Minnesota Physician • April 2021 by Minnesota Physician Publishing

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Volume XXXV, No. 01

The Future of Gastroenterology Incorporating Artificial Intelligence BY JONATHAN NG, NBBA, MPA, MBA

rtificial Intelligence (AI) in gastroenterology is not just about gastroenterology. It has the potential to democratize a ton of knowledge that historically has only been held in the hands of specialists. For example, the expert scoring of endoscopic findings in inflammatory bowel disease can now be done automatically and placed in the hands of primary care physicians, nurses, and even patients. AI in gastroenterology is no longer limited to polyp detection–it now includes automated documentation, automated trial recruitment, and many other exciting new advances. AI in gastroenterology is still a nascent field, dependent very much on narrative development using physician input, including primary care physicians, as we continue in partnership to develop these powerful tools that streamline care while providing better outcomes.

Responding to Human Trafficking Victims Core Competencies for Health Care Providers CAROLINE PALMER, JD

ver the past decade, many states have increased their abilities to serve victims of human trafficking. For example, in Minnesota, state law and funding priorities have focused particularly on the needs of sexually exploited and trafficked youth under age 25 through the Safe Harbor program, while more recent legislation as well as federal grants have increased awareness of labor trafficking and exploitation. None of this activity would be possible without a robust multidisciplinary approach. Health care providers, specifically, have enhanced the scope and competency of Minnesota’s Responding to Human Trafficking Victims to page 104

Defining Parameters AI technology augments the physician’s expertise and optimizes their ability to deliver patient care. The Future of Gastroenterology to page 144

Peter Schultz, MD, MPH Medical Director Nura Pain Clinics R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers David Schultz, MD Chief Executive Officer Nura Pain Clinics

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APRIL 2021 MINNESOTA PHYSICIAN

APRIL 2021

Volume XXXV, Number 01

COVER FEATURES Responding to Human Trafficking Victims Core Competencies for Health Care Providers

The Future of Gastroenterology Incorporating Artificial Intelligence By Jonathan Ng, NBBA, MPA, MBA

Caroline Palmer, JD

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 Creating a WellCare Ecosystem O S M O VÄ N S K Ä

Craig Samitt MD, MBA Blue Cross Blue Shield of Minnesota

MINNESOTA HEALTH CARE ROUNDTABLE..................................... 16 The COVID-19 Pandemic PAIN MANAGEMENT.................................................................. 24 The MinuteMan Advances in Spinal Fusion

By R. Scott Stayner, MD, PhD

ERIN KEEFE

JUHO POHJONEN

Strategies moving forward

HEALTH CARE EQUITY................................................................. 26 The Minnesota EHR Consortium A unique pandemic-born partnership

By Deepti Pandita MD, FACP, FAMIA PUBLIC HEALTH........................................................................... 28 Engaging Families in Health Care Everybody Wins

Tai Mendenhall, Ph.D., LMFT and Aalaa Alshareef, MS, LAMFT

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ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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PHOTOS Vänskä: Courtney Perry; Pohjonen: Lisa-Marie Mazzucco; Keefe: Nate Ryan. All artists, dates and programs are subject to change.

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CAPSULES

The Metropolitan Area Agency on Aging is now Trellis The Metropolitan Area Agency on Aging, one of seven agencies authorized under the federal Older Americans Act (OAA) and designated in Minnesota by the Minnesota Board on Aging, has changed its name to Trellis. Minnesota Area Agencies on Aging (AAAs) are seven regional organizations (one represents Minnesota Indian Tribes) that provide services, supports and information for a wide range of services for older adults. The Metropolitan Area Agency had grown beyond its original mission as the area agency and now provides services, information and innovations that connect and improve the lives of people across Minnesota and in ten other states. “I am proud of the work that we have done as Metropolitan Area Agency on Aging over the past 26 years,” said Dawn Simonson,

president and CEO of Trellis. “We have provided trusted and responsive support for individuals and organizations in our community and have developed strong, resilient networks. Trellis—with the imagery of life, growth and a structure for support—will take our work to new heights, helping people optimize well being as they age. I am particularly encouraged by the progress we are making in developing partnerships with healthcare organizations to provide whole-person care to older adults in our communities. Trellis serves the older population with many innovative partnerships that integrate health and social care to produce better life and health outcomes while containing costs. They create and support community-wide efforts to address complex issues, such as building age-friendly and dementia-friendly communities, the Volunteer Driver Coalition, the Juniper Project, assistance with Medicaid-certified

nursing facility preadmission screening, working with the Senior Linkage Line and much more. Trellis awards and manages Older Americans Act funding to support older adults in living healthy and connected lives. The funding provides services such as home-delivered and congregate-dining meals; caregiver support and respite care services, assisted transportation, health promotion, and chore and homemaker services. In 2020, Trellis awarded $13+ million to 37 organizations.

Mayo Study Finds Genomic Research Disparities Low representation of minority groups in public genomic databases may affect therapy selection for Black patients with cancer, according to a new a Mayo Clinic report. Researchers investigated the use of genomic databases and found that tumor mutation burden (TMB)

was significantly inflated in Black patients compared to White patients. As a result of the study, clinicians who are using public genomic databases need to be aware of the potential for these inflated values and how that may affect therapy selection and outcomes, especially for patients from underrepresented groups. Most of the time TMB is calculated, normal cells are not used, and genomic databases of mutations or algorithms are used to filter results. The Mayo team collected data from 701 patients who were newly diagnosed with multiple myeloma, including 575 self-reported White patients and 126 self-reported Black patients. They analyzed DNA from patients’ tumor cells and healthy cells to determine the differences. Since autoimmune toxicities can be severe, it is critical to have accurate TMB data which improves the ability to predict optimal treatment for patients. “Determining tumor

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CAPSULES

mutation burden becomes difficult when you do not have DNA from a patient’s normal cells,” says Aaron Mansfield, M.D., a Mayo Clinic medical oncologist and an author of the paper. “For this reason, reference genomes are used for comparisons to tumors to estimate the burden.” He added, “It needs to be recognized that we performed this proof-of-principle study in patients with multiple myeloma”. Accurate TMB is also important in treating other cancers including breast, bladder, cervical, colon, head and neck, liver, lung, renal cell, stomach and recta, as well as Hodgkin lymphoma, melanoma and any other solid tumor that is not able to repair errors during DNA replication. Based on Dr. Mansfield’s experience, the current approach to determining TMB is inaccurate, especially in patients with ancestral backgrounds that are not well-represented in the reference genome databases. The lack of representation of diverse backgrounds in genomic research is well-known. Of more than 60,000 people genotyped and sequenced, only 8.6% are of African ancestry, while 54.9% are of non-Finnish European ancestry “At the level of an individual patient, our findings suggest that when we sequence tumors, it is also important to sequence paired normal tissues to accurately identify differences,” says Dr. Mansfield. “At the level of the research community, we need to continue to improve the representation of patients with diverse ancestral backgrounds in reference genome databases.”

HealthPartners and Allina Announce Partnership Recently two of Minnesota’s largest health care insurance companies announced a five-year partnership that implements value-based care across both organizations with the goal of providing better outcomes, better access to care and lower premiums

for members and patients. The partnership builds on the non-profit organizations’ collaborative approach, including their work together over the past 10 years on the Northwest Metro Alliance, an accountable care organization (ACO). The Northwest Metro Alliance has improved patient experience and resulted in medical cost trends that are 6 percent lower than the metro area – a savings of $40 million over the last decade. Prior to the work of the alliance, the cost trend was consistently higher than the metro average. The new value-based care partnership elevates the quality of care delivered over the quantity of care provided. Reimbursement structures are directly connected to patient outcomes and improving quality of care based on specific measures, such as reducing hospital readmissions, improving coordination of care using electronic exchange of documents, and improving preventive care, ultimately leading to the improvement of both individual and community health. Additionally, the length of the partnership is longer than previous partnerships to allow for a longer-term focus on population health strategies. “This partnership is an extension of what is possible when health care organizations work together to improve the physical, mental and financial health of patients,” said Penny Wheeler, MD, Allina Health CEO. “We are proud to build on our partnership with HealthPartners – a partnership that has proven that by working together, we can better improve the lives of those we collectively serve and change health care for the better.” “Today, we are expanding the strong partnership between our organizations,” said Andrea Walsh, HealthPartners President and CEO. “Our shared commitment to deliver high quality, affordable care and coverage has translated into better health and cost savings through the Northwest Metro Alliance. We are excited to bring that same spirit of innovation to build better health in all of the communities we serve.”

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Medical Liability Premium Show Highest Increases in 15 Years New analysis from the American Medical Association shows professional liability insurance premiums have begun an upward trend after holding more or less steady during the past decade. In 2020, during the height of the COVID-19 pandemic, more than 30% of premiums reported on a survey of liability insurers increased from the previous year, the highest percentage since 2005. For a second consecutive year there has been an exceptional surge in the percentage of premiums with a year-to-year increase. Between 2010 and 2018, the share of premiums that increased maintained a somewhat stable pattern, ranging from 12% to 17%. In 2019, that proportion almost doubled to 26.5% and went up again in 2020 to 31.1%. Increases varies by state, county, specialty and provider. Some Minnesota practices

have reported increases. According to the AMA analysis the responsiveness of premiums to changes in their determinants and external factors takes considerable time in the medical liability insurance market. Therefore, although some 2020 premiums may have been set after the onset of the COVID-19 pandemic, it was still too early for them to be affected by it. “Increases in medical liability premiums compound the economic stress on medical practices as the COVID-19 pandemic resulted in significant reductions to patient volume and revenue, and higher expenses for scarce medical supplies,” said AMA President Susan R. Bailey, M.D. “Practice revenue has not fully recovered as the pandemic has stretched on and a protracted upward trend in medical liability premiums will threaten the viability of many practices that already face a difficult road to recovery. Keeping medical liability premium growth in-check is imperative to ensure patient access to

care is not jeopardized by unaffordable liability insurance costs that make it impossible for physicians to remain in practice,” said Dr. Bailey. “This concern is particularly pressing given the negative impact that the COVID-19 pandemic has had on access and practice viability, as many physicians have had to suspend patient visits or elective procedures, and some have had to close their practices.”

Studies Find Tear Gas Producing Delayed Health Problems In troubled times nationwide, and between the George Floyd and Duante Wright killings especially in Minnesota, street protests and police use of tear gas have increased dramatically. This has lead to a growing body of health care data that suggests long-term negative consequences from tear gas exposure and a redefinition of its use from non-lethal force to chemical weapon. Medical

professionals at HennepinHealth have seen many patients in the ER treated for tear gas effects where the most serious reactions have occurred in people with breathing disorders like asthma or emphysema. Some however have been exposed at least 10 times and mounting evidence raises serious concern. Medical research on the long-term health impact of repeated exposure to chemical irritants like tear gas has just started and includes work by Kaiser Permenta based on over two thousand people from Portland, Oregon and an article currently under peer review co-authored by Asha Hassan, a public health doctorate student at the University of Minnesota. The Kaiser study showed 80 percent of respondents reported ongoing physical health problems. Erika Kaske, a third-year medical student at the University of Minnesota who led a recent New England Journal of Medicine report examining non-lethal weapons used in Minneapolis last summer during the Floyd protests, said

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such examples underscore the public health problems that come with police using tear gas. Beyond the immediate effects research reports delayed physical health issues after exposure at a rate of over 80%, many of which were severe and lasted for weeks. The Hassan report showed these concerns ranged from diarrhea, with blood in some persons, to menstrual cycle problems, to being exhausted and unable to carry out their regular work, to worsening of an existing health condition. In addition there were numerous behavioral health-related concerns. Another factor drawing concern is the use chemical irritants and its proximity to nearby homes, apartments and schools. Thought to dissipate rapidly and not penetrate closed windows and doors recent anecdotal evidence from Brooklyn Park suggests otherwise. Direct links of tear gas use to negative health effects are yet to be scientifically established however such evidence is growing.

Children’s Minnesota Challenges Ban of Transgender Student Athletes Dr. Goepferd and Dr. Chris Dunne, clinical lead of the Gender Health Program at Children’s Minnesota have recently added their voices in opposition to a recently introduced bill at the Minnesota state capitol bill seeking to ban transgender athletes from competing in girls’ sports. This proposed legislation, like over 20 others nationwide, some already passed, would prevent transgender or gender non-conforming kids who want to play sports at school. While some bills penalize transgender student athletes who participate on a team that aligns with their gender identity the Minnesota bill is the first to propose criminal penalties for these students. For example, a transgender girl using a girl’s locker room would be guilty of a petty misdemeanor, which could show up in future background checks and carry a fine of hundreds of

dollars. Dr. Angela Goepferd, Medical Director of the Gender Health Program at Children’s Minnesota points out that there is no scientific justification behind the bill and, further, that there are very few transgender or gender non-conforming kids who choose to play sports in middle or high school. Stating that the bill could not only impact student athletes who are transgender or gender non-conforming, but all kids and teens who identify as transgender. Dr. Goepferd points out that transgender children tend to struggle with self-esteem more than peers who identify with the sex they were born with, and sports are one way that kids can work toward overcoming self-esteem issues. Whether or not they play sports, this type of legislation can have a negative impact on kids because it singles out and “others” transgender and gender non-conforming kids. Excluding transgender youth hurts everyone, because it encourages gender policing, potentially leading to

accusations of girls being “too masculine” or “unreasonably good” at their sport. Including trans athletes benefits everyone, as it promotes non-discrimination and inclusivity.

IBM Recognizes HealthPartners As National Leader For the fifth consecutive year IBM Watson Health as named HealthPartners as one of the top 15 health systems in the country. The annual study from IBM Watson Health evaluates more than 300 health systems and 2,500 hospitals within those systems to determine the top performing organizations in the nation. Compared to other health systems, top performers had fewer patient deaths, fewer infections and complications, lower readmission rates, shorter length of stay, higher patient satisfaction and lower costs.

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MINNESOTA PHYSICIAN APRIL 2021

INTERVIEW

Creating a WellCare Ecosystem Craig Samitt, MD, MBA Blue Cross Blue Shield of Minnesota As a payer, you have a fairly unique perspective on the pandemic. What are some of the most surprising things you have seen that you can share with physicians?

is that a transition to an ecosystem centered on wellness will put our industry back on track.

In our professional lifetime, we have not seen, or been taught, how to deal with one crisis − let alone many simultaneous ones. A pleasant surprise for me, both as a physician and payer, has been how much the local care delivery and business communities have rallied and worked in lockstep to care for the sick and needy, to keep employees safe, and to work hard to preserve jobs and protect livelihoods.

What evolution do you see in this field?

Many people say the employer-sponsored health insurance model is unsustainable.

The explosion of telehealth has been a major byproduct of the pandemic. What can you share about your plans around ongoing reimbursement for these services as well as experiences with your own Doctor on Demand program?

Some of the current thinking at BC/BS MN involves the idea of the health care ecosystem. Please tell us about this.

While we currently reference our industry as a Healthcare System, I’d prefer that we aspire

APRIL 2021 MINNESOTA PHYSICIAN

“...”

Our industry cannot be the barrier to progress.

“...”

I’ve long hoped that virtual care would become more of a mainstream option for care delivery, but would not have wanted that transformation to be fueled by a pandemic. In 2019, we paid about 65,000 telehealth claims, and through the first three quarters of 2020, we saw more than 2 million telehealth claims. Patient response to no-cost access for services offered by Doctor On Demand was tremendous. We will continue offering expanded virtual care benefits for members and pay parity with in-person visits for providers into 2021. Before extending the program further out into the future, we first want to assure that telehealth delivers all that patients hope and expect − more convenient, high quality, and over lower cost healthcare. Through telehealth and other improvements that are needed in our industry, we have an opportunity to pivot to value in response to this pandemic. We should not squander that chance.

to be something better. Let me call it a Wellcare Ecosystem. What if our industry truly lived the expression “an ounce of prevention is worth a pound of cure?” What if we rewarded prevention, avoidance, social health, mental health, wellness, eliminating systemic racism − everything we can argue is in the “ounce?” Similar to a rainforest, health care has a complex ecosystem with interdependent stakeholders that don’t all need to work in lockstep at the same time. Healthcare stakeholders need to be aligned around the same goals and incentives, with everything focused on delivering better care at a lower cost for patients and better health for our community. I believe our current system is unsustainable if left on its current course. The fewer that can afford health care, the fewer in our community that benefit. The more that industry stakeholders work in opposition, the more patients are caught in the middle. My hope

I’m a strong advocate for universal coverage, and believe that all Minnesotans should have access to high quality, affordable healthcare. To achieve this goal, and to preserve consumer choice, I’m hoping that we can adopt a “no wrong door” approach that offers high-value care options for all that want and need it. 180 million Americans are insured by employersponsored coverage today. While that amount may erode over time, many employers enjoy this model and view it as a key tool in attracting and retaining top talent. That said, the primary reason employer-sponsored health insurance is unsustainable is the rising cost of care. As such, I envision that we will see employers become more aggressive in working with plans and providers to use price transparency, innovation, technology, virtual care, selective networks, and other means to improve quality and drive down costs. Another problem involves hospital costs. How will the role of the hospital change, both in the metro and outstate?

From the start of the pandemic, we have witnessed the critical role that hospitals play in providing emergent and intensive care. Postpandemic, I predict we will see the role of hospitals in our ecosystem continue to change. As the population ages, there will be increasing demand for complex and emergent care and appropriate elective inpatient care. In the future, hospitals will likely address this growing demand not through additional bed capacity, but by safely and effectively shifting lower acuity, non-emergent, non-intensive care delivery to other venues, such as ASCs, doctor offices, patient homes and telehealth. As we have seen at Blue Cross via our growing partnerships with North, Allina, Mayo, Minnesota Oncology, Minnesota Healthcare Network and others, I envision that high-performing hospitals will

increasingly become population health companies − with an intensified focus on ambulatory, social and behavioral health as a complement to inpatient care. What work is BC/BS MN undertaking to address cultural diversity and systemic racism?

One of the challenges in our industry is we’ve been asked to − or forced to − stay in our lanes. As I mentioned previously, I believe systemic racism and cultural bias is part of the “ounce of prevention.” If we are to play a role in transforming healthcare, organizations like Blue Cross and Blue Shield of Minnesota need to be more than just a claims company, a sickness management company, and a payment company. Given that our strategic plan is all about reinventing our industry by reinventing ourselves, we are undertaking a bold and comprehensive portfolio of racial and health equity and diversity equity and inclusion efforts. In doing so, we are getting into the equity business, social determinants of health business, and racial justice business. While I don’t have the space here to add all that we’re doing, I’d be happy to fully share all that we’re doing for those that are interested. Needless to say, we aren’t being shy,

remaining silent, or avoiding risks in this space. We are taking bold action to advance true racial and health equity for our team, for those that we serve, and for our community at large. You have said that the biggest problem facing health care is the resistance to change. What can you tell us about this?

My hope is that all that we’ve been through in 2020 will lead to a fundamental reinvention of our industry. How is it possible that we can cost so much as an industry and yet preserve the gaps we’ve seen through this crisis? I’m referring to coverage gaps, care delivery gaps, equity gaps and others. If we come out of this crisis and see premiums rise, ongoing inequities, worsening coverage, or a return to a fee-for-service payment chassis, that would only compound the tragedy. Our industry cannot be the barrier to progress. We must be the drivers of reinvention of our own industry. Another concept you have put forth is the idea of becoming the “un-health plan”. What does this mean?

At a recent meeting, I heard someone appropriately point out that “if the healthcare

industry doesn’t propose change, change will likely be imposed.” I’ve long advocated for reinvention of our industry from the inside-out rather than awaiting disruptive innovators or regulations driving change from the outside-in. For me, reinvention isn’t incremental change. It requires transformation. So becoming an un-health plan isn’t about becoming modestly better. It’s about leading a paradigm shift that drives material improvement in patient satisfaction, access, quality and affordability. Are there any final thoughts you would like to share with physicians as we move into 2021?

In addition to my heartfelt thanks and gratitude, I wish our physician colleagues much health, safety, rest and healing heading into the New Year. Craig Samitt, MD, MBA is the President and CEO of Blue Cross Blue Shield of Minnesota. Since 2018 he has been responsible for overseeing the strategy and operations of the state’s first and largest health plan.

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MINNESOTA PHYSICIAN APRIL 2021

3Responding to Human Trafficking Victims from cover response, which spans across state agencies (health, human services, and public safety), tribal nations, nonprofit organizations, and various systems.

researchers, and health educational institutions. HEAL Trafficking, the International Centre for Missing & Exploited Children, and the National Association of Pediatric Nurse Practitioners were key partners along with the National Human Trafficking Training and Technical Assistance Center in this project. The report, “Core Competencies for Human Trafficking Response in Health Care and Behavioral Health Systems” was released earlier this year and is available on-line.

Health care providers play a critical role in identifying and assisting human trafficking survivors. Whether seen in an emergency room, community clinic, dentist’s office, or treatment center, survivors seek care from several different medical and behavioral health professionals, yet these providers may not always Survivors are often hesitant… know that their patients or clients are suffering when it comes to sharing details. from, or are at risk of, trafficking or exploitation. Survivors are often hesitant, ashamed, or even fearful when it comes to sharing details beyond what is necessary to meet their immediate health care needs. For these and many other reasons, experts from around the United States were summoned by the United States Department of Health and Human Services, Administration for Children and Families, Office on Trafficking in Persons for a three-year-process to develop a set of “core competencies” to better identify and respond to the health care and behavioral health needs of human trafficking survivors. These core competencies were designed with four key constituencies in mind: Individual practitioners, health institutions or organizations,

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Summarizing the Core Competencies

The core competencies, which the report defines as “skills needed for professionals to most effectively conduct their work,” were developed according to a set of guiding principles based in public health approaches. These approaches include prevention; trauma-informed, culturally responsive, and patient- or client-centered practices; promotion of individual agency and empowerment; holistic responses; coordination across disciplines for wraparound services; and referrals to appropriate service providers. So too, the core competencies take into account other factors such as access to quality health care; societal or environmental influences; relationships with other disciplines including law enforcement, child protection, and legal services; and conscious or unconscious biases held by providers. There are six core competencies and one universal competency outlined in the report, briefly described below:

Universal Competency: Use a Trauma and Survivor-Informed, Culturally Responsive Approach The universal competency of using a trauma and survivor-informed, culturally responsive approach is considered an “umbrella framework” for all of the other competencies in the report. Trauma-informed care is focused on building trust and rapport with patients or clients while recognizing that trauma experiences, including racial, cultural, and historical trauma, determine willingness or hesitancy to disclose harm. Policies and practices should include informed consent for all aspects of patient or client care and intake or screening protocols that do not cause further harm. Organizations and institutions must ensure that their professionals are well-trained in trauma-informed approaches. Further, supports should be in place for professional responders in the event of vicarious trauma and burnout that can come from serving individuals and populations experiencing extreme trauma like human trafficking. In terms of research and education, universal competency promotes multidisciplinary-focused research strategies designed to identify health disparities and develop innovative approaches to care provision. Educational settings should strive to equip students with trauma-informed approaches to identifying human trafficking survivors while also giving them the tools they need to identify their own vicarious trauma resulting from service provision.

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Finally, universal competency promotes the active engagement of persons with lived experience in human trafficking in advisory and leadership roles both on the direct-care and organizational or institutional levels as well in the development or delivery of curriculum. Researchers should strive to create partnerships with persons who have lived experience and fully integrate their expertise into all aspects of research design and delivery.

This engagement of persons with lived experience dovetails with the priority of ensuring all efforts to respond to human trafficking, whether in direct care or through institutional policy, research, and education, are culturally responsive, driven by cultural humility, and inclusive of all races, genders, sexual orientations, ethnic and religious groups, and abilities.

trafficking survivors, many of whom have had their sense of control stripped away, the ability to participate in – and even lead – decision making is a critical part of healing. Creating an individual plan of action, especially in partnership with a trusted health care or behavioral health provider, can give a survivor options where they did not have them before.

This competency also promotes the importance of a multidisciplinary teams approach bringing together health care, behavioral health, law enforcement, Competency 1 uses a social-ecological model to public health, social services, the legal system, schools, demonstrate the connections between society, and other organizations, as well as persons with lived community, relationship, and individual Providers can connect clients experience, to develop protocols for responding to the dynamics in responding to human trafficking. In with community-based services. needs of survivors. These teams can conduct needs so doing, this competency recognizes the dynamic assessments of community resources that span from interplay of activities that encompass trafficking individuals to organizations and institutions and and exploitation (sex and labor), as defined under identify critical gaps. Such assessments can be created law as well as through policy and practice. This in partnership with researchers and educators to competency supports research that looks at the ensure that they are not only rigorous in methodology distinctions between sex and labor trafficking but also specially tailored to different populations, (as well as their interrelationships) and promotes sustainable, and supported by training for all involved. integration of human trafficking curriculum in all levels of education, and

Understand the Nature and Epidemiology of Trafficking

particularly for future health care and behavioral health professionals.

Provide Patient- or Client-Centered Care

In terms of trafficking and related social determinants of health, Competency 1 highlights the many economic, cultural, and social contexts that enhance trafficking risks, including adverse childhood experiences, poverty, racial inequities, homelessness, disabilities, mental illness, migration, and more. The competency promotes understanding of risk/ protective factors in direct services, organizational and institutional policy, research approaches, and curriculum.

Competency 4 promotes patient or client-centered interviewing practices, which span from the setting in which the interview occurs to the parameters

Responding to Human Trafficking Victims to page 124

Evaluate and Identify the Risk of Trafficking Competency 2 underscores the concept that disclosure of trafficking is not the goal of an interaction with a survivor; instead, screening tools should be tailored toward detecting indicators (sometimes referred to as “red flags”), tailoring care based on these indicators, and making appropriate referrals. These tools are most effective when evaluated for their reliability and even validated. When the focus is taken off of a disclosure (which can feel like pressure to a patient or client) and directed toward identifying risks, creating harm reduction and safety plans to reduce risk, and building trust and rapport, it is more likely that a survivor will feel comfortable seeking help either in the moment, or at a future time, from the provider. Risk assessment is most effective when a patient or client is assured that they are in a confidential setting. Any instances of when confidentiality is broken (such as mandated reporting) should be explained up front so the patient or client can make informed decisions about what to share. Organizational and institutional policies should be written in the strongest terms to protect information gathered from patients and clients. So too, researchers and educators should seek to promote concepts around confidentiality and autonomy as part of trauma-informed and patient- or client-centered practices.

Evaluate the Needs of Individuals Who Have Experienced Trafficking or Individuals Who are at Risk of Trafficking Competency 3 underscores the importance of engaging the patient or client in shared decision-making when developmentally appropriate. For

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3Responding to Human Trafficking Victims from page 11 of informed consent, the types of questions asked, and the availability of professional language interpreters. Centering the patient or client entails meeting them where they are – using age-appropriate language, being aware of trauma responses or triggers, collaborating on a care plan, explaining procedures, ensuring safety, and promoting informed consent by explaining confidentiality protections as well as mandated reporting requirements.

apt to meet their needs. It is crucial that health care and behavioral health specialists actively engage survivors in recovery and healing, a process that can last a lifetime.

Use Legal and Ethical Standards

Competency 5 underscores protection of legal rights of trafficking survivors. For example, mandated reporting (for child or adult protection) may be required when a youth or family is involved. The patient or client should be informed about a mandated reporter’s responsibilities. Mandated reporting can also change the relationship with the patient Screening tools should be tailored toward detecting indicators. or client, particularly if the patient or client feels betrayed by the health care or behavioral health specialist inviting intervention of systems like law enforcement, child protection, or adult protection.

Organizations and institutions can support these direct service interactions by writing clear policies and procedures and ensuring that all staff are trained to follow them. Case review may be helpful to address complex situations or to provide learning experiences. “No Wrong Door” access to health services will ensure that policies and training give staff the ability to meet the needs of a survivor no matter where they seek help; this may entail adjusting service provision in the moment or making a warm hand-off to more appropriate services. Researchers and educators will benefit from this knowledge in terms of better understanding survivor needs, the efficacy of team approaches, and promoting effective ongoing training for professionals. Trafficking survivors are resilient – they have many strengths that can be leveraged into their care plans, ensuring they receive assistance most

Organizations and institutions should have clear policies in place for how and when mandated reporting occurs as well as how patients and clients are informed about reportable events; so too, educational programs should explain the different forms of reporting. Researchers may want to engage in further study about how mandated reporting influences the delivery of health care or behavioral health services. Other legal considerations include HIPAA, patient consent compliance, health care record protections, ICD-10 documentation of trafficking in patient records, patient rights laws, minors consent to health care laws,

A Human-Centered Approach to Behavioral Health Promoting a caring and healing environment through the power of relationships from staff, patients, and their families. EAPC.NET

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victim rights laws, consequences of immigration status, parental rights, and much more. It is not incumbent upon all health care or behavioral health practitioners to know how to respond to every legal issue but they should have a clear idea about where to find resources, how to address certain situations without causing harm, and where to access educational materials for patients and clients.

Integrate Trafficking Prevention Strategies into Clinical Practice and Systems of Care

What is human trafficking?

Competency 6 promotes prevention as part of any public health strategy to address human trafficking. A primary prevention focus, for example, includes screening for adverse childhood experiences and the social determinants of health, implementing knowledge of parenting and child development, and connecting patients and clients, as well as their families when appropriate, with community resources that address the risk factors for human trafficking and perpetration. Organizations and institutions are encouraged to develop training to raise staff awareness about the relationship between violence and health, as well as the intersections of human trafficking with other forms of harm such as domestic violence, sexual violence, and child abuse. Researchers and educators should integrate elements of health disparities, health equity, and the social determinants of health into their efforts.

Human trafficking is the sale of a person for the purpose of sexual acts or forced labor. Minnesota law uses the following definitions:

In terms of secondary prevention, providers should apply concepts of risk and harm reduction in work with individuals currently experiencing human trafficking or exploitation. All staff and providers should have training on how to help patients and clients work to reduce risk – and such training and approaches should be made without bias or judgment. In addition, providers can connect clients with community-based services to support basic needs. Researchers can amplify the importance of risk reduction models and strategies for survivors of trafficking while educators can incorporate risk reduction concepts into curriculum.

Report suspected human trafficking

Finally, tertiary prevention focuses on long-term strategies, sustaining health and safety planning for patients and clients, and continuing to address protective factors and resiliency strategies with patients to reduce further trafficking and exploitation. This approach requires a long-term commitment to quality health care access, research into effective aftercare and support services, and education about the long-term recovery needs of trafficking survivors – all informed by the wisdom of persons with lived experience.

Minnesota Efforts The Minnesota Department of Health is in the process of developing statespecific human trafficking training for health care providers based on input from practitioners and survivors for release later in 2021. Input is welcome in the development of this curriculum. Please contact caroline.palmer@ state.mn.us if interested. Caroline Palmer, JD is Safe Harbor Director, Injury and Violence Prevention Section, Minnesota Department of Health.

• Sex trafficking – receiving, recruiting, enticing, harboring, providing, or obtaining by any means an individual to aid in the prostitution of the individual; or receiving profit or anything of value, knowing or having reason to know it is derived from an act (of sex trafficking). • Labor trafficking – recruitment, transportation, transfer, harboring, enticement, provision, obtaining, or receipt of a person by any means, for the purpose of debt bondage or forced labor or services; slavery or practices similar to slavery; removal of organs through the use of coercion or intimidation; or receiving profit or anything of value.

• If you or someone you know is in immediate danger of being trafficked, call 911. • To report a suspected trafficking situation, call the National Human Trafficking Hotline at 1-888-373-7888, send the text HELP to 233733, call the BCA at 1-877-996-6222 or email bca.tips@state.mn.us.

Victim resources • Safe Harbor Minnesota connects trafficking victims with support services. Get information online or by calling 1-866-223-1111. • The National Human Trafficking Resource Center provides a map-based list of victim resources. Information can also be obtained by calling 1-888-373-7888.

Human Trafficking Investigators Task Force The Human Trafficking Investigators Task Force is led by the Bureau of Criminal Apprehension with assistance from metro area sheriffs and police, Homeland Security Investigations and the Ramsey County Attorney’s Office. Task force members work with more than two dozen agencies to identify incidents of human trafficking and apprehend and aid in the prosecution of such crimes.

Criminal justice agency resources Task force members and affiliate agencies are specially trained to investigate human trafficking crimes. Contact the BCA at 651-7937000 for assistance with a human trafficking investigation. BCA Training and Auditing also provides advanced training and support to local agency personnel.

MINNESOTA PHYSICIAN APRIL 2021

3The Future of Gastroenterology from cover It serves as a second set of eyes for polyp detection and identification, enhancing the quality of patient care and patient outcomes with aided detection of cancerous and benign polyps, diagnosis of irritable bowel disease (IBD), and other gastrointestinal issues. AI also serves as an extra hand for EHR documentation with tools that automatically learn and adapt based on the data entered, improving clinical efficiency and accelerating workflows. In doing so, AI can reduce physician burnout, redundant data entry, and the likelihood of missed information and human errors.

to make sure the technology meets their needs, while physicians can lean on AI developers to develop solutions that can help them keep pace with the ever-growing demand. Primary care providers should start asking patients if they would like AI to be a part of their care plan. We have shown that through augmentation with AI we are able to help providers to practice at the top of their license.

Physicians and AI developers must work together.

AI-augmented screenings can improve patient outcomes, while AI-powered data collection can help providers ensure more complete patient communication and education. For advancing therapies, AI often uses machine learning to expedite the process of trial and error, and for clinical trials AI can assist with recruitment through the automated surfacing and qualification of patients.

Collaborating with Primary Care Physicians and AI developers must work together to advance GI care–it won’t happen without both parties actively participating. AI developers like Iterative Scopes need clinicians to offer their expertise and guidance

Through the use of AI, we are able to standardize the interpretation of what is and isn’t a polyp, what constitutes severe IBD disease and what doesn’t. This really reduces the disparity in outcome that we are seeing today in medicine and also reduces patient anxiety in which physician they should be entrusting their lives to.

Present State of Artificial Intelligence When providers think of AI in gastroenterology, they typically only think of polyp detection. Here are new ways AI is being used in GI. Machine learning Machine learning is an application of artificial intelligence that enables software to learn and adapt using algorithms and statistical models, not explicit instructions. The application analyzes and draws inferences from data patterns and adjusts accordingly. One example of machine learning that is being used in GI today is with Provation Apex Procedure Documentation, which uses machine learning on two distinct levels: facility and individual user. On the facility level, the software learns the most common and most logical selections across the organization over time to predict the most likely choices and elevates them for the physician’s consideration. At an individual user level, machine learning further limits mouse movements with “Smart Buttons” that augment each physician’s favorites menu. Optical character recognition (OCR) Optical Character Recognition (OCR) is a type of AI that makes it possible to recognize the text in scanned documents and images of various file formats, and convert the text into a searchable and editable format. One example of OCR in healthcare software can be found in an anesthesia quality reporting solution, Provation SurgicalValet. Plans are underway to enhance the anesthesia billing ‘Charge Capture’ feature to use OCR to convert scanned or faxed invoices and other documents of various file types into discrete data to auto-populate data like date of birth, name, and MRN, and then auto-sort and store these documents in the electronic patient record. National language processing (NLP) Natural language processing (NLP) gives machines the ability to read, understand and derive meaning from human languages. One example of NLP use in GI can be found in a leading procedure documentation solution, Provation MD, for automated Adenoma Detection Rate (ADR) reporting. The software’s NLP engine automatically extracts data from scanned lab results and codifies the pathology data into discrete results. Data processing is conducted dynamically, on the fly, and is not stored in physical memory to help protect PHI. The results then automatically populate the electronic pathology follow-up form for review, sign-off, and ADR reporting.

APRIL 2021 MINNESOTA PHYSICIAN

Adenoma Detection Rate, or ADR, is a quality measure for endoscopy facilities and professionals that is defined as “the rate at which a physician finds one or more precancerous polyps during a normal screening colonoscopy procedure for patients over 50 years old.” Professional societies, including the American College of Gastroenterology (ACG), have determined the benchmark rate should be at least 25% in men and 15% in women.

A look at the future The future of AI in gastroenterology is very exciting. Advances are coming almost faster than the industry is able to keep pace with. As we move forward here are some of the areas to follow: Enhanced voice to text Voice to Text has become fairly commonplace in GI documentation solutions, replacing the popular process of manually transcribing and coding procedures notes that were dictated by a physician into a recording device. However, today, the text collected is very likely to be “free text” and not tied to discrete data and automated coding. That means any procedure notes captured using Voice to Text still requires significant manual review and coding and will be nearly impossible to data mine.

For any site that performs gastrointestinal (GI) procedures, determining endoscopy ADRs Providers should start asking and understanding their importance is crucial. patients if they would like AI Physicians with the best ADRs are most successful to be a part of their care plan. in detecting precancerous adenomas in the colon and helping patients avoid colorectal cancer. In fact, according to the New England Journal of Medicine, for every 1% increase in a physician’s ADR, a person’s risk of developing colon cancer AI can enhance Voice to Text enabling the over the next year decreases by 3%. Risk of death decreases by 5%. captured text to be automatically converted into structured data, making it AI for clinical trials available immediately for data mining and analytics, quality reporting, and AI has a broad application in clinical trials, including that of assisting clinical trial recruitment–drastically reducing manual entry, calculations, with clinical trial recruitment through the automated surfacing and and human error. qualification of patients into the trial as well as automated end-point Intefrated AI-powered scopes and documentation software scoring or determination of severity of diseases. We are working on Today, AI-augmented polyp detection is normally done at the scope a few such projects including being able to replicate currently used endoscopic severity grading but with a lower variance and bias, and higher The Future of Gastroenterology to page 314 reproducibility than clinicians are able to achieve on their own.

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MINNESOTA PHYSICIAN APRIL 2021

MINNESOTA HEALTH CARE ROUNDTABLE

52ND SESSION

The COVID-19 Pandemic Strategies moving forward

CHRISTOPHER (KIT) CRANCER,

is director of the Center for Diagnostic Imaging (CDI) and serves as Senior Director of State Legislative Policy. He is a registered lobbyist in a number of state capitols, including Hartford CT, and manages CDI’s contract lobbyists and legislative priorities. Prior to joining CDI, Mr. Crancer served as chief of staff to multiple Missouri state senators.

JESSE BETHEKE GOMEZ, MMA, is a member of the Over 51 previous sessions, the Minnesota Health Care Roundtable was held before a live audience. In response to the pandemic we have pivoted the format of this “conference-in-print” editorial feature to bring you essentially the same information, however distilled from electronic responses vs. the transcript of a discussion. In many capacities this new process presents a superior report on any subject. It allows participants more time to prepare their thoughts and increases the range of potential participation. Not without some irony the first topic to be explored in this new format is lessons learned from, and preparing for life after, the pandemic. We extend our special thanks to the participants and sponsors for their commitments of time and expertise in bringing you this report. In November we will publish the 53 session of the Minnesota Health Care Roundtable on the topic of improving clinical and non-clinical care team interoperability. We welcome comments and suggestions. What were the biggest problems your organization faced as a result of COVID? KIT: The confusion surrounding the elective procedure prohibition. It

resulted in a significant drop in patient procedures and a patient backlog that was difficult for all concerned to work through. As an additional consequence many providers were forced to go through reductions in force due to the extreme drop in patient volumes. RUTH: The uncertainty, the broad sense when it was announced. What would be the impact on our employment setting, on doctors, how would our services be effected and how would they be delivered? How would we do what we do? We went to 100% remote in 10 days. An immediate problem was getting all the council members set up to access data remotely. There were technology challenges, and daily problems with lost connectivity. It happened during our peak period to process licenses – going from working in the office to working from home was enough of a hurdle but doing it at one of our busiest times of the year made the problems more difficult. The bulk of our complaints come in writing and processing mail became another work-around. Finally, a lot of our work is accomplished through conferences which were forced to stop and we had to find new ways to facilitate interaction. JESSE: Metropolitan Center for Independent Living is among the 405 Centers

of Independent Living in the United States. We assist with direct services for

APRIL 2021 MINNESOTA PHYSICIAN

leadership team for Disability Hub MN and Executive Director of Metropolitan Center for Independent Living, a provider of comprehensive services assisting people with disabilities in the seven county Minneapolis–St. Paul area. He has worked in leadership roles in behavioral health care at CLUES, the American Red Cross and the United Way.

SCOTT KETOVER MD, AGAF, FASGE, is president and CEO at Minnesota Gastroenterology, where he holds a leadership role with the Board of Directors. He is also the founding president and CEO of the Digestive Health Physicians Association. A Diplomate of the National Board of Medical Examiners, he is board-certified in internal medicine and gastroenterology.

RUTH MARTINEZ MA, is Executive Director, MN Board of Medical Practice. She oversees protecting the public’s health and safety by assuring that the people who practice medicine or as an allied health professional are competent, ethical practitioners with the necessary knowledge and skills. She is also a liaison to related national organizations and professional associations. VICTOR MONTORI, MD,

is professor of medicine at Mayo Clinic. He is a practicing endocrinologist, researcher, and author. He co-developed the concept of minimally disruptive medicine and works to advance person-centered care for patients with diabetes and other chronic conditions. He is the author of the book Why We Revolt: A Patient Revolution for Careful and Kind Care.

DEEPTI PANDITA MD, FACP, FAMIA, is the Chief Health Information Officer for Hennepin Healthcare. She is the Program Director of the clinical Informatics Fellowship at Hennepin Healthcare and a member of the EHR consortium steering group. She oversees EHR, Informatics and Analytics at Hennepin Healthcare.

over 7,000 people with disabilities in the seven-county metro area of St Paul/ Minneapolis and 25,000 callers as an operations center for Disability Hub MN throughout the State of Minnesota. Our Mission Statement is “Removing Barriers, Promoting Choices.” We are very concerned the impact that COVID is having for high-risk populations including but not limited to: people with disabilities, healthcare providers (PCAs and non-paid care givers included), diverse populations, people with complex health conditions and people over 60. It is vitally important that our agency works very closely with the Minnesota Department of Human Services, Disability Services Division, Minnesota Department of Health and the Minnesota Department of Employment and Economic Development/Vocational Rehabilitation Services along with local county government in addressing the human services, health, benefits, housing, employment, education, direct care support, resources and public health needs for people with disabilities. When communication with these agencies is disrupted our services can be disrupted. DEEPTI: As a healthcare system the biggest challenge

public health. New Zealand for example, has led all countries with the lowest infection rates throughout the world. We studied how they deployed their top ministers to focus on the public health needs of the citizenry. Two areas of their model had areas of application for governments throughout the world, whether that be for a country, a state or a county. They had metrics to monitor on COVID and they had a high response that was adaptable. They looked at the pandemic over the arc of its progression and, as importantly, had begun around year 2005 to adopt the “Ottawa Accords on Health Promotion”. Health promotion is vital to inform people on the tenets of public health and the importance of well-being is the responsibility of everyone. DEEPTI: We did a lot of advocacy around the

financial piece at federal, state and county level and received some assistance, but it was not enough to compensate for the high cost of care. We are continuously balancing our supply and demand and tailoring our staffing and resourcing to be the best stewards of our finances.Telehealth has been a welcome solution to close the gaps in care and keep the line of communication and care delivery open between patients and providers.

COVID has created is how to keep care available for the routine healthcare needs while also serving Everyone had a different the needs of the pandemic. This has created an definition of “elective”. enormous stress to our system both financially and KIT: We offered significant flexibility in in terms of resources. Being a safety net system scheduling, and we work with patients and —Kit Crancer we cater to those that are predominantly on state referring offices to ensure patients are able assistance or often are not able to afford any to come into one of our advanced imaging health insurance but we don’t turn anyone away centers, feel safe, and get the answers they which does then affect the bottom line. Other need. Additionally, in some states we’ve seen an huge problems were the potential for delays and increased willingness among health systems to breakdowns of care for patients, the aftereffects of delays in routine care such work with non-affiliated providers to ensure that the communities health as well child checks for children, and chronic disease management in all ages. needs are met, regardless of site of care. We hope to see more of this type of SCOTT: The Executive Order from Governor Walz to cease all elective

collaboration in Minnesota in the future.

procedures had a significant impact on out practice. Our patient volume plummeted and we had to deal with cosing the clinics to avoid potential contacts and viral spread. We experienced a huge loss of revenue and there were considerable problems maintaining PPE inventory.

SCOTT: We established an employee furlough program to help minimize

VICTOR: My patients have diabetes and other chronic conditions. The

shutdown of routine health care and the identification of at-risk patient for severe COVID isolated my patients. They took shelter in their own home and were afraid of personal contacts even with close family members. What were some of the best solutions you found to these problems? JESSE: As a Kellogg Fellow in Public Health from the University of North Carolina, Chapel Hill, health promotion is essential to understanding

salary expenses while maintaining medical and dental benefits. We went from zero telehealth to 100% in 2 weeks, and after 2 months cotinued to evaluate 90% of clinic patients via telehealth. We found multiple vendors to supply PPE to allow us to develop sufficient inventory. RUTH: We developed a rotating schedule for staff members coming into the office

to manage the things that had to be done on-site. In doing this we made sure there were the fewest possible staff members in the building at any time. While we were developing this method for assuring work flow we set up a virtual work schedule that included meetings and deadline schedules. It took some patience and concentration but we were able to establish enough of a baseline to meet our goals and obligations.

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MINNESOTA HEALTH CARE ROUNDTABLE

What have been the most positive things from the increased use of telehealth? VICTOR: Telehealth during COVID has enabled the recognition that there

is a range of ways in which clinicians can work with patients – in person, at home, via virtual video visits, and asynchronous communication – and that all of these forms have a role to play in meeting our patients where they need us without unnecessary and unjustifiable disruption to their lives. RUTH: Access to and continuity of care for isolated patients, making timely appointments and keeping them. Perhaps the best thing has been how it allows at risk patients to minimize the potential for exposure.

VICTOR: We quickly recognized how virtual visits could fail people who could

only access us through the phone, and how clinicians struggled to connect with patients virtually. These experiences have identified areas in need of further innovation, while moderating expectations of a future of care that cannot be digital by default. DEEPTI: While telehealth is a game changer, it does not lend itself well to many

specialties. For example an eye exam via telehealth is challenging. Additionally even after a remote appointment a lot of patients still need to come in for lab or imaging studies. Some healthcare facilities do not lend themselves well to the “social distancing” concept. SCOTT: Video quality varied, often based upon

geographic broadband access. We had to find ways to ensure that our doctors and APP’s had quiet, comfortable and secure telehealth workspaces, whether in the office or from home. There are issues around variable insurance coverage from the third party payers.

SCOTT: As we are not constrained by the “bricks

and mortar” of clinic rooms, we are providing more clinic access, more quickly and efficiently. It provides ideal social distancing for patients and staff. Many providers and staff can perform excellent telehealth encounters while working away from the office and clinic. For patients, no time is lost commuting to the clinic, sitting in the waiting room and exam room, cueing up for clinic discharge/lab/orders, etc. It provides the ability for the patients and providers to see each other without masks. KIT: Patients have still been able to receive the

care that they need without physically entering a facility. Over 10 million Medicare beneficiaries received telehealth services from within the first three months of the pandemic.

Many people do not have access to adequate internet services.

when the pandemic first hit to connect with the each other. Telehealth improved access and helped patients find care in the comfort of their own setting, without having to worry about transportation, child care, time away from work etc. What have been the most negative things from the increased use of telehealth? JESSE: For people with disabilities with economic challenge, many do not

have access to the internet, or if they do, often have solely a cell phone. This means that many go without access to telehealth. We know that for thousands of people with disabilities who are on waivered programs, many have limited minutes of use and therefore communication with case managers, social workers and health care service providers are limited, because people are seeking to retain as much time as possible on a monthly basis. RUTH: So far we have received no complaints from telehealth. We expect telehealth may lead to pressure from facilities needing to waive or defer licensing requirements- to keep people out from other states. We have always worked closely with the state and medical associations around this issue. That said, the telemedicine registration statute is generous –intermittent use is generous, there is a lot of exemption language. Within an executive order from Governor there could be ways to rewrite or maintain a relationships with a provider and facility. These issues are being resolved but the lack of clarity around potential areas of malpractice concern could be considered a negative thing. APRIL 2021 MINNESOTA PHYSICIAN

KIT: In the face of high-profile health data breaches,

questions surrounding individual privacy and freedoms after the relaxation of HIPPA laws during the pandemic. We expect that Congress will take a re-invigorated look at health privacy in general. Additionally, we’ve seen a number of state policy makers across the country that are working to encourage telehealth visits by ensuring payment parity regardless of setting or site in which a consultation takes place. There’s efficacy in telemedicine, and further, particularly during this public health emergency, there is safety for both providers and patients, and that’s something that’s very attractive to policy makers.

—Jesse Betheke Gomez, MMA

DEEPTI: Patients and providers were desperate

Moving forward what are the most important things to consider as telehealth becomes an increasingly common tool for health care delivery?

SCOTT: Establishing a good rapport with patients during electronic

encounters. The loss of many non-visual cues, places more importance on verbal communication to gain the trust of the patient. The cognitive work, the medical decision making of doctors and advanced providers is the same with telehealth as in person visits. Payers need to appreciate that and avoid differential payment models for telehealth. Millennials and most patients under the age of 70 have smartphones and appreciate the improved access and communication with their providers. DEEPTI: All healthcare systems have realized that telehealth is here to stay although

the volumes may decline from the peak of the pandemic when almost 65% of all care delivery was via telehealth. The most important consideration for all systems will be to study their patient populations and define a telehealth strategy that is best for their patient populations. There is also the question around “TeleEquity” –does telehealth widen the health disparities gap as technology favors the use by the fortunate few? So far studies have shown that technology in terms of devices is not a barrier as most residents of MN have a smart phone but other barriers like language, digital competency, broadband access and confidence in this modality of care may play a larger role in the patients using this modality.

JESSE: We have to think about access to Wi-Fi as a necessity for the common

SCOTT: At any time, 40-60% of our staff are working from home. This

good of all, especially in times of a public health crisis. It needs to become affordable for everyone. We have to find a way for high-speed Wi-Fi to be available throughout Minnesota. We know from the other seven Centers for Independent Living in Minnesota, there are many areas where providing remote services is difficult because of the limitations on access to Wi-Fi.

includes schedulers, patient coordinators, health information management providers, human resource management personnel, marketing staff, billing and coding specialists, finance, compliance and credentialing department members, and even leadership.

What is most concerning is that during this public health crisis, for significant percentages of the high-risk populations as I stated earlier, there is evidence of a growing cyber-divide in which many people do not have access to adequate internet services, or band-with, or even computers. RUTH: Telemedicine is a tool, not a specialty. It is just a mode. There is a lot of confusion as to what it does and how it can be used. In some cases it offers clear and immediate benefits, in others it does not. Our interests are in monitoring and maintaining patient safety. We are active in local & national discussions around these topics and looking at how changing location of care impacts them. We are also concerned with issues around money. How will approval for remibursement be different? If payment is outside the structure of regulatory boards how can we assure there will be no abuses? Another topic is what if patients pay in cash for telehealth services, how can this be safeguarded.

Please share some of the impact this has created – both positive and negative JESSE: We have found more ways to deliver

services in the most efficient manner possible. We are committed to continual improvement, and learn from our operations on real-time adaptions that allow us to assure meeting the needs of the people we assist in the most responsive manner possible. It is very important that we do all we can to help inform everyone in Minnesota about public health and health promotion. SCOTT: Productivity has remained high, regardless

We went from zero telehealth to 100% in 2 weeks —Scott Ketover MD, AGAF, FASGE

What kinds of employees have shifted to working from home in your organization? DEEPTI: Health care is typically a space where human interactions are important and there was not template or provision for working from home when the pandemic started. A lot of our workforce shifted to remote to preserve social distancing. What we learned was there is a subset of employees that could easily keep this model and be just as productive. A lot of our IT staff, finance personnel and call center employees will continue to work remotely for the foreseeable future. Some staff, including clinical staff, can have a hybrid model where they can work from home when doing telemedicine or administrative duties and come in only when seeing patients face to face.

of site of work. It is more challenging to maintain and grow comradery via electronic meetings (Zoom). Electronic meetings longer than an hour create difficulty for attendees to remain engaged. Shorter more frequent meetings seem to work better. Spontaneous interactions amongst staff are much less frequent, and this may have a long term impact on creativity and “cross fertilization” between departments. RUTH: A clear benefit is the reduced exposure

to infection. An unexpected benefit has been an expansion of our skills leading to more efficient communcation. Somehow it is now easier and better to remain engaged. There is a downside to the lack of social interaction and personal support. DEEPTI: The positive impact has been creation of space in terms of parking, less crowding etc. For some it has also allowed improved work life balance as they can be close to families and continue to work. The negative impact is not all can embrace the technology driven remote work culture and sometimes the best problem solving can only happen when folks are interacting in person.

work from home environment.

What are the most common questions you have heard from patients about the pandemic?

JESSE: Our human service providers are providing remote services, and we

KIT: We’ve worked hard to offer patients a safe, high-quality, community based

have instituted a direct-client activity platform with associated forms and criteria so that we have optimal safety precautions for a client direct contact. Our Personal Care Assistants (Direct Care Professionals) continue to assist people directly with direct care support.

option to receive health care. Safety is top of mind for patients when scheduling an exam or going into a health care facility. Ensuring that they’re comfortable and safe is our top priority. It’s been remarkable to see how quickly providers have adapted their practices and facilities to our COVID reality.

KIT: Most of our employees outside of the clinical setting have moved to a

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SCOTT: Will this ever end? Is it really as bad as “they” say? Is your faciliuty

safe for my condition? DEEPTI: For us too. “Doctor when will this be over” is the most common

question from my patients. Unfortunately I have no clear answer for this. A lot of them delay care, essential screening tests and elective surgeries in anticipation that this will all be over soon. We have to explain to them that what with the numerous ebbs and surges we cannot tell when there will be is an end date and that they hould continue to seek care as usual.

and Washington State, which allowed “elective procedures” to take place in settings that didn’t draw from vital PPE or decrease hospital capacity to treat COVID patients. RUTH: There are risk variations depending on what the procedure might be- we need to establish priority – what should be first? There is no need for premature panic. It is important to maintain both the safety of the general public and risk mitigation in serious illness. SCOTT: We must make clear that free-standing

JESSE: We have recently begun an outreach

program in working directly with the Minnesota Department of Health. We assist people with disabilities to learn how they can receive COVID testing throughout the Metro area. People ask questions about what they can do to protect themselves, to mask-up, to practice social distancing and have the information they need in order to receive testing. RUTH: We have not received questions from

patients. Most of the questions we have dealt with were from physicians, primarily retirees asking how they could help and if they needed waivers for exam requirements. VICTOR: Some of my patients did well, with

In absence of clear regulations it is important for us to be concerned with potential abuses.

work-from-home conditions reducing their stress, stabilizing their routines, and improving their own capacity for self-care. Others found themselves coping through overeating, stressed by an overexposure to news and social media, and unable to exercise outside their house. As time has gone on, some adapted and others did not, falling into depression and loneliness. Without an end in sight, patients are asking me when they will be able to hug and touch loved ones, to trust the space between them and those with which they make family, community, or business. What lessons should be learned from the Governor’s executive orders around the ban on elective surgeries?

KIT: The prohibition wasn’t limited to “surgeries” and also included

“procedures” like imaging. Additionally, everyone had a different definition of “elective” since the order was written in such a broad and vague manner. As the order dragged on, it became more and more difficult for providers to discern what procedure was “elective” and what was emergent. For example, a patient experiencing chronic cramping and pain was referred to us by a gastroenterologist. This imaging could have been dismissed as an “elective procedure”, but we proceeded with the scan which revealed an abnormality in the colon. Subsequent emergency surgery indicated early stage colon cancer. The patient’s cancer was removed, which spared her from chemotherapy and a colostomy. Had we waited to see the patient until the order was lifted, she could have had metastatic disease and a far more dismal prognosis. Unfortunately, we have a number of examples of delayed care that have resulted in long-term negative health outcomes and families that are suffering the consequences. In the future we should look to other states, like Texas

APRIL 2021 MINNESOTA PHYSICIAN

—Ruth Martinez

surgery centers do not pose a threat to inpatient care or ICU beds. We must recognize the critical role they can play in an overwhelmed health care system. We must establish clinically based and mutually accepted definitions of “elective”. There are differences between what is urgent or emergent versus elective with medical necessity, versus purely for screening or cosmetic reasons. Also, “elective” refers to timing and scheduling of a procedure, but it does not mean the procedure isn’t needed. Finally we must identify interim steps between “survival” shutdown mode and “all clear” that can be activated during future executive orders. Interim steps would recognize that there are dangers to postponing all procedures within a broad category. Deferring care for one to two weeks might be acceptable for some patients, but a continued postponement can ultimately be harmful when those same patients are deferred longer.

DEEPTI: At the time the initial executive order was released it seemed to be the right call, the problem is all “elective” surgeries cease to be elective after a period of time-someone dealing with knee pain and needing an elective knee replacement cannot suffer for months just because elective surgeries are cancelled. Similarly surgeries for work up of cancer etc., which are elective in nature, can only be delayed for finite periods or else they can lead to catastrophic consequences.

What are the biggest issues you see around the COVID vaccine? JESSE: We need to continually provide health promotion with

information about the importance of well-being, clear information about why vaccination is important and assure that information is accessible to all. In addition, we must think about preparing and responding to the needs of communities and populations over the arc of the pandemic. We have to also think about continuity of services, supports, resources and responsiveness to high-risk populations over a longer view of time, that follows the arc of the pandemic, beyond 2021. SCOTT: There are many issues. Distribution/vaccination based upon

categories of need (elderly, congregate facilities, health care workers….). Maintianing adequate supply for the all populations, the costs of purchase, distribution, vaccination. Dealing with deniers and how to document when a sufficient percentage of a population has been vaccinated to move towards pre-COVID activity are some of these issues.

DEEPTI: The vaccines have been the ray of hope everyone needed. The biggest

KIT: I wasn’t surprised because of the ingenuity of our provider community, but I

issue right now is getting the critical 80% of the population vaccinated to reach herd immunity. Already we are seeing that the number of people eager to take the vaccine is declining. We need to educate the masses about the role of vaccines in fighting this pandemic and build trust in all communities around vaccines.

was happy to see how quickly providers were able to adapt to safely seeing patients in a COVID world. Additionally, I was pleased to see how vocal providers were with respect to their needs, and the needs of their patients, to policy makers.

What is your organization doing to prepare for these issues? JESSE: Since the beginning for the pandemic, MCIL has worked directly with key officials in Minnesota on the necessity of preparing to address the needs of people with disabilities - throughout the duration, and arc of the pandemic. I am deeply grateful being a Kellogg Fellow in Public Health in their Leadership Program and learning about best practices to respond to epidemics. During this pandemic I have relied greatly upon my formal education in public health.

We will continue to work in assisting people with disabilities in the safest manner possible. We also will continue to be part of many highlevel working groups on addressing the public health of all in Minnesota throughout the arc and duration of the pandemic. DEEPTI: At Hennepin Healthcare we have taken

JESSE: One of the most concerning items that I have learned is the need

for health promotion as a fundamental requirement of informing people about public health. We must learn from this pandemic to institute all the time a commitment to the well-being of all in Minnesota and in the United States.

Patients are asking me when they will be able to hug and touch loved ones.

In addition, we have to assure that when we focus on healthcare, we recognize that there are many platforms for healthcare that are also home-based, community-based and that it is the entirety of our healthcare platform from hospitals, clinics, ambulatory services to home-based care including long-term services and supports. Furthermore, we must assure that we think about public health not only encompassing all aspects of the emerging delivery model for health and human services in Minnesota, but that health promotion is a key foundation in order to inform people about health, and well-being as essential.

SCOTT: The politization of public health measures a data driven approach to vaccinations. From the and too many people identifying as “me only” very first phase of vaccination we did targeted rather than “we together”. The lack of helpful outreach to communities that had the highest federal leadership from the former administration. —Victor Montori, MD COVID burden, which are typically communities RUTH: The general sense of premature panic and of color living in low income neighborhoods. the absence of support around PPE distribution. We also know that some individuals will never It was surprising there was no better plan in place come to a healthcare facility to be vaccinated. for a pandemic. Everyone presumed there were contingencies but we found We have to take vaccine to them. We created pop up vaccination clinics out that what we thought we knew was inaccurate. at homeless shelters, places of worship, and other community centers. We also had vaccine clinics over extended hours and weekends so that people What are things the pandemic has done to accelerate/reinforce who work during the office hours could get vaccinated. A lot of outreach needed changes in health care? and educational material has been created in multiple languages and trusted community partners have been engaged in educating the communities on JESSE: The need for all in Minnesota and healthcare providers to be safe the importance of getting vaccinated. and protected during this dangerous pandemic, elevated the need to break through barriers in meeting the healthcare needs of people. We need to SCOTT: We will mimic our influenza vaccine program, and try to vaccinate build upon the gains and insights we have made. There is an increasing those at higher risk from COVID first. role for telehealth, for access to high-speed internet and Wi-Fi access for all throughout all of Minnesota. What have been the most surprising things you have encountered

from the pandemic so far? DEEPTI: Despite all the scientific evidence there is still a subset of the

population that believes that COVID is a hoax. This subset questions everything from masking to social distancing. Educating this group is very important to curb the spread.

DEEPTI: One thing we have learned is that health care needs to be nimble and

flexible to prevent the kinds of breakdowns in care delivery that happened at the onset of the pandemic. Every healthcare system in every state needs to have drills and procedures to ensure they have supplies and infrastructure to support a pandemic-like situation. Telehealth will continue to be a viable

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care delivery model well into the future. It goes without saying that we need to build our infrastructure and public health resources and develop health policies to support this.

emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.”.

RUTH: How to work at a distance. That we must pay attention to science-

SCOTT: We need a national plan to take off the shelf for the next

we must be personally and collectively responsible- our choices impact the health and safety of others.

pandemic. This would include non-politization, two way federal and state communications, supply chain, domestic vs. international reliance on PPE, and uniform messaging to the public on how to mitigate a public health emergency.

VICTOR: From now on, we cannot be told that in times of crises the main response we have is to fight or flight. We also tend and befriend. We now know that our world does not have to be careless because in fact, when everything is brought to basics, our default behavior is to be careful. This caught me by surprise, but I will never forget it and it fills me with hope for a patient revolution. Because careful communities cannot harbor greedy and industrial healthcare, but rather they will foster careful and kind care for all.

What are the most important things we can take from COVID to be prepared for the future?

DEEPTI: We may have the most advanced care

delivery systems in the world for “sick care” but what the US lacks is proficient public health infrastructure. We can learn from countries that fared well in the pandemic and the common thread to all of them is a robust public health system. This is a key area to support and grow if we are to get better at syndromic surveillance and fighting future pandemics or epidemics. VICTOR: My generation has seen now that the

notion of individualism, personal responsibility, and each person to itself with which we grew up as the basis for global prosperity is not natural to us. It is an operating system that when our KIT: We saw a plethora of hasty, knee-jerk policy humanity is threatened fails to respond. We have making that came from governors across the Does telehealth widen the seen that individualism is a delusion – we are all country due to the absence of strong federal health disparities gap? as vulnerable as the most vulnerable among us. guidance. Should there be another pandemic in Instead, we have seen with our very eyes the most —Deepti Pandita MD, FACP, FAMIA our lifetimes, I hope that our elected leadership massive, global, near universal manifestation of looks to policies that worked, like expansion of solidarity in the history of humanity. Millions telehealth and modernization of prior authorization suspended their ways of life and their livelihoods strictures, in addition to what policies or tactics to protect the lives of others, to care for and failed. Additionally, I would hope that our elected about each other. Thousands organized to leadership relies more greatly upon input from our care for others, to put together protection for caregivers and healthcare physician community as well as their clinical judgment. professionals, to feed children and support their parents, to protect and JESSE: From a view of public health, my training tells me to assess and learn accompany nursing home residents, even if across the street and with a song where others have been successful, like as mentioned in New Zealand. or a game of bingo. We need to continue to focus on the status of our healthcare delivery capacity throughout the entirety of our larger view of our healthcare platform. It is incumbent upon our generation to learn the lessons from this pandemic and to think about the betterment of society for many generations to come. Certainly, there is much that we are learning in realtime right now, and at the same time what can we learn from others as the This Fall the Minnesota Health Care Roundtable will discuss Ottawa Accords. Here is the opening paragraph of the Ottawa Accords: the topic of clinical and non-clinical care teams: improving “Health Promotion -Health promotion is the process of enabling people interoperability. If you have ideas for this subject or would like to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept

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PAIN MANAGEMENT

The MinuteMan Advances in Spinal Fusion BY R. SCOTT STAYNER, MD, PHD

Indications for Use & Comparative Advantages:

arlier this year, Nura Pain Clinics was the first facility in Minnesota to treat patients suffering from symptoms of lumbar spinal stenosis with or without mild to moderate misalignment of the lumbar spine (grade 1 – 2 spondylolisthesis) using the Spinal Simplicity Minuteman™ MIS Fusion Plate. This device was developed by Dr. Harold Hess, MD, a Board Certified Neurosurgeon, who has spent his career creating and performing cutting edge procedures. In May 2011, Spinal Simplicity received CE approval to make the MinuteMan device available to patients in Europe. In January 2015 the MinuteMan G3 device was granted FDA 510(k) clearance for use in the United States. In January 2017 the updated version, HA MinuteMan G3 that incorporates hydroxyapatite to promote bone fusion was also granted FDA 501(k) clearance. To date the device has provided more than 2000 patients worldwide with a minimally invasive solution that delivers long-term relief of leg and back pain. There have been no reports of device failure or serious complications. The procedure is a notable evolution in the treatment of spondylolisthesis and offers several significant benefits compared to other alternatives currently available. Our patient data and testimonials further support the effectiveness of this new procedure.

Patients with mild to moderate spondylolisthesis often undergo surgery to decompress and fuse the spine, often called spinal fusion surgery. This is done to correct the underlying anatomical abnormalities that often develop with age such as instability of the lumbar spine (spondylolisthesis) and subsequent narrowing of the spinal canal (spinal stenosis). Spinal fusion surgery requires dissection of muscles and resection of bone to open the narrowed spinal canal. Rods and screws are often placed in the spine for stabilization. A traditional posterior fusion surgery requires 142 minutes of OR time with a blood loss of 290 mL on average. The surgery also requires general anesthesia and a hospital stay of 2.9 days.

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Traditional spinal fusion surgery is rigorous so patients with comorbidities such as uncontrolled diabetes, significant heart disease and advanced age are often left untreated out of concern for intraoperative and postoperative complications. Recovery for many patients requires several months of intense physical therapy. Over time, areas of the spine surrounding the fused spinal level also tend to be affected – a phenomenon termed adjacent segment disease (ASD), transitional syndrome or adjacent segment degeneration. This is thought to occur because the fused level is extremely rigid and exerts mechanical stress on the levels above and below. Sometimes a second or even third surgery is required years after the initial surgery to treat recurrent symptoms due to degeneration of the adjoining levels. The Minuteman device® is a minimally invasive, interspinous-interlaminar fusion device FDA approved for the fixation and stabilization of a single level in the lumbar spine. This procedure can be performed in under an hour at an outpatient surgery center through a 1-inch incision with less than 20 mL of blood loss. The patient goes home the same day and is usually able to resume activities of daily living within 24 hours. Additionally, the spine stabilizing muscles, bones and ligaments remain intact after the surgery. Even though the device promotes eventual fusion of the unstable level, it allows for micro movement at the adjacent levels which minimizes the risk of adjacent segment disease.

Treatment & Features: Patients with symptomatic spinal stenosis often report difficulty walking upright due to back and leg pain, weakness, heaviness and/or general discomfort. This is called neurogenic claudication. These symptoms resolve when the patient sits down and rests. Additionally, many patients with lumbar spinal stenosis report the ability to walk with greater ease when they lean forward. The classic finding is that the patient is able to walk much more comfortably when leaning over a shopping cart at the grocery store or when using a walker. This is termed the “shopping cart” sign. The act of leaning forward opens the spinal canal at the narrowed level, which relieves pressure on the crowded nerves in the spinal canal and results in less discomfort while ambulating. One function of the MinuteMan device is to prop open the spinal canal at the unstable and narrowed level. This allows the patient to walk upright with greater comfort but does not affect overall posture. The device is placed between the two spinous processes at the narrowed spinal level. Two

plates flank the spinous processes at the strongest, most ventral point. A central screw is used to bring the plates close together so that they adhere tightly to the upper and lower spinous processes. This opens the narrowed spinal segment while stabilizing the spine.

• Reduced risk of adjacent segment disease (degeneration of levels below and above the treated level)

Additionally, the MinuteMan device is designed to fuse the spine at the affected level. Prior to implantation, hydroxyapatite is deposited in the window engineered into the center post screw. Over time, the hydroxyapatite promotes bony fusion that further stabilizes the unstable level.

• Alternative option for patients with clinical symptoms of lumbar spinal stenosis that either do not want to undergo the traditional invasive lumbar decompression fusion surgery or have mild radiographic findings that make the more invasive surgery less necessary

The procedure is performed on an outpatient basis under “twilight sedation” with Monitored Anesthesia Care (MAC). Patients generally recover within 45 minutes and are discharged home. Patients can resume activities of daily living within 24 hours of the surgery. An 8-week course of weekly or twice a week physical therapy is recommended to help patients recondition the paraspinal muscles that have been weakened by years of hunched posture. The MinuteMan device is designed to remain permanently in the spine but can be easily excised by a spinal surgeon if a more invasive fusion surgery is deemed necessary in the future.

• Reduced cost compared to traditional spinal fusion surgery.

An on-going study of patients who were treated with the MinuteMan device for lumbar spinal stenosis showed long term results in pain and function. Most impressive was that patients reported an 80% reduction VAS score for leg pain 12 months after implantation. Back pain VAS was 50% compared to baseline pain scores. Oswestry Disability Index, a measure of function, improved by 50% at 12 months compared to baseline scores. There are additional economic benefits for this procedure compared to traditional spinal decompression and fusion surgery. The average cost of a traditional spinal fusion surgery in Minnesota is $36,433. Much of this cost is due to the increased length of surgery and the need for at least one overnight stay in the hospital. This does not reflect additional costs such as extensive physical therapy and rehabilitation, extended nursing care for elderly patients or time off work for younger patients. The MinuteMan device costs roughly $20,000 in the outpatient setting, does not require an overnight hospital stay and patients are able to resume activities of daily living within 24 hours of surgery. Minimum post-operative pain medication is needed after the procedure due to the small incision and shortened surgery time.

Summary

• Safer for patients with comorbid diagnoses who cannot tolerate traditional open spine surgery (obesity, diabetes, older age, osteoporosis)

Immediate Relief We have performed approximately 20 Minuteman procedures since midJanuary 2021. Most patients comment that walking upright is much more comfortable within 20 minutes after completing the surgery. Leg symptoms tend to resolve completely after device placement. One patient has even scheduled a removal of her spinal cord stimulator because her relief after placing the MinuteMan device has been so profound. Many patients report being able to reduce their use of opioid and other pain medications after the procedure. The most profound pain relief observed is pain or discomfort associated with walking in an upright position. Most patients also note a reduction in back pain. However, many of our patients have multiple pain generators contributing to low back and leg pain. We have observed that after we correct underlying spinal stenosis and instability with The MinuteMan to page 344

ENGAN ASSOCIATES

Creating Healing Environments for 40 Years

Compared to traditional open spinal decompression and fusion surgery, treating mild spondylolisthesis with associated lumbar spinal stenosis using the MinuteMan device has many advantages for the right patient. Advantages include: • Reduced surgery time (35 minutes compared to 142 minutes for posterior fusion surgery) • No overnight hospital stay • No general anesthesia required • Minimal post-op pain • Return to activities of daily living within 24 hours • Decreased blood loss (less than 20 mL compared to 290 mL on average for posterior fusion surgery) • Minimally invasive (1-inch incision) • Spine stabilizing structures such as the supraspinous ligament, paraspinal muscles and bones are spared and remain intact

“We wouldn’t hesitate to work with Engan Associates again.” (Matt Reinertson, Heartland Orthopedic Specialists)

HEALTH CARE EQUITY

The Minnesota EHR Consortium A unique pandemic-born partnership BY DEEPTI PANDITA MD, FACP, FAMIA

t was a Friday afternoon in March, already over a year ago. The scope of the pandemic was just starting to emerge, and everyone was rapidly trying to adjust to the new reality of practicing medicine with limited physical contact. Hospitalizations were rising and our emergency rooms, ICU’s and other care delivery outlets were getting challenged, not only by the gravity of the pandemic but also by lack of visibility and transparency as to what it meant for us as a state in terms of impact and magnitude. We had limited data to give us a state wide snapshot and no template of data sharing among healthcare systems. It became apparent that health care delivery systems, both public and private were operating in silos, which clearly hindered the best responses to the pandemic. State health agencies and care delivery systems needed to know in a rapid manner how the pandemic was affecting its residents and where help should be deployed most quickly. The realization came that despite being cutting edge in technology and innovation, our state did not have adequate capacity to respond to a pandemic. It also became apparent that systems in place at state agencies did not have up to date information on race, ethnicity, preferred language, and geography. This is the best

information available to address disparities in disease prevalence and testing, which helps health systems and the State develop a proactive testing strategy. All these challenges lead to the birth of the MN EHR Consortium-the first such collaboration in the country. The Consortium has a unified mission “to improve health by informing policy and practice through data-driven collaboration among members of Minnesota’s health care community” Participation in the Consortium is open to any health system serving patients in the state of Minnesota. Current systems participating and contributing summary data include Allina Health, CentraCare, Children’s Hospitals and Clinics of Minnesota, Essentia Health, M Health Fairview, University of Minnesota, HealthPartners, Hennepin Healthcare, Mayo Clinic and Mayo Clinic Health System, and North Memorial Health, Sanford Health and the Minneapolis VA Health Care System. Other affiliated organizations include Institute for Clinical Systems Improvement, Minnesota Community Measurement, and Minnesota Department of Health (MDH). Summary information is provided by each contributing health system and combined to provide weekly reports. No patient-level data is shared across member health systems and each health system controls their data within their firewall which has typically been the push back from care systems around data sharing with competing health care systems. The guardrails and assurance that the Consortium data would still “belong” to the organization, along with the unique threat of the pandemic, were the primary reasons most health systems signed on without much hesitancy.

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Volume XXXII, No. 05

CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

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CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

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ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

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The first project tackled by the Consortium was the COVID-19 crisis. The project provides summary information to identify geographic areas where medical encounters for viral symptoms are increasing and aims to determine whether those symptoms are due to influenza or COVID-19, where COVID-19 testing is inadequate, and where COVID-19 positivity rates are concerning. These data can help health systems better prepare and respond to the unfolding COVID-19 pandemic. Through the many waves of the surges and ebbs of the pandemic the Consortium data guided care groups and state agencies to set up testing sites and understand the impact of the pandemic on various ethnic groups and design programs to create equity in care delivery. Early 2021 vaccines became available for residents in the state. While this was welcome news and some light at the end of the tunnel, another reality became apparent- The Minnesota Immunization Information Connection (MIIC) had some limitations. This is a confidential system that stores electronic immunization records at the MN Department of Health. Health care providers, schools, child care centers, health plans, pharmacies and other locations that can provide immunizations are all participants in the system. MIIC did not have any race or ethnicity information due to privacy rules. The MN Department of Health reached out to the EHR Consortium and a healthy public-private partnership emerged. The Consortium has access to more granular information and capabilities to merge novel data

cover approximately 92% of Minnesotans who have received the COVID-19 sources de-identified, and to report vaccine administration by race/ethnicity, vaccine to date. Patients who have never been seen at any of the participating language, comorbidity status, and other factors. The consortium data became health systems are the ones who have no data included. It’s important to crucial to inform the equitable distribution of COVID-19 vaccines and the point out that data on race/ethnicity are missing for approximately 15% state welcomed this partnership. Now not only could the State display this of vaccinated Minnesotans as these are typically data on their public website, but plans could be required to be self-reported in health care systems. developed around equitable Vaccine distribution by SVI (social vulnerability index), zip code and What have we learned thus far? county to identify hot spots and high need areas Morbidity and mortality related to COVID-19 to target. Prior to the EHR consortium data has been higher and occurred at lower ages for availability, MDH was lacking an equity metric During a pandemic, health systems Black and Hispanic Minnesotans, so vaccination aligned with strategy. Developed by the CDC, cannot operate in silos. disparities are especially important to address. The Social Vulnerability Index uses 15 census variables health systems participating in the CDS Coalition to identify communities that may need support that runs vaccine allocation for the health care before, during, or after disasters. In addition to a systems have designed health equity plans using the summary score, there are 4 themes: Socioeconomic EHR consortium data in order to close disparities. status (below poverty, unemployed, income, no Initial results from the MN EHR Consortium high school diploma), household composition & indicate that vaccination rates among White, non-Hispanic Minnesotans disability (aged 65 or older, aged 17 or younger, older than age 5 with a are two times higher than Black Minnesotans and four times higher than disability, single-parent households), race/ethnicity & language (minority Hispanic Minnesotans. Among people ages 65 and older, disparities are status, speak English “less than well”), and housing type & transportation smaller but persist. The overall results are partly due to the age distribution (multi-unit structures, mobile homes, crowding, no vehicle, group quarters). of these populations in Minnesota, as well as the racial/ethnic composition These data elements provide information on demographic and clinical of essential worker populations that have been vaccinated. Black and trends in Minnesota’s COVID-19 vaccination effort. This information is Hispanic Minnesotans are, on average, younger than White Minnesotans, critical for identifying gaps and disparities in vaccination efforts that can be acted on by health systems, state and local public health, and other health The Minnesota EHR Consortium to page 324 care organizations. This data was so compelling that MDH stepped up to fund some of the work being done by the EHR Consortium around these needs. The consortium also has experience merging different data sets. This is particularly important for its work around social determinants of health, where they are looking at vaccine rates among key populations experiencing housing insecurity, homelessness or incarceration. The Consortium has only really been a collaborative for about 13 months. In 12 of those months, we’ve been working on COVID, putting out fires pretty much day to day. So we are looking forward to Summer when, theoretically, we’re going to start talking as a group about Quality Transcription (located in Minnesota) the potential for adopting a common data model across the 11 health systems.

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The technical work for the Consortium data support utilizes a distributed/federated analytic model where the MIIC vaccine data is linked to EHR data via secure one-way hashing algorithm. Each health system creates a standardized data set indicating COVID PCR test results, COVID-like-illness, vaccine date, demographics, comorbidities, zip code, etc. and summary data is produced and sent to the coordinating center at MDH where a dedicated group has been created to monitor and manage all the pandemic related data and analytics. Data is aggregated for public view on an easy-to-use internet dashboard tool. Prior to the EHR consortium creating this granular data around race, ethnicity and language, MDH could only show total numbers vaccinated by age but after this new methodology was implemented the data could be parsed out not only by race/ethnicity but also by zip code and SVI index which is crucial to drive vaccine equity in order to get shots in arms of those getting left behind. This methodology has been diligently designed to generate needed summary data on COVID19 vaccination efforts while centering on privacy and data security. Only summary level data are collected for the reports, and the reporting and storage standards comply with state and federal regulations. The Consortium data

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PUBLIC HEALTH

Engaging Families in Health Care Everybody Wins BY TAI MENDENHALL, PH.D., LMFT AND AALAA ALSHAREEF, MS, LAMFT

attended to and included; they can ignored or excluded (purposefully or passively). We argue that they be included and purposefully attended to.

t is well-established that up to 40% of patients who present in primary care have a diagnosable mental illness, and that more than 70% of all clinical presentations carry some kind of exacerbating psychosocial foci (e.g., workplace stress, housing instability, unemployment, institutional racism, legal troubles, academic struggles). These statistics are arguably more diverse – and often higher – across secondary and tertiary care environments.

Data Talk: Families are Important

What appears less universally agreed-upon – or even recognized – is the role(s) that patients’ families play in health, wellness, illness, disease, injury, and/or recovery. Modern Western medicine conventionally focuses on onepatient at-a-time. Patients’ physical illnesses, mental health struggles, and psychosocial stressors are usually addressed absent consideration of family dynamics. Our third-party payers and HIPAA rules reinforce this practice. But families play important roles in the lives of our patients. They can be a source of support or a source of stress; they can be part of a solution or part of a problem. They are almost always “there” somehow, and are consequently influential to the courses and outcomes of medical advice. They can be

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Proponents of the “medical home” – from pediatric to geriatric care contexts – agree. The Joint Principles of the Patient-Centered Medical Home (PCMH), advanced by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association, call for physicians to engage with patients and their families in active partnership(s) across all care processes so as to improve health. Compelling data – across both individual studies and systematic reviews – are emerging to support such efforts. In primary care, family medicine studies have long-paired the inclusion of family members in preventive and therapeutic interventions to positive outcomes (e.g., physical activity, blood pressure, metabolic control, dyslipidemia, smoking, overall cardiovascular risk). In pediatrics, stalwart support for the involvement of multiple family members in treatment is extant for care targeting child/youth diabetes, asthma, and obesity. In internal medicine, similar trends are recognized in the treatment of patients with multiple and complex morbidities, including diabetes (and other weight-related foci) and substance use/abuse. Examples supporting the inclusion of families in secondary care include: intensive care practices involving families have been paired with greater trust for care teams, satisfaction with care-related decision-making, and patient/ provider consensus in decision-making. In OBGYN contexts, familyinclusion in care is well-established in the reduction of perinatal distress, allayment of chronic genital pain, and improved coping with unexpected pregnancy termination for fetal abnormality. In emergency medicine, family involvement is strongly predictive of reduced psychological distress and improved follow-up with discharge planning. In oncology, it outperforms individual approaches in the promotion of coping, improved problemsolving skills, decreased psychological distress, and reduced depression. In psychiatry, including families in care has shown superior outcomes in the treatment of ADHD, anxiety, PTSD, depression, and suicidal ideation. Examples of compelling data in tertiary care are also myriad. In palliative and hospice contexts, including families in treatment is strongly predictive of improved patient/caregiver coping, increased self-efficacy, better qualityof-life, and reduced caregiver burden. In endocrinology, diabetes-related outcomes (e.g., A1c, BMI, BP, dietary practices, physical activity) are consistently better when care includes patients’ family members as opposed when patients are treated in isolation from them. In alcohol and drug treatment, family-interventions almost universally outperform individual care for use/abuse of substances (ETOH, opioids, etc.) and other addictions (gambling, pornography, etc.) across both adolescent and adult samples.

Everybody Wins The inclusion of family members in treatment processes within other care environments and target populations that do not fit neatly into conventional

primary, secondary, or tertiary “boxes” are also being evaluated. These include – but are not limited to – community health centers, communityengaged (i.e., “push” vs. “pull”) initiatives, disaster response teams, spiritual care, employee assistance programs, and military / veteran health systems. All show promise for the inclusion of family members in the care of individual patients, alongside outcome data that support doing it.

pressures to produce clinic revenue – to see 30, 50, or even more patients per day – communicate clearly to physicians that their “relative value units” (RVUs) are more important to job-security than the outcomes of the care that they provide.

Doing Something “New” without Doing “More”

Doing something “new” is almost always heard It is also important to note that including by busy students, residents, and established patients’ families in care, regardless of where the physicians as doing something “more”. This can Training future physicians to care is positioned and/or who the patients are, be an impossible call, as outlined above, insofar as comfortably engage with saves money. From improved health per se (which there is no room to do more. Further, such messages patients’ families is essential. means less money paid-out by 3rd party payers for are easy to interpret as criticism – which are often visits, prescriptions, procedures, etc.) to reduced then understandably met with defensiveness by frequency of acute and/or emergency visits (which trainees and/or professionals who are already cost a great amount of money from intake to all working hard to meet the administrative quotapoints forward) and reductions in “frequent-fliers” demands that they are under while synchronously (who repeatedly take-up valuable appointment slots and otherwise encumber offering high-quality care. clinic scheduling), the administrative worlds of health care benefit from all The good news here is that learning (and continuing) to include families of this too. And finally, data show that providers themselves benefit through is rarely something that requires more time. Classroom teachings about improved job satisfaction, lower burnout rates, and higher staff retention. common ways that patients and families respond and adjust to a variety In short, everybody wins. of illnesses, for example, could be integrated into existing year one courses or those that explicitly include multiple members in care (e.g., pediatrics, Are Families missing in Health Care? family practice). More sophisticated learning and skill sets related to family Despite extant and growing data that support the inclusion of family members in care practices, it continues to be the “exception” as compared to Engaging Families in Health Care to page 304 the “rule” of treating patients in a vacuum. Responding to this circumstance effectively is complex and necessitates both thoughtful insight(s) regarding where we have been and realistic steps toward where we are going. Training future physicians to comfortably engage with patients’ families is essential. However, it is not clear whether and/or how consistently our country’s medical schools are doing this. For example, the authors recently conducted a thematic analysis of the top-ten ranked (according to U.S. News & World Report) R-1 institutions’ course descriptions. We found no-to-minimal mention of communicating, working, and decision making with patients’ families. Follow-up inquiries to said schools’ administrative and curricular personnel – albeit with a low (30%) response rate – yielded comparatively favorable findings, wherein patient/family/physician communication was recognized as a learning objective. However, this objective was described as a “process” topic that comes up along the way – as opposed to a specifically articulated component of any specific classs content. Reasons for the relative paucity of attention to working with patients’ families in medical education are numerous, and parallel reasons for why any other host of topics (e.g., health maintenance organization management, business modeling, public health planning, community engagement, team building, compassion-fatigue prevention / mitigation) are neglected. With only four years to adequately prepare students before residency, preference for time / attention to baseline domain knowledge is essential. The same can be said for residency training, insofar as no length- or amount- of education or timeframe is adequate to cover all foci that are required. In post-residency practice, most physicians will not argue that families are important (they have families, too!). However, said physicians regularly and almost categorically reject engaging patients’ families in care because it will take too much time. This connects directly to what scholars across both biomedical and psychosocial fields call “time-famine”. Contemporary MINNESOTA PHYSICIAN APRIL 2021

3Engaging Families in Health Care from page 29 encouraging / ensuring compliance with medication regimens / routines, processes of adaptability, cohesion, and communication – and the manners sobriety maintenance), and a variety of other care-related activities. We can in which these often change and/or respond to health-related situations and improve outcomes when we include patients’ family members and other crises – could follow. Commonplace watch one, loved ones in our work. Doing this empathically, do one, teach one sequences could be integrated sensitively, curiously, and respectfully – and into internship and/or residency practices wherein with appropriate regard for the complex ethnic/ novice trainees observe more-advanced trainees cultural, intergenerational, interpersonal, and and/or faculty work with families, followed other intricacies of “family” that patients bring Patient/family/physician by working with families themselves (under with them will translate into better care. communication was recognized appropriate supervision paired with feedback Other – and overlapping – ways of engaging as a learning objective about strengths and areas for growth), followed patients’ families in care do not require anything by teaching newer cohorts the skills that they (“more”) from physicians other than a willingness have learned. to participate in the integrated care teams that In practice, physicians are presented daily PCMH advocates are calling for. As these teams with opportunities to encourage patients to invite slowly replace less effective models of practice, family members into clinical visits. Examples of these opportunities, and the interdisciplinary efforts that engage behavioral care providers (e.g., medical ways that families can help in the care are myriad: facilitating conversations family therapists, health psychologists) and other care advocates (e.g., social about health decisions (e.g., birth control options, pros-and-cons related to workers, care coordinators) can translate into non-physician providers different medications), medical interventions (e.g., elective surgeries, DNR engaging families on physicians’ behalf. Shared-charting, curbside directions), delivering bad news and/or assisting in the communication of consultations, joint problem-solving, and other collaborative efforts have such news to others (e.g., parents diagnosed with cancer disclosing it to their all shown (through care outcomes, cost savings, etc.) that the energy is children), ongoing care processes (e.g., managing home-care services across worth the effort. Third-party payers like BlueCross/BlueShield, CMS, multiple providers and/or agencies), health behaviors (e.g., sharing in dietaryHealthPartners, Medicare, and Medicaid, while not historically supportive and/or physical activity- activities in diabetes management, reminding / of preventive (versus reparative) services, are quickly catching on to the value of these types of efforts and team-models.

Concluding Thoughts

HARDWOOD FLOORS ARE THE SUPERIOR CHOICE FOR FLOORING.

Highly competent practice necessitates physicians’ purposeful attention to multiple systems – biological, psychological, relational/social – that patients inhabit (or that inhabit patients). And while most physicians are highly skilled in the physical and psychological arenas of their work, engaging patients’ families in health and health care is oftentimes not pursued. However, learning how to navigate these territories is worth the effort – and that “effort” does not need to take any more time away from providers who are already-overextended in terms of (un)available time. Patients benefit. So do their families. We do, too. Everybody wins. Tai J. Mendenhall, Ph.D., LMFT, is a Medical Family Therapist and Associate Professor in the Couple and Family Therapy Program at the University of Minnesota (UMN) in the Department of Family Social Science. He is an adjunct professor and clinician in the UMN’s Department of Family

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3The Future of Gastroenterology from page 15

software systems requires its own login, password, and even multi-factor authentication prompts.

vendor level with the help of AI experts like Iterative Scopes. However, if we take that a step further and integrate the AI-powered scope software into the documentation platform, it could not only detect the polyps, but could also suggest the characteristics of the polyp (i.e. type, size, and location) and capture that information as discrete data points for the physician’s review and sign-off.

Fingerprint and face recognition will help alleviate much of the burden, while still remaining highly secure. Fingerprint and face recognition for sign-in authentication and e-signatures is something that is becoming more common in GI software, but is not readily available in most applications.

AI in Gi is creating better patient outcomes More dynamic machine learning AI can reduce physician burnout. and new opportunities for specialists and primary As mentioned earlier, the current state of care providers to collaborate to achieve the best machine learning in GI documentation allows patient outcomes. the software to learn and suggest common selections. In the near future, machine learning AI can provide enhanced data but will never will evolve to being able to recommend full replace the art of medicine- the ability gained templates based on what the physician has through years of experience to know how one documented in the past. AI will not only provide documentation individual metabolism will respond differently than another to very suggestions, but also clinical decision support (i.e. identifying similar conditions. It is already speeding and improving care and forging contradictory indications, suggested medications, and alerts), allowing valuable new industry partnerships. nurses and physicians to be extremely thorough and efficient in their patient charting and procedure documentation. Jonathan Ng, NBBA, MPA, MBA, is the CEO at Iterative Scopes, a Authentication software-only company, spun out of MIT, working to deliver AI Although absolutely critical, secure authentication and e-signing can toolkits to the practice of gastroenterology. still be burdensome for physicians and members of the care team. With healthcare cybersecurity threats still on the rise, it is likely each of your

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3The Minnesota EHR Consortium from page 27 so current allocation phases have resulted in smaller proportions of these groups being vaccinated. Vaccination rates among White, non-Hispanic and Native American populations were similar and may reflect early efforts to allocate vaccines to Native American Minnesotans As vaccination became available to all Minnesotans 16 and over effective April 19th, the EHR Consortium data will further inform the state, federal and local vaccination sites on strategies to provide vaccinations where the need is the highest with the lens to health equity. Minnesota has always been on the forefront of novel healthcare innovations but despite repeated attempts over the past decades and despite high use of electronic health records in the state since the early 1980’s, we have not succeeded in creating a seamless state level data exchange. The EHR consortium fills a much needed gap and we hope the value this effort has brought forth will result in a more permanent data sharing structure for the State. During a pandemic, health systems cannot operate in silos. Collaboration is needed to understand where and how the disease progresses and to plan for capacity and operational needs. This work also benefits the State’s response efforts by complementing other data.

support decision-making, and make improvements. The coalition now has several sub groups who work on niche problem solving such as research and publications, refining data and analytics, public relations and outreach etc. This work is adapting to address future COVID-19 surges, the potential for other epidemics/pandemics and improving future vaccination activities. Other topics, such as long-term impacts of COVID-19 infection and other public health issues may be addressed and the data can be used to drive future public policy. The Consortium’s partnership, infrastructure and methodology for producing summary data will help Minnesota be prepared for future public health crises, syndromic surveillance and even for chronic disease management with the ultimate goal of creating healthy communities and improving the health of the residents of Minnesota. The data can guide clinicians and other care providers in the state to dive deeper into their own patient populations to identify gaps and better serve the needs of the populations they serve. In the future there is the potential to have partnerships with health plans, patient advocacy groups and other nonprofits that support health equity. Through this research we can design human-centered solutions for the health of our state using a lens of equity.

Looking Ahead The Consortium meets weekly and has representative members from all its participant systems. Each week there is a review of summary reports, ongoing needs and gaps to address the pandemic, develop governance structures to

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3The MinuteMan from page 25 the MinuteMan device, other neuromodulation therapies such as spinal cord stimulation are more effective.

Patient Selection:

cord stimulation or targeted drug delivery. The MinuteMan fusion device offers the opportunity to correct the underlying anatomical problem for these patients via a minimally invasive, outpatient surgery. If other treatments, such as spinal cord stimulation or targeted drug delivery are needed to treat irreversible neuropathic pain after placing the MinuteMan fusion device, they are likely to be more successful.

Patients who demonstrate clinical signs of lumbar spinal stenosis such as neurogenic claudication (i.e., increased back and leg discomfort when Younger patients with mild to moderate walking upright that is relieved by resting and/ Patients report being able to lumbar spondylolisthesis can also benefit from the or hunching forward) are ideal candidates for reduce their use of opioid and MinuteMan fusion device. Such patients often treatment with the MinuteMan fusion device. other pain medications. have fewer lumbosacral issues. Therefore treating Radiographic findings on lumbar MRI or CT scan lumbar spinal stenosis with this minimally of central stenosis or lateral recess and foraminal invasive technique can result in profound changes stenosis at a single level are obtained to determine in function and pain. Coverage for this treatment the spinal level to treat. Flexion/extension X-ray for non-Medicare plans is expanding as well. studies are also needed to ensure that the patient does not have more than Grade 2 spondylolisthesis and to determine if the spinous processes at the treatment level are adequately sized. R. Scott Stayner, MD, PhD, is the Medical Director of Nura Ambulatory Currently, the MinuteMan device is on formulary with Medicare and most Surgery Centers. He is board certified in anesthesiology and pain management. Medicare Advantage plans. Elderly patients, especially those with symptomatic He completed his anesthesiology residency at the University of Minnesota, his spinal stenosis, are often ideal candidates for the MinuteMan fusion device since Fellowship in Pain Management with the University of California, Davis, and is spine surgeons are hesitant to recommend open fusion to correct lumbar spinal a graduate of the University of Minnesota Medical School. He earned a PhD in stenosis due to increased risk of postoperative complications. Until recently, Bioengineering from the University of Utah. the only interventional treatment options for such non-operative patients with spondylolisthesis and spinal stenosis have been injections and potentially spinal

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Holly Boyer, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

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Minnesota Physician • April 2021

Articles inside

PUBLIC HEALTH Engaging Families in Health Care

MINNESOTA HEALTH CARE ROUNDTABLE The COVID-19 Pandemic

PAIN MANAGEMENT The MinuteMan

INTERVIEW

HEALTH CARE EQUITY The Minnesota EHR Consortium