more traditional practice, and all are within an hours’ drive of the Twin Cities and a major airport. HealthPartners continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and benefits 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, 952-883-5453, toll-free: 800-472-4695. EOE

Family Practice Physician Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.

WORK-LIFE BALANCE: • Competitive salary • Significant starting & residency bonuses • 4-day work weeks • 51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 tluedke@scenicrivershealth.org 218-361-3190

healthpartners.com MAY 2016 MINNESOTA PHYSICIAN

Provider burnout from page 21

Services offered by the OPW include: one-on-one discussions about work-life; advocacy with leadership for ways to improve balance between work and life for providers; and partnering with the Provider Wellness Committee, wellness champions, and department chiefs to ensure that the needs of providers are heard and addressed. They hope that by elevating work/life balance to the level of this office that providers will know this is an important issue and that help is there. In 2016, the OPW will promote sustainability and self-preservation, create a more supportive tone in messaging from leadership, support more time for self-care, advocate for less EMR work at home, develop transparency in values among leadership, and promote engagement as a means to decrease burnout.

A place to recharge One unique feature of the OPW is the Reset Room where providers can go for quiet time to recharge during the busy workday. It serves as an oasis for providers during stressful times. Providers work

Addressing issues before they cause burnout is critical.

very hard and are dedicated to delivering compassionate, high-quality care for those in need. Addressing issues before they cause burnout is critical to making sure that providers are practicing medicine in the best environment possible. The room includes soft lighting, a sound machine (with waves and a babbling brook) and comfortable chairs for relaxation and rejuvenation.

WORK-LIFE BALANCE

SURROUNDED BY LAKES POSITIONS AVAILABLE: INTERNAL MEDICINE– No call EMERGENCY MEDICINE FAMILY MEDICINE – Full-scope practice avail. (ER, OB, C-Section, Hospitalist, Clinic)

Erik Dovre, OB/GYN

Lakewood Health System is seeking to expand the care team for its progressive and patient-focused clinics and hospital. Located in Staples, Minnesota, Lakewood is an independent, growing healthcare system with ﬁve primary care clinics, a critical access hospital and senior living facilities. Practice consists of 14 family medicine physicians and 10 advanced practice clinicians, as well as a variety of on-staff specialists. Competitive salary and beneﬁts. Relocation and sign-on bonus available.

Visit www.lakewoodhealthsystem.com, or contact Brad Anderson at 218-894-8587 or bradanderson@lakewoodhealthsystem.com.

www.lakewoodhealthsystem.com

A wellness center The latest OPW initiative is the transition of a doctors’ dining room at the downtown location into the Provider Dining and Wellness Center. The new 24-hour Center will offer breakfast and lunch to the provid-

MINNESOTA PHYSICIAN MAY 2016

ers and will have a facelift to brighten the space and create areas for exercising and relaxing. The Center will include a workout space, a shower and changing room, eating space, and meeting areas. Soft carpet and moveable tables will enable groups to sit on the floor to debrief challenging events.

Conclusion We have been working with national partners to increase awareness and decrease provider burnout. The American Medical Association, the American College of Physicians, and the Association of Chiefs and Leaders in General Internal Medicine have all collaborated with us, spreading the word concerning the “Hennepin model” of addressing burnout issues. We are very happy to have these national organizations as partners who can carry the message to other health care delivery systems nationwide. Sara Poplau is assistant director of the Office of Professional Worklife at HCMC. Elizabeth Goelz, MD, is the chair of the Provider Wellness Committee and a general internist at HCMC. Mark Linzer, MD, is director of the Office of Professional Worklife and a general internist at HCMC.

BEYOND TREATING, THERE’S CARING W E L L A N D BE YO N D Fairview Health Services seeks physicians with an unwavering focus on delivering the best clinical care and a passion for providing outstanding patient experience.

The perfect match of career and lifestyle.

We currently have opportunities in the following areas: • • • • • • • • •

Allergy/Immunology Dermatology Emergency Medicine Family Medicine General Surgery Geriatric Medicine Hospitalist Internal Medicine Med/Peds

• • • • • • • • •

Neurology OB/GYN Orthopedic Surgery Pain Medicine Palliative Care Pediatrics Psychiatry Pulmonary Medicine Urology

To learn more, visit fairview.org/physicians, call 800-842-6469 or email recruit1@ fairview.org fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer

Sorry, no J1 opportunities.

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: • Dermatology • ENT • Family Medicine • Gastroenterology • General Surgery • Geriatrician • Outpatient Internal Medicine

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

F O R M O R E I N F O R M AT I O N :

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

Employment Opportunity

Sioux Falls VA

Health Care System

Clinic Administrator Orthopaedic Associates of Duluth, P.A. is a physician-owned, highly reputable, well established clinic with ten physicians, eight physician assistants, and nine physical and occupational therapists. We are seeking an experienced Clinic Administrator to provide strategic and operational leadership for the medical practice within our three northern MN locations. The position is responsible for overall financial and operational management of the daily activities including operations, accounting, medical and business information systems, marketing/public relations, personnel administration,

• Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Sleep Medicine • Urgent Care

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

and planning and development. The selected candidate will have

Cardiologist

Orthopedic Surgeon

superior management, interpersonal, and analytical skills and be a

Endocrinologist

Psychiatrist

be comfortable in a clinic environment. The position continually

ENT (part-time)

Pulmonologist

monitors operations as well as corporate compliance, HIPAA, risk

Emergency Medicine

management, and patient satisfaction. Represents the clinic in

Gastroenterologist

Rheumatologist (part-time)

strong communicator. Must have a solid financial background and

its relationships with other healthcare organizations, government agencies, and third party payers. The Administrator is accountable

Hospitalist

to the physicians. Bachelors degree with 7-10+ years of experience

Oncologist

in physician practice management required. Position offers a competitive salary and excellent benefits package. Email resume to marisa.haggy@slhduluth.com or fax to attn: Marisa 218-722-6515.

Urologist (part-time)

(605) 333-6852 www.siouxfalls.va.gov Apply online at www.USAJOBS.gov MAY 2016 MINNESOTA PHYSICIAN

What’s new in osteoporosis? from page 15

• Stopping the use of tobacco. While smoking has been connected to bone loss, it is difficult to separate smoking from other risk factors common to smokers, such as alcohol intake, small body mass, physical inactivity, and poor diets. Women who smoke also have an earlier menopause than nonsmokers. • Making the home safe. Most falls take place in the kitchen, bath, or on steps. I encourage patients to assess the risk of falling and remove any risk factors, such as throw rugs, dark hallways, or slippery floors. • Increasing exposure to sunlight or ultraviolet light to 30 minutes per day, five days a week. Sunlight contributes to our body’s production of vitamin D.

New medications Most physicians today recommend bisphosphonates, including alendronate (Fosamax) or ibandronate (Boniva) as a first-line medication for osteoporosis. These medications are usually well tolerated and cost less than some of the newer pharmaceutical agents on the market today. I usually stop them after five years, as fewer patients are willing to take medications due to the risk of femur

Teriparatide, marketed as Forteo, is an anabolic agent that treats osteoporosis and also stimulates bone formation. Other similar drugs are in clinical studies, as are drugs that communicate with the chemical that signals bone-eating cells (osteoclasts) to block that signal. Scientists believe there may be other ways to speak to osteoclasts through signaling mechanisms.

Prevention is much easier than managing osteoporosis. fractures and jaw necrosis, both of which have had a lot of media coverage in recent years. Other common osteoporosis medications include selective estrogen receptor modulators (SERMs) like raloxifene (Evista) or newer SERMs such as lasofoxifene.

Osteoporosis in men More attention is being given to osteoporosis in men, although guidelines for testing are less clear than they are for women. Bone density measurements are obtained infrequently in men. Therefore, the diagnosis

of osteoporosis is often made as a result of incidental osteopenia seen on radiographs or by fracture or height loss. Routine screening is not yet widely recommended, but the Male Osteoporosis Risk Estimation Score (MORES) is a scoring algorithm to identify men at risk for osteoporosis and therefore candidates for DEXA screening. Taking the time I recommend that physicians take the extra time to address bone health during annual exams. We have a lot of health screenings to go over in a short time, and bone health can be overlooked, along with counseling for risk factors, calcium, and vitamin D, but prevention is much easier than managing osteoporosis or treating painful fractures. Yasmin Orandi, MD, is a family medicine physician at the Apple Valley Medical Clinic.

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

Opportunities available in the following specialties: ENT

Rochester Southeast Clinic

General Surgery Hospital

Plastic Surgery

Psychiatrist – Child & Adolescence

OMC Hospital – Women’s Health Pavilion

Rochester Southeast Clinic

Psychiatrist

Sleep Medicine

Rochester Southeast Clinic

Rochester Northwest Clinic

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

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

www.olmstedmedicalcenter.org 34

MINNESOTA PHYSICIAN MAY 2016

Urology Hospital

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

Cuyuna Regional Medical Center is seeking two full-time Family Medicine physicians for its Crosby Clinic. Located in the heart of the Cuyuna Lakes Area, CRMC’s Crosby clinic has recruited 22 New and dedicated, quality physicians & APC’s in the last 2 ½ years that, along with the required up-to-date technology, have developed CRMC into a regional resource for advanced diagnostic and therapeutic healthcare services.

• 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

Our Family Medicine opportunity: • MD or DO • Board Certified/Eligble in Family Medicine, Internal Medicine or IM/Peds • Full-time position equaling 36 patient contact hours per week • Work 4.5 days a week. • 1 in 11 Peds call. (Majority of calls handled by phone consultation) • Practice supported by 14 FM colleagues, APC’s and over 35 multi-specialty physicians • Subspecialty providers—Internal Medicine, OB/GYN, Orthopedics, Urology, Surgery, Oncology, Pain Management and more • Competitive comp package, generous signing bonus, relocation and full benefits • New Residients are encouraged to apply A physician-led organization, CRMC has grown by more than 40 percent in the past three years and is proudly offering some procedures that are not done elsewhere in the nation. The Medical Center’s unique brand of personalized care is characterized by a record of sustained strength and steady growth reflected by an ever-increasing range of services offered.

Contact: Todd Bymark, tbymark@cuyunamed.org (218) 546-3023 | www.cuyunamed.org

Family Medicine & Emergency Medicine Physicians

Great Opportunities

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tors to and doc nyms patients of acro hat are the bev y daily? of ease ation) make to incr organiz ials, ance that seem init mainten e set of ounts) plac (hea lth acc HMO n a common savings age lth efit man Patient has bee HSA s (hea e acy ben (the as hav (pharm have ACA e Act), and PBM now we rdable Car ACOs But with ment). ion and Affo confused ns), one of ly atio easi Protect aniz . may be e Org which table Car cost control are of of us (Accoun ’s means that all and an s, happen the ACA did it , its ACO s, e.g., So how to the ACA nym ject ; P4P er acro now sub t soup of oth lth records) ance, hea per form alphabe ctronic (ele “value” pay (fee EH Rs ly pay for (the FFS rm); IPA B ing y (typical ment refo aten Adv isor ce aka pay ice); or a thre Pay ment insuran EHR data at ndent for-serv look hea lth n feaIndepe huge A have bee federal Recently, radar MPP, and ergers Johnson, w the Bob belo Boa rd)? n mega-m ngBy spi- berg, MS Soder atio s (ho Flyi Karen cor por the news. een ACO porations) in betw cor tured i-mergers going sysrance t’s insu r record (EHR) ed, wha k…o are min ical staf f wor ic health e commonplace lectron happen things tal/med Os. What becom these tems have care sysHM all and sota’s health als how do in Minne and all hospit on, and k? EHRs. 18 most clinics s charts to tem, with to page not wor from paper report ractice rate, provid malp transitioning cian adoption d, MD Political physi this high the tools e Lynfiel ize of h Despit optim disRut lue ling to t care, ctious and ers are strugg to support patien The va er infe What are MPH, alities or oth PhD, l health inform and capabi ases nesota? disease, Danila, ge clinica own virus there in Min or other dise easing hard and to exchan ers outside of their is By Ric s incr these provid ease us disds in tion with cha rnumber infectio lth . the tren e? Are the how are the ents ature nce for health system lic hea on pati sota Legisl over tim ing, and urveilla a core pub preventi s and factors or the Minne to reas EHR is case l e 2007, s its In dec s perabl the ntia risk or ease y in Thi als ics of 2015 Intero n esse ce earl are the the cases? rm all hospit passed the acterist g? What functio rts. Sin Minnesostates that re for effo use an to info te, which the ngin H has osu must trol 0s, Manda ers cha H) of exp s, and (MD d by MD care provid and con in the 188 health record sources tion is use trol measure ition, and health Hea lth selected , of ee electronic creation ent of add sicians artm informa on and con eness. In orting interoperabl by Jan. 1, 2015 (Minn sourcby phy ta Dep d the rep Health care cases preventi r effectiv and private (EHR) system 62J.495 Electronic thei cate and mandateus disease hea lth comveile§ mental and allo assess other impor tant sota Statut for sur ds govern infectio ries, and ology). An ers not reasons of the of other ana lyze tren Record Techn law is that provid laboratoiona ls. The the hea lth 16 this page that they es can burden ponent of logy, but ase to profess to assess sure the much and s dise the techno are only adopt in their EHRs Infectiou lance ion, and mea i.e., how t Nile available inforota; s, Wes nt health use the tools populat in Minnes releva losi ge exchan tubercu securely disease to page 18 disease, technology Lyme information

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Prescribing medications from page 13

Report” in 2015 (http:// www.health.state.mn.us/ divs/eh/risk/guidance/dwec/ pharmwaterrept.pdf). • The One Health MN Antibiotic Stewardship Collaborative is working with a range of public and private partners across human, animal, and environmental health to protect health and preserve antibiotics. The Collaborative members include the Minnesota Department of Health, the Minnesota Department of Agriculture, the Minnesota Board of Animal Health, the Minnesota Pollution Control Agency, and the Minnesota Department of Human Services. • The Grand Portage Indian Reservation Ecosystem Health Collaboration Group is a multidisciplinary group studying how the state of the

ecosystem affects the health of the Grand Portage tribe. Their focus is on emerging and unregulated chemicals and pharmaceuticals and determining how they interact with the ecology of the region, and in particular the food supply.

individual activities that can make a difference. Conclusion All of these Minnesota groups are to be commended for addressing the issue of groundwater contamination. However, eventually the decision on using

Restrict new prescriptions to no more than 30 days.

• The College of Pharmacy at the University of Minnesota has a team looking to borrow from the Swedish, “Environmentally Classified Pharmaceuticals” and implement a similar document with Minnesota use and dilution data. This group will work with other professional and consumer organizations, and managed care to raise public awareness of

and disposing of unwanted medicines is an individual one. Will the prescriber consider the actual prescription quantity needs of a patient and the best medicine with the least risk? Will the pharmacist be an information resource and advocate for optimal disposal? Will managed care implement rational drug benefit designs that do not encourage surplus and un-needed medicines?

And most of all, will the consumers of medicines understand that every pill, taken or not, may eventually contribute to the pollutant profile of our water supply? Walleye laced with DEET and ethinyl estradiol is a bizarre food we probably shouldn’t try! Lowell J. Anderson, DSc, FAPhA, is a pharmacist who formerly practiced in St. Paul. After leaving practice in 2006, he joined the faculty of the College of Pharmacy at the University of Minnesota. He is a professor in the department of Pharmaceutical Care and Health Systems and co-director of the Center for Leading Healthcare Change. He has served as president of the Minnesota Pharmacists Association, Minnesota Board of Pharmacy, and the American Pharmacists Association.

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Richfield Medical Group is looking for two Board Certified/ Eligible Family Physicians / Internal Medicine. Our practice defines full time as 3.5 days per week, with no evenings, weekends, or hospital rounding. We enjoy a very vibrant, satisfying professional practice and are committed to providing exceptional patient care. As an independent primary care clinic, we maintain our autonomy and control our destiny.

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MINNESOTA PHYSICIAN MAY 2016

It’s your life. Live it well.

Family Medicine

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

with or without OB

Our independent, physician-owned clinic is seeking a BC/BE physician (with or without OB) for our clinic. 1:7 Calls. Competitive salary/benefits, with opportunity for ownership within 1 year. Paid malpractice, health and dental insurance, 401(k), CME and more. Cloquet is an historic, vibrant community just 15 minutes from Duluth and 10 minutes from Jay Cooke State Park. Adjacent to the St. Louis River, Cloquet has hiking, biking and ATV trails; skiing; boating; fishing; parks; and the only white water rafting in Minnesota. Residents enjoy locally performed plays, concerts and the arts; community festivals; dining and more.

Send CV to: cward@raiterclinic.com 218.879.1271 ext. 108 • www.raiterclinic.com 417 Skyline Blvd. • Cloquet, MN 55720

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

• Associate Chief of Staff, Primary Care • Dermatologist • Internal Medicine/ Family Practice

• Physician (Compensation & Pension) • Physician (Pain Clinic)/Outpatient Primary Care

• Occupational Health/ • Psychiatrist Compensation & Pension Physician

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. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

You focus on taking care of patients. We’ll take care of the rest. To learn more, visit allinahealth.org/physicianjobs.

For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 MAY 2016 MINNESOTA PHYSICIAN

Diagnostic errors from page 11

a process failed and look on failure as an opportunity to improve. In order to move toward becoming an HRO, an organization’s culture must support reporting errors.

• Re-evaluate autopsy policies and procedures: Clarification and education concerning autopsy expectations may provide necessary data as it relates to diagnostic error and other adverse events.

Although the benefits of a non-punitive environment

Averting blame Effective feedback should be actionable, timely, individualized, and non-punitive. A non-punitive culture helps foster an environment in which mistakes are viewed as opportunities for growth and improvement.

have been well-studied and acknowledged for quite some time, many health care workers are reluctant to admit fault out of fear of retribution. If the behaviors that perpetuate diagnostic error are to be changed, it is essential to foster a culture

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ealth care has been at the cente of federa l r and state politics for decad the political es. No matter which way winds are care in Minn blowing, health esota and country has the rest of the been in a state severa l years . While much of change for tion recen of the attently has focus ed on the able Care AffordAct and the ever-changi ronment in which ng enviit continues there are to operate, a number of fundamenta that Minn esota will l issues face in the years. One coming issue that has garne cant attent red signifi ion recen tly is state will have the workf whether the meet the growing health orce in place to care dema There seems nds. to be a gener sus in Minn al conse esota that nthe state a physician will face shortage in the very future as near more of retirement physicians reach the age and fewer and reside nts fill those new graduates the numb gaps. Altho ers vary based ugh analysis, on who does most peopl the e who have at the issue looked in recent years, includ the Minn esota Medic ing al Association The comin and g physic ian shorta

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increasing the protections it offers provides a safer environment for reporting errors and sharing lessons learned.

Mark Chassin and Jerod Loeb, both with the Joint Commission, detail the necessary steps to achieve high-reliability

Because diagnostic error is the most common source of payments made by medical professional liability carriers, it is mutually beneficial for organizations to work with their carriers to improve processes. Insurance companies have access to risk management expertise and data on potential and actual claims that could serve to enhance feedback.

Diagnostic error prevention represents the next movement in patient safety.

The fifth goal of establishing a work system and culture that supports the diagnostic process and improvements in diagnostic performance is also very important. Health care systems on the journey to becoming high-reliability organizations (HROs) are focused on failure. They seek to understand why

epen The I nd

of open communication where health care professionals at all levels feel safe to discuss medical errors.

MINNESOTA PHYSICIAN MAY 2016

in their 2013 article, High- Reliability Health Care: Getting There from Here. For those organizations approaching high-reliability, “Close calls and unsafe conditions are routinely reported, leading to early problem resolution before patients are harmed; results are routinely communicated.” In essence, feedback is a key component to cultural change. Overcoming the fear of legal action The sixth goal to develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses involves national policy changes. In 2005, Congress passed The Patient Safety and Quality Improvement Act, which provided some peer protections for specific types of information shared with a designated Patient Safety Organization (PSO). Progress has been slow though and challenges remain concerning collection and meaningful aggregation of this data. Organizations must feel safe to report diagnostic errors in order to extend learning beyond their own system. Fear of legal action impedes open sharing of information and stifles feedback on a larger scale. Extending the PSO network and

Conclusion Physicians are expected to practice medicine in an environment that is growing increasingly complex with expansive regulatory requirements, spanning from reimbursement requirements to the HIPAA Privacy and Security Rules to the implementation of electronic medical record systems. All of this complexity often results in high levels of stress. The responsibility for improving diagnostic error cannot lie solely on the shoulders of physicians. By implementing process improvement methodologies that are team-focused and include structured feedback, organizations can positively impact diagnostic error rates. Diagnostic error prevention represents the next movement in patient safety. It is imperative that we seize the moment and harness the sense of urgency explained in the committee’s report. As part of this effort, current feedback mechanisms need to be examined and enhanced to support process improvements. Health care providers and patients deserve nothing less than our full attention. Ann Fiala, RN, BSN, CPHRM, CHC, is a senior claims consultant at Coverys. She has more than 30 years of health care experience with extensive experience in medical staff credentialing, regulatory readiness, patient-centered care, utilization and case management, and data analytics.

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

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

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

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MINNESOTA PHYSICIAN