2008julaug

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MetroDoctors The Journal of the East and West Metro Medical Societies July/August 2008 1

C O N T E N T SV O L U M E 1 0 , N O . 4 J U L Y / A U G U S T 2 0 0 8

Physician Co-editor Lee H. Beecher, M.D.Physician Co-editor Peter J. Dehnel, M.D.Physician Co-editor Thomas B. Dunkel, M.D.Physician Co-editor Charles G. Terzian, M.D.Managing Editor Nancy K. BauerAssistant Editor Doreen M. HinesWMMS CEO Jack G. DavisEMMS CEO Sue A. SchettleProduction Manager Sheila A. HatcherAdvertising Representative Betsy PierreCover Design by Outside Line Studio

MetroDoctors (ISSN 1526-4262) is publishedbi-monthly by the East and West Metro MedicalSocieties, 1300 Godward Street NE, BroadwayPlace West, Suite 2000, Minneapolis, MN55413. Periodical postage paid at Minneapolis,Minnesota. Postmaster: Send address changesto MetroDoctors, East and West Metro MedicalSocieties, 1300 Godward Street NE, BroadwayPlace West, Suite 2000, Minneapolis, MN55413.

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On the cover: Althoughprogress is being made, thereis still no cure for HIV.Article begins on page 7.

MetroDoctorsT H E J O U R N A L O F T H E E A S T A N D W E S T M E T R O M E D I C A L S O C I E T I E S

Doctors

2 Health Reform—What Happened and What’s Next?

5 Capitol Rounds Connects Members With Legislators

7 SPECIALTY UPDATEThe State of the Struggle Against HIV

9 Reinventing Primary Care

11 YOUR VOICEWhat About Single Payer?

14 The Promises—and Perils—of Electronic Health Records

15 Classified Ad

16 Universal Pediatric Influenza Vaccination—How Will We Accomplish This?

17 COLLEAGUE INTERVIEWJon S. Hallberg, M.D.

20 Intentional Culture Change: Working Better Together

23 Creating a Better Experience for our Caregivers

24 Index to Advertisers

25 St. Francis Serves Scott and Carver Counties

36 Career Opportunities

Member News

EAST METRO MEDICAL SOCIETY

28 President’s Message

29 Foundation Works on Advance Directive Project/Caring Hearts

30 Caucus/Sr. Physicians/New Board Members/In Memoriam

31 Asthma and Tobacco-Free Supporters Team Up with Saint PaulSaints/Legislators Presented with Defender of Clean AirAwards/Dakota County Smoke-Free Communities Partnership

WEST METRO MEDICAL SOCIETY

32 Chair’s Report

33 WMMS In Action

34 Congressman Ellison Participates in Community InternshipProgram/Sr. Physicians Association/In Memoriam

35 Alliance News

2 July/August 2008 MetroDoctors The Journal of the East and West Metro Medical Societies

OON A JUNE AFTERNOON in 2007, a hand-ful of representatives and senators met at theCapitol to begin charting a new course towardhealth care reform. Nearly one year later, thelegislature approved a bill that seeks to containthe rapidly rising costs of health care.

Approved the night before adjournmentand signed by the governor shortly thereafter,the final bill gives more than 12,000 Min-nesotans without health insurance access tohealth coverage via MinnesotaCare eligibilityexpansions and newly authorized tax creditsfor money spent on insurance premiums.Expansions and outreach efforts tied to Min-nesotaCare include:

Authorizing coordination with the freeschool lunch program to identify uninsuredfamilies eligible for medical assistance orMinnesotaCare.Making applications for state programsavailable online.Increasing the incentive bonus from $20 to$25 for assisting MinnesotaCare enrolleesin applying for coverage.Making single adults at or below 250percent of the Federal Poverty Guidelines(FPG) eligible for MinnesotaCare (currentlevel is 215 percent of FPG).Effective 7/1/09, children in families at orbelow 250 percent of FPG are eligible forMinnesotaCare.Authorizing a sliding fee scale pegging Min-nesotaCare premiums to families’ annualincome. The purpose of this provision isto define and achieve affordable Minneso-taCare premiums.

The bill strives to make it easier for con-sumers to understand the health care servicesthey are purchasing, and lays the groundworkfor eventually rewarding providers for helpingpatients manage chronic conditions, such asdiabetes, asthma and congestive heart failure.

The Health Care Home provision in thebill seeks to accomplish this by authorizingper-person, per-month “care coordination”payments to reward preventive and coordi-nated care. Rep. Tom Huntley (DFL-7A), whoauthored the House version of the reform bill,often cites the St. Mary’s/Duluth Clinic HealthSystem’s Heart Failure Disease ManagementProgram as the type of program he would liketo see rewarded. This program places a heavyemphasis on coordination of care by havingnurse practitioners maintain frequent com-munication with patients and closely monitortheir health conditions. The program, accord-ing to Huntley, has been successful in keepingpatients out of the operating rooms, but theprovider loses hundreds of thousands of dollarseach year because its preventive care efforts arenot reimbursed.

The reform bill also includes languagethat requires health plans and third partyadministrators to submit encounter data to aprivate entity designated by the commissionerof health. These data will eventually be used

to help the commissioner of health develop apeer grouping system for providers based ona combined measure that incorporates therisk-adjusted cost of care and quality of care.Beginning in July 2010, MDH will dissemi-nate to physicians peer grouping data on theircost of care, quality of care, and the results ofthe grouping. Physicians will have 21 days toappeal if they do not agree with the findingsbefore the information is publicly dissemi-nated.

The commissioner of health will also berequired to develop a uniform method of calcu-lating physicians’ relative cost of care, definedas a measure of health care spending includingresource use and unit prices, and relative qual-ity of care.

The bill authorizes the Commissionersof Health and Human Services to form aminimum of seven baskets of care for whichproviders can voluntarily submit bids in 2010.The commissioners will use the services of anonprofit entity to aid in crafting these baskets,and form work groups consisting of “membersappointed by statewide associations represent-ing relevant health care providers and healthplan companies and organizations that workto improve health care quality in Minne-sota.” Once the baskets are formed, and theaforementioned entities have developed amechanism for determining uniform pricesfor the services identified in these baskets,participating physicians would not be allowedto vary the price of services for these services.The commissioners are not allowed to factorservices provided to patients through workerscompensation insurance, no-fault auto insur-ance or public programs into the calculationof these single prices. Physicians will have theoption of submitting bids for these baskets ofcare in 2010.

Health Reform—What Happened and What’s Next?

BY MATT SCHAFER,Lockridge Grindal Nauen, P.L.L.P.


While these changes lay the foundationfor changing the way health care is paid for,the final measure was a product of multiplecompromises. Authors Huntley and Sen. LindaBerglin (DFL-61) made no secret that the billwas a shadow of the original proposal leavingsome advocates under-whelmed.

The original bill contained a number ofcontroversial items that physicians, insurersand employers cautioned would have gener-ated a host of unintended consequences,including a payment reform proposal, whichessentially would have capitated health systems.To further complicate matters, the bipartisanpolitical desire for health reform made theact of questioning the contents of the bill aprecarious engagement as nobody wanted tobe perceived as “anti-health reform.”

The stakeholders’ concerns led to an un-likely alliance of Republican Representativeswho felt the state was being asked to take ontoo much responsibility, a surprisingly large co-alition of Democrats who believe health reformcan be achieved by some form of a single payersystem, and rural legislators who felt the billfailed to consider issues and challenges uniqueto Greater Minnesota.

This unlikely alliance of liberals andconservatives aligned against the DFL leader-ship and the governor led to House leader-ship adopting an amendment that delayed theimplementation of the payment reform sectionof the bill. The amendment also authorizedestablishing an advisory council consistingof members of a host of stakeholder groupsincluding the Minnesota Medical GroupManagement Association (MMGMA), theMinnesota Medical Association (MMA) andthe Minnesota Hospital Association (MHA).

In addition to the politics at play, legisla-tors needed to grapple with a projected budgetdeficit of $935 million that significantly re-duced resources that could have been investedin health reform. More than 70 percent of thespending cuts in the supplemental budgetpassed on the last night of session came outof the Health and Human Services Depart-ments.

Hospitals bore the brunt of the cuts witha 3 percent outpatient rate reduction, and a3.46 percent inpatient rate reduction in 2008which will be phased down to 1.9 percent inJuly 2009, and to 1.79 percent in July 2010.

Additionally, the rebasing for hospital rateshas been delayed by two years. Bruce Rueben,President of the Minnesota Hospital Associa-tion, was recently quoted saying the cuts tohospitals’ reimbursement rates alone willlikely offset many of the savings achieved bythe health reform bill. This is because somehospitals may have to shift costs to patientswith commercial insurance to make up for themoney lost from the rate cuts.

Reflecting a request from the governor, theSupplemental Budget “borrows” $50 millionfrom Health Care Access Fund (HCAF) to bal-ance the budget, but backfills the money us-ing projected savings resulting from the HealthCare Reform Bill. The $50 million used outof the HCAF replaced money the legislatureplanned to raise by reinstating caps on healthplan reserves, and implementing an assessmenton the monies above that cap.

Among the proposed cuts that did notmake the final bill was a 3 percent reductionin physician reimbursement rates for publicprograms. Legislators also decided againstusing federal funds set to be allocated to Min-nesota hospitals that deliver a higher amount of

uncompensated care under the Federal Dispro-portionate Share Hospital (DSH) program.

Another proposed amendment statedthat more than 60 services listed in the Or-egon Health Plan would no longer be coveredby MA, GAMC or MinnesotaCare. Soldto conferees by Sen. Berglin as a “technicalamendment” dropping reimbursement for“obsolete medical procedures,” the list ofservices included multiple medical proce-dures across numerous medical specialtiesthat are used frequently. Fortunately, thisproposal was also unceremoniously scuttled.

Because of the fiscal and political chal-lenges, the health reform bill passed in 2008is already being characterized as a step towardbigger objectives, including universal healthcoverage across the state and achieving as highas 20 percent cost savings from the system.

So what does this say about future de-bates? First, the work groups, commissions andadvisory committees authorized in the healthreform bill will hold their meetings and at-tempt to find a more effective way to pay

(Continued on page 4)

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for health care. Physician organizations have argued this can be accomplished by improving coordination of care, which they hope can be achieved through the implementation of the Health Care Home section of the bill. Republicans remain committed to rely-ing on the private sector to contain costs, but remained stumped by the market’s perceived inability to deliver affordable coverage to a growing number of citizens. Democrats gen-erally believe the state has an obligation to step in and provide coverage to people when the market does not offer a viable option. Defining who potential public program enrollees are and what the role of government should be remains an evolving debate even within the Democratic Party. This health reform bill may very well save money in the long run. However, in an era of instant gratification, it is often difficult to quantify and implement long-term objectives. The question remains whether the legislation passed in 2008 will truly contribute to lower health insurance premiums in a timely fashion, and what will happen if it doesn’t.

Other BillsIn addition to the Health Reform bill and the Supplemental Budget, there were a host of other initiatives that surfaced this session. Some were successful, while others are sure to resurface.

Constitutional AmendmentIn the wake of the debate over the appropriate use of the Health Care Access Fund, Sen. Linda Berglin (DFL-61) introduced and started ac-tively pushing SF3835, which prohibits using the Health Care Access Fund to supplant gen-eral funds. Introduced late in the 2008 session, Sen. Berglin has already expressed an interest in pursuing this legislation in future years.

Prairie St. John’sLegislation requesting an exception to the hospital moratorium to build an inpatient psychiatric facility in Woodbury proved to be a bill to watch through the 2008 legislative session. At the eye of the storm was Prairie St. John’s, a Fargo-based for-profit hospital

wishing to build a new 144 bed facility in the Twin Cities. MDH reviewed Prairie St. Johns’ proposal and found the project was not in the public interest. According to Julie Sonier, Director of the Health Economics Program with the Minnesota Department of Health, there is significant room for improvement regarding the mental health system in Minnesota, but additional capacity does not fill that need. Sonier said there is currently not a need for additional mental health beds in the Twin Cities, but there is a need for additional mental health professionals. Adding another provider to the network, according to MDH, would likely have a negative impact on exist-ing hospitals’ ability to maintain their staff. These concerns were also echoed by several health systems in the Twin Cities Metropolitan Area. Additionally, the department considered the fiscal implications of the state being unable to use federal Medicaid funds for any patients treated there. Undaunted, Prairie St. John’s attacked the credibility of MDH and attempted to advance its bill regardless of the analysis. When that wasn’t successful, PSJ started asking for 66 beds. This bill eventually passed the House, but was unsuccessful in gaining comparable momentum in the Senate. While no beds were authorized, the Prairie St. John’s debate was tremendously successful in compelling legislators to have a serious discussion about the availability of mental health beds and providers in Minnesota. This is an issue that has often been paid lip service in recent years, but the bill prompted more discussion than previously seen. Missing from the discussion, however, was any reference to the role that outpatient mental health services plays in Minnesota. The dialogue is certain to continue in future sessions, and Prairie St. John’s may very well be a part of the equa-tion.

Medical Debt Privacy ActIntroduced by Rep. Diane Loeffler (DFL-59A) in the House and Sen. Linda Scheid (DFL-46) in the Senate, the Medical Debt Privacy Act would prohibit health care providers from disclosing an individual patient’s financial or medical debt information to another entity.

This bill was an initiative led by the attorney general, and its purpose was to restrict com-panies that assign credit scores to a consumer’s medical debt, and then sell that information to health care providers. Although the bill was introduced with the best of intentions, its contents had some potential negative ramifications. The attorney general’s staff attempted to alleviate the concerns of health care providers with a number of modifications, but the final product still had some problems, and was ul-timately vetoed by the governor. It is sure to return in 2009.

Modified Physical Therapist Bill Becomes LawThe legislature passed, and the governor signed into law legislation changing the requirement that physical therapists refer patients to a physi-cian after 30 consecutive days of treatment to 90 days, and requiring physical therapists to maintain communication with the referring physician. Known as the “Physical Therapist bill,” this measure in previous years deleted the physician referral requirement all together—a proposal the MMA opposed. This 90-day refer-ral compromise and ultimately the bill’s suc-cess was attributed to off session negotiations between the Physical Therapists Association, the MMA, the Minnesota Orthopedic Soci-ety and the Minnesota Academy of Family Physicians.

Moratorium on Construction of Radiation FacilitiesLegislation became law this session impos-ing a moratorium on the construction of any radiation facility located in 14 counties across the state. The new policy would not apply to the relocation or reconstruction of any facility owned by a hospital if the reloca-tion or reconstruction is within one mile of the existing facility. Legislation was passed in 2007 imposing a two-year moratorium on the construction of new radiation facilities in these counties, and this bill made the moratorium permanent.

Matthew S. Schafer, grassroots coordinator and lobbyist, Lockridge Grindal Nauen P.L.L.P.

Health Reform

(Continued from page 3)



A

East Metro and West Metro Members Flex Legislative Muscle

Capitol Rounds Connects Members with Legislators

AFTER A SUCCESSFUL Day at the Capitol inearly March, East Metro and West Metro mem-bers took the power of advocacy to the nextlevel and participated in Capitol Rounds—apersonalized, member-driven discussion withlocal legislators.

More than a dozen physicians from theTwin Cities area took the time to sit down face-to-face with their legislative representativesover the past two months to deliver a unitedmessage on protecting the Health Care AccessFund, well-reasoned health care reform, anda host of other issues. Capitol Rounds offersparticipants a chance to discuss issues, lobbyon behalf of organized medicine and developlong-term relationships with their local legisla-tors.

“I found Sen. Michel (R-Edina) to be veryopen to me as a health care professional,” re-marked Peter Dehnel, M.D. of his visit to St.Paul. “He has reached out since our visit foradvice and opinions.”

While some physicians found a role asadvisor, others got into the middle of thingslike Jack Bert, M.D. “It was great. Rep. Swails(DFL-Woodbury) asked me to be a part of apress conference on the Health Care AccessFund,” wrote Dr. Bert of his Capitol Roundsvisit. “I think getting directly involved is vital.”Later that week, Dr. Bert would publish an OpEd piece in the Star Tribune on preserving theHCAF.

Other physicians had the opportunity toget directly involved in influencing policy dur-ing their Capitol Rounds. The Minnesota Sen-ate and House recently advanced public healthand safety provisions to strengthen Minnesota’sGraduated Drivers License law. Forty-six stateshave nighttime and/or passenger restrictions toaddress the issue; Minnesota has neither. Theprovision included in the Transportation Policy

Bill (HF3800) restricts for the first six monthsthe number of passengers a newly licensed teendriver may have in their vehicle to one otherperson under the age of 20, and it prohibitsthem from driving between midnight and 5a.m. unless for work or a school function.

The day the measure was going to bedebated on the House floor, West Metromember Laurie Drill-Mellum, M.D., workedto persuade her representative, Rep. Paul Kohls,(R-Victoria), to support the bill, HF2628, totoughen Minnesota’s existing Graduated Driv-ers License law and save teen lives.

She offered her perspective as an emer-gency room physician on the bill to placerestrictions on teen drivers during the firstsix months they have their license. She toldhim that no state in the country has a higherpercentage of teenagers behind the wheel indeadly crashes than Minnesota. Previouslyuncommitted on the issue, Rep. Kohls votedwith the majority in the House that night toenact the new legislation.

This was not her first Capitol Rounds.Drill-Mellum, who is a member of the board

for MEDPAC, is no stranger to fighting forbetter public health. She played a role in secur-ing the passage of Freedom to Breathe in theLegislature last spring, and has been part ofother efforts as well.

Drill-Mellum also discussed the impor-tance of using the Health Care Access Fundto help those in need of health care, and urgedRep. Kohls to oppose using it to balance the

Nathan Noznesky, M.D. met with Representative John Berns (R) on the Minne-sota House floor. (Photo courtesy of the Minnesota House of Representatives.)

John Wust, M.D., and daughter, visitwith Representative Melissa Hortman(DFL) at MMA’s Day at the Capitol.(Photo by Scott Smith, MMA.)


budget. During her April 24 Capitol Rounds,Drill-Mellum also met with Senate MajorityLeader Larry Pogemiller, (DFL-Minneapolis)as well as her local senator, Julianne Ortman,(R-Chanhassan).

“Rep. Kohls voted with us in large partbecause of Dr. Drill-Mellum’s visit,” said MMALobbyist Sara Noznesky. “It makes a huge dif-ference when legislators hear directly from theirconstituents—especially those with the respectthat a physician garners. It clearly made thedifference.”

Participating in Capitol Rounds during the2008 session:Jack M. Bert, M.D. (Rep. Swails, DFL-

Woodbury)Peter F. Bornstein, M.D. (Rep. Garner, DFL-

Shoreview & Sen. Rummel, DFL-WhiteBear Lake)

Nadia A. Sam-Agudu, M.D. (Sen. Pariseau &Rep. Garofalo, R-Farmington)

James J. Jordan, M.D. (Sen. Cohen & Rep.Murphy, DFL-St. Paul)

Abraham K. Jacob, M.D. (Rep. Knuth,DFL-New Brighton & Sen. Chaudhary,DFL-Fridley)

Peter J. Dehnel, M.D. (Sen. Michel, R-Edina)

Amy C. Burt, D.O. (Sen. Bonoff, DFL-Min-netonka)

Lisa D. Erickson, M.D. (Rep. Hornstein,DFL-Minneapolis & Sen. Dibble, DFL-Minneapolis)

Michael D. Smith, M.D. (Rep. Hornstein,DFL-Minneapolis)

Nathan M. Noznesky, M.D. (Sen. Olson, R-Minnetrista & Rep. Berns, R-Wayzata)

Richard Morris, M.D. (Rep. Berns, R-Way-zata)

Laurie C. Drill-Mellum, M.D. (Rep. Kohls,R-Victoria & Sen. Ortman, R-Chanhassen& Sen. Pogemiller, DFL-Minneapolis)

Kristin A. Benson, M.D. (Sen. Bonoff, DFL-Minnetonka & Rep. Benson, DFL-Min-netonka)

Want to know more about CapitolRounds? To schedule your own personalizedday at the Capitol that includes a tour andmeetings with your lawmakers, contact theCapitol Rounds team at (612) 378-1875.

Capitol Rounds


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S P E C I A L T Y U P D A T E

T

The State of the Struggle Against HIV:The Good, the Bad and the Ugly

BY FRANK S. RHAME, M.D. (Continued on page 8)

TWENTY SEVEN YEARS after AIDS firstsurfaced, there continues to be rapid develop-ment in knowledge about this difficult challengeto our species. Unfortunately, while some of thenews is favorable, other findings are quite theopposite. I’ll proceed from the good to the badin this update.

The GoodThe most salutary arena is the science and biologyof HIV. In 1983 we had only an electron micro-graph. Now, this pathogen is understood betterthan any other. I’ll touch on three aspects, hopingreaders will permit me a bit of oversimplifica-tion: reconstruction of the history of HIV usinggenetic sequence analysis, recruitment of ourcellular systems in the course of viral replicationand discovery of innate antiretroviral defensessuggesting that our and our ancestral species havebeen repeatedly assaulted by retroviruses.

Comparing genetic sequences of HIV-1,group M, the cause of the global AIDS epidemic,with sequences of multiple strains of simianimmunodeficiency virus (SIV

cpz) collected from

wild chimpanzee stool have established withcertainty the ancestral virus has long been es-tablished in two of the four chimp subspecies.Furthermore, after collection of hundreds ofdifferent SIV

cpz samples from the entire range

of these two subspecies it has been shown thatdifferent sequences cluster in different locales.This is known as phylogeographic clustering. Bycomparison of these variants with HIV, it can bedetermined which SIV

cpz strain is the most like

HIV-1. It turns out that the species jump respon-sible for HIV most likely occurred in a small areaof southeastern Camaroon, just up the Congo

River from Kinshasa. The fact that the greatestvariation in HIV sequences is present in isolatesfrom Kinshasa supports the belief that the virushas been circulating the longest there. Two otherHIV-1 groups, responsible for few cases, probablyrepresent separate species jumps.

So far, three human defenses against retro-viruses have been found. Most likely we long agoevolved them to fight off retroviruses. I’ll describethe APOBEC system because two University ofMinnesota scientists, Hiroshi Matsuo and Reu-ben Harris, have been major contributors to itscharacterization. The APOBEC proteins are aseries of cytoplasmic cytidine deaminases thathad been identified independently of HIV. Byclipping an amine from cytidine they convert itto uridine. Soon after HIV was sequenced, oneof its accessory genes was found to be necessaryfor efficient HIV replication. It was named vif for“viral infectivity factor.” But how vif worked tooka decade to unravel. It turns out that one of ourABOBECs, ABOBEC3G targets retroviral RNA.It converts it into nonsense. It’s long been in ourgenome in wait for the next retroviral attack. AndHIV has acquired vif specifically to counteractthis defense!

Since HIV has only three major structuralproteins, three replicative proteins and three ac-cessory proteins, it might not be surprising thatHIV depends on our cellular systems for replica-tion. But evidence published this spring, usingsmall interfering RNAs to knock out thousandsof human proteins indicates that more than200 of our proteins might be needed. Evenmore remarkable is how these proteins are oftenspecifically recruited by HIV. For instance, theway vif works is to add ubiquitin molecules toAPOBEC3G. Ubiquitination is the universalsignal for protein destruction. Ubiquitin-dependent degradation utilizes cytosolic systemsto efficiently cart marked proteins off to the pro-teosome for destruction and recycling. Anyonewho imagines that HIV was manufactureddecades ago out of malevolence has no idea howcomplex this virus is. It uses systems that werewholly unknown even a few years ago.

Also falling into the “good” category is theremarkable advancement in antiretroviral therapy.Say what you will about Pharma, there has beensteady advancement in treatment. I would havelost a bet made three years ago that there would besignificant improvement in antiretrovirals. Afterwatching nothing but death from 1981 to 1996,what we had three years ago seemed remarkablygood. But even in the last year we’ve had licensureof three new drugs that have much reduced toxic-ity and improved efficacy: raltegravir (Isentress),etravirine (Intellence) and maraviroc (Selzentry).Etravirine and darunavir (Prezista) are importantadvancements within the original three antiret-roviral drug classes. Raltegravir and maravirocobstruct HIV replication in brand new ways; noHIVs could have had resistance prior to theirusage.


Specialty Update


I’m now convinced that patients who have HIV strains with little resistance who also take their meds well will not die of HIV in the former way: progressive CD4 cell depletion with im-munosuppression and opportunistic infection. To be sure I can’t be certain without more time. And HIV positive persons do seem to get many of the ills that afflict us all at a more rapid rate: arteriosclerotic cardiovascular disease, a tendency to diabetes, bone mineral loss. Whether this is due to HIV itself, the antiretrovirals or both is under active investigation.

The BadInto the “bad” category, I’ll put two elements: achieving timely detection and treatment and transmission prevention. Even in Minnesota we are too often late in diagnosing HIV infection. In spite of all the publicity about HIV, as much as 40 percent of HIV positive Minnesotans don’t know of their diagnosis. In 2007, 96 Minnesotans were first diagnosed HIV positive at the stage of AIDS (30 percent of all new HIV diagnoses). Every one of these diagnoses is a failure: a prop-erly managed HIV infection is diagnosed and treated long before the CD4 count gets into the hazardous range or any HIV-associated symp-toms occur. The failures are multiple: patients who know of their risks who don’t seek testing and health care systems that don’t recognize risk histories and promote testing. Even more disturbing, 63 patients who already had an HIV diagnosis progressed to AIDS (40 percent of all AIDS diagnoses). These cases represent failure to get treatment started at the right time. With respect to prevention of HIV trans-mission, we have two solid achievements: preven-tion of transfusion transmission and substantial reduction in mother-to-child transmission. In the U.S., the addition of nucleic acid testing (NAT) to antibody testing has largely eliminated trans-mission during the “window period” between infection and the development of anti-HIV antibody. NAT has been made economical by the testing of 20 unit pools. Aggressive testing of all pregnant women and strong intervention programs to achieve high rates of antiretroviral treatment of HIV positive pregnant women have brought the transmission rate to <1 per-cent of pregnant women. In Minnesota, we’ve

had only five mother-to-child transmissions in the last eight years. Rates of HIV transmission by needle transmission have also been sharply reduced—there’s little disincentive to using clean works. But rates of sexual HIV transmission remain depressingly high. HIV is an infection that should never occur. Sexual restraint and use of condoms should rapidly eliminate it. But HIV successfully exploits powerful human impulses. In fact, the CDC is about to declare an increased national incidence of new HIV infection. Rates of chla-mydia, gonorrhea and syphilis remain high. Our ability to change behavior is dismal.

The UglyI have two entrants into the “ugly” category: the underdeveloped world and vaccination. HIV has always been a probe for many things: attitudes to sexuality, homophobia, and access to health care, to name a few. Likewise it sharply illustrates the disparities in the provision of health services in the prosperous and non-prosperous worlds. In sub-Saharan Africa to a great extent and in the former Soviet states, South & Central America and much of Asia to a lesser extent, antiretrovi-rals are unavailable for a large fraction of those persons who need them, response monitoring by viral load testing is unavailable and second line regimens are non-existent. This is true not-with-standing large donations from the U.S. and Europe. President Bush, for all the dissatisfactions many find in him, has, in fact, successfully pushed for large U.S. donations. The President’s Emer-gency Plan for AIDS Relief (PEPFAR) will have provided $28B by the end of 2008 and is seeking $30B more. This support may well be one of the most positive aspects of his legacy. The vaccine situation is indisputably ugly. Last September a large randomized trial of a promising vaccine consisting of three HIV genes in an adenovirus carrier was halted for lack of ef-ficacy. Even worse, there was greater rate, possibly statistically significant, of infection in recipients who had pre-existing adenovirus antibody. This has prompted great soul searching in the HIV vaccine investigators’ community. Many feel that our understanding of what it will take to produce a successful vaccine is so lacking that we should shift resources to basic science. The NIH has been roughly dividing funds 50:50 between basic sci-

ence and clinical trials. Undoubtedly, there will be a change. We need to recognize that a successful vac-cine may not be possible. Vaccines against viral infection generally don’t prevent early, silent re-infection. Recipients of measles vaccine get re-infection on re-exposure. A few viral replica-tions occur, but the immune response is prompt. The exposed person doesn’t get ill; there is just a boost in antibody titer. But that may not be good enough for HIV. All the immunity we can muster doesn’t seem to keep it from killing us. A vaccine may never prevent the first few HIV replications and that may be all HIV needs. Many HIV “superinfections” (HIV infection with a new strain in a person already infected by a different strain) have now been described, to reinforce the point. It’s hard to imagine how a vaccine could better stimulate immunity than a natural infec-tion. If that’s not good enough to prevent a new infection, what could be? On a personal note, as a physician involved in HIV care and research from the beginning, this has been an amazing experience. I can’t imagine anything scientifically more exciting. I’ve seen HIV bring out the best in many and the worst in others. The patients I’ve worked with —success-fully and not—have been wonderful, frustrating, inspirational, instructive, entertaining, demand-ing, grateful and generous. And it doesn’t look like the pace of change is going to slow down for a good long while.

Frank Rhame, M.D. received his medical degree from Columbia University’s College of Physicians and Surgeons, did internal medicine residency train-ing at Harlem Hospital Center, the University of Michigan Hospital and Stanford Hospital and In-fectious Diseases fellowship at Stanford University. He served for two years in the Epidemic Intelligence Service at the Centers for Disease Control. He joined the University of Minnesota faculty in 1979 rising to Associate Professorship with tenure; he is now an Ad-junct Professor in Infectious Diseases, Department of Medicine, School of Medicine and an Adjunct Associate Professor in the Division of Epidemiol-ogy, School of Public Health. He established the HIV Clinic at the University Hospital in 1987. In 1996, he moved to the Allina Medical Clinic – The Doctors and the Infectious Diseases Clinic at Abbott Northwestern Hospital, where he maintains an ac-tive research program in HIV treatment.


F

Reinventing Primary Care

BY DAVID W. ALLEN, JR.

FOR PRIMARY CARE, change is in the air. Itis not simply the evolution of time or even thewinds of a political season; it is a deep, organicchange growing out of the very foundations ofour health care system. Change is coming toprimary care and it is inevitable.

The change will be nothing short of atransformation. The patient relationship, therole of the primary care physician, reimburse-ment for primary care, and relationshipswith specialists and facilities — all will besubstantially different in the coming years.This article describes why these changes willoccur, speculates about key characteristics ofthe transformation, and suggests what primarycare organizations should be doing now to pre-pare.

Primary care will transform becauseit must. The first force requiring change isthat the supply of primary care physicians isinsufficient to meet demand. People seekingthe services of a primary care physician havea hard time finding one who will accept newpatients, especially if their insurance coveragedoes not reimburse well. According to U.S.News & World Report, in 2007, 29 percent ofpeople covered by Medicare reported troublefinding a primary care physician willing to ac-cept them—up from 24 percent in 2006. A2006 California HealthCare Foundation sur-vey suggests that almost one-half of emergencyroom patients could have been cared for bya primary care physician and that difficultygetting a physician appointment was the mostfrequent excuse for using the ER instead. Pro-jections by the U.S. Department of Health andHuman Services suggest that the shortage ofprimary care physicians will get worse, notbetter, in the coming years (see Table 1).

Yet it is not simply a shortage of primary

care physicians forcing change; it is a funda-mental deficiency in the way primary care isprovided. Service is often abominable in com-parison to the service levels of other professionsor, for that matter, most other industries. Ap-pointments may not be available for weeks,locations are frequently inconvenient, parkingis often a problem, and many find that theuncertainty of when their appointment willstart and finish leads them to take a half dayoff from work for what may turn out to be a15 minute appointment.

In addition to the service deficiencies as-sociated with the current way primary care isdelivered are quality deficiencies. For many pri-mary care physicians, the pressure to produceRVU’s (Relative Value Units) limits the timethat can be spent with any individual patient.Patients with multiple or complex problems,patients who have trouble understanding, orpatients needing education or guidance (inother words, most patients) get inadequateattention. Perhaps the most serious qualityissue is the emphasis on dealing with the im-mediate problem at hand, at the expense oflong-term issues like prevention and wellness;many physicians see their role as treating a dis-ease or condition, rather thanhelping a patient avoid futureproblems.

Certainly, the finger ofblame for the problems in pri-mary care can be pointed inmany directions. Primary carephysicians are, to a large extent,prisoners of a system that givesthem little opportunity to fixthese problems. The prevalentprocedural-based reimburse-ment structure leaves littlealternative to primary carephysicians but to endeavor

to see high volumes of patients as quickly aspossible. Additionally, the sizeable number ofpeople without insurance or the ability to payfor care combined with the low reimbursementfrom government programs leads many physi-cians to avoid accepting new patients who don’thave private insurance.

The fact is that no one is being well servedby the current primary care situation. Physi-cians would undoubtedly be happier if theycould spend more time with each patient, carefor them more completely, and be better com-pensated as well. Patients generally like theirphysicians, but are deeply concerned aboutthe costs of health care, access to services andservice levels. Health plans recognize that theyare an integral part of a system that is not cost-effective and does not deliver good quality orservice. Employer sponsors of health plans arefrustrated with rising costs and perceptions ofpoor value. The government is facing a crisis asthe cost of programs like Medicare and Med-icaid consume ever-larger portions of our taxdollars. And all of us are concerned about howto care for people who don’t have insurance orthe means to pay for care.


Source: “Physician Supply and Demand: Projections to 2020”; U.S.Department of Health and Human Services, Health Resources andServices Administration, Bureau of Health Professions; October 2006.

Table 1: Primary Care Physician (PCP)Supply and Demand

PCPPhysician

Supply

PCPPhysicianDemand Shortage

2000 214,810 267,100 (52,290)2005 228,660 281,800 (53,140)2010 244,370 297,500 (53,130)2015 259,910 316,300 (56,390)2020 271,440 337,400 (65,960)


Collectively, these are the conditions that will force primary care to transform. This transformation will come from two directions: first, from payers changing reimbursement and contracting methods, and second from physi-cians or health systems proactively changing their method of delivery. Payers are starting to change the way they reimburse and contract with primary care pro-viders. One large Minnesota health plan has initiated several pilot projects to compensate primary care physicians directly for doing “disease management” (engaging, educating and coaching patients on the management of chronic health conditions) — instead of relying on the more widespread practice of having an internal health plan department or separate organization perform this function. At least one large Twin Cities’ employer is in negotiations with a primary care organization to open a work site clinic for the purpose of providing employees and dependents more ac-cessible care. The Institute for Clinical Systems Improvement (ICSI), a collaboration between health plans and clinical groups, is currently promoting the DIAMOND project as an effort to pay primary care physicians a fixed monthly coordination fee for managing patients diag-nosed with depression. At this writing, the Minnesota Legislature is in negotiations with the governor regarding legislation that would introduce per-patient monthly care coordina-tion fees, payable to primary care physicians, for MinnesotaCare insureds that enroll in a primary care “medical home.” In the long run, it will probably be the actions of those who provide health care services who actually effect the greatest trans-formation. In addition to responding to the opportunities brought to them by the payer community, change is occurring within pri-mary care. Academic medicine is promoting the medical home concept as a way to put the primary care physician with their patients at the center of all medical care. New ancillary primary care givers are entering the scene, such as the new doctoral level nurse practitioner. And new business models are also joining the party, with convenience care centers staffed by nurse practitioners sprouting up in pharmacies and other retail outlets across the country. As this transformation occurs, here are

some of the changes we believe primary care physicians will see: The role of the primary care physician will

evolve to become the captain of a team of caregivers.

The physician-patient relationship will be restored to a more permanent and holistic status as the medical home develops to be-come the dominant primary care treatment model.Wellness, prevention and management of chronic health needs will become as important to primary care physicians as providing episodic care.Physician extenders will provide much of the routine care to patients, sometimes at other locations such as work sites or retail outlets.Care Coordinators will play an important role in maintaining communications with patients and keeping them engaged in managing their health.Care Tracks staffed by ancillary person-nel following protocols and supervised by primary care physicians (for individual patients) and specialists (for the overall pro-tocol) will manage a myriad of health issues (e.g., diet and exercise, nicotine addiction, diabetes, depression, chemical dependency, asthma and allergies, spine care, pain man-agement, and healthy heart care).Home Visits will be an important treat-ment option for many primary care teams and telemedicine devices will be used to monitor at-home patients’ health metrics.Electronic Health Records will become an essential tool for keeping the primary care physician informed and communicating information between team members and locations.Reimbursement will evolve as health plan sponsors partner with providers (e.g., to promote wellness or manage chronic dis-ease), health plans move disease manage-ment back to primary care, and patients themselves increasingly pay out-of-pocket for what they perceive as superior value.Compensation of primary care physicians will increase as they transform from being cogs in a production machine to becoming lead caregivers for a panel of patients.

As more primary care is delivered in this way, a tipping point may be reached and all of health care could be affected. Emergency de-

partments may operate at much lower volumes as primary care provides 24/7 access for urgent care. Certain specialty services and facilities may also see declines in volume as prevention has its effect and treatment becomes more con-servative. Competition between primary care teams may become focused at a market niche level, such as by geography, age, gender, health issues, language or ethnicity. Service levels may become an important competitive factor; ap-pointments may not be required for many services and some care teams will compete by offering value-added benefits like transporta-tion, exercise facilities or dietary programs. Implementation of a significantly differ-ent form of primary care will not be easy for any health care organization. Full transforma-tion will impact a wide cross-section of clini-cal, administrative, staffing, financial, facilities, marketing and informatics systems. The saving grace is that complete transformation is not something that can or should occur immedi-ately. Transformation will be gradual, allowing systems a chance to evolve and, importantly, changes in the way primary care is reimbursed to keep pace. The essential task at this time for a primary care organization is to develop and begin implementing a plan that maps the critical path from the present to the future. Primary care physicians who recognize the inevitability of this transformation and act first to embrace, plan and implement it will have a significant advantage in the marketplace. It will be difficult for physicians who fail to prepare to catch up later, as the first movers secure contracts and employ the available ancillary work force. Change is always difficult and often unpleasant. The changes that will be occur-ring in primary care, however, are desperately needed. These changes will help address the shortage of primary care physicians by allow-ing an individual physician to oversee care for a larger population of patients. These changes will improve the quality, accessibility, service levels and value of primary care. Primary care physicians should embrace these changes not only for these reasons, but also because they should make being a primary care physician more fulfilling and rewarding.

David W. Allen, Jr. is a managing partner and consultant with The Chancellor Group, LLC, a consulting firm that helps health care organiza-tions implement and cope with change. He can be reached at (952) 746-1309.

Reinventing Primary Care



Y O U R V O I C E

What About Single Payer?An Answer to the Question About How to Reform Our Health Care System

BY EDWARD P. EHLINGER, M.D. , MSPH,AND SUSANNE KING, M.D.

In discussions of health care reform, consensus is rapidly develop-ing around the urgent need for universal health care coverage inthe United States. There is also an almost universal understand-

ing that this coverage is not feasible without cost containment. Giventhe facts that over 47 million people in the U.S. are uninsured andan even greater number are underinsured and that the percentage ofthe U.S. Gross Domestic Product (GDP) going to health care is over16 percent, it’s not surprising that the issues of access and cost havebecome priority issues in our country.

An increasing number of health care professionals and policymakers are claiming that a single-payer system is the only rational ap-proach that can actually contain costs, achieve universal coverage, andmaintain or improve quality. They argue that only a single-payer ap-proach can address the economic pressure on businesses and the risingcosts of health care for individuals and still be able to expand coverageto everyone. However, these statements are guaranteed to bring fortha series of questions about single payer. Here are responses to some ofthe questions that are frequently raised.

1) What is single-payer health care?“Single payer” means that there is one payer— one insurer—who re-imburses health care providers for their services. This is in contrast tothe current system that provides payment through multiple insurancecompanies. This one payer has the authority to negotiate limits onwhat providers, pharmaceutical companies, and equipment manufac-turers charge just as insurance companies do now. This payer couldbe either the state or the federal government. Every industrializedcountry in the world, other than the U.S., has some form of nation-ally administered health coverage. Medicare is a single-payer systemthat has been in place in the U.S. since 1966. However, Medicare isa less than ideal single-payer system because it cannot set budgets forhospitals nor negotiate prices with pharmaceutical companies.

2) Is single payer socialized medicine?Single payer is not socialized medicine because hospitals and clinicswould still be privately owned, rather than owned by the government,

and doctors would still be in private practice. “Single payer” simplyrefers to the taking in and paying out of the health care dollars, whichwould replace the current multiple-payer system dominated by privateinsurance companies. Single payer refers to the mechanism used topay for health care services not how the services are delivered. Manyindustrialized countries have a single-payer system; some provideservices through a national health service, but most provide servicesthrough physicians in private practice. All of the leading single-payerbills introduced in the U.S. at the federal and state level would leavethe health care provider sector in the hands of private practitioners.

3) Doesn’t Medicare have big problems?Traditional Medicare has worked very well for patients and they havebeen happy with it. Because the traditional Medicare program spendsa lot less money on administrative functions than private-sector insur-ers, Medicare is the most efficient health insurance program, publicor private, in America. However, the partial privatization of Medicaresince the 1980s and the recent total privatization of the Medicaredrug benefit have raised costs and brought prosperity to many healthplans and insurance companies. Their administrative costs have cre-ated an economic burden for the program of billions of dollars peryear. Subsequently, payments to doctors, the actual providers of care,have been cut.

In many ways it is the actual need for Medicare that is caus-ing some concern. As the U.S. population ages, there will be anincrease in demand for Medicare services. That means there will bean increased need for funding to provide those services. This is not acrisis but a predictable occurrence that needs to be addressed by policymakers and health care planners.

There is a need to find a way to finance that increase in services.Reducing administrative waste through a single payer would be one ofthe mechanisms of doing that. Funding Medicare Part B (which is theprimary revenue source for the physician and drug parts of Medicare)from general revenues rather than payroll taxes would also help elimi-nate the illusion that somehow Medicare Part B could “go bankrupt.”Imminent bankruptcy is never a concern for government programs,like the Pentagon, which are financed by general revenues.



Your Voice


4) Can we afford single payer, if that means covering 47 million uninsured people?Compared to other countries, the United States already pays enough to provide comprehensive coverage for everyone. However, cover-age for everyone isn’t realized because 31 percent of our health care spending goes for administration through the patchwork of private for-profit and not-for-profit insurance companies and health plans. Potential savings from eliminating the administrative waste and mar-keting expenditures of insurance carriers have been estimated at $350 billion per year.

5) Won’t there be waiting lines or rationing with single payer?A poll done in the late 1990s showed that rationing was worse in the United States than in Canada, which has a single-payer system. At that time, 12 percent of Americans said they couldn’t get necessary health care in the previous year compared to 8 percent of Canadians. In 2005, the median wait for specialists or elective surgery was four weeks. A 2007 study highlighted the fact that 37 percent of Ameri-cans reported being unable to get necessary medical care “because of cost during the past year” versus 12 percent in Canada. The United States already rations care based on ability to pay and 18,000 Americans die every year because they lack health insurance. Canadians live longer and are more satisfied with their health care than Americans, while paying half as much per person. If waiting problems in Canada are an issue, it’s because the health care system is underfunded rather than because it is single payer. No single-payer ad-vocate is proposing that the United States lower health care spending to Canadian levels.

6) Won’t our aging population break the bank in a single-payer system?Japan and European countries have a higher percentage of elderly citizens, yet they spend much less on health care than we do— andhave better outcomes. Universal access to health care will improve the health of the population. The issue is what is the best way to get to that universal access in a way that is economically sustainable? A single-payer approach is the most likely approach to achieve that goal. A single-payer system that provides universal access would also be better able to address the lifestyle and behavior issues, like obesity and tobacco and alcohol use that are major contributors to health care costs.

7) Some people believe that their insurance is meeting their needs; why should they change?While some people may be comfortable with their present insurance coverage, that coverage is unstable and often inadequate when it is most needed. Because our current system is tied to employment, if people change or lose jobs, their coverage and care is disrupted. Oth-

ers find their coverage fails when they get sick: 75 percent of the one million Americans experiencing medical bankruptcy each year were insured when they got sick. Insurance premiums are going up every year for policies that cover less and less.

8) How would single payer be financed?There are a variety of ways that a single-payer system could be financed. Currently, about 60 percent of our health care system is publicly financed (via our taxes), 20 percent is financed by private employers, and 20 percent is financed by individuals. With a state or national single-payer health program, that funding formula could be maintained as a way to finance universal access. Another option would be a payroll tax on employers (approxi-mately 7 percent) and an income tax on individuals (approximately 2 percent). The payroll tax would replace all other employer expenses for employee health care. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and any other out-of-pocket payments. For the vast majority of people, a 2 percent income tax is less than what they now pay for insurance premiums and out-of-pocket payments. This is particularly true for anyone who has had a serious illness or has a family member with a serious illness. Small employers would also benefit from this payroll tax approach since many now have to pay 25 percent or more of payroll for health insurance compared to the 8.5 percent currently paid by large em-ployers. While most people and businesses would pay less with a single-payer approach, everyone would have more comprehensive coverage. In addition to medical care and drugs, benefits would include mental health care, dental care, and long-term care.

9) Who would run a single-payer plan?It is a myth that with national health insurance the government will be making the medical decisions. The government would only be the administrator of the health care funds. In a publicly financed, uni-versal health care system, medical decisions are left to the patient and doctor. Cost containment measures like negotiating limits on what providers, pharmaceutical companies, and equipment manufacturers could charge would be publicly managed by an elected and appointed body. This body, in consultation with medical experts in all fields of medicine, would decide on the benefit package, negotiate doctor fees and hospital budgets, and be responsible for health planning and the distribution of expensive technology. Right now, insurance companies make many health care decisions behind closed doors. Their primary interest is in profits, not the health of the people.

10) Won’t doctors dislike a single-payer system?Because of its administrative burdens and the hurdles to care created by insurance companies, most physicians are very dissatisfied with the current health care system. Physicians would like to make medical decisions with their patients, without the intrusion of profit-moti-vated insurance companies. In addition, when patients are unable to


pay because they are uninsured or underinsured, doctors often providecare for which they don’t get reimbursed. More and more physiciangroups are also supporting single payer.

In 2007, almost 60 percent of physicians supported govern-ment legislation to establish National Health Insurance—a 10percent increase in support since 2002. This level of support is similarto that found among physicians in Minnesota and Massachusettswhere two-thirds of physicians support single payer. This increasein support for National Health Insurance is distributed across everymedical specialty. The largest increase was seen among physicians who“strongly support” National Health Insurance; now almost twice asmany physicians support it as oppose it. It has been reported that thenumber of physicians currently supporting National Health Insuranceis much larger than the entire membership of the American MedicalAssociation.

In addition to individual physicians, a single-payer approach issupported by multiple professional organizations like the AmericanCollege of Physicians, the American Medical Student Association, theNational Medical Association, the American Public Health Associa-tion, and the American Nurses Association to name just a few.

11) How would we get to a single-payer system?There are multiple paths to achieving a single-payer system. The mostlogical would be to develop an expanded and improved “Medicare

for all” approach at the national level. National single-payer legisla-tion (HR676) has been introduced and has more supporters than anyother proposal for health care reform.

While a full-scale conversion seems unlikely in the short-term,there are steps that could move the country and states in that direc-tion. One approach at the national level would be to add children toMedicare followed by adults. In Minnesota, single-payer legislationcould be adopted for children with adults gradually added. AnotherMinnesota option would be to open MinnesotaCare to small employ-ers and individuals and then expand it to large employers.

Single-payer legislation for Minnesota (SF2324) has beenintroduced in the Minnesota legislature by Senator John Marty andhas garnered a great deal of support. In Canada, single-payer healthlegislation was introduced province by province, rather than at thenational level which gives credence to this state-based approach as away of moving toward a national single-payer system in the U.S.

Support for single-payer health care is increasing as people learnabout the benefits of this solution for our ill-conceived health caresystem.

Edward P. Ehlinger, M.D., MSPH is the director of Boynton HealthService in Minneapolis, MN. Susanne L. King, M.D. is a child andadolescent psychiatrist in Lenox, Massachusetts.

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The Promises—and Perils—of Electronic Health Records

IMAGINE THE FOLLOWING courtroom scenario played out in the life of one of your close associates:

Plaintiff ’s Attorney: “Dr. Smith, you per-formed a pre-operative exam on this child prior to his dental cleaning and extraction on December 10, 2007, is that correct?”

Dr. Smith: “Yes, the record indicates that I did.”

Attorney: “And on the pre-operative form, you failed to mention that the child had a congenital heart condition that necessitated the use of antibiotic prophylaxis before dental work, is that correct?”

Dr. Smith: “That is correct.”

Attorney: “Why is that Dr. Smith? It is infor-mation clearly indicated on the consultant’s report that is contained within your electronic health record.”

Dr. Smith: “I was unaware of that consultant’s report at the time that I filled out the form.”

Attorney: “Doctor, do you not thoroughly review the record at the time that you are fill-ing out a form as important as a pre-operative exam, especially for a child that has a number of underlying medical conditions such as my client?”

Dr. Smith: “The consultant’s report I got was, I will use the term, electronically buried within our record and there was not a way to even

know it was there, much less review it at the time of the pre-op examination.”

Attorney: “How does a report of this impor-tance get buried within what should be a much safer system than a paper-based chart?”

Dr. Smith: “The report gets scanned in as a JPEG image into our electronic record, without a standardized way to catalog the nature or source of the report. It was also scanned in on the same day as some physical therapy autho-rization and an orthopedic report, and the per-son who scanned in the document combined them all together as a single document.”

Attorney: “What is the training level of the person you have scanning in these important documents?”

Dr. Smith: “It is a high school graduate we’ve hired to do the work of scanning in docu-ments.”

Attorney: “And so, Dr. Smith, as you sit there today, can you defend to this court or my client’s family why you chose to delegate such an important job to someone with no medical training?”

Dr. Smith: “We are a small practice and the electronic record has been very costly, far be-yond the initial purchase of the equipment. We couldn’t afford anyone else, and even if we had hired someone with a medical background, there is not a way to incorporate outside docu-ments in a way that effectively catalogues their source and diagnosis.”

Attorney: “Does this also account for why you did not include any mention from the hema-tologist about the inherited clotting disorder and the child’s likely predisposition to throm-botic events at the time of anesthesia?”

Dr. Smith: “That one is a little more compli-cated. We had some original reports from the hematologist about the child’s iron deficiency anemia, and that history, as you will notice, was included on the pre-op form. The Factor V – Leiden mutation report was on a letter that was inadvertently shredded prior to get-ting scanned into our system. Someone in the office must have thought that it was simply a duplicated report and would take up excessive memory within our system.”

Attorney: “So Dr. Smith, do you have any-thing else to say to this family whose child has suffered the complications of bacterial endocarditis and a major stroke related to a dental procedure under anesthesia?”

Dr. Smith: “I am so terribly, terribly sorry. If we had been using our old paper-based sys-tem, this would not have happened to your child………..”

Electronic health records (EHRs) are going to happen, regardless of what any of us in the medical field say. It “happened” in my own BY PETER DEHNEL, M.D.


office nine months ago. At this point in theirdevelopment, however, EHRs are not goingto automatically bring increased patient safety,efficiency and effectiveness of care or significantcost savings. All of these are, however, assumedin the popular press and in legislative bodies atboth the state and federal level. These systemsare expensive, both in terms of purchase andinitial training as well as the required constant“tweaking” for their continued performance.Interoperability is still a distant promise—in-formation cannot flow easily between differentsystems at this point. Security and privacy arechallenges yet to be mastered. Interacting witha patient is now at least partially replaced byinteracting with a laptop in the exam room.Finally, significant problems with “wrong sitedsurgery” can remain in spite of the establisheduse of electronic records.

This assessment comes to you by someonewho has also seen the very best side of an elec-tronic system. Through my 11-year experiencewith a nurse triage service that uses a comput-erized decision support system and electronicpatient record, I have seen that patient carecan be almost “mistake-free.” The collective

experience of pediatric nurse triage programsacross the country over the last several yearsthat utilize this technology has resulted in liter-ally several million telephone care encounterswithout even one serious adverse patient out-come. That is beyond “six sigma” in terms ofquality of care and is on par with the safety ofcommercial airliners and nuclear power plants.This level of quality has not been automatic oreasy. This has taken the very hard and dedicatedwork of many committed professionals bothwithin health care as well as in IT services. Eventhen, the scope of this care is limited relativeto what we encounter within a primary careoffice on a day-to-day basis.

So what is the take home message of this“personal reflection”? Electronic records arealmost as certain as death and taxes, and canbe just as painful. While there is a significantfuture “upside” potential to patient safety, weare a long way from the functionality thatis currently assumed by politicians and thepublic. The complexity of electronic-basedquality patient care is far greater than anyother information systems application ineither business or government. Even the full

extent of the complexity is yet to be defined,much less mastered.

At the end of the day, my personal opinionis that this is a challenge that we, as physicians,must embrace to ensure that it meets the needsof the patients that we serve. There is no oneelse who can do that for us, for this is a profes-sional responsibility that is uniquely ours.

Peter Dehnel, M.D., is the medical director forChildren’s Physician Network and is in privatepractice at All About Children Pediatrics, EdenPrairie.

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Universal Pediatric Influenza Vaccination—How Will We Accomplish This?

BY PATRICIA K. STINCHFIELD,RN, MS, CPNP

BEGINNING THIS FALL, annual influenzavaccine is recommended for ALL children, 6months to 18 years of age unless they haveegg allergy or other medical contraindication.1

This historic vote was taken by the Center forDisease Control’s Advisory Committee on Im-munization Practices (ACIP), on February 27,2008. One of the main points discussed wasthe issue of implementation of such a sweepingpolicy. How will we accomplish this?

I had the honor of being one of the 15

members to vote for this new recommendationthat moves us closer to a universal influenzarecommendation for all American’s, regardlessof age or risk. I was convinced we had metthe major hurdles of establishing the diseaseburden (need), the efficacy and safety of annualinfluenza vaccine in children, and the manufac-turers’ ability to create adequate vaccine supplyto meet demand (a record high of 130 milliondoses will be available in 2009-2010).2 Thelast hurdle that was greatly discussed at theACIP as well as the National Influenza Summitwas implementation of the policy. Questionsincluded: “Who will vaccinate every child inAmerica? Medical home? Schools?”; “Howwill we accomplish this in such a short time?”;and “How will we communicate with patientsabout this change in policy?”

In actuality, many clinics are reachingmost of these patients who are in the cur-rent age recommendation (6-59 months,have high risk conditions or are householdcontacts — siblings — of these high prioritypatients). Many clinics in the Twin Citiesalready provide influenza vaccine to all chil-dren. This new recommendation now affordsinsurance and government coverage throughthe Vaccine For Children (VFC) program.

For those clinics that have not begun tovaccinate all children in their practice, thereare many specific interventions we can engagein to immunize all children against influenzaannually. They include:1. Change the paradigm about influenzavaccine being a late fall activity only. We mustextend the vaccination season in the front endby beginning to vaccinate all children as soonas we receive vaccine, which manufacturers tellus will begin as early as August and September.Also, extend the season by vaccinating throughthe entire influenza season. In Minnesota, ourseason peaks in February but can be present

well into April and May as is noted for thisyear with sporadic influenza.3

2. Reduce missed opportunities to vacci-nate. Consider all visits an influenza vaccinevisit from late summer through spring. If not tovaccinate, a discussion about influenza vaccineand the need to make an appointment for oneshould be a year-round conversation. Vaccinat-ing hospitalized patients prior to discharge isalso effective.3. Use multiple creative approaches to pro-vide influenza vaccine. In addition to vaccinat-ing during well-child checks and scheduled illvisits, consider “vaccine-only visits” which areparallel track vaccine appointments during regu-lar clinic hours. Special evening and weekendhours or large mass influenza vaccine onlyclinics are an efficient way to reach numerouspatients. Standing orders, a reminder/recall sys-tem and strong provider recommendations areproven ways to increase immunization rates.4

4. Communicate well with patients. Thiscan be done through reminder post-cards, amessage on the appointment line as patientswait, posters in waiting rooms stating howyour clinic advocates influenza vaccine, andan influenza information line during the peakof influenza season that gives updated infor-mation about supplies, clinic times, etc. are allhelpful ways to increase demand.1. Tentative MMWR publication scheduled for June, 2008.2. National Influenza Summit presentation, May 12, 2008.

Euler, Gary, Dr.Ph, MPH.3. Minnesota Department of Health Influenza Web site

at http://www.health.state.mn.us/divs/idepc/diseases/flu/stats/index.html).

4. Centers for Disease Control and Prevention (CDC).Vaccine-preventable diseases: improving vaccinationcoverage in children, adolescents, and adults: a reporton recommendations of the Task Force on CommunityPreventive Services. MMWR Morb Mortal Wkly Rep1999: 48(RR08): 1-16.

Patricia K. Stinchfield, RN, MS, CPNP, directorInfectious Disease & Immunology Infection ControlChildren’s Hospitals and Clinics of Minnesota.


AQ

Jon S. Hallberg, M.D.

C O L L E A G U E I N T E R V I E W

What was your major in college?

I majored in chemistry, though I really consider myself a liberal arts major.Like many of my freshman classmates, I went to St. Olaf College as apre-med, and, like some, I was freaked out by all the competition. I spentmy first year taking care of a lot of distribution requirements rather thantypical pre-med classes. Then in the summer of 1985, my grandfatherdied. It was that experience that convinced me I had to pursue medicine.I was a little behind with the courses I needed, but I found that if I ma-jored in chemistry I could take care of a lot of the required courses, geta major, and still have room for a lot of electives. Most of those electiveswere in English, biology and religion, and some of my absolute favorite(and most applicable) courses were Expository Writing, Poetry, ReligiousTraditions of the World, and Shakespeare Seminar.

Your medical career has been unique. Have you had anyrole models for the path you are taking? If so, who are they?

I’ve had (and have) a lot of role models. Since starting med school, I’vealways admired the physician-writers and the physician-poets —indeed,all physicians who live in “two worlds,” the world of medicine and thesciences and the world of the arts and humanities. My early heroes

were Lewis Thomas, David Hilfiker, William Carlos Williams, RichardSelzer, Oliver Sacks, Gerald Weisman, and Sherwin Nuland. Lately,I’ve been inspired by Rafael Campo, Pauline Chen, Danielle Ofri, andDavid Watts.

But I’ve also been inspired by physicians who “simply” practice theart of medicine. These heroes include my medical school advisor, NancyBaker; residency teachers like Greg Gepner and Patricia Fontaine; my firstpractice colleagues Jerry Mullin and Bill Hedrick; consultant colleagueslike Dan Zydovicz, Vic Sandler, Dan Stein, and the late Tom Cheng;and med school colleagues like Greg Vercelotti. From them I learnedand saw how to practice, how to listen, and how to care.

Given that you were in the RPAP program, I assume thatyou were, at one time, considering a more rural practice.What caused you to change that plan?

Well, I was born in New Ulm and lived there for almost eight years. ThenI lived in Northfield for college. So I felt that living and practicing in asmaller community (especially a small college town) was a very real pos-sibility. I also knew that RPAP was one of the jewels in the crown of themed school; I really wanted to participate in that amazing program.

At some point during residency, I realized that for my wife, a banddirector, to have the best possible job opportunities and flexibility, we’dneed to be in the Cities. I also realized that I wasn’t going to do OB, andI was starting to get interested in caring for the creative and performingarts communities.

Jon S. Hallberg, M.D. received his medical degree from the Universityof Minnesota and was a participant in the Rural Physician AssociateProgram (RPAP). He completed his residency at the Department ofFamily Medicine and Community Health, Riverside-University Fam-ily Practice (Smiley’s) Unit, University of Minnesota, Minneapolisand served as a Bush Medical Fellow. He is board certified in familymedicine. Dr. Hallberg is an assistant professor, Department of FamilyMedicine and Community Health, University of Minnesota and co-founder and creative director, Center for Arts and Medicine, Universityof Minnesota. Dr. Hallberg is a regular health and medical analyst onthe regional All Things Considered, Minnesota Public Radio. Hisperforming arts medicine includes clinic and on-call coverage for: theGuthrie Theater, Historic Hennepin Theater Trust, JAM Produc-tions, Minnesota Opera, Minnesota Orchestra, Northrup Dance Series,Ordway Center for the Performing Arts, St. Paul Chamber Orchestraand ValleyFair.

Questions were provided by: Drs. Lee Beecher, Kathleen Brooks,Edward Ehlinger and Jo Ann Wood.



You have an impressive CV and you’ve done a variety of things…but I’m wondering, can you read a map? (This is an “in-joke” with some of the folks who went with him to help with Hurricane Katrina.)

Yes! I’ve always loved geography and maps. I think I get this from my dad and from living in Belgium as a child (from 1973-76). Virtually every weekend and every school break we’d travel somewhere in Western Europe. My wife (jokingly) calls me “compelius,” god of directions, for my uncanny ability to find places I’ve never been, to find shortcuts I’ve never taken, to get un-lost. When I was in Louisiana, providing relief after hurricane Katrina, I was dubbed (affectionately, I hope!) “Map Boy” by my team. I loved riding shotgun and being the team’s navigator.

Your talents seem to take you regularly to the intersection of medicine and the arts where you are on the edge for both. Do you ever feel “out of the mainstream” of those areas? If so, how do you maintain your unique focus?

I never set out to find a way to literally combine a career in medicine and the arts. Had I done so, I think I would’ve failed miserably. It’s all happened in an amazing, serendipitous, organic way. And it’s been great fun! But I do find it difficult at times to stay focused, to not be pulled in too many different directions. I think it’s hard because I don’t see clear distinctions between medicine and the arts, between my life as a physician and as a creative person. I really believe that medicine is easily half science, and half “art.” I’ve been very intentional about keeping patient care as my top priority; it’s never been less than 60 percent of my commitment. One of the hardest things for me, as a clinician-scholar at the medical school, has been trying to make my work “scholarly.” I love to create and try new things; I love to “do.” I’m much less interested in writing about these things for the sake of publishing an article.

Doing the work you do requires high energy. You have to stay current in medicine, and up-to-date in the arts world. How do you maintain your energy?

The simple answer is that I love what I do. I love patient care, I love teaching, I love working with MPR, and I love learning. Working with MPR, recording a new piece each week, forces me to review the medical literature, use Up To Date (and a number of other resources), and talk to colleagues. (I know a lot of medical people listen to MPR, so I have to know the material well.) As to keeping up in the arts world, that’s easier. Many of our friends are artists and musicians and we’re very close to several arts organiza-tions, especially the Guthrie and the St. Paul Chamber Orchestra. (We have season ticket packages with each.) But we also love to attend Rose

Ensemble and Minnesota Orchestra concerts when we can — as well as a number of other plays and concerts. As a family, we love movies and we watch several dozen a year. We also read voraciously; I typically read over 20 books a year myself and several more with my kids. Also, since my wife is a high school band and orchestra director, the kids and I attend many musical events to support her. Finally, our kids sing in choirs, take piano lessons, and now our son plays trombone in band. Not a day goes by that we aren’t participating in some kind of artistic, creative endeavor or event.

How does your performing arts background influence the way you practice medicine?

I played the saxophone through college; unfortunately, I’m not really playing anymore. But having that background, being married to a musician-conductor, and having many musician friends, I’m certain that I relate better to performing artists because of it. I can speak their language in a way; I understand the pressures they face; I know the show must often go on. I really admire the level of professionalism I see in performing artists; they’re perfectionists, yet they’re also incredibly creative. I try to apply that to my practice. And because of this background, I think of medical practice in general more creatively than I used to.

What triggered your interest in medicine (given your strong background in the performing arts?).

My interest in medicine precedes my interest in the arts by many years. I somehow knew I wanted to be a physician when I was a child, perhaps 9 or 10 years old. (I don’t know why; no one in my family was in medi-cine.) I didn’t really become aware of my passion for the arts until I was in the St. Olaf Band, making incredible music with amazing musicians, many of whom have become professional musicians and many of whom remain friends. But I suppose my love of the arts was always there. My dad was an engineer and executive at 3M, but he was always making art: paint-ings, string art, leaded-glass windows. My mom, an elementary school teacher, was and is incredibly creative. And I created my own darkroom in an empty closet at home when I was 12, a couple years after I started playing the saxophone.

What advice do you have for doctors who have little time to spend and listen to their patients?

I think we’ve all been there — or are there. I mean really, there’s never enough time to do everything we could or should do for every patient, every time. So the trick is to maximize the time we have. I love the idea of medical homes in primary care—and I really do feel that the more I know a patient, the more efficient I can be with the time we have together. I try to be present, I try to listen carefully. (Through my work with MPR, I’ve learned to listen to the human voice more carefully; I find I now listen more intently, more carefully.) But I’m still trying to figure out how to practice medicine in the best and most efficient ways.

Colleague Interview



I’m constantly learning from colleagues I admire, and, as a result, I’malways trying new things, figuring out new ways to listen, trying to bemore efficient.

Do you find your celebrity clientele different from your“regular” patients and lessons about modifying currentfamily medicine practices? For example, do you recom-mend house calls to accommodate patients?

First, I should note that my celebrity clientele is a small fraction of myprimary care base. For the most part, these patients are more “regular”then we might imagine. The biggest difference is that someone from outof town, who’s here to perform, has an enormous amount of pressure onhim or her for the show to go on; there’s little time to get better. That’schallenging. But I try to treat everyone the same. I’m truly interested inpeople, no matter what they do, where there’re from, or who they are.And yes, I love doing house calls, whether it’s in an arena, backstage,in a hotel, or in someone’s home. When I make one, I feel like a “real”doctor, like I’m returning to the roots of medicine.

How do you get paid for this work and does this influenceyour accessibility?

For lots of reasons I prefer to see all my patients in the clinic. I like thisfor billing, documentation, liability, and diagnostic reasons. But if I seesomeone off site (which is rare), I typically don’t charge for the visit.In exchange, I’ll often get tickets for the show, aCD…or a sincere thanks. With my new clinic,I’ll work with UMP to figure out an easier way toregister a new patient off-site and arrange for bill-ing. So far, doing off-site visits has never affectedmy accessibility; I always do them after hours.

As a psychiatrist I am interested in yourtake on helping your celebrity artists from apsychological perspective—how this relates to“spirituality” doctoring and mental therapies?

I am awed by performing artists. Their abil-ity to perform with near perfection day afterday, night after night, while playing, speaking,singing, dancing, is simply amazing. They areperfectionists, yet they’re creative and adaptable.Though they seem fearless on stage, many dealwith anxiety and stage fright. Though some takemedications for this, many of them focus insteadon pre-performance rituals, such as deep breathingexercises, meditation, yoga, or exercise. I (we) canlearn a lot from them.

I understand you are building a new clinic across fromthe Guthrie. What will the focus of this clinic be?

The University of Minnesota Physician (UMP) Mill City Clinic isscheduled to open sometime this fall. It will be a full spectrum primarycare clinic. It’s going to be in a beautiful space in the new Zenith condo-minium complex, with the waiting room looking onto the Gold MedalPark. We’ll have extended hours, same-day scheduling, and it will bestaffed by an inter-professional team of providers. Our task is to createan outstanding clinic with high patient satisfaction and to be a leader andinnovator in what clinics can be. As it gets established, I’d love to see ithave a strong sub-focus on caring for the creative and artistic community.All the pieces are falling into place to make this the best performing artsmedicine clinic in the country outside of New York City.

Where do you see yourself professionally in 10 years?What will you be doing?

In 10 years my new clinic (The Mill City Clinic, across from the Guth-rie) will be thriving; I’ll be doing all my patient care there, with a largeramount of my time taking care of performing artists. I hope that I’ll stillbe working with MPR, possibly with NPR, doing creative health-relatedwork. I also hope that I’ll be expanding the work I do with the arts com-munity, helping to produce lasting creative works that address medicaland social issues (like I did with the actor Charles Keating and his pieceon aging entitled, “I and I: A Sense of Self ”). I’d like to be doing moreteaching in the medical school as well.

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A

Intentional Culture Change: Working Better Together

BY ROB LUND, M.D.

ALTHOUGH RECENTLY retired I am still associated with Suburban Radiologic Consul-tants, a large private radiology practice in the Twin Cities. My journey into this topic actually began over four years ago, when St. Catherine’s College sponsored a conference entitled: “An Abuse-Free Work Place in Medicine.” It was rather fortuitous that I wound up attending that conference, as it has really made a signifi-cant difference in our practice. We started with a process of culture change, naming our project a “Healthy En-vironment Initiative” or HEI. It is somewhat unique in that it is cross-corporate, spanning both Suburban Radiology and the Fairview Hospital System whom we invited to partner with us in this effort. The Fairview side of the equation includes the radiology departments at Fairview Ridges in Burnsville, Fairview Southdale, Fairview University Riverside Campus and Faiview Lakes Hospital in Wyo-ming. Our radiologists wanted to include this hospital component because a large part of our practice is carried out in the hospital setting. We have been very gratified by this decision as Fairview has been a very willing and actively helpful partner with us in HEI. The question commonly comes up…“Why are you doing this?” The implication is that we must have had some horrific problems in our practice. The answer is “No, we did not.” Suburban and Fairview were already good places to work, but there is always room for improvement. Every work place has issues and it is best not to ignore them. In my experience, abusive behaviors in the workplace are commonly ignored as irritations that blend into the routine. Only the less com-

mon “blow-ups” get people’s attention. Still the destructive effects are there under the surface just the same. It is like friction in a machine you would like to think is well oiled. The first step for us was to recognize and name these for what they really are. Suburban Radiology is a busy practice with about 400 employees who work at numerous sites. If some of those points of friction were going to get addressed, there needed to be:

More clarity on what really constitutes abusive or healthy behavior.Recognition of abusive behavior when people see it.Conversation about this issue.Raised expectations for how we will be treated at work.And, these new expectations needed also to apply to how we treat others.

Our job as the HEI committee was to help this process of change actually happen across the whole continuum of job descriptions. One of the strategies we used to accomplish this was our skits program. For each of the last two years we have written six skits that illustrated abusive situations at work with respectful resolutions. Volunteers from Suburban and from Fairview were our actors and actresses. The skits were videotaped and made into a DVD that was shown at numerous small employee meetings. We had great fun doing the skits and people loved seeing their co-workers acting parts. They especially enjoyed seeing radiologists and managers who took roles. The skits have been a wonderful icebreaker technique for engaging people in this conversation about abusive behavior. In my own experience, the radiologists in our practice have a much more powerful role in setting the tone for an office or depart-ment than they realize. None are ever out to

be “nasty” to the technologists, but on a busy day, poorly chosen words or a sharp comment made under stress, can easily lead to a bad outcome. The radiologist will probably be oblivious to the ripple effects that change the mood of the whole office for the rest of the day. The radiologist is stressed. The technologist may feel unjustly chastised and worse, probably feels powerless to change the situation. We will return later to this scenario. A couple of years ago our HEI commit-tee developed what we call our “One-on-One” algorithm for conflict resolution. We did train-ing for employees on how to use it as a guide in preparing to speak to that one co-worker whose behavior is a problem. It might just be grouchiness, or a cubicle radio that is too loud. We presented this as a workable alternative to just reporting the problem to a supervisor. Su-pervisors spend way more time than we would ever imagine dealing with squabbles between employees. Encouraging people to try a One-on-One resolution has not only relieved some of the burden on supervisors, but results in


a much more satisfying resolution. The “of-fender” doesn’t feel reported, and the onewho initiated the “can we talk” conversationis usually surprised at how easy it was and gets aboost in self-esteem for having pulled it off! I’veheard many stories about such encounters.

These resolutions, however, don’t work ina vacuum; they very importantly happen in acontext. Everyone in our practice knows whatHEI is all about. It is about a level playing fieldwhen it comes to treating others with respect.It is a part of our culture now and an expecta-tion we have for ourselves and each other. Thesimple mention of HEI immediately bringsall this to mind and it undergirds those One-on-One conversations in a way that tends toshepherd them to a good conclusion.

Now in our fourth year of HEI, I’veheard story after story of technologists who,on a stressful day (remember the scenariowe left earlier?), venture forth to talk to aradiologist about his or her behavior, and aresurprised and gratified to find a receptive at-titude on the part of the radiologist. Again itis the HEI context that gives the technologistthe courage to speak up, and the radiologist thereceptivity to listen. The radiologist is typicallya bit surprised, chagrined to be so clueless, butpleased for the opportunity to clear the air andmake amends. The technologist, on the otherhand, feels elated and newly empowered to bea respectful agent of change when such situa-tions arise. “HEY, we can talk to each other!”That sort of attitude can be infectious in adepartment and everyone benefits.

New employees at Suburban Radiologyand in Fairview radiology departments arenow getting some HEI training to help themtransition into their new positions. The HEIculture is something we want new employees tounderstand and embrace, as they are in manyways our future.

So, have we solved all the problems?Certainly not!

Do bad interactions still happen?Yes they do.

Is life at work better?Absolutely! We are encouraged, but there iscertainly much yet to be done.

Does HEI have a future?Very definitely! Even the most entrenched


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skeptics are now starting to come forwardand express appreciation for what this processhas done for our workplace.

In conclusion, I thought it might be helpful tooutline what I see as key elements to buildingand maintaining a healthy interpersonal workenvironment.

1. A Vision of the Goal:What do you want your workplace to look likein two, four or six years? This is a combina-tion of both defining hopes and reigning inunrealistic expectations.

2. A Plan to Get to the Goal:Suburban Radiology addressed this by con-tracting with a consultant for developing aplan. This worked beautifully for us. Tryingto do it on our own would have been muchmore difficult.

3. Tenacity:Expect ruts in the road and challengingroadblocks. Expect naysayers, pessimists and

PivotPoint’s beginning started at Hen-nepin Medical Society in 1984 with the

creation of Responses, Inc. Its mission wasto prevent family abuse. In 1990 Responses,Inc. evolved into Respond 2, Inc. focusingon behavior at work. In 2008 Respond 2,Inc. was renamed PivotPoint, changing busi-ness by changing behaviors.

Consistently applied throughout allthese years of experience, a 5-stage, 18-month process has driven success. Drs.Rob Lund and Lorraine LaRoy co-lead theSRC/Fairview Radiology 5-Stage Processwith stellar results.

The 5-Stage Process is not a clinicaltrial, nor is it a traditional quality improve-ment project. It is a collaborative model,based on action learning and action researchtheory.

The goal is to increase healthy behav-ior and eliminate harmful behavior at work.Healthy behavior drives it all—engagement,innovation, open communication, respect,and performance. How we treat each other

at work is measurable and is directly linked topatient experience and care. This is all aboutengaging the brainpower of everyone, first-lineto senior leadership.

Stage 1:TEAM BUILDING –A 12-18 member teamis formed which reflects the job, role and staffdiversity of the health care workplace. Theteam meets once a month for an hour over an18-month period.1-3 months

Stage 2:ASSESSMENT–The staff is surveyed and theresults are shared and used to develop an actionplan. (62,000 survey respondents in database)2-6 months

Stage 3:IMPLEMENTATION –The team developsan action plan with a timeline and measur-able outcomes.4-18 months

skeptics. Without tenacity the whole projectmight collapse. A critical part of tenacity is acommitted core of workers. It may be only oneor two, but you need those people to carry theproject across the ruts and hard times.

4. Patience:Don’t expect glowing results in six monthsor even a year. Culture change is slow, so bepatient.

5. Long-Term Commitment:That new culture of respect will never be self-maintaining. It will need nurturing. Like yourhouse, if you don’t maintain it, it will graduallyfall apart.

6. Have Fun Doing This!If it ever deteriorates to drudgery, your projectis on its way to extinction. New people on theteam add new energy. There is plenty of roomfor creativity, so keep it fresh.

Rob Lund, M.D. is a retired radiologist withSuburban Radiology and has served as co-chairof the HEI project from its inception.

Intentional Culture Change


Stage 4:EVALUATION – Concrete outcomes areidentified, measured and used for tracking,trending, and analysis.3-24 months

Stage 5:HARDWIRING –The work of the teamis used in hiring, employee orientation,performance reviews, accountability andimproving patient care and experience.Begins month 4-ongoing

The following outcomes have been expe-rienced in 125 health care organizations,large and small: broad engagement by 90percent of staff; 50 percent drop in turnover;$90,000 yearly savings in recruitment; 85percent drop in grievances; 15-25 percentdrop in reported employee medical prob-lems; 25 percent increase in employeesatisfaction; and 40 percent increase inpatient satisfaction.

Deborah Anderson, PivotPoint.


P

Creating a Better Experiencefor our Caregivers

BY MICHAEL P. CORNELISON ANDSTEVE J. KNUTSON

PHYSICIANS, DOES THE following sce-nario sound all too familiar? “You’re busy see-ing Margaret, a longstanding patient in themiddle of a busy afternoon schedule. As you’refinishing up with her, she begins to ask yourprofessional advice on obtaining home-basedservices for her elderly father who has multipleneeds. You quickly discover that Margaret hasbecome the primary caregiver for her agingparent who wants to remain independent inhis home. You sincerely want to help yourpatient, but you know this conversation willcause you to be 15 more minutes behind yourappointment schedule, and other than limitedexposure to some senior services organizationsor home care companies; you likely won’t havethe kind of specific information Margaret willneed. Both you and your patient leave this en-counter dissatisfied; you because you couldn’tbe more helpful to a longstanding patient, andyour patient because she remains frustrated andunsure about where to get help.

Margaret’s situation is becoming all toofamiliar and will become even more so asMinnesota’s baby boomers begin to reach age65. In fact, the number of Minnesotans overage 65 is expected to double to 1.3 million bythe year 2030. As this number of Minnesotan’sover 65 increases, so will the number of Minne-sota caregivers, currently estimated at 610,000.Family members, community organizations,and commercial businesses will scramble tomeet people’s desire to age independently andsafely in their own homes. For physicians inmany practices, if you have not yet experiencedthe type of questions suggested above, chancesare good you will in the future.

Until now there has not been a single,

comprehensive resource that gives yourpatients who fulfill this important caregiverrole, the tools needed to effectively manageand resource their caregiving needs. This isone reason underlying Margaret’s inquiriesduring her visit. This is not to suggest thatthere are not good resources in the markettoday that provide assistance to caregivers andseniors—there are. However, the task of beinga caregiver continues to be much more difficultthan necessary. Fragmentation of resources, un-coordinated services and the lack of meaning-ful tools all contribute to common complaintssuch as high stress, problems in the workplace,financial difficulties, diminished health statusand life balance issues to name a few.

Well, there’s a new and unique productbeing introduced that might make your nextsuch encounter with a caregiver patient a bitmore satisfying for both of you. IndependentHome Living, LLC (IHL) is a new organizationthat has been designed specifically to createbetter experiences for our caregivers. Thisis accomplished through a comprehensiveone-stop solution that will assist caregivers inassessing their needs, identifying resource op-tions, choosing a course of action and accessingservices. The system also provides mechanismsto effectively manage the day-to-day details ofcaring for a loved-one.

This unique approach to addressingcaregiver needs is based upon the followingfundamental principles:

Empowering the Caregiver.Many people are unwilling or financiallyunable to pass caregiving responsibilitiesfor loved-one’s along to a hired, profes-sional caregiver. These individuals desireto be closer to the daily/weekly provisionof care. And, like other important aspects of

our lives, want to exercise a certain amountof control over this activity. However, his-torically this option has been very difficultfor a caregiver to achieve due to a numberof factors including the fragmented natureof resources and lack of meaningful tools.We strongly believe that individuals shouldhave a realistic option in caring more di-rectly for their loved ones by eliminatingmany of the barriers typically associatedwith this activity.

Making Sense of Available Resources.When faced with the responsibility of be-ing a caregiver, almost everyone attempts toidentify helpful resources. These resourcesoften include family members, friends andneighbors who are often times willing toparticipate in caregiving activities. Thereare also religious groups and numerousother non-profit organizations currentlyavailable to provide services to seniors.And, of course, there are also a wide va-riety of commercially-based senior serviceorganizations. We are fortunate that mostcommunities in our 11 county metropoli-tan area have numerous resources availableto support those wishing to live in theirhomes. However, finding and accessingthe right resources for a given loved-one’sparticular needs is a guaranteed problemfor caregivers. Especially for new caregiv-ers. The market is simply too fractured andconfusing for non-professionals to navigate(in fact, even some industry experts experi-ence this difficulty). In response, we haveworked extensively to identify all resourcesavailable today and created an easy-to-un-derstand approach to determine and ac-cess the right services for each individual



situation. Linked with certain educational components, the caregiver simply indicates her loved-one’s zip code and the full array of available resources are displayed. Remem-ber that your family, friends, neighbors and community-based organizations can all be considered resources and are included in this approach. We have also made accessing services easier as well. Through the use of the integrated calendar and e-mail tools, arranging for Aunt Maria to provide an ev-ery-Tuesday meal, or arranging a ride to the doctor’s office from a transportation vendor, is just a few clicks of the mouse away. Using these tools, caregivers will be less burdened from making a large volume of telephone calls to arrange for services and can do so at a time more convenient to the caregivers schedule. Also available is a mechanism to understand the quality and cost of vendors who provide services to seniors.

Managing Daily Caregiver Details.Many caregivers are employed full-time and have children of their own living at home. As a result of their additional responsibili-ties, many caregivers report increased stress levels and a diminished quality of daily life. Although it is not feasible to eliminate all drivers of increased stress, we believe many can be positively impacted. We have cre-ated a number of Web-based tools that are designed to assist in the daily manage-ment of care. For example, a scheduling and calendar system keeps track of all care activities, including details of the specific activity. This calendar is automatically up-dated when Aunt Maria agrees to provide an every-Tuesday meal or when the transporta-tion service agrees to provide that ride to the doctor’s office. This utility can be made available to multiple parties (security en-abled) in order to coordinate multiple care activities. Communication tools have also been developed to limit the time commonly spent repeating the same update message to those involved in your loved-one’s care. Now, communicating between your family, friends, neighbors and other care providers is made easy.

Educating the Caregiver.Education is absolutely critical in helping individuals assess their own unique caregiv-ing challenges, create realistic options and choose an appropriate course of action. The needs of loved-ones can vary greatly based on a number of factors —there is no single formula for successful caregiving. Robust education and checklist tools are a must, in addition to links to deeper, more specific information that a caregiver may desire (e.g. disease specific sites such as Parkinsons, Al-zheimers, etc.)

Safety and Security. There is a significant and legitimate concern over the safety and security of our vulner-able loved ones. Today, if you contact an organization to transport your mother to her doctor visit, you don’t always know who will be showing up or if they have potentially fraudulent motivations. We are committed to integrating the right safeguards and security features to protect both the caregiver and the care recipient.

The following are a few additional facts that could apply to your patient Margaret, and her caregiver situation. Margaret fits the average age/sex profile of a

caregiver; 46 years old, female, some college education. 80 percent of all caregivers are female.

Margaret may be experiencing negative health related issues of her own as a result of her caregiving activities. According to one recent study, 41percent of caregivers say their health has gotten “a little worse;” 44 percent say their health has gotten “moderately worse;” and 15 percent say their health has gotten “a lot worse.”

Margaret is part of a caregiver group that provides over $7.1 billion in unreimbursed care in the state of Minnesota annually ($350 billion nationally). In Minnesota, for every 1 percent decline in family caregiving, it costs the public sector $30 million.

There is a good chance Margaret is em-ployed. Almost one in five (19 percent) of the national workforce is in a caregiving role.

Now let’s return to your exam room encoun-ter with Margaret. Wouldn’t it be great if you could immediately respond to Margaret’s inquiries with an easy answer? Imagine if you could direct Margaret to an IHL link located on your practice’s Web site to answer her questions and to provide her with a one-stop spot to obtain additional resources. You would have the professional satisfaction of meeting the needs of your patient, enhanc-ing the quality of care for your patient’s loved one and you would not find yourself running further behind your afternoon’s schedule due to an unanticipated patient conversation. Look for more information on this product in the coming weeks.

Michael P. Cornelison is the Founder and CEO of Independent Home Living, LLC, an organiza-tion dedicated to empowering caregivers to cre-ate successful caregiving experiences. Mike can be reached at: [email protected].

Steve J. Knutson is a partner with Consentia-Health, Inc., serving the health care industry by providing a variety of business and managed care services. Steve can be reached at (651) 247-6726.

Better Experience for Caregivers


July/AugustIndex to Advertisers

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Children’s Physician Network ...............................

Outside Back Cover

Classified Ads.........................................................15

Crutchfield Dermatology...................................19

Healthcare Billing Resources, Inc. .................... 6

Hennepin County Medical Center......................

Inside Front Cover

Lockridge Grindal Nauen P.L.L.P. .................... 6

Medical Billing Professionals, LLC.................21

Minnesota Physician Services, Inc. .................13

Minnesota Epilepsy Group, P.A.......................21

The MMIC Group ..............................................15

Neurosurgical Associates, Ltd................................Inside Back Cover

ProSource.................................................................. 3

Uptown Dermatology & Skin Spa, P.A. .......26

Weber Law Office ................................................16


S

St. Francis ServesScott and Carver Counties

BY MICHAEL BAUMGARTNER, CEOSt. Francis Regional Medical Center

The MetroDoctors editorial board has invitedseveral hospitals located in the east and westmetro communities to submit an article thatwould “showcase” their hospital and commu-nity health outreach initiatives. St. FrancisRegional Medical Center is the third hospitalto be highlighted in this series.

St. Francis entered into a unique partnership tobuild a hospital whose foundation consisted ofmore than bricks and mortar...our hospital wasbuilt on partnerships. This commitment simplystated that we would make lives better by pro-viding the finest health care services in the area.This reality—of health care partners workinghand in hand to bring state of the art facilitiesand technology to our communities —is oneof which we are very proud. Our mission is toprovide all people the healing experience wewould expect for ourselves and our families.After recent years of explosive growth withinour communities, we’ve completed expansionprojects that bring even greater capabilities forservices our patients previously had to leave thecommunity to get.

A History of PartnershipWe are proud of our rich history of coopera-tion. Founded by community members and theFranciscan sisters in 1938 out of a spirit of careand concern, we were entrusted to the Benedic-tine Sisters of St. Scholastica in 1987. Knowingthat partnership was a good way to addressthe increasing complexity of health care, theBenedictines partnered with the organizationthat became Allina Hospitals and Clinics in1993. Allina serves as our managing partneron campus. To meet the increasing demandfor specialty services in our area, Park Nicollet

Health Services also became a partner in 2001.Today, the Benedictines continue their owner-ship of St. Francis through Essentia Commu-nity Hospitals and Clinics. Partnership in thiscomplex environment cannot be mere ideology,it must be intentionally nurtured. As Dr. BrianProkosch, medical director has said, “Whenyou have three partners, you have to walk thewalk.” We must put the patient first, and thatwill always involve working together.

Partnerships Bring GreaterAccess to CareThis unique structure enables us to combinethe caring and compassion of a communityhospital with the modern medical technology,specialties and services found in the metro area.We provide a full range of inpatient, outpatientand emergency care services on a collabora-tive medical campus with more than 30 otherproviders.

St. Francis primarily serves residents inScott and Carver Counties, including Shako-pee, Jordan, Chaska, Prior Lake, Savage, BellePlaine, and Carver.

We currently have 86 private hospitalrooms (private bedroom and bathroom) (93licensed), 53 medical/surgical rooms, eight

intensive care rooms, 17 family birth rooms,eight children’s care pediatric rooms, 18 same-day surgery rooms, five operating rooms andone C-section suite, 21 emergency room treat-ment bays and two endoscopy rooms.

Partners’ CommitmentWe value the contributions of our physicianand clinic partners, not only as providers ofquality health care, but as community andorganizational leaders. Recognizing the needfor strong medical services in this rapidly grow-ing area, they have committed to meeting thatgrowth with added resources and services. Wecurrently have 400 total medical staff. This isan increase of over 100 percent since 1996,illustrating the rapid growth we have experi-enced in this part of the Twin Cities metro area.And we continue to grow. We will welcomea Hospitalist program, new OB/Gyn practiceand neonatal nurse practitioners in the nextfew months. Our oncology and spine surgeryprograms continue to grow as well.

Partnership Strengthens MissionWe maintain our identity as a ministry in car-ing partnership with our sponsors, the Sistersof St. Scholastica Monastery in Duluth. Wecontinually look for ways to increase theunderstanding of our identity and make itvisible to our employees, volunteers, medicalstaff, patients, families and the community.Our identity inspires each of us to live ourmission more fully.

Community Benefit; Living theMission in the CommunityAlthough our rapidly growing communityis quite prosperous, as a faith-based hospital



we are called to give special concern for thosein need. The strength of our communitybenefit program is one way we demonstratethis concern. We rely on the Catholic HealthAssociation (CHA) and VHA guidelines fortracking community benefit, using these stan-dard guidelines; we have estimated our annualcommunity benefit for 2007 to be $5,442,000.Our real community benefit story is about thelives we touch through our varied programs.

Community Partnerships YieldsBig Payoff for the Uninsuredand UnderservedWe are proud of the innovative way we areable to help provide access for the uninsuredand underinsured through the River ValleyNursing Center. Our partners on the Nurs-ing Center include Scott and Carver CountyPublic Health Agencies, our campus clinicpartners, the Allina Medical Clinic, and ParkNicollet Clinic-Shakopee, St. Mary’s HealthClinics, and the CAP (Community ActionProgram) Agency.

The Nursing Center is a unique model wewould like replicated in other places; combin-ing public health nursing care with social ser-vice referrals. In this model there is an emphasison prevention, with an independent publichealth nurse and bi-lingual outreach workerproviding public health nursing care, educa-tion, and social service referrals in a warm,compassionate and friendly environment.

Since opening, the Nursing Center has

helped over 1,000 uninsured and underinsuredclients. Even though the majority of the clientsare working, the cost of insurance continues tobe a barrier to obtaining care. Although visits tothe Nursing Center are often prompted by theclient’s unmet health need, due to the uniquepartnership that has been developed, a vastnumber of clients also have a need for hous-ing, food and fuel. The social service referralcomponent of the project is able to help clientsmeet these needs.

Soon after the Nursing Center opened,an unemployed and uninsured gentlemanwas leaving the Shakopee Workforce Center(located adjacent to the Nursing Center), onhis way to the St. Francis Emergency Depart-ment. He was suffering from an oral infectionthat began in his mouth and was spreadingdown his neck. Seeing the Nursing Centersign, he decided to see what it was all about.The Nurse Coordinator was able to schedulean appointment for the client at a dental clinicat the University of Minnesota. The cost of thevisit would be $300. The client had $300, butit was his rent money. Because the partnershipincludes the social services sector, the on-siteoutreach worker knew of a program provid-ing emergency services funds through theCAP Agency. These funds are not available topeople for dental bills, but they are available forhousing assistance. The client was ultimatelygranted $300 toward his rent, used his own$300 for his dental bill and, most importantly,received appropriate care. This story gives all ofus a glimpse into the daily life and challenges ofour uninsured and underinsured patients. St.Francis has been a proud partner and supporter

St. Francis


Phil M. Ecker, M.D.Dermatologist

Uptown Dermatology & SkinSpa

Welcomes Phil M. Ecker, M.D.Mayo Trained Dermatologist.

Uptown Row, Suite 208 1221 W. Lake Street Minneapolis, MN 55408612-455-3200 www.UptownDermatology.com

Dr. Phil Ecker joins the staff of Uptown

Dermatology & SkinSpa and specializes in

Medical, Surgical and Cosmetic Dermatology.

Same week appointments available. We are

conveniently located in Uptown Minneapolis-one

block east of Calhoun Square. We accept all

major insurance and offer free parking. Call

us at 612-455-3200 to schedule an appointment.

Treat your skin. Transform yourself.


of the Nursing Center since its inception. Ourphysicians refer patients to the Nursing Center,our staff members sit on its board and the hos-pital and St. Francis Foundation have donatedover $100,000 to this project in the past andfor the coming year. We are confident thatthe Nursing Center will continue to be a veryimportant part of the safety net for uninsuredand underinsured people living and workingin our community.

Partnering for Community BenefitWe find working collaboratively with others inthe community leads to increased ease of usefor our community members. Listening to ourlocal public health agencies and other commu-nity health and social service providers allowsus to address additional community healthneeds. A sampling of additional programs andservices offered to our community include:

As part of the Partnership for a Smoke FreeScott County, St. Francis provided supportto pass the state’s Freedom to Breathe leg-islation. We continue to support efforts toprevent erosion of this law.Emergency department nurses are trainedin EnCARE, a program to educate teensabout the dangers of drinking and driving,

using stories and footage of real people andreal events. This program has been expe-rienced by thousands of young people inour community because of our partnershipwith our local drivers’ education programs.In 2007, alone, it was seen by over 450students.We offer a Breast Feeding Support Groupto aid breastfeeding mothers before, dur-ing and after the birth of their babies. Thisgroup is open to all members of the com-munity, regardless of where they deliveredtheir baby. The Breast Feeding SupportGroup is staffed by a lactation consultantfrom our Breastfeeding Support Center andbuilds on work done through the Carver/Scott Breastfeeding Coalition.Our community health fairs have uniquethemes. We’ve hosted a Community WideFamily Safety Fair and will host our sec-ond Community Baby Fair this year, withsessions on a wide array of topics offered,from Car Seat Safety (a compliment toour Car Seat Safety Classes and Clinics) toPre/Postnatal Yoga, Baby Sign Language,and children’s behavioral issues.This summer we will partner with localdaycare providers to share the Power Hour

program, which combines fun physical ac-tivities and challenges with learning abouthealth and nutrition for elementary agestudents.Physical therapists from St. Francis are onhand at local sporting events through ourSports Care Program. Over 12,000 studentsbenefited from these services in 2007.Our nutrition services staff continues toprepare nutritious meals each day to sup-port our local Mobile Meals program. In2007 over 4,600 meals were prepared fordelivery by local volunteers.We knew that due to our large EmergencyDepartment volume we would be able toassist a large number of currently uninsuredpatients with enrollment into governmentsponsored health care programs. Our ED fi-nancial counselors help hundreds of peoplewith these complicated applications.

The partnerships we form in our com-munity are as valuable to us as the partnershipswe have on our campus. We are excited to bestrengthening healthy communities, creat-ing healthy workplaces and partnering withpatients and families to provide access to thefinest health care services in the area.

PRESIDENT’S MESSAGEPETER B. WILTON, M.D.

EMMS OfficersPresident Peter B. Wilton, M.D.President-Elect Ronnell A. Hansen, M.D.Past President V. Stuart Cox, M.D.Treasurer Thomas Siefferman, M.D.

EMMS Elected Board MembersArthur A. Beisang III, M.D., DirectorPeter J. Boosalis, M.D., DirectorPeter J. Bornstein, M.D., DirectorKatherine M. Clinch, M.D., DirectorCharles E. Crutchfield III, MMB, M.D.,

At-Large DirectorLaura A. Dean, M.D., Specialty Director,

Obstetrics & GynecologyAndrew S. Fink, M.D., At-Large DirectorJames J. Jordan, M.D., DirectorNicholas J. Meyer, M.D., DirectorRobert C. Moravec, M.D., At-Large DirectorAnthony C. Orecchia, M.D., DirectorJerome J. Perra, M.D., DirectorLon B. Peterson, M.D., DirectorScott A. Uttley, M.D., DirectorMarie L. Witte, M.D., Director

EMMS Appointed Board MembersStephanie D. Stanton, M.D., Resident PhysicianLinnea K. Engel, Medical StudentJo Ann Wood, M.D., Young Physician

MMA Officers and Board MembersLyle J. Swenson, M.D., MMA Speaker of HouseTodd D. Brandt. M.D., MMA East Metro TrusteeCharles G. Terzian, M.D., MMA East Metro TrusteeDavid C. Thorson, M.D., MMA East Metro Trustee

EMMS Ex-Officio Board Members &Council Chairs*Arthur A. Beisang III, M.D.,

Public Policy Council Co-ChairBlanton Bessinger, M.D., AMA Alternate Delegate*Peter J. Boosalis, M.D.,

Public Policy Council Co-Chair*Peter F. Bornstein, M.D., MPS, Inc. ChairRichard J. Burton, M.D.,

Sr. Physicians Association PresidentKenneth W. Crabb, M.D., AMA DelegateRobert W. Geist, M.D.,

Professionalism & Ethics Council ChairNeal R. Holtan, M.D.,

Community Health Council ChairFrank J. Indihar, M.D., AMA Delegate,

Chair of MN DelegationMark Kleinschmidt, Clinic Administrator*Anthony C. Orecchia, M.D.,

Education Resource Council ChairKent S. Wilson, M.D., EMMS Foundation President

*Also elected EMMS Board Member

EMMS Executive StaffSue A. Schettle, Chief Executive OfficerKatie R. Snow, Executive AssistantDoreen M. Hines, Manager, Member Services


HMinnesota’s NewHealth Care Legislation

HEALTH CARE REFORM was a major focusof the recent legislative session. After the gover-nor rejected a health care reform bill from theHouse and Senate, intense last-minute nego-tiations produced a compromise—a processcomplicated by the budget deficit of almost abillion dollars. The Health Care Reform Billaddresses public health, advances the conceptof “health care homes,” begins the process ofreimbursement reform to reward complexcare coordination, and increases care access.Most of the provisions of the new bill werealigned with the MMA’s “Physicians’ Plan for aHealthy Minnesota,” the reform plan outlinedby the MMA in January 2005.

The major components of the bill are:Standards for “health care homes’’ are tobe developed and implemented, focusinginitially on chronic conditions. Provisionis made for reimbursement based on carecoordination for these conditions. Ambigu-ously—and possibly ominously—if savingsdo not accrue from this model, the commis-sioner of human services “may make recom-mendations to the legislature on reallocatingcosts within the health care system.”Access to MinnesotaCare is expanded toanother 13,000 uninsured patients.Payment reform to give providers incentivesto reduce health care costs, improve qualityand provide more price transparency. Thisincludes a peer grouping system that ranksproviders based on cost and quality of care,to be operational by 2010.“Baskets of care” will be established for atleast seven chronic diseases. Providers billingfor these baskets must use a single price forall private payers.Employers with 11 or more employees mustoffer Section 125 Plans, allowing their em-ployees to purchase health care insurancewith pretax dollars.

The bill was also notable for what it didnot contain. Missing from the final packagewas the so-called “Level 3” provision, underwhich physicians and health care entities wouldsubmit bids to cover the total cost of medical

care for a population —a return to the failedconcept of capitated care. This proposal wasopposed by the medical community, and vigor-ous advocacy efforts were made by the EMMS,WMMS and MMA to explain the pitfalls ofthis approach and oppose its passage. We aregratified that our efforts were rewarded. Butthough it was missing from this year’s bill,the concept still has support at the legislatureand it may well reappear in the future. Otherobjectionable proposals omitted from the finalpackage include a 3 percent cut to physicianoutpatient services, new prior authorizationrequirements for services and procedures,and a licensing fee increase for professionallicenses.

In addition to opposing the Level 3 provi-sions, advocacy efforts prevented a raid on theHealth Care Access Fund for general budgetbalancing. There will be a one-time transfer of$50m from the fund to the General Fund, tobe repaid once cost savings due to measures inthe bill reach the $50m mark. This “loan” iscertainly better than the original proposal (atransfer of $250m, and $48m annually there-after). Nonetheless, we remain adamantlyopposed to the Provider Tax, and if we are tobe saddled with this unfair tax, we continueto insist that the Fund be used for its namedpurpose: health care access.

Cost concerns will not be solved by thislegislation alone, and we anticipate further re-form initiatives. Commissions, work groupsand advisory councils authorized by the cur-rent bill will monitor the health care systemand attempt to improve it. Future changes areunlikely to be favorable to the physician com-munity, with increasing demands in the faceof diminishing reimbursement. It will requirevigilance from physicians and their represen-tative societies to inform the debate, and toprotect our patient’s interests from misguidedlegislative initiatives. The EMMS stands readyto act on your behalf.


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EMMS Foundation Works onAdvance Directive Project

The East Metro Medical Society Foun-dation recently received support and a

matching dollar for dollar financial commit-ment from the EMMS board of directors to beused for a project that has the potential to havea significant impact in the way that advancedirectives are carried out in the east metro.The goal of the project is to make accessiblethe wishes of the patients by coordinatingacross systems information that is needed inthe course of a patient’s treatment. Realizingthat this would be a long-term commitmentfor EMMS, it would be the goal to start small,in the east metro, with pilot sites. These pilot

sites could serve as the training ground for amore impactful program.

This collaborative concept originated inLa Crosse, Wisconsin in the mid-1990s andcame together as a result of a community need.Their model is called “Respecting Choices” andit effectively takes the wishes of the patient andputs it in the hands of the health care workerswho need the information.

Next steps…The EMMS Foundation will work over thesummer months to identify key stakeholderswho may be interested in this type of collabora-tive effort. Key stakeholders include physicians,

hospitals, hospice programs, faith based orga-nizations, nursing, social workers, and manyothers. The EMMS Foundation will then con-vene a conference in the late summer wherekey stakeholders can come together in a roomwhere the issue can be discussed further with agoal of having the group come to a consensusas to next steps. If the conferees feel as thoughthere is merit in pursuing a more formal col-laborative, the EMMS Foundation will serveas the catalyst for making this happen.

The date for the conference is tentativelyset for August 5, 2008 at the U of M Continu-ing Education Conference Center.

East Metro Medical Society Foundation and HealthEast Care System, have jointly sponsoredthe “Caring Hearts for Homeless People,” supply drive for 16 years. It was held this year

from February 1 through February 28, 2008 and was very successful. We collected medicationand personal hygiene items for St. Paul programs that offer services to homeless people. In ad-dition to area clinics and HealthEast’s staff, faith congregations and area schools participatedin the drive.

This year 11 medical clinics, 20 congregations, the HealthEast Care System, and manyvolunteers from the former Ramsey Medical Society Alliance, Thrivent Corp., Boy ScoutTroops, and Scandia Elementary pitched in to collect and sort over $43,054 (5,058 lbs.) worthof hygiene and medical supplies. Supplies are distributed to Health Care for the Homeless,Listening House of St. Paul and SafeZone. In addition, over $6,000 in cash contributions wascollected. These organizations rely heavily on donated medications, hygiene supplies, toys,juice and monetary donations to help meetthe physical, emotional and mental healthneeds of their clients. This drive contributesthe majority of their supplies needed for theentire year.

Carole Nimlos coordinated the activi-ties of the former RMS Alliance memberswho donated their time by picking up thedonations from the 11 participating medi-cal clinics and delivering items to the maindrop-off site at St. Joseph’s Hospital.

Thank you to the clinic managers, staff,and physicians of the following clinics thatparticipated:

Advanced Skin Care Institute Allina Medical Clinic–Shoreview Aspen Medical Group– Highland Associated Nephrology Consultants, P.A. Dermatology Consultants, P.A. Minnesota Medical Joint Services Organi-

zation (MMA, WMMS, EMMS) Partners Obstetrics and Gynecology, P.A. St. Croix Orthopaedics, P.A. St. Paul Infectious Disease Associates, Ltd. St. Paul Surgeons, Ltd. University Affiliated Family Physicians

–Phalen Village Clinic

Caring Hearts Planning Committee mem-bers help with the sorting of donateditems. From left: Doreen Hines, East MetroMedical Society, Sister Marian Louwagie,HealthEast Care System, Helene Freint, pro-gram director, and Kali Aro, office coordi-nator, Health Care for the Homeless.

Organizations interested in participating inthe February 1-29, 2009 supply drive shouldcontact Doreen Hines at (612) 362-3705or e-mail: [email protected].

Cash donations can be sent anytime to theEMMS Foundation, P.O. Box 131690, St.Paul, MN 55113. Please indicate that it isfor Caring Hearts.


JESSE E. EDWARDS, M.D., a physician who revolutionized cardiology by using pathology to identify heart disease, died of heart failure on May 18 at the age of 96. Dr. Edwards earned his medical degree from Tufts University Medi-cal School. He commanded an Army medical lab unit in Europe during World War II and was part of a war crime team that surveyed the Dachau concentration camp three days after it was liberated. Dr. Edwards worked at the Mayo Clinic in Rochester from 1946 to 1960 and then at Miller (now United) Hospital in St. Paul. He started a registry (Jesse E. Edwards Registry of Cardiovascular Disease) of cadaver hearts in the 1960s, and the collection at the St. Paul Heart and Lung Center now includes 22,000 donated cardiac specimens. It is one of the largest collec-tions in the world, and Edwards’ organization made it one of the most useful. Dr. Edwards has written 16 books and nearly 800 medical journal articles. He retired in 1987, but doctors world-wide still consulted with him. Dr. Edwards was a past president of the American Heart Association. He joined EMMS in 1961.

RICHARD B. EDWARDS, M.D., age 76, died April 25. He graduated from the University of Manitoba Medical School, specializing in or-thopedics at the University of Minnesota. Dr. Edwards joined his father in family practice and later practiced in orthopedics in the Twin Cities and Grantsburg, WI. He served as the medical director for Summit Orthopedics and was Chief of Surgery for HealthEast. Dr. Edwards joined EMMS in 1973.

LEONARD O. LANGER, M.D. died March 7 of complications from Alzheimer’s disease at the age of 79. He graduated from the University of Minnesota Medical School and trained in radiology at the University of Michigan. Dr. Langer’s career included private practice with Suburban Radiologic Consultants and years spent in research and teaching at the Universi-ties of Minnesota and Wisconsin. He achieved worldwide recognition for his expertise in bone deformities and co-authored the Atlas of Bony Dysplasias. Dr. Langer acted as a medical advisor for the Little People of America and was awarded L.P.A.’s first honorary life membership for his contributions to the understanding of dwarfism and the care of people with this condition. He also established a bone dysplasia registry at the University of Minnesota Hospital.

MS. LINNEA ENGELjoins the EMMS board as our medical student rep-resentative replacing Kim-berly Viskocil. Ms. Engel is a 2nd year medical student at the University of Minnesota —graduatingin 2010. She is a Mounds View High School graduate and attended Carleton College in Northfield where she received her under-graduate degree. She also studied abroad for a semester at the University of Sydney in Sydney, Australia.

KATHERINE CLINCH, M.D. joins the EMMS board as a director. She is an anesthesiologist prac-ticing primarily at United Hospital in St. Paul. She’s employed by Associated Anesthesiology, PA. Dr. Clinch received her medical degree from St. Louis University Medical School where she also completed her internship. She then moved to Minnesota and completed her residency at the University of Minnesota. Dr. Clinch lives in St. Paul.

Meet Two New EMMS Board Members

East Metro Medical Society Holds Caucus

The East Metro Medical Society held its caucus on Wednesday, May 21 at United

Hospital in St. Paul. The resolutions discussed included efforts to educate physicians and patients about the Mental Health Parity Act of 2007; asking the MMA to explore their advocacy outreach efforts; asking the MMA to support, help develop and lobby for the use of high deductible health plans for ap-plicable Medicaid populations and for other public sector programs; asking that the MMA work with the Minnesota Hos-pital Association, the Minnesota Department of Health and others to incorporate the collection of im-munization historical information on physicians into the licensure process; asking the AMA to work

with the Joint Commission to clarify the low volume credentialing and privileging standards for physicians applying for privileges at hospi-tals; asking the AMA to lobby for federal legis-lation prohibiting contracts between physicians and insurance corporations in which clinic payments are contingent on underwriting the cost of patient services and referrals. These resolutions and others will be submitted to the MMA at their annual meeting September 19-21 in St. Paul.

The EMMS Senior Physicians Asso-

ciation met in April to hear a presentation on “Public Health Is-sues and the Home-less Population” from Sue Grosse Macemon, CNP. Ms. Macemon works with Health Care for the Homeless and HouseCalls, which are programs sponsored by West Side Community Health Services. The group learned some of the reasons behind homelessness and the dif-

Sr. Physicians Association

ficulties that the population faces. Health Care for the Homeless served nearly 550,000 men, women and children in 2007 and partners with other community outreaches to provide excellent care and services with an ultimate goal of helping people find long-term solutions to homelessness.

In Memoriam


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Legislators Presented With Defender of Clean Air Awards

Dr. Peter Wilton throws out the first pitch at the Saint Paul Saint’s game on Friday, May 23, 2008 in St. Paul.

The Defender of Clean Air awards were pre-sented to the seven Legislators who voted

“Yes” on the Freedom to Breathe Act which was implemented October 1, 2007 making all of Minnesota work places smoke-free. Two of the legislators were presented their awards at the

six month anniversary event hosted by Smoke Free Washington County. For those legislators that were not able to attend the event, Cynthia Piette, Project Coordinator for the Smoke Free Washing-ton County project and Sue Schettle, CEO of the East Metro Medi-cal Society, visited the remaining five at their Capitol office. Senator Charles Wiger was not available for a photo.

Asthma and Tobacco-Free Supporters Team Up With Saint Paul Saints May 23

Smoke Free Washington County and Smoke Free Dakota County partnered with

asthma, tobacco-free and other smoke-free groups across the metro to sponsor a smoke-free St. Paul Saints baseball game Friday, May 23, 2008. In celebration of Asthma Awareness Month, these eight organizations have joined forces to raise awareness about asthma and secondhand smoke through trivia, exhibits, on-field activities and announcements at the game. “Almost 400,000 Minnesotans have asth-ma, and a large number of people with asthma and other respiratory conditions attended this game,” said Cynthia Piette, project coordinator for Smoke Free Washington County. “We ap-preciated how cooperative the St. Paul Saints have been in agreeing to go smoke-free for this game.”

Each organization had a representative throwing out the first pitch. Representing Smoke Free Washington County was Dr. Pe-ter Wilton, surgeon and president of the East Metro Medical Society. Smoke-Free Dakota County also had a supporter throw out the first pitch.

The Dakota County Smoke-Free Commu-nities Partnership has had an active winter

and transition to spring. The Partnership has continued to engage community members, elected officials, and East Metro Medical Society physicians in its activities. They have encouraged healthy lifestyle activities, hosting events ranging from snow tubing to bowling to having a life coach discuss getting rid of one’s gremlins. The Partnership has also mobilized its core volunteers throughout the legislative session, in response to the smoking shack amendments and the so-called “theatrical pro-ductions.” Numerous phone calls and e-mails have been sent to elected leaders and letters to the editor published. The Partnership contin-ues to table at local fairs and festivals, speaking to community and civic groups, to share recent studies indicating 76 percent of Minnesotans support the smoke-free law. The impact on hospitality worker health has also been compel-ling for showcasing the benefits of smoke-free workplace policies — levels of cotinine and NNAL, a cancer-causing agent, decreased by 83 percent and 85 percent respectively, after the smoke-free law was implemented. As the Partnership looks forward to its fourth year, its objectives will remain focused on thorough implementation of the Freedom to Breathe provisions to the Minnesota Clean Indoor Air Act, through connecting to the business community, leveraging earned me-dia, and encouraging those who wish to quit smoking to enroll in cessation programs. The Partnership’s funder, ClearWay MN, encour-ages organizing campaigns on college cam-puses, efforts around the exciting political and election season ahead, as well as collaboration with their Native American funded community programs. The Partnership welcomes physi-cian advocates and spokespersons to become involved with their efforts throughout Dakota County. Please contact Diane Tran, Project Coordinator, at [email protected] or (651) 789-0036.

Dakota County Smoke-Free Communities Partnership

Senator Kathy Saltzman (DFL-56) and Anne Harris (Woodbury Resident).Senator Katie Sieben (DFL-57) and Sue Schettle.

Cynthia Piette and Representative Marsha Swails (DFL-56B).

Representative Nora Slawik (DFL-55B).


AWMMS Officers

Chair Anne M. Murray, M.D.

President Richard D. Schmidt, M.D.

President-elect Edward P. Ehlinger, M.D.

Secretary Peter J. Dehnel, M.D.

Treasurer Eric G. Christianson, M.D.

Immediate Past Chair Paul A. Kettler, M.D.

WMMS Board Members

Alan L. Beal, M.D.

Edwin N. Bogonko, M.D.

Carl E. Burkland, M.D.

J. Paul Carlson M.D.

Laurie Drill-Mellum, M.D.

Kenneth N. Kephart, M.D.

Stephen MacLeod, M.B.

J. Riley McCarten, M.D.

Robert Mittra, M.D.

S. Rita Puri, MB, BS

Frank S. Rhame, M.D.

Thomas C. Tunberg, M.D.

David J. Walcher, M.D.

WMMS Ex-Officio Board Members

Michael B. Ainslie, M.D., MMA TrusteeMartha Arneson, Co-Presiding Chair, WMMS AllianceBeth A. Baker, M.D., MMA TrusteeRichard E. Burman, M.D., Sr. Physicians Association

RepresentativeDavid L. Estrin, M.D., AMA Alternate DelegateDonald M. Jacobs, M.D., MMA TrusteeRoger G. Kathol, M.D., MMA TrusteeChad E. Roline, M.D., Resident RepresentativeCandace S. Simerson, MMGMA RepresentativeWade G. Swenson, Medical Student RepresentativeKarin M. Tansek, M.D., MMA TrusteeTrish Vaurio, Co-Presiding Chair, WMMS AllianceElizabeth R. Vogel, Medical Student RepresentativeBenjamin H. Whitten, M.D., AMA Alternate DelegateJames A. Young, II, M.D., MMA Trustee

WMMS Executive Staff

Jack G. Davis, Chief Executive OfficerJennifer Anderson, Smoke-Free Project CoordinatorNancy K. Bauer, Assistant Director, and

Managing Editor, MetroDoctorsKathy R. Dittmer, Executive Assistant

CHAIR’S REPORTANNE M. MURRAY, M.D.

Physicians Came to the Table

ALL WAS NOT LOST in the latest turbulentlegislative session that drew to a close on May18. It ended literally with a bang as the 150thanniversary of the State of Minnesota wascelebrated at the Capitol between last minutenegotiations. The greatest accomplishmentfrom our perspective throughout the HealthCare Reform Bill negotiation process was thetremendous amount of bipartisan physicianinput. Physician involvement grew more in-tense as the session deadline approached, andended only hours before the final documentswere signed by the governor. Physicians trulystaked out a place at the table and defendedit with passion.

The joint efforts of East Metro and WestMetro Medical Society members also playeda major role in last minute negotiations withlegislators. The coming together of seeminglyunlikely physician and legislator bedfellowsin a bipartisan effort to avoid the inclusionof level 3 language was impressive. It was alsoa pleasure to see the skillful hand of HouseSpeaker Margaret Kelliher behind many of thegovernor’s compromises. Although in the endthe Health Care Access Fund was still raided, itwasn’t the grand larceny the governor initiallythreatened, at $50 million instead of $250million. Some of it may eventually be repaidif any of the promised health care savings viathe reform legislation appear.

Somewhat surprising, but encouraging,was the single-payer movement that gainedmomentum across party lines, and will likelycontinue to gain steam before the next legisla-tive session. Although there are clear advan-tages to a single-payer system such as slashingadministrative costs and leveling the playingfield of the “non-profit” HMOs, the abilityto maintain high quality medical care withoutcompetition in the classic sense is a formidablechallenge.

Competing on baskets of care may even-tually be part of the answer, but many detailsneed to be worked out before physicians will

be ready to come on board with this businessmodel. Although there has been much positivelingo employed regarding the need to rewardphysicians and their staff adequately for carecoordination and preventive care, we have yetto see it happen in Minnesota. We need to beconfident that physicians and their supportstaff will be adequately compensated for thelarge amount of time needed to maintain amedical home for chronically ill complex pa-tients, and that our care coordination will beacknowledged as truly valuable.

In any case, the fact that support fora single payer system not only survived butflourished is a sign that some walls betweenpreviously polarized groups have been torndown and that we are clearly moving forwardin a positive direction toward health care re-form.

Physicians must maintain our high levelof involvement in preparation for the fall leg-islative session. We no longer have to startfrom scratch. Now that initial steps in healthcare reform have been taken and relationshipsestablished, we know which issues GovernorPawlenty and other stakeholders hold dearest.We will come armed. Especially important isthe need for the East Metro and West MetroMedical Societies to continue their successfulcollaborative efforts together with the MMAto craft more optimal health care legislationnext year.

Physicians need to reinforce their place atthe health care reform table in Minnesota. Stayinvolved. If you’re not involved, get involved.There is an ideal opportunity this fall at theannual MMA House of Delegates meeting.Become a delegate and bring your resolutionsfor change. As one physician you can truly affectchange in health care reform in Minnesota.


WMMS IN ACTIONJACK G. DAVIS, CEO

WMMS in Action highlights activities thatyour leadership and executive office staffhave participated in, or responded to, be-tween MetroDoctors issues. We solicit yourinput on these activities and encourageyour calls regarding issues in which youwould like our involvement.

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Jack Davis, chair of the Minnesota Pro-vider Coalition (MPC) reported that theMPC met throughout the legislative sessionon an every three-week basis. Issues thatwere closely monitored included: health carereform, language interpreter bill, worker’scompensation, HSA direct assignment, useof health care access funds, scope of practiceand other issues as they arrived. The MPCplans to meet regularly for the balance of2008 in anticipation of the 2009 session.

Many WMMS physician members partici-pated in the MMA Capitol Rounds asreported elsewhere in this issue of MetroDoc-tors. Please consider participating during the2009 legislative session.

Jennifer Anderson continues her work asWMMS project coordinator for Partner-ship for a Smoke Free Scott County.Jennifer’s focus is implementation of thestatewide Freedom to Breathe law in Scottand Carver Counties. In celebration of MayAsthma Awareness Month, the Partner-ship for a Smoke-Free Scott County andseven asthma and smoke-free organizationsco-sponsored the Saint Paul Saints gameagainst the Fort Worth Cats on Friday, May23, 2008. All eight organizations joinedforces to raise awareness about asthma andsecondhand smoke. Through trivia, tabling,on-field activities and announcements theyspread the word about chronic lung diseaseand that asthma can be controlled.

Richard Schmidt, M.D., Edward Ehlinger,M.D. and Jack Davis were in WashingtonD.C. in April to attend the AMA Nation-al Advocacy Conference. While there,

attendees were briefed on AMA positionson issues currently in debate on the Hill andmade several visits to the offices of our Sena-tor and Representatives. Attendance providesgood insight into the legislative process andemphasizes the importance of advocating forpatients and physicians.

At its May Annual Meeting, the HennepinMedical Society Alliance officially approved itsname change to the West Metro Medi-cal Society Alliance (WMMSA).

Tom and Mary Kay Hoban were intown on May 15 to attend the 2008 HobanScholarship Educational Event chaired by H.Thomas Blum, M.D. Several of this year’s

Hoban Scholars provided a presentation ona project or paper prepared in the course oftheir studies. Tom and Mary Kay reside inBonita Springs, Florida and they warmlygreet all their friends and former associates.

WMMS Caucus was held on May 21.A number of resolutions were discussedand approved for submission to the MMAAnnual Meeting, which is scheduled forSeptember 17-19, 2008. It’s not too late tosign up as a delegate. Carl Burkland, M.D.,Caucus Chair, encourages his colleagues tobecome a delegate and participate in settingthe policies and agendas for the future workof the MMA.

Current and former Hoban Scholars attended the 2008 Educational Event. Fromleft: Thomas Hoban, Mary Kay Hoban, Debra Thingstad Boe (2005 Scholar),Azza A. Zarroug (2005 and 2007 scholar), Kara O. Mitterholzer (2005, 2006, 2007scholar), Christina Servetas (2007 scholar), and Darla Morris-Preble RN (2003-2004scholar and member, Hoban Scholarship Selection Committee).

Several WMMS physicians attended theCaucus and discussed resolutions.

Attending the WMMS Caucus: Drs. Benja-min Chaska, David Estrin, Michael Anslie;and Dr. Mary Kathol in back.


Robert E. Doan, M.D., president, opened the April 22 meeting of the Senior Physi-

cians Association with Jane Eastwood, director, External Relations and Partnerships from the Minneapolis Public Library. We learned that T. B. Walker, a Minnesota lumber magnate and art collector—yes Walker Art Center, had a vision to share his books with the citizens of Minneapolis so it could become the educated city that it is. A horse and buggy “library” traveled throughout the area. Did you know that the city of Minneapolis refused to accept his art collection as a gift?

Senior PhysiciansAssociation

Congressman Keith Ellison along with

his Constituent Services Coordinator Mike Sie-benaler, participated in a surgical care team obser-vation at Abbott North-western Hospital under the auspices of the West Metro Medical Society’s Community Internship Program. The purpose of the experience was to provide the Congressman and staff with an opportunity to see what really goes on in a hospital, how patients receive care, and to “walk in the moccasins” of the physicians, nurses and other professions as they provide care to our citizens. The Congressman was greeted by Dr. Michael Tedford, past president of WMMS and Abbott Northwestern Hospital medical staff, Dr. Robert McKlveen, Northwest Anes-thesia, Jeffrey Peterson, Abbott Northwestern president, Jim Sieben, government relations

Congressman Ellison Participates in Community Internship Program

attorney for Health Billing Systems, and Jack Davis, CEO of WMMS. Congressman Ellison and Mr. Siebenaler were exposed to surgery through an observa-tion of procedures and learned a lot about sur-gical care teams at ANW, the daVinci robot, and the use of iMRI in neurosurgery. Special thanks to Jim Sieben for his as-sistance in recruiting Congressman Ellison and his staff for this observation experience.

Robert E. Doan, M.D., with Jane Eastwood.

Congressman Keith Ellison and staff participate in Community Internship Program at Abbott Northwestern Hospital. From left: Mike Siebenaler, constituent services coordinator; Congressman Ellison; T. Michael Tedford, M.D.; and Jeffrey Peterson, president, Abbott Northwestern Hospital.

MILTON ETTINGER, M.D., died recently at the age of 77. He graduated from the University of Minnesota Medical School. Dr. Ettinger specialized in neurology and served as the Chief of Neurology at HCMC. He co-founded the multidisciplinary MN Regional Sleep Disorders Center in 1978.

WILLIAM R. FIFER, M.D., 84, died April 30, 2008. He received his medical degree from Columbia University College of Physicians and Surgeons, New York, and he completed gradu-ate training at the University of Minnesota. He was certified by the American Board of Internal Medicine, made a Fellow in the American Col-lege of Physicians, was a practicing internist for 15 years at St. Louis Park Medical Center, and served as president of the medical staff at Meth-odist Hospital in 1969. His second career was in academic administration at the University of Minnesota, where he directed the University’s

Regional Medical Program and Area Health Education Center. Dr. Fifer spent two years in health policy analysis at InterStudy, fol-lowing which he directed the North Central Regional Medical Education Center. In 1980, he founded Clayton, Fifer Associates, with a commitment of teaching and consulting with hospitals, health care institutions and profes-sional societies nationwide.

GLENN E. NELSON, M.D. died on April 30, 2008. He was 90. He graduated from the Medical College of Wisconsin, Milwaukee. Dr. Nelson specialized in family medicine.

GLENN L. “SKIP” PETERSEN, M.D. died May 23, 2008 at the age of 89. He graduated from the University of Minnesota Medical School. Dr. Petersen specialized in anesthe-siology.

SUMMER OUTING: The 2008 Summer Get-Together is scheduled for Tuesday, August 12. The event will include Lunch at Pracna On Main—the oldest restaurant (built in 1890) on the oldest street in Minneapolis. And then we will board the Twin City Trolley for a tour of Minne-apolis, including stories from the drivers. Think you know all about Minneapolis? We challenge you! Watch your mail for more information to be mailed to members of the Senior Physicians Association.

Not a member of the Senior Physicians Associa-tion? If you are 62 years or older or may have just retired, we invite you to become a member and take advantage of the mutual support, the social opportunities of meeting with your peers, and the opportunity to hear interesting and in-formative talks. Meetings are held four times a year for lunch and guest speaker at the Zuhrah Shrine Center.

Upcoming meetings:June 10: Patricia Porter, program director, Minnesota Medical FoundationSeptember 16: Senator David Durenberger November 11: speaker to be confirmed.

For more information, contact Kathy Dittmer, (612) 623-2885 or [email protected].

In Memoriam


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Celebration and Change for the HMS Alliance

ALLIANCE NEWS

THE HMS ALLIANCE held their 98th AnnualMeeting and luncheon on May 2, 2008 at theEdina Country Club. It was a day of change,celebration and education.

HMS Alliance members voted to changetheir name to West Metro Medical SocietyAlliance (WMMSA) to maintain their identi-fication with the West Metro Medical Society(formerly Hennepin Medical Society).

In addition to the name change, the WestMetro Medical Society Alliance will be chairedby six past-presidents. Each past president willbe responsible for presiding over meetings andother Alliance activities during a two monthperiod from July 1, 2008 to July 1, 2009. Allother WMMSA Board of Directors positionsremain unchanged.

The Alliance celebrated their new forty-year members Dianne Schottler, Shirley Ka-

plan, and Carol Nelson, Dianne Fenyk’s yearas AMA Alliance President, and recognized theAlliance’s ongoing good work of communityhealth education and other health related proj-ects.

Charles and Lara Foley presented anupdate on their elephant study in TarangireNational Park, Tanzania, East Africa. Larais the daughter of member Peggy Johnson.Charles and Lara have been studying the el-ephant population of Tarangire National Parkin northern Tanzania for 15 years. Tarangire ishome to 3,000 elephants and has become oneof the best parks in Africa to see large herds ofelephants.

For informationregarding this event,membership, projects,newsletters etc. please

go to: www.metrodoctors.com, click WMMS,and then click WMMS Alliance.

Minnesota Medical AssociationAlliance (MMAA)The MMA Alliance held their 85th An-nual Meeting on May 17, 2007 at the DuluthWomen’s Club.

Martha Arneson, WMMSA, received theMMAA Karen A. Tourdot Award in honor ofher years of community service. June Cavertand Janice Kleven, WMMSA members wererecognized as new MMAA Forty-Year mem-bers. In addition, the following WMMSAmembers were installed on the 2008/2009MMAA Board of Directors: Dianne Fenyk,treasurer and Eleanor Goodall, recordingsecretary.

MMAA Past Presidents.

Martha Arnesonreceived theMMAA Karen A.Tourdot Award.

Eleanor Goodall and Dianne Fenyk,WMMS Alliance, Judy Bernhardt andLinda Wiig, Lake Superior MedicalSociety Alliance.

Martha Arneson expressesher appreciation to KathyDittmer, executive assis-tant, WMMS, for her untir-ing support and assistanceof the Alliance.

Dianne Schottler is con-gratulated by Becky Finneas a 40 year member. Notpictured: Shirley Kaplanand Carol Nelson.

Becky Finne recognizedMarion Kelsey, long timeAlliance member.

Candy Adams, MMAApresident, addressed theAlliance.

Marlene Ellis pre-sented the namesof Alliance mem-bers deceased thispast year.

Eleanor Goodall, TrishVauria, Martha Arnesonand Diane Gayes are in-stalled as “presiding presi-dents” of the Alliance byMMAA president-elect,Linda Wiig. (Not pictured:Dianne Fenyk and PeggyJohnson.)

Trish Vaurio and MarthaArneson, co-presidingpresidents, 2007-08.

(WMMS photos by Janet Cardle.)


C A R E E R O P P O R T U N I T I E S

CHARLES E. CRUTCHFIELD, III, M.D. wasrecognized in the May issue of Black Enterprise asone of the 140 physicians named in “America’sLeading Doctors.” Dr. Crutchfield is adjunctclinical professor at the University of Minnesotaand the founder of Crutchfield Dermatology.

ROBERT W. EMERY, M.D. has joined St.Joseph’s Hospital as medical director of cardio-vascular surgery. He was most recently the head ofthe Division of Cardiovascular Surgery at RegionsHospital in St. Paul.

JAMES GAGE, M.D. was honored at the GilletteChildren’s Specialty Healthcare NeuroscienceConference for his work as the former medicaldirector at Gillette and pioneer of the gait andmotion laboratory technology used in medicine.Dr. Gage is currently the director of the Centerfor Cerebral Palsy at Gillette and has written sev-eral books on the analysis and treatment of gaitproblems in children with cerebral palsy.

PAUL GOERING, M.D. has been appointedexecutive medical director of mental health for

Allina Hospitals & Clinics. Dr. Goering has beenaffiliated with United Hospital in St. Paul formore than 15 years.

LYNNE LILLIE, M.D. has been selected as thenew medical director for Woodwinds HealthCampus. She has been practicing family medi-cine for more than 10 years in Minnesota and isa family medicine physician at the HealthEastWoodbury Clinic.

Minnesota Physician Publishing honors physi-cians who have volunteered medical services incommunities here in Minnesota and abroad. TheCommunity Caregivers recognized in 2008 are:

JAMES T. YOUNG, M.D., a family physi-cian and hospitalist at United Hospital, for hisinvolvement with the American Cancer Society.He began volunteering with the Cancer ResourceNetwork and is currently on the board of direc-tors for ACS’ Minnesota division and spendsmuch of his time getting the word out aboutACS and the Cancer Resource Network.

DOUGLAS PRYCE, M.D. is director ofthe Somali Medical Clinic at Hennepin CountyMedical Center (HCMC) and a board member ofthe Somali Health Project. He was recognized forhis efforts in educating the Somali on health carewith community meetings that are then broad-cast on Somali radio and the Somali languageprograms on cable access channels. He also givestalks to health care providers on how to best carefor Somali patients.

LAKEVIEW HOSPITAL was named one of thenation’s 100 Top Hospitals by Thomson Health-

care, a leading provider of information and solu-tions to improve the cost and quality of healthcare. The award recognizes hospitals that haveachieved excellence in clinical outcomes, patientsafety, financial performance, and efficiency.

The Minnesota Academy of Family Physicianselected PATRICIA FONTAINE, M.D., a Uni-versity of Minnesota Physician as their president.LYNN LILLIE, M.D., a family medicine physi-cian at Woodwinds Health Campus is theirimmediate past president. DAVID THOR-SON, M.D., family medicine at Family HealthServices Minnesota was elected AAFP Delegateand CAROL FEATHERSTONE, M.D., familymedicine at Park Nicollet Clinic–Brookdale waselected AAFP Alternate Delegate. Also receiv-ing awards were: GWEN HALAAS, M.D.,M.B.A., director of Interprofessional Educa-tion at the University of Minnesota AcademicHealth Center; assistant professor, University ofMinnesota Department of Family Medicine andCommunity Health received the Teacher of theYear; MICHAEL HERVEY, M.D., third-yearresident, University of Minnesota–St. Joseph’sHospital Family Medicine Residency Programreceived the Resident of the Year.

Allina’s UNITY HOSPITAL has earned aLevel III trauma designation from the Minne-sota Statewide Trauma System of the MinnesotaDepartment of Health (MDH). Unity is one ofonly seven hospitals in Minnesota to receive thisdesignation.

Members in the NewsThe Members in the News section recognizesthe appointments, presentations, awards, hon-ors and other professional accomplishmentsof EMMS and WMMS members. Submitphysician news by fax (612) 623-2888, e-mail([email protected]) or mail to Editor,MetroDoctors, 1300 Godward Street NE, Suite2000, Minneapolis, MN 55413 for consider-ation by the editorial board. Questions? CallDoreen Hines at (612) 362-3705.

Introducing the new “Career Opportunities” section of MetroDoctors!

A great avenue for professionals to learn about job opportunities ANDa perfect place for recruiters to promote openings!

Recruiters, call for our special recruitment rate.Betsy Pierre, ad [email protected]

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Relate clinical pearls from the nationalguideline experts, Barton Schmitt, MD andDavid Thompson, MD

Examine challenging clinical topics:anaphylaxis, asthma, respiratory distress,under and over referrals, patient safety,telemedicine for acutely ill, injured childrenin remote emergency departments, and more

Learn more about relevant business topics:leadership, reigniting the passion for service,creating the ideal environment for callcenters, doctor-nurse interventions,managing a triage call center, legal issues,trends in telephone triage, plus others

Details and registration form available atwww.cpnonline.org. Or, email your requestfor full details to:[email protected], call 952-931-3545

www.cpnonline.org

Reach for the StarsReach for the Stars

A limited number of Sponsorship and Exhibitor Opportunities arestill available. For details, email [email protected] call 612-813-7435.

This activity has been planned and implemented in accordance with the EssentialAreas and Policies of the Accreditation Council for Continuing Medical Educationthrough the joint sponsorship of the Minnesota Medical Association and

Children's Physician Network. The Minnesota Medical Association (MMA) isaccredited by the Accreditation Council for Continuing Medical Education to providecontinuing medical education for physicians.

The MMA designates this educational activity for a maximum of 13 AMA PRACategory I credits™. Physicians should only claim credit commensurate with theextent of their participation in the activity.

Children’s Physician Network is an affiliate of Children’s Hospitals and Clinics of Minnesota.

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