Minnesota Physician April 2012

While homicide ratesand other indicatorsof violence fluctuate

from year to year, youth vio-lence remains a leading publichealth problem in Minnesotaand across the nation.

For physicians heeding the call toaddress this preventable cause of morbidityand mortality among young people, there arenumerous policy statements and counselingrecommendations. For example, in 2006the American Academy of Pediatrics (AAP)developed a violence prevention guide called“Connected Kids,” accessible on the AAPwebsite at www2.aap.org/connectedkids/

material.htm. Counseling sched-ules list violence prevention top-ics to introduce and topics toreinforce at each visit, includingfirearms, bullying,and conflict reso-lution skills. The

guide is well organized,strength-based, and thoroughin providing resources thatcover many important areas.

Certainly, child and adoles-cent health professionals areuniquely positioned to inter-vene before violent behaviors

VIOLENCE to page 10

Volume XXVl, No. 1

April 2012

Transformationsin careSystem-wide innovationaddresses challenges

By Paul Johnson, MD; Pamela Clifford,RN, MPH; Jennifer DeCubellis, LPC;Sheila Moroney; and Mark Linzer, MD

Public hospitals are facingmany challenges, includingrevenue issues, complex

patient populations, and operationalchanges due to health care reform.To address these challenges and in-novate in the face of shrinkingresources, Hennepin County MedicalCenter (HCMC) launched the Centerfor Healthcare Innovation (CHI) in2011. CHI encourages and overseesnew, unique, and state-of-the-artprograms that will transform careat HCMC.

We have several transformationsto report. Last year HCMC launcheda coordinated care delivery system(CCDS) to care for 10,000 patientswho had lost state-supported insur-ance. This year, we have partneredwith Hennepin County and

TRANSFORMATIONS to page 12

The Independent Medical Business Newspaper

Evidence-basedapproachesBy Iris Wagman

Borowsky, MD, PhD

IN THIS ISSUE:New Generation TechnologyPage 20

Preventing youth violence

Several space options metro-wideExisting or build to suit

Mark A. [email protected]

Jill K. Rasmussen, CCIM, [email protected]

MEDICAL OFFICEFOR LEASE

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Ritchie Medical Place, St. Paul

High Pointe Health Campus, Lake Elmo 2800 Medical Building, Minneapolis

Southdale Medical Center, Edina Physicians Building, Edina

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6405 Medical Building, EdinaMidtown Medical Building, Minneapolis

Gardenview Medical Building, St. Paul

You wouldn’t give a 4-year-old a drink, so why would you give one to an unborn child?

As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy.

Share 049: Zero Alcohol For Nine Months.

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CAPSULES 4

MEDICUS 7

INTERVIEW 8

POLICYThe heartbeat ofhealth reform 14By Sanne Magnan, MD, PhD

PHYSICAL THERAPYPhysical therapy forParkinson’s disease 17By Rose Wichmann, PT

New horizons fortelehealth 20By David Hemler

Pediatric medical devices 26By Bradley F. Slaker, BSME, MBA

Getting connected 28By McLain Causey

Bridge-building 30By Cheryl Stephens, PhD

Re-igniting the spark 34By Dale Wahlstrom

DEPARTMENTS

SPECIAL FOCUS: NEW-GENERATION TECHNOLOGY

C O N T E N T S APRIL 2012 Volume XXVI, No. 1

APRIL 2011 MINNESOTA PHYSICIAN 3

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Ouraddress is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601;email [email protected]. We welcome the submission of manuscripts and letters for possible pub-lication. All views and opinions expressed by authors of published articles are solely those of theauthors and do not necessarily represent or express the views of Minnesota PhysicianPublishing, Inc., or this publication. The contents herein are believed accurate but arenot intended to replace legal, tax, business or other professional advice and counsel. Nopart of this publication may be reprinted or reproduced without written permission ofthe publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

PUBLISHER Mike Starnes [email protected]

EDITOR Donna Ahrens [email protected]

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ART DIRECTOR Elaine Sarkela [email protected]

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ACCOUNT EXECUTIVE Iain Kane [email protected]

TheIndependentMedicalBusinessNewspaper

Preventing youth violence 1Evidence-based approachesBy Iris Wagman Borowsky, MD, PhD

Transformations in care 1System-wide innovationaddresses challengesBy Paul Johnson, MD; Pamela Clifford, RN, MPH;Jennifer DeCubellis, LPC; Sheila Moroney;and Mark Linzer, MD

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Mayo FinancesAre Strong,Annual Report FindsMayo Clinic has nearly doubledits income since 2009, and itshealthy financial results willlead to major capital projects incoming years, officials with theRochester-based system say.Mayo Clinic is seeing total

annual revenues of $8.5 billion,according to financial figuresrecently released. After expenses,the system had $610 million inincome in 2011, compared with$515 million in 2010 and $333million in 2009.The annual report listed sev-

eral areas of booming operationsfor Mayo Clinic, including morethan 1 million patients cared forat facilities in Arizona, Florida,Iowa, Minnesota, and Wiscon-sin. Mayo research programsbrought in nearly $367 millionin funding from outside sourcessuch as government grants.Researchers were involved inclose to 8,000 study projects in2011. Mayo’s College of Medi-cine educated 2,446 medical stu-dents, with 1,491 residents and

fellows also receiving training.Officials say Mayo Clinic’s

operating margin of just over7 percent will allow it to pursueits long-term objectives, includ-ing upgrading and expandingcapital assets. “In 2012, MayoClinic will launch $600 millionin capital projects. We estimatespending $700 million per yearin capital projects for the nextfive years,” says Shirley Weis,the clinic’s vice president andchief administrative officer. “Weanticipate that the next three tofive years will be marked byhigher-than-average job growthand continued capital spendingas we execute a set of strategicinitiatives designed to meetpatients’ evolving needs.”

MDH ReportsUninsured RatesRemain High in StateDespite better economic times,uninsured rates in Minnesotaremain high, officials withMinnesota Department ofHealth (MDH) say.A biannual report from

MDH has found that the unin-sured rate for Minnesotansremained at 9.1 percent in2011, un-changed since 2009.In the 2009 report, data showedthe rate of uninsured people inMinnesota increased, from 7.2percent in 2007. That followedan upward trend since 2001,when the uninsured rate was6.1 for state residents.Officials say an estimated

490,000 Minnesotans wereuninsured in 2011, compared to480,000 Minnesotans in 2009and 374,000 in 2007. MDH saysapproximately 70,000 childrenwere without health coverage in2011.“This report indicates that

we have not recovered from thelosses in health insurance cover-age that we sustained subse-quent to the Great Recession,”says Commissioner of HealthEd Ehlinger, MD. “It is also clearthat the cost of insurance is abarrier to coverage. We abso-lutely must redouble our effortsfocused on disease prevention,public health, and paymentreform so that health coveragebecomes more affordable for

Minnesotans.”The report notes several

areas of concern. For one, thefact that the economy hasimproved would normally leadto more people having insurancethrough employer-sponsoredprograms. The fact that unin-sured rates have stayed the samesuggests that jobs being createddo not offer insurance, or thatsome employers are droppingcoverage for existing workers. Inaddition, the report finds a de-cline in the number of peoplewho choose to enroll in employ-er-sponsored health plans—per-haps an indication that healthinsurance is becoming too ex-pensive for some Minnesotans.Another concern is the num-

ber of people uninsured for anentire year, a group that is some-times called “long-term unin-sured.” Officials say those num-bers are increasing. “For thefirst time in 2011, the all-yearuninsured accounted for morethan half—51.1 percent—of [theuninsured], up from 44.3 per-cent in 2009, potentially repre-senting a trend toward morelong-term uninsurance that

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deserves to be monitoredclosely,” the report says.

EMRs Still AChallenge, OptumStudy SaysA study on how hospitals areadopting health informationtechnology (HIT) finds thatalthough 87 percent of hospitalsnow have electronic medicalrecords (EMRs), significantchallenges remain with thetechnology.The study was released by

Eden Prairie-based Optum, adivision of UnitedHealth Group.Optum commissioned a surveyof 301 hospital executives on theoverall progress of adapting newHIT systems in their facilities.According to the survey,

87 percent of hospitals nowhave EMR systems in place,which is an increase over anearlier survey that found slightlymore than 50 percent of hospi-tal systems had EMRs in place.“Hospitals are making sub-

stantial gains in adopting elec-tronic medical records, partici-pating in health informationexchanges, and achieving ‘mean-ingful use,’” said Simon Stevens,chairman of the OptumInstitute. “But hospital chiefinformation officers are clearlysignaling that technology gapsremain, genuine interoperabilityremains elusive, and—as aresult—most U.S. hospitals arestill some way off from beingfully ready to play their part inmanaging population health andits related financial risk.”Among the challenges iden-

tified in the survey, the reportfinds that many EMR systemshave required serious upgradesor changes. Nearly 80 percent ofrespondents said they had tomodify their EMR systems sig-nificantly or purchase anothersystem entirely. This has led toincreased spending; hospitalCIOs say that so far, EMRs haveraised hospital operating costsrather than reduced them.Other problems identified

include gaps in care informa-tion, interoperability issuesamong components of healthorganizations, and complianceissues.

Dueling ExchangeBills Signal ImpasseAt CapitolRepublican and DFL lawmak-ers offered competing healthcare bills in recent weeks, withthe DFL side embracing theinsurance exchange conceptrequired by the federalAffordable Care Act (ACA) andthe Republican lawmakersrejecting insurance exchangesand instead calling for free-market solutions to the state’shigh rate of uninsured citizens.The two sides introduced billsaddressing the health exchangeissue on March 5 in St. Paul.The DFL bill was sponsored

by Rep. Erin Murphy (DFL–St.Paul) and Sen. Jeff Hayden(DFL–Minneapolis). This legisla-tion would create a marketplacefor consumers and provideresources for purchasing healthinsurance based on the ex-change model. It is similar to abipartisan insurance exchangebill introduce by Rep. Joe Atkins(DFL–St. Paul) in February, withsupporters of the new bill sayingit better addresses conflict ofinterest concerns regarding gov-ernance of the exchange.The Republican bill is

essentially a rejection of thehealth insurance exchange con-cept, not a surprising develop-ment given Senate GOP leaders’insistence that the ACA is anunconstitutional, big-govern-ment solution forced on states.At a March 5 press conference,the bill’s authors were highlycritical of the state’s ongoingefforts to plan for the exchange.“We have a governor … who isin lockstep with the federal gov-ernment in creating a federalprogram to take away people’schoice on insurance inMinnesota. We don’t believethat’s right,” said Sen. DavidHann (R–Eden Prairie), one ofthe co-authors of the bill.The developments cast

doubts on the prospects forcompromise during this session,as the Republican bill seems farremoved from the frameworkenvisioned by the ACA. TheGOP approach would allowindividuals to pool money fromsources such as families, part-

CAPSULES to page 6

C A P S U L E S


time employers, and charitableorganizations in a kind of healthsavings account.

Supporters of the bill say aninsurance exchange is not neces-sary, since there already areonline tools to compare insur-ance plans. Rep. Steve Gottwalt(R–St. Cloud) said Minnesotapreviously has put in place manyof the ideas promoted by theACA, such as high-risk pools andaccountable care organizations.

In a testy exchange withreporters, the GOP leadersrejected the idea of leaving theircurrent taxpayer-supportedhealth insurance plans for thekind of system they envisionwith their bill. “The state ofMinnesota is our employer, theyoffer health care coverage totheir employees,” Gottwalt said.

Medica, FairviewRoll Out AccountableCare OrganizationMedica and Fairview HealthServices have begun rolling outtheir accountable care organiza-

tion (ACO) for Medica membersin the Twin Cities area.

For employer-based healthplans, the ACO will be availablethrough Medica’s My Plan insur-ance product, under the nameFairview Health Advantage withMedica. The My Plan product isalso available with the MedicaChoice Passport network, butofficials say the ACO optioncould lower payroll deductionsby as much as 50 percent forenrollees.

For individuals, a productcalled Harmony with Medicaand Fairview will be offered.Officials note that the individ-ual market is more expensivein general, so savings are some-what more modest—approxi-mately 10 percent less thanproducts with traditionalprovider networks.

Medica officials say thenew ACO model will provideseveral new innovations tomembers, including care teamsto manage health, online healthassessments, and virtualappointments.

MDH Says SHIPNeeds More Time toImprove OutcomesThe Minnesota Department ofHealth (MDH) has given theMinnesota Legislature a reporton the Statewide HealthImprovement Program (SHIP),saying the program has promoted wellness, good nutrition,and healthy lifestyles in commu-nities throughout the state.

The report comes at a timewhen the GOP-controlled legisla-ture has questioned whether theprogram is worth the state’sinvestment in a time of tightbudgets.

SHIP was passed in 2008as part of bipartisan health-carereform legislation, and legisla-tors saw it as a strategy for curb-ing rising health care coststhrough prevention efforts. Offi-cials say SHIP's goal is to im-prove health and reduce healthcare costs by reducing the num-ber of Minnesotans exposed totobacco and the percentage ofMinnesotans who are obese oroverweight.

The new report finds that inits first two years, the programhas promoted good health in avariety of settings. In the work-place, SHIP has helped morethan 870 employers sponsorworksite wellness initiatives. Ithas increased access to localproduce for more than 200,000Minnesotan students. It also haspromoted exercise and tobaccocessation programs.

Despite the report of pro-gress towards its goals, SHIP islikely to receive greater scrutinyfrom lawmakers. With last year’sdeficits, many health programssaw cuts and SHIP programswere cut by 70 percent, whichthe report says had a negativeimpact on the program’s results.

The report adds thatimproving health outcomestakes time. “In order for healthcare savings to be realized,progress may be more likelywhen measuring it from thebeginning of SHIP in 2010 andviewed as a long-term invest-ment,” the report says.

Capsules from page 5

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Howard Epstein, MD, has joined the Institutefor Clinical Systems Improvement (ICSI) aschief health systems officer. He had been themedical director for quality and health manage-ment at Blue Cross and Blue Shield of Min-nesota. Epstein has long been involved in ICSIactivities, having chaired the Committee on Evi-dence-Based Practice and served on committeesfor several ICSI health-care redesign initiatives.In addition to his new position with ICSI,

Epstein is a general internist and hospitalist on staff at RegionsHospital, and is past president of the board of directors for the Min-nesota Network of Hospice and Palliative Care.

Nancy Raymond, MD, has been named associate dean forfaculty affairs for the University of Minnesota Medical School. Aprofessor in the Department of Psychiatry, Raymond also providespsychiatric consultation to the Department of Family Medicine &Community Health’s Program in Human Sexuality. In her new role,Raymond will be responsible for overseeing and directing the MedicalSchool Office of Faculty Affairs. Raymond will continue serving asdirector of the Deborah E. Powell Center for Women’s Health andcontinue her efforts with the Building Interdisciplinary Research Ca-reers in Women’s Health grant from the National Institutes of Health.

The Twin Cities Medical Society has pre-sented Robert Geist, MD, with the First aPhysician Award. The First a Physician Award,established in 2007, recognizes a member of themedical society who has made a positive impacton organized medicine by selflessly giving ofhis/her time and energy to improve the publichealth, enhance the medical community’s abilityto practice quality medicine, and/or improve thelives of others in our community. Geist practicedat Metropolitan Urologic Specialists, PA in St. Paul for 30 years priorto his retirement in 1997. He also founded and organized committees,which have served as open forums to encourage direct dialogue be-tween physicians and diverse policy experts, to examine and criticallydissect public policy direction on health care as it affects physiciansand patients within Minnesota and nationally. The award called Geist

an “advocate of the highest integrity on behalf ofthe profession of physicians, and for the protec-tion of patients. He is truly the thinking person’sphysician and patient advocate.“

Laurie Drill-Mellum, MD, MPH, hasbeen named chief medical officer of MMIC, aMinneapolis-based company that provides pro-fessional liability insurance, risk and claimsmanagement, and health information technologyservices to health care providers. In this newlycreated role, Drill-Mellum will work to develop

integrated risk reduction and risk mitigation strategies, and will builda network of physician consultants that will work closely with physi-cians and hospitals throughout MMIC’s eight-state region. Drill-Mellum has practiced emergency medicine since 1991 at RidgeviewMedical Center in Waconia, where she held roles as chief of themedical staff and medical director of the emergency department.

The American Academy of Family Practice (AAFP) has an-nounced that two members of the Minnesota Academy of FamilyPractice (MAFP) have been appointed to serve on national commis-sions. David Hutchinson, MD, Duluth, has been appointed to theAAFP Commission on Education. Hutchinson, a former MAFP presi-dent, is an assistant professor in Family Medicine and CommunityHealth in the University of Minnesota–Duluth Medical School, and isassistant director of the Duluth Family Medicine Residency. LynneLillie, MD, Woodbury, has been appointed to the AAFP Commissionon Quality and Practice. She is medical director at Healtheast’s Wood-winds Campus in Woodbury, and is also a former MAFP president.

M E D I C U S

Howard Epstein, MD

Robert Geist, MD

Laurie Drill-Mellum,MD, MPH


Exp. Date

� Check enclosed � Bill me � Credit card (Visa,Mastercard, American Express, or Discover)

Please mail, call in or fax your registration by 05/31/2012

MINNESOTA HEALTH CARE ROUNDTABLEMINNESOTA HEALTH CARE ROUNDTABLE

Background and focus:Medications treating chronicand/or life-threatening diseases arefrequently new products, whichare often more expensive thangeneric or older, branded productsthat treat similar conditions. Theterm specialty pharmacy has cometo be associated with these med-ications. Exponents claim the newtechnology improves quality of lifeand lowers the cost of care byreducing hospitalizations. Oppo-nents claim the higher per-dosecost spread over larger populationsdoes not justify the expense.

The cost of research, both failedand successful, is reflected in product pricing. Current federal guidelinesallow generic equivalents marketplace access based on the patent date,not the release date, of a product. This considerably narrows the windowin which costs of advances may be recovered. A further complicatingdynamic involves the payers. Physician reimbursement policies some-times reward utilizing lower-cost “proven” products and cast those pre-scribing higher-cost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access.

Objectives: We will discuss the issues that guide the early adoptionof new pharmaceutical therapies and how they relate to medical devices.We will examine the role of pharmacy benefit management in dealingwith the costs of specialty pharmacy. We will explore whether it ispenny-wise but pound-foolish to restrict access to new therapies andwhat level of communication within the industry is necessary to addressthese problems. With the baby boomers reaching retirement age, morepeople than ever will be taking prescription medications. As new prod-ucts come down the development pipeline, costs and benefits will con-tinue to escalate. We will provide specific examples of how specialtypharmacy is at the forefront of the battle to control the cost of care.

Panelists include:� Sara Drake RPh, MPH, MBA, Pharmacy Program Manager,

Minnesota Department of Human Services� Alan H. Heaton, PharmD, RPh, Director, Pharmacy Management, UCare� Daniel Johnson, MEd, Vice President of Public Policy, National Multiple

Sclerosis Society� Timothy Stratton, PhD, BCPS, FAPhA, Professor, College of Pharmacy, UMD

� Gene Stringer MD, Stillwater Medical Group

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Sponsors include: Daiichi Sankyo • Novartis

� Tell us about how you see your role as commis-sioner of DHS.

An important part is really running a very large,very complex agency that does very importantwork. As you think about it, we touch the lives ofover a million Minnesotans every year, many of themost vulnerable of our citizens. We have over 6000employees and a budget of, just in state dollars,almost $11 billion—twice that if you include thefederal funds.

A large part of the job is really just running acomplex agency. I also have a role as a policy-maker, advising the governor on how we should bedoing our work. Because 80 percent of our dollarsare spent on health care, I spend a lot of my timetrying to think about how we can further the tripleaim—better patient experiences, lower cost, andhigher quality.

� What is the role of DHS in health care reform?

A large part of the way wecontribute at DHS to healthreform is through using ourpower as a payer. It’s not justabout saving money. We’regoing to be developing gain-sharing models and driving towards better out-comes so we’re not just paying on a fee-for-servicebasis. That’s an example of where we’re using ourpower as a big purchaser to try to get better out-comes.

For example, take our role as the state author-ity for mental health and substance abuse. Thatsystem, the way we do mental health, has thepotential to dramatically change under healthreform. If you think about it, most people in theirinsurance policy now, don’t have real chemicaldependency coverage. It’s going to be an essentialhealth benefit under the Affordable Care Act (ACA).We need to redesign our system for a system wherepeople have that coverage.

Obviously, the health insurance exchange isvery important to us because the ACA says thatpeople on public programs enter through theexchange. We have a great interest in making surethat exchange is up and running, and that it’s goingto work well for public program enrollees. Peoplethink about it in the individual and small groupmarkets, which are important, but our publicenrollees may have different needs for anexchange, so we want to be very involved in that.

� What are some of the challenges and achieve-ments you’re seeing in implementing state andfederal health reforms?

One of the obvious challenges is the political divideover the ACA. It is unfortunate; so many things inthe ACA are things that we were doing here inMinnesota years before the federal governmentstarted to do them. If you think about health carehomes, for an example, that’s something that

Minnesota started long before. Some of the pay-ment reforms that are important, the ideas behindthe ACOs, we started that long before the federalreform.

I’m glad the Supreme Court took the case[challenging the ACA]. I want to have some deci-sions. I believe that most of us in Minnesota arepreparing for implementation. In some places yousee holding patterns, and that’s not helpful.

I think there’s a real excitement, and we aremoving towards a better system. Not just becauseit will save us money, but it will [also] be payingfor better outcomes.

� What will health exchanges mean for patientsand providers in the state?

A great thing for consumers is you should be ableto make apples to apples choices amongst healthplans. You are able to put in what’s important toyou, whether it’s important for you to have a low

deductible or a high de-ductible. You can makechoices between plans andlook at their quality ratings,because that’s going to bebuilt in, to dive deeper and

say, who are the providers for this plan?As an individual, I can go to the exchange, and

then it tells me whether or not I qualify for a pub-lic program subsidy, and then knowing what thatsubsidy is, I go shopping.

It will provide consumers a lot more informa-tion and get them more involved in their healthcare choices. If we don’t get consumers moreinvolved in their health care and how much they’repaying for it and see the incentives to take chargeof their health care, we’re never going to get ourarms around the challenges we have.

For providers, there’s an opportunity—if we doit right—for provider networks to be a part of thisso that there are organizations for providers whowant to contract with Medicaid. While I thinkthere’s a real role for health plans, and someprovider organizations absolutely want to be work-ing through health plans, some don’t. This givesthem some more options.

Obviously, if there’s more transparency aboutprovider choice, that’s a good thing for providers.The other thing about the health exchange with themandate, more people are going to have insurance,just with the Medicaid expansion, even before youthink about people following the mandate. Morepeople having insurance means less uncompen-sated care.

� Lawmakers have been calling for more trans-parency for Medicaid programs. Talk a littleabout what DHS has done in this area.

One of the big changes we made coming in was toput our largest contracts out for bid. There havebeen questions about what the state was spending

Lucinda JessonDepartment of Human Services

Lucinda Jesson isthe Minnesota

Commissioner of theDepartment of HumanServices (DHS). Jessonhas formerly served asthe founding director ofthe Health Law Instituteat Hamline University,attorney general for

health and licensing inthe Minnesota AttorneyGeneral’s Office, andchief deputy Hennepin

County attorney.Jesson is in charge of

an agency that providesa range of health careservices, with a mix ofstate and federal fund-ing. Minnesota spent$4.7 billion on healthcare programs in the

most recent fiscal year.DHS provides health

insurance coverage formore than 700,000

Minnesotans and workswith approximately118,000 providers.

Overseeing a time of change at DHS


I N T E R V I E W

We are moving towarda better system.

all of these billions of dollars on? Are wegetting our money’s worth?

In the past, what we have done is lookat what we paid the health plans over thepast three years and then add a medicaltrend, and then that’s what we paid themthe next year. There wasn’t a lot of incentivefor efficiency.

That’s why I think the competitive bid-ding process really just kind of pushed areset button. It was competition; there werewinners and losers. It was a hard thing forthe marketplace, but I believe it answeredsome questions. And it told us, I think, thatwe were paying too much. That’s how wecaptured the savings. That’s one piece oftransparency.

The governor, in his executive order lastMarch, also made it clear that he wantedaudits of the health plans to be conducted.The Department of Commerce is going tocontract with an outside auditor on a rotat-ing basis to audit the health plans, whichwill be another piece of transparency.

The proposals in the Legislature are foradditional outside audits; I’m supportive ofthat. I think there really is a question on thepart of the public, are we getting ourmoney’s worth? There’s a gap in public trust.The outside audits, just like competitive bid-ding, are a way to address that.

� Sometimes we hear that providers ques-tion why their reimbursements from thestate are being frozen or cut back, andthen they see an increase going to theplans for Medicaid programs.

I can only talk about what’s happened sinceI’ve been commissioner. Let me tell you, lastyear the plans did not get an increase. That’swhat we learned through competitive bid-ding, and overall, they took a significant hit.

The other thing I would say on providerreimbursement rates, that’s why we’ve got toget a different, better way of paying pro-viders. That’s what we’re trying to do withthese demonstration projects and embed-ding that in all the contracting that we do,whether it’s through the plans or directlywith providers, to make sure that any incen-tives are pushed down to the provider level.It’s not just risk sharing with the plans, be-cause then they can just keep the money,right? We’re insisting in our contracts withthem that it be pushed down to the providerlevel.

� What message do you have for physiciansof the state?

I feel lucky to be commissioner of humanservices in this state with so many outstand-ing providers, especially physicians. I wouldencourage them to join us in embracingchange. Change in the way we pay for healthcare, but also in the way we think about

population health. I think a lot about thesocial determinants of health and how weall need to do a better job at keeping peoplefed and eating healthy food and getting exer-cise and living in places where they haveaccess to all those things.

That’s not something you can delegateto government. That’s something we all haveto do as a society. And that’s something I feelthat physicians as a group probably under-stand better than most other groups.

And finally, tell me what we can dobetter!

� You mentioned embracing change. That’snot always easy. Not everyone in theprovider community is resistant, but I’msure you get some foot-dragging.

Well it’s not just physicians, I’m a lawyer,and nobody drags their feet more thanlawyers do!

I think physicians, the ones I work with,are usually very focused on their patients.When you think about what’s best for thepatient, they will see the way the incentivesin our current fee-for-service system do notbenefit patients, for the most part.

So when people focus on that, thenwe’re willing to look at options. I think mostof us would say the status quo isn’t sustain-able. Once you understand that, there’s awillingness to look at other options.


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occur. The question is, which ofthese counseling recommenda-tions are backed up by evidenceshowing that they are effectivein the clinical practice setting?While a counseling recommen-dation may sound like a goodidea and certainly not harmful,time spent on screening or coun-seling that is not evidence-basedcan take away from other physi-cian tasks of proven benefit.

Randomized controlled eval-uation studies in clinical settingsare greatly needed to guide prac-tice. However, decades of re-search have revealed muchabout what works and whatdoesn’t work in preventing youthviolence. Effective interventionsinclude strategies at the individ-ual level, such as training forelementary school students toincrease their social problem-solving skills; at the family level,such as parent training pro-grams; and at the extrafamilialenvironmental level, such asmentoring programs.

The following discussionhighlights “Minnesota Best

Bets,” a set of recommendationswith a locally inspired mnemon-ic (LAKES) and some localresources to draw upon. Thesepractices are both feasible in theclinical setting and worth clini-cians’ time because there is atleast some good evidence thateach reduces violence amongchildren and adolescents.• Lower media exposure• Address behavior and mood• Key adults: mentoring pro-

grams• Education and support for

parenting: parent training and

home visitation programs• Safe firearm storage

Lower media exposure

Hundreds of studies demon-strate the link between exposureto media violence and real-lifeviolence. As reported in Archivesof Pediatrics and AdolescentMedicine in 2001, Robinson andcolleagues conducted a random-ized controlled study of a class-room curriculum to reducemedia use among third- andfourth- grade students. Theyfound that the curriculum suc-cessfully reduced media use andaggressive behavior among stu-dents in the intervention group.Regarding office-based counsel-ing about media exposure, astudy by Barkin and colleagues,published in Pediatrics in 2008,found that brief motivationalinterviewing by pediatriciansand offering minute timers forlimiting media use were signifi-cantly associated with mediause reduction among childrenages 2 to 11.

Motivational interviewinggenerates patient-centered solu-tions through assessment of1) family interest in changingbehaviors, e.g., How importantis it to reduce your [the pa-tient’s] media use? and 2) confi-dence in changing behaviors,e.g., How confident are you thatyou [the patient] can cut backon media use? Following AAPguidelines, recommend no morethan one or two hours a daytotal screen time, includingwatching TV and movies, play-ing video games, and using thecomputer (unrelated to home-work). Also ask how many hoursthe TV is on in the home evenwhen the child is not watching

it. Research shows that chil-dren’s exposure to backgroundTV is high and may be just asstrongly associated with conductproblems as the amount of TVwatched.

Address behavior and mood

In 1975, R.J. Haggerty describedpsychosocial problems as the“new morbidity”; now they arethe most common chronic con-dition for pediatric visits. Sev-eral studies have found thatroughly one in five childrenattending pediatric practiceshave significant mental healthproblems. The new morbiditiesare “hidden” because many stud-ies have shown that most childmental health problems are notdetected in pediatric practice.They are “unheeded” becausethere is evidence that once theproblems are identified, only afraction of children with emo-tional and behavioral disordersreceive appropriate mentalhealth treatment.

In addition to occurringfrequently, untreated emotionaland behavioral disorders con-tribute to severe health conse-quences, including violence.There are effective or promisingtreatments for many childhoodmental disorders. One approachto facilitating recognition ofpsychosocial problems is to usea screening questionnaire. ThePediatric Symptom Checklist(PSC) was developed specificallyto facilitate recognition of psy-chosocial problems as part ofroutine primary care visits. The35-item tool is short, well-vali-dated in diverse populations ofchildren and adolescents, feasi-ble to administer in primarycare practices, and has a cut-offpoint for easy scoring. A newerversion of the screen, the 17-item PSC, is not only shorterbut also incorporates three sub-scales, allowing providers toquickly see where their patient ishaving problems. The three sub-scales—internalizing problems,attention problems, and exter-nalizing problems—addressimportant risk factors for vio-lence involvement among youth,

The PSC is available forpublic use and versions areavailable in multiple languages(including Spanish, Hmong, and

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“Minnesota Best Bets” practicesare both feasible in the clinical setting

and worth clinicians’ time.

Somali), at www2.massgeneral.org/allpsych/psc/psc_home.htm.Developed as a parent-complet-ed screening questionnaire byJellinek and colleagues, the PSChas also been validated for com-pletion by youth.

It is important to rememberthat the PSC is a screening,rather than a diagnostic, tool. Apositive test should prompt adiscussion with the family toassess the child’s functioningand the seriousness of any prob-lems. This brief interview addssome time to the visit, but it istime recovered by not pursuingfurther questioning of childrenwho score negative on thescreen. Studies have shown that20 to 25 percent of youth pre-senting to pediatric practicesscore positive on the PSC. Psy-chosocial screening may helpidentify youth who would bene-fit the most from violence pre-vention interventions.

Key adults: mentoring

Mentoring programs haveshown promise in preventingyouth violence and thus, forappropriate patients, are an

important referral resource forphysicians. These programsrecruit an adult to meet with ayoung person on a regular basis,in an effort to duplicate the kindof relationship with a caringadult that is so protective foryouth against an array of health-risk behaviors. Most mentoringprograms have not been evalu-ated as anti-violence interven-tions. A large-scale evaluation ofthe Big Brothers Big Sisters(BBBS) program in 1992 and1993 in eight U.S. cities foundthat mentored youth were lesslikely than wait-listed controls toskip school, initiate alcohol anddrug use, or hit someone over an18-month period. Providers canfind a local BBBS agency atwww.bbbs.org. Parents can calldirectly or providers/office staffcan make the initial call, and theprogram will contact the familyto start the intake process.

Education and supportfor parenting

Parent training and education.Family-level interventions areamong the most promisingyouth violence prevention

approaches known to date.Many randomized controlledstudies have demonstrated theeffectiveness of parent trainingprograms in improving parent-ing skills and family cohesion,and in reducing behavioral prob-lems, violent and delinquentbehavior, and substance useamong children and adolescents.Yet, despite their effectiveness infamilies from diverse economicbackgrounds and among chil-dren and adolescents with seri-ous as well as milder behavioralproblems, parent-training pro-grams have not been widely dis-seminated.

In a 2004 study in Pedia-trics, Borowsky et al. combinedtwo strategies that we thoughtwere both feasible in the pri-mary care setting and mightreally make a difference inreducing violence involvementamong youth:• Identify, prevent, and treat

mental health problems amongyouth through psychosocialscreening using the PSC-17and appropriate mental healthreferral and follow-up.

• Promote healthy child-parent

relationships through psycho-social screening and appropri-ate referral to a telephone-based positive parentingprogram.

In a randomized controlledtrial, we found that the interven-tion significantly decreased ag-gressive and delinquent beha-vior, attention problems, bully-ing, physical fighting, and fight-related injury for which medicalcare was sought among theyouth at nine-month follow-up.

In Minnesota, our legisla-ture supports parenting educa-tion for parents of infants andyoung children ages birth to fiveyears through Early Childhoodand Family Education (ECFE).A resource to help direct parentsto ECFE programs is the Minne-sota Parents Know website athttp://parentsknow.state.mn.us/parentsknow/index.html. Thewebsite has links to contactnumbers for ECFE programs inevery school district, as well asparenting education on a varietyof topics for parents of infants,children, and adolescents. Addi-tional resources include the


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Metropolitan Health Plan(MHP) to produce a novel caremodel for 10,000 vulnerablepatients through an accountablecare-like organization demon-stration project, HennepinHealth. We have also initiated aMedicine Psychiatry Programfor integrated care of medicalpsychiatric patients, and con-vened a Vibrant Clinic DesignGroup to redesign our medicineclinics.

Finally, HCMC continuesto drive improvement of thepatient experience. Usingpatient- and family-centeredcare as our platform for engage-ment, HCMC is undergoing acultural revolution that puts thepatient and family at the centerof everything we do.

Coordinated caredelivery system

Hennepin County MedicalCenter is a 477-bed publicteaching hospital in downtownMinneapolis. The hospitalserves diverse populations withcomplex social determinants ofhealth. Sixty-five percent of our

patients are people of color,and 20 percent are immigrantsor refugees. The state providedhealth insurance for poor,nondisabled, single adults(General Assistance MedicalCare, or GAMC) until June2010, when this arrangementwas dissolved due to a budgetcrisis. In place of GAMC, thestate provided four hospitals(HCMC, North Memorial,Fairview, and Regions) withminimal funding to cover essen-tial health services. HCMC sud-denly was faced with responsi-bility for 10,000 indigent adults.Given the modest funding, therewas a strong incentive to avoidunnecessary expense and elimi-nate wasteful services.

The GAMC population wasa high-cost group. Health issuestypically were complicated byhomelessness, mental healthproblems, chronic pain, andchemical dependency. HCMCtargeted care managementresources to the highest-costsegment: the 250 intensive usersof inpatient services. TheCoordinated Care Clinic (orCCC, described in “Hot spot-

ters,” Minnesota Physician,September 2011) was estab-lished to provide enhanced,intensive outpatient care to thispopulation. Meanwhile, theother 9,750 patients were seenin HCMC’s medicine and com-munity clinics, at NorthpointHealth and Wellness Center,and in other affiliated sites.Advanced access clinics (threeto four sessions per week) werestaffed by HCMC generalinternists and advanced prac-tice providers. New programsand linkages were developedfor mental health care, painmanagement, and chemicaldependency. Most of thisoccurred at lightning speed:Quite simply, all four CCDShospitals had to respond, andwe did.

The CCC Care Model

The CCC was developed forthe highest-utilizing patients(>2 hospitalizations per year).Current CCC staff, managing150 patients, includes a 0.5 FTEphysician, 1.0 FTE nurse practi-tioner, 1.0 FTE RN care coordi-nator, 1.0 FTE licensed socialworker, 0.5 FTE chemicaldependency counselor, 0.5 FTEpharmacist, 0.1 FTE clinicalpsychologist, and other clinicoperations staff.

We have identified eightfactors underlying the need forcomplex care coordination:1) chronic pain, 2) impairedcognition, 3) chemical depend-ency, 4) medical nonadherence,5) mental health problems,6) unstable housing, 7) medicalcomplexity, and 8) lack of com-munity or family support. Thesechallenges are addressed indaily staff “huddles” and twice-weekly team meetings. A clinicpatient registry is regularlyreviewed. Clinic visits involvemeetings with two to four teammembers (MD/NP, SW, CDcounselor, PharmD), andprovider schedules are inten-tionally light (approximatelysix visits per session).

The CCC model has re-sulted in dramatic improve-ments in utilization. Recentanalyses show hospitalizationsreduced by 54 percent andemergency department visitsreduced by 41 percent, with an

attendant increase in outpatientCCC visits. Keys to successinclude patient engagement,care coordination, multidiscipli-nary teamwork, walk-in avail-ability, and high-intensity care.

Lessons from CCDS. CCDSended in the spring of 2011,when Gov. Mark Daytonendorsed Medicaid expansion.But CCDS’ nine months in oper-ation left an indelible impres-sion. We learned that we couldrally around our mission of car-ing for those in need to providea comprehensive, patient-focused model of care for alarge number of patients in ashort period of time. Althoughthe resource constraints wereextraordinary—and, in thatsense, unsustainable—welearned how to maximize whatcould be done for patients witha minimal amount of support,and which programs wereworth carrying forward intothe future.

Developing Hennepin Health

Shortly after CCDS ended,Hennepin County HumanServices and Public HealthDepartment (HSPHD), and theHennepin County Board con-vened a workgroup to create amodel of care for a demonstra-tion project to expand upon thebest practices of CCDS. TheHennepin Health project usesthe concepts of an accountablecare organization: improvingquality, improving the patientexperience, and driving downcosts. A new care model (seeFig. 1) based on the patient-cen-tered medical home was devel-oped to address medical, social,and behavioral determinants ofhealth. Partners for this pro-gram are HSPHD, HCMC,NorthPoint Health and WellnessCenter, and MetropolitanHealth Plan.

The 10,000 HennepinCounty patients who will par-ticipate are similar to thosecared for under CCDS: ages 21to 64, nondisabled, withoutdependent children, and at orbelow the federal poverty levelof 75 percent. The care model ispatient-centered, focusing oncare coordination within healthcare homes. Once enrolled,patients will undergo assess-


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ment in medical, behavioral,and social domains. Patientsand their care teams will col-laboratively develop careplans. Utilization data and dis-ease complexity will be used to“tier” patients, and the CCCwill care for the high-utilizingtier. These patients will haveprioritized access to housingservices, chemical dependencycounseling, mental healthcare, financial assistance andvocational counseling, and willhave ready access to primarycare clinics with expandedhours.

Community health work-ers, care coordinators, socialworkers, chemical dependencycounselors, and mental healthprofessionals will collaboratein caring for patients. Apatient registry will help inmanaging patient panels.Pharmacists will perform med-ication reconciliation and sup-port medication home delivery.Providers will order what isnecessary to ensure quality out-comes while avoiding duplicatetesting or tests of questionablevalue. A total-cost-of-care fund-ing arrangement has beennegotiated, with financial riskfor all partners.

There are numerous admin-istrative hurdles to overcome.Organizations that are not usedto working together must createseamless interfaces and readyaccess to services. Dozens ofnew health care workers willneed an efficient structure thatconnects them and allows themto function and communicatewell with clinicians andpatients. And patients will seenew efforts to enroll them inshared medical decisions andto address life issues outsidethe traditional medical model.If Hennepin Health is effectivewith its first 10,000 vulnerablepatients, there are plans to rollthis out to as many as 140,000patients cared for annually atHCMC.

Integrated medicine-psychiatry program

The CCDS experience made usaware of our patients’ tremen-dous needs for integrated carefor mental and physical health:thus was born HCMC’s Inte-grated Medicine Psychiatry

Program. First, we built a groupof mental health clinicians(three PhDs, a psychiatrist, andan advanced nurse specialist) towork in the medicine clinic.This decentralized approach tomental health care will bring asubstantial proportion of themental health care for medicineclinic patients onsite where gen-eral medical care is provided.

We also moved an internistone half-day per week to theday treatment program wherepsychiatric outpatients are seenon a daily basis. This programmanages acute and chronicmedical issues for the psychi-atric outpatients and will soonperform structured risk assess-ment for cardiac and diabetesrisk. We have a highly regardedpsychiatric consultation liaisonservice on the medical inpa-tient wards, and we have insti-tuted strong support for med-ical care on the 102-bed psychi-atric inpatient service. Weeklyrounds with medicine andpsychiatry chiefs of service,attending physicians, advancedpractice providers (PAs andNPs), residents, nurses, phar-macists, and students addresschallenging cases, as well assymptoms, laboratory values,or signs that triggered a med-ical consultation.

Integrated medicine-psychi-atry units are also being devel-

oped for the inpatient medicineand psychiatry services. Theoverarching theme is that a uni-fied approach to mental andphysical health can improvepatient satisfaction, the patientexperience, and care outcomes.

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FIGURE 1. Hennepin Health care model

P O L I C Y

The beat of health reform iseverywhere—and it isquite loud. Some think it

will soon fade away; others hopethe beat stops altogether; andstill others are invigorated bythe increasing steady rhythm. Iwould argue that just as physi-cians are constantly monitoringthe heartbeat of their patients,we must attend to and be moti-vated to action by the heartbeatof health reform.Why? Because our society

demands it. We spend moremoney on health care than anynation in the world, yet we donot have commensurate qualityoutcomes. Many people have nohealth care at all. Rising healthcare costs are limiting invest-ments in other sectors of oursociety, such as healthy commu-nities, education, affordablehousing, and job development,that arguably are stronger fac-tors for population health thanis access to health care.Locally and nationally, many

health reform efforts are inalignment with the concept ofthe Triple Aim introduced byDon Berwick, MD, while he was

at the Institute for HealthcareImprovement (Health Affairs,27, 759–769, 2008). In Minne-sota, we often talk of the TripleAim as improving the health ofthe population; the experience ofcare, including quality; andaffordability by reducing percapita costs of care. These aimsare designed to help us trans-form a fragmented, fee-for-serv-ice, volume-driven, provider-focused system that is veryexpensive and unsustainableinto a coordinated, outcome-based, value (quality/costs) -driv-en, patient-centered system thatis affordable and sustainable.When I was Minnesota com-

missioner of health (2007–2010),Minnesota State Economist TomStinson, PhD, and Minnesota

State Demographer TomGillaspy, PhD, created a presen-tation called “Minnesota and theNew Normal” (www.amsd.org/docs/2011%20winter%20confer-ence/Gillaspy%20Stinson%20ppt.pdf) that forecast some signifi-cant changes in our state. Forexample, there will be more peo-ple over age 65 than school-agechildren by 2020, with increas-ing diversity among those chil-dren. While they predict in-creased state revenue over thenext 25 years, rising health carecosts mean the state cannotincrease spending on other serv-ices such as education, housing,community and job develop-ment, transportation, and parks.Referencing Minnesota

health reform initiatives toaddress costs, I asked Gillaspyand Stinson what else we shoulddo to address the new normal.Gillaspy said, “Invest in our chil-dren.” Much is going to bedemanded of a smaller andsmaller group, so they must bethe brightest, most productive,healthiest children our state canhave. Stinson said, “Change thesocial compact,” meaning wemust re-evaluate what we “giveand get” in our society—fromour governments and from eachother—and what roles we playin our communities.Certainly, their words

reinforced the need for healthreform and tackling risinghealth care costs. However,thriving in the new normal andchanging the social compactpresent tremendous challenges.Following is what I see as theright chemistry, the right signals,and medical alerts of which tobe mindful, so the heartbeat ofhealth reform remains strong.

The right chemistry

First, leaders in Minnesota’shealth community are increas-ingly understanding the newnormal with its imperative to

address health care costs. Aphysician on the board of theInstitute for Clinical SystemsImprovement (ICSI) has calledrising health care costs “thenational issue of the day.”Another physician recentlyremarked that “with risinghealth care costs, we are creat-ing unsustainable communities.”Second, the payment system

is changing from a fee-for-serv-ice model to varying forms of“total cost of care” models, pro-viding a needed technical andphilosophical alignment with theTriple Aim. Many nonprofit localhealth plans are entering intoprovider contracts with account-ability and incentives forimproving total costs along withimproved health outcomes andexperience.In 2010, the Minnesota

Legislature mandated that theDepartment of Human Servicesdevelop a “… demonstrationproject to test alternative andinnovative health care deliverysystems, including accountablecare organizations that provideservices to a specified patientpopulation for an agreed-upontotal cost of care or risk/gain-sharing payment arrangement”(Minn. Statute § 256B.0755).And in 2011, the Centers forMedicare & Medicaid Services(CMS) Innovation Centerlaunched its Pioneer Account-able Care Organization (ACO)model, which also moves pay-ment away from fee-for-serviceto a shared savings model basedon total costs.Minnesota medical groups

are early adopters of these initia-tives. Nine proposals have beensubmitted for the state’s HealthCare Delivery System Demon-stration Project, and threeMinnesota provider groups havebeen selected for participationfor the CMS Pioneer ACOmodel. An aligned payment sys-tem heading toward the TripleAim is an important element ofhealth reform.Although a different pay-

ment system is a needed techni-cal change, it must be accompa-nied by adaptive changes in theculture. Stakeholders must talkabout different roles, identities,corresponding losses andchanges in power and control.Articulating our fears and uncer-

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tainties openly and honestly is ahuge step toward true healthreform. Subsequently, we mustdevelop plans to address neededtransitions, lest our losses andfears become insurmountablehurdles.The chemistry created by

leadership in the health carecommunity, payment reform ini-tiatives, and needed adaptivechanges within our health sys-tems and communities support astrong heartbeat for healthreform.

Encouraging signals

Promising signals and signs alsoabound. We are seeing increas-ing transparency of qualitymeasures and anticipated trans-parency in total cost of caremeasures, through the state’sProvider Peer Grouping and/ornational/local measures such asthe Total Cost of Care measurerecently approved by theNational Quality Forum. Whilesome may hope measures ontotal cost of care will go away,we should find ways to makethem better. An example is thelocal improved quality measure-

ment through MN CommunityMeasurement (MNCM) over thepast eight years, and alignmentof measurement with stateefforts. Let’s do the same formeasuring total cost of care.We are solidifying the

importance of primary care forthis health reform effort. Clinicscontinue to be certified as healthcare homes in Minnesota. Medi-cal groups are building team-based care that embraces inno-vation and patient-centeredness.There is increasing focus on out-comes, not just on activities. Wemust show that different pay-ment models such as coordinat-ed care payments produce betterpatient results and save money.The new normal requires us

to form new and broader collab-orative alliances that help usaccelerate change across thestate. RARE (Reducing Avoid-

able Readmissions Effectively) isan example of using our hospi-tals more effectively (www.rarereadmissions.org). Thecampaign has brought togetherICSI, Minnesota Hospital Asso-ciation, and Stratis Health asoperating partners; MNCM andMinnesota Medical Associationas supporting partners; andmore than 60 community part-ners to set an aggressive goal:Decrease avoidable hospitalreadmissions by 20 percent byDec. 31, 2012. This translatesinto 16,000 more nights of sleepin their own beds for patientsand families.We are creating pathways

that go upstream, to focus onthe social determinants of healthor factors that make us healthy.The Statewide Health Improve-ment Program (SHIP), part ofMinnesota’s 2008 health care

legislation, seeks to reducechronic diseases by addressingthe two leading causes of illnessand death—tobacco use andobesity—through policy, sys-tems, and environmentalchanges. I am very encouragedthat the state has continued tofund this program in 2012.Campaigns such as Honor-

ing Choices, from the TwinCities Medical Society and itsFoundation with support fromTwin Cities Public Television, areengaging citizens in crucial con-versations around end-of-lifecare planning (www.honoringchoices.org).

“Medical alerts”

Despite the improving chemistryand promising signals for theheartbeat of health reform, cur-rent efforts face several majorhurdles. First, the problems weare trying to solve are the sameones that “managed care” triedto address in the 1970s throughmid 1990s—rising costs withoutcorresponding improvements inquality and productivity. Wehave many more tools available


REFORM to page 19

Leaders in Minnesota’s health communityare increasingly understanding

the “new normal” with its imperativeto address health care costs.

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Statistics indicate that onein 100 people over the ageof 60 will be diagnosed

with Parkinson’s disease (PD).This chronic progressive illnessresults in dopamine depletionin the basal ganglia, causingbradykinesia, resting tremor,muscle rigidity, and posturalinstability.

An interdisciplinary teammodel of care is recommendedto best achieve comprehensivemanagement of complex PDsymptoms. Physical therapistsare trained, licensed profession-als who are experts in restoringand improving motion toachieve greater physical func-tion. As integral members of aninterdisciplinary team approachto management of PD, physicaltherapists play an important rolethroughout the continuum ofcare, from time of diagnosis toadvanced stages of the disease.

Referrals to physical therapyare beneficial to address func-tional deficits in mobility, de-velop an individualized exerciseprogram, improve posturalawareness/alignment, andreduce/eliminate pain. Patient

and family education providedby physical therapists offersgreater understanding of PD’simpact on mobility as well asinstruction in movementenhancement strategies, com-pensation techniques, safety,and stress reduction.

Just as physicians refer their

patients to colleagues in appro-priate specialties, it is importantto refer PD patients to physicaltherapists with the appropriateinterest, training, and experiencein treating patients with move-

ment disorders. Skilled observa-tions during a physical therapysession can be extremely helpfulto physicians in regard to opti-mizing patient medications ormanaging secondary symptoms.Familiarity with and use of ele-ments from widely accepted PDscales provide a common lan-

guage for rating Parkinson’s pri-mary and secondary symptoms.(Visit www.toolkit.parkinson.org,designed by National ParkinsonFoundation, for a comprehen-sive overview of recommendedevaluation, tests, and treatment.)The physical therapist should befamiliar with current, evidence-based, validated test measuresfor examination of individualswith PD. Interventions are basedon the impact of PD symptomson patient function, and treat-ment goals should be writtento accurately measure improve-ment of these daily functionaltasks.

Physical therapy in early-stageParkinson’s disease

The widely accepted Parkinson’streatment algorithm notes theimportance of exercise in earlystages of Parkinson’s, and cur-rent research demonstrates neu-roplasticity (exercise-inducedbrain repair) in animal modelsof early stage PD. Unfortunately,many PD patients do not receivea referral to physical therapy atearly stages of the disease, leav-ing them unaware of the impor-tance of exercise, or unsure ofwhat exercises would be mostbeneficial.

Exercises should include afoundation of stretching activi-ties due to muscle rigidity andits accompanying potential for

loss of flexibility. Inclusion ofexercises promoting spinal flexi-bility appears to be particularlyneeded in early stages of Parkin-son’s. Movement enhancementstrategies with attention to mak-ing motions more mindful andcomplete further enhance exer-cise performance. Amplitude-based therapies emphasize theo-ries of neuroplasticity, includingretraining of normal use, inten-sive practice, repetition, increas-ing complexity, and regular feed-back. Regular conditioning exer-cises are incorporated to main-tain activity tolerance and car-diovascular fitness. Recent stud-ies have demonstrated benefitsusing treadmill training, tandembiking, and dance. Physical ther-apists also address concernsregarding posture and gaitchanges, stress reduction/relax-ation, workplace issues, leisureinterests, or pain at this stage ofParkinson’s.

Physical therapy in moderate-stage Parkinson’s disease

As Parkinson’s disease pro-gresses, patients begin to exper-ience greater difficulties withphysical mobility skills such asgetting out of bed, rising froma chair, or getting out of the car.Gait pattern changes becomemore pronounced, with in-creased shuffling, difficulty turn-ing, and occurrence of festina-tion and/or freezing of gait.Many patients experience signif-icant balance problems andreport episodes of falling. Motorfluctuations often develop, fur-ther complicating mobility skillsas patients experience variationsin function throughout the day.Physical therapy is helpful withall these mobility challenges,offering interventions andinstruction in compensatorystrategies, adaptive equipment,and appropriate exercise toeffectively cope with changes inthese daily tasks.

Gait changes in Parkinson’sinclude narrowed base of sup-port; decreases in step size, heelstrike, and arm swing; en blocturns; and reduced gait velocity.Excessive dyskinesia or dystonicposturing also negatively affectsthe gait pattern. Motor fluctua-tions, often seen as Parkinson’sdisease progresses, cause someindividuals with Parkinson’s to

Physical therapy forParkinson’s disease

An important role in the continuum of care

By Rose Wichmann, PT


As Parkinson’s disease progresses,gait pattern changes become

more pronounced.

experience only periodic deficits,or to exhibit significant changesin function between “on” and“off” periods throughout the day.Retropulsion, festination, andfreezing of gait are frequentlyseen at this stage of Parkinson’s,requiring gait training in physi-cal therapy to most effectivelycope with these deficits. Instruc-tion in attentional, visual, audi-tory, and/or kinesthetic cueing isoften helpful to reduce freezingepisodes (inability to move).Taped lines in a doorway thresh-old, use of metronomes, and/orfocused attention on weight shiftprior to initiating gait allow PDpatients to bypass the depletedbasal ganglia and use intactfrontocortical pathways to“break” the freeze and initiatemovement.

A referral to physical ther-apy is essential to receive recom-mendations regarding appropri-ate gait-assistive devices andensure proper sizing. Physicaltherapists are also a resource forinformation about locations forequipment purchase and med-ical reimbursement.

Postural instability is theprimary symptom of Parkinson’sthat is least responsive to avail-able medications. A 2005Struthers Parkinson’s Centersurvey of 1,061 patients withParkinson’s disease showed55.4 percent reporting at leastone fall within the past year,with 65.3 percent of fallersreporting injury, and 32.9 per-cent of fallers reporting a frac-ture. If a patient is falling,instruction in safe techniques toget up from the ground is essen-tial to minimize injury risk. Inthe event of a fracture, illness, orother injury, a physical therapyreferral should be initiated assoon as the patient is medicallystable, as prolonged bedrest orinactivity significantly impairsmobility and complicates therehabilitation process.

Physical therapy referral forcare partner instruction shouldnot be overlooked in this stageof Parkinson’s disease. Manyfamily care partners begin tooffer assistance with transfers,exercises, or other daily careswithout instruction in propertechnique or body mechanics.The likelihood of care partnerinjury can be significant without

proper instruction. Instructionin providing clear, concise cueswith reduction of excessive ver-bal stimuli is particularly helpfuland reduces frustration for bothpatient and care partner.

Physical therapy in advanced-stage Parkinson’s disease

Although some physicians orother members of the healthcare team may feel that an indi-vidual lacks “rehab potential,”there is still a role for physicaltherapy in comprehensive man-agement of individuals withadvanced-stage Parkinson’s dis-ease. In advanced PD, medica-tions may become less effectivefor symptom control, and med-ication side effects may becomemore prominent. Immobilitycoupled with advancing cogni-tive changes cause patients torequire assistance with almostall activities of daily living, andwith performance of a dailyexercise program.

At this stage, care partnersplay a larger role in care of thepatient and frequently needinstruction, support, and respitecare to cope with these compli-cated problems. Physical ther-apy referrals are beneficial inareas of posture, positioning,pain control, transfers, and carepartner-assisted exercise. AsPD advances, this treatmentoften transitions to a home-based setting where these needscan be assessed and treated.

As care needs increase,many patients are faced with thetransition to a new living envi-ronment. A move to assisted liv-ing, a skilled nursing facility, orother new environment can beextremely stressful for bothpatients and their care partners.Unfortunately, not all healthcare providers within these facil-ities are familiar with the symp-toms or challenges of living withParkinson’s. Physical therapyevaluation of the new livingenvironment is helpful to maxi-mize patient safety and comfort.A physical therapist can helpprovide staff education for

assisting patients experiencingfluctuating mobility, freezing, orother mobility challenges relatedto Parkinson’s disease. Instruc-tion in Parkinson’s symptoms, aswell as specific transfers andmovement enhancement strate-gies, aids staff understandingand improves patient care.

Evidence-based practice:research and physical therapy

An increasing amount ofresearch has been published thatdemonstrates the effectivenessof physical therapy for patientswith Parkinson’s disease. A con-tinued focus on evidence-basedpractice is needed to establishbenefits of treatment and bestpractice patterns for all physicaltherapy professionals.

Comprehensive explanationof current physical therapy prac-tice is available in the “Guide toPhysical Therapist Practice,” acollaborative work published by

the American Physical TherapyAssociation. Physical therapistsuse the information developedfor the guide within their clini-cal practice, as well as for pro-fessional education purposes.The guide defines physicaltherapy’s scope of practice,and provides preferred practicepatterns grouped into severalmajor categories.

Throughout the continuumof care, physical therapists playan important role in comprehen-sive PD management. Referralsto PT professionals with interestand expertise in treatment ofmovement disorders providepatients with opportunities formaximized function and qualityof life.

Rose Wichmann, PT, is the managerof Struthers Parkinson’s Center inMinneapolis. She has co-authoredseveral publications for NationalParkinson Foundation, including“Advanced Stage Parkinson’s” and“Practical Pointers for People withParkinson’s.” To download these andother patient resources free of charge,visit the National Parkinson Foundationwebsite at www.parkinson.org.


Read usonlinewherever you are!

www.mppub.com

Resources

To find physical therapists in your area, visit www.parkinson.org(National Parkinson Foundation), www.lsvtglobal.com (lists therapistscertified in the LSVT BIG exercise program for Parkinson’s patients, orwww.nfnw.org (lists therapists who have attended a Parkinson’sWellness Recovery exercise and treatment course), or contact StruthersParkinson’s Center at 888-993-5495 (www.parknicollet.com).

electronic medical record(EMR), and relatively low reim-bursement compared with sub-specialists. HCMC has begun aredesign process to change thestructure and culture of themedicine clinics to be morewelcoming to both patientsand providers. The Center forPatient and Provider Experienceat HCMC performs research toalign patient and provider goalsfor care. Martin Stillman, MD,senior medical director for themedical specialties at HCMC,has convened the Vibrant ClinicDesign Group to develop, fromthe ground up, clinics that willembody what is desired andneeded for both patients andhealth care workers. Stillmansays, “Better functioning teamswill improve patient care andprovider satisfaction. We wantpatients to see a new system ofcare, and make health care amore personal experience.”

Patient experience initiative

Over the past several years, acultural revolution has takenhold at HCMC and in organized

medicine throughout the coun-try. Care systems and behaviorsare becoming more patient- andfamily-centered, with patientinvolvement driving care reor-ganization. More than 550 doc-tors, nurses, advanced practiceproviders, and hospital leadershave participated in fourpatient experience rallies. Morethan 60 patients and familieshave shared their stories andoffered feedback at these full-day events. Interactive sessionslead attendees through princi-ples of patient-centered careand offer simple steps for howcare team members can workwith our patients, rather thandoing things to them.

In this era of electroniccommunication, human con-tact and interaction remainthe bedrock of health caredelivery. The rallies, andHCMC’s “Centered Around You”campaign, highlight what mat-

ters to patients beyond theirphysicians’ clinical expertise.They help us recognize thatpatients notice the nuances ofwhat we say and do—evensomething as simple as walkinga patient to the door or invitinga family member into a bedsidediscussion.

Patients are now attendinghospital meetings, and morethan 40 patients are activelyinvolved as advisers or focusgroup members. When a newproject is considered, patientand family feedback is part ofthe planning process. A patientstory starts many leadershipmeetings, and patients’ com-ments about their care areshared with the medical staff.

When we can tell ourpatients that we are truly “cen-tered around you” at HCMC, itgrounds us in the real reasonswe come to work every day.

Medical homes fornew “family members”

HCMC is well known as a level-one trauma center providingexceptional care for those inurgent need. Now we are imple-menting system-wide programsto provide exceptional, patient-centered primary and subspe-cialty care for all patients, in-cluding those with few resourceswho need our support the most.We are enthusiastic about ourfuture plans and look forward toimplementing them for ourpatients, our providers, andHennepin County residents, whowill all be family members inour new “medical homes.”

Paul Johnson, MD is clinic lead for theCoordinated Care Clinic; PamelaClifford, RN, MPH, is director of theCenter of Health Care Innovation; SheilaMoroney is director of patient experi-ence services; and Mark Linzer, MD, isdirector of the division of general internalmedicine, all at Hennepin County MedicalCenter. Jennifer DeCubellis, LPC, isarea director for the Hennepin CountyHuman Services Public Health Depart-ment and director of the Hennepin Healthproject.


Transformations from page 13 The Hennepin Health projectuses the concepts of an

accountable care organization.

today, but a key to health reformworking this time is to co-createour future by engaging ourpatients, families, and communi-ty stakeholders.Ideally, citizens should be

helping us interpret and trans-late the Triple Aim into action.Both the private and public sec-tors in Minnesota are exploringhow we include patients’ per-spectives even more, and howwe engage communities inimproving health as well as ad-dressing costs. This would be astep toward “changing the socialcompact.” How do we helpstakeholders see their differentroles in health and health care ata local level that creates differ-ent “gives and gets”? Withouttheir involvement, we run therisk of missing the mark again—only instead of “managed carebacklash,” we will have“accountable care backlash.”Clearly, there is a great deal

to learn from one another abouthow to enter this new territorytogether. We must measure andmanage going forward with anenvironment for continuous

learning. But we must not let the“organization” part of ACOs takethe front seat; the focus must beon accountable, responsible carefor those we serve. And we mustengage patients and citizens inour communities in new ways—ways that change the powerstructure and really make themthe center of our concerns. Todo it well, we will have to listendeeply—and hear hard thingsthat we need to change. A realdanger is that we risk a greatdeal if we fail this time, as thewindow is narrowing to turnthe trajectory on rising healthcare costs.Although many activities are

moving us from a fragmentedsystem to a coordinated system,we have been unclear about theoutcomes needed for ourpatients and communities. Cleargoals are critical. Don Berwick

once said, “Some is not a num-ber and soon is not a time.” Alocal health care leader recentlysaid, “When we set a goal ofdecreasing our total cost of careover the next three years by 20percent, it galvanized our think-ing and creativity.“Just as the RARE goal has

centered our thinking on how totackle avoidable readmissions,so can other community-widegoals. To achieve the Triple Aim,we need to co-create someSMART (specific, measurable,actionable, realistic, and time-bound) goals along with ourpatients and community stake-holders.

A strong heartbeat

I am optimistic that with theright chemistry, the right signals,and attention to our medicalalerts, physicians and other

health leaders will step up to thechallenges ahead with a collec-tive wisdom and a building oftrust with communities to tackleproblems, seize opportunities,and co-create solutions. Therehas never been a greater timefor collaboration and for learn-ing from one another. No oneorganization can figure this out.Changing the health system islike turning the mother ship,and we need all hands on deck.The health reform heartbeat

in Minnesota is as strong asever. Part of our job will be tofind the right pace and rhythmfor the days, months, and yearsahead. There are certainly forcesthat would speed up or slowdown that heartbeat. But thereis no doubt that the leaders inour state plan to keep the heart-beat of health reform alive andwell.

Sanne Magnan, MD, PhD, is thepresident and CEO of the Institute forClinical Systems Improvement (ICSI)and former Minnesota commissionerof health. She is also a practicingphysician at the Tuberculosis Clinic atSt. Paul–Ramsey County Public Health.


Reform from page 15 A real danger is that we risk a great dealif we fail this time, as the window is

narrowing to turn the trajectory on risinghealth care costs.

In personInboxWhen changes in the local health care landscape promised a major influx of new UCare members coming through metro-area clinics and hospitals, we made sure those providers were prepared. In a span of just two weeks, May Ly was among the UCare staff that personally visited 449 unique health care locations to offer a heads-up and explain the impacts. Because being responsive to our partners’ needs isn’t just talk—it’s what we mean by health care that starts with you.

| provider assistance: 1-888-531-1493 | ucare.org/providers | ©2012, UCare.

The intersection of tech-nology and health careis nothing new. We’ve

witnessed an unprecedentedadvance in public health overthe last 70 years, thanks to theavailability of disease-fightingvaccines and antibiotics andinnovations such as robots andlasers that improve surgicalprecision and recovery time.Yet, with all the lives saved andbenefits delivered by these tech-nologies, none have materiallyimproved what is arguably themost critical and fundamentalasset in the delivery of healthcare: communication.

Enter telehealth. Telehealthis an expansion of telemedicine,encompassing the delivery of

both clinical and nonclinicalhealth-related services andinformation via telecommunica-tions technologies. It’s a rela-tively broad practice aimed atbridging communication gapsin the care delivery process,ranging from basic utilizations—for example, allowing multi-ple health professionals todiscuss a case over the tele-phone or enabling physiciansto communicate with patientsand order drugs by email—tohighly sophisticated applica-tions such as facilitating consul-tation, during robotic surgery,among members of a medicalteam in facilities at oppositeends of the globe.

Telehealth as a conceptemerged decades ago, but it isnow on the verge of becomingubiquitous and routine as aresult of factors, including alooming physician deficit, agrowing elderly population, andmore connected and demandinghealth care consumers. How-ever, because telehealth com-prises such a wide range ofapplications and technologies,physicians are faced with com-plex decisions about which tele-health solution, if any, is a wiseinvestment of time, money, andresources, given their care deliv-ery needs and objectives.

The case for connecting

When considering whether toembrace telehealth, physiciansmust ultimately place a valueon the role effective communi-cation plays in fulfilling theirduties to patients, in terms ofboth quality of care and effi-ciencies in delivering it. Phys-icians can look to the followingkey benefits of telehealth tech-nologies as criteria to help them

New horizons fortelehealth

Enhanced communications =enhanced health care and efficiencies

By David Hemler


Innovation in health care

technology comes in myr-

iad forms. This month’s

special focus articles

describe improvements in

communications technol-

ogy—whether through

interoperable electronic

health records, as a

means of delivery care, or

to enhance security and

information protocols;

a unique organization

aimed at improving pedi-

atric care products; and

trends in the medical

device industry and how

to support physician-

industry collaboration in

creating, testing, and

marketing new devices.

S P E C I A L F O C U S : N E W - G E N E R A T I O N T E C H N O L O G Y

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Victoza® (liraglutide [rDNA origin] injection)Rx OnlyBRIEF SUMMARY. Please consult package insert for full prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treat-ment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions].

INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve gly-cemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied.CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiv-ing liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a compara-tor-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have sub-sequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most fre-quently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consis-tent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calci-tonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evalua-tion. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other poten-tially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medica-tions known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing con-clusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer.Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial

All Victoza® N = 497 Glimepiride N = 248Adverse Event Term (%) (%)Nausea 28.4 8.5Diarrhea 17.1 8.9Vomiting 10.9 3.6Constipation 9.9 4.8Upper Respiratory Tract Infection 9.5 5.6Headache 9.1 9.3Influenza 7.4 3.6Urinary Tract Infection 6.0 4.0Dizziness 5.8 5.2Sinusitis 5.6 6.0Nasopharyngitis 5.2 5.2Back Pain 5.0 4.4Hypertension 3.0 6.0

Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials

Add-on to Metformin TrialAll Victoza® +

Metformin N = 724Placebo +

Metformin N = 121Glimepiride +

Metformin N = 242Adverse Event Term (%) (%) (%)Nausea 15.2 4.1 3.3Diarrhea 10.9 4.1 3.7Headache 9.0 6.6 9.5Vomiting 6.5 0.8 0.4

Add-on to Glimepiride TrialAll Victoza® +

Glimepiride N = 695Placebo + Glimepiride

N = 114Rosiglitazone +

Glimepiride N = 231Adverse Event Term (%) (%) (%)Nausea 7.5 1.8 2.6Diarrhea 7.2 1.8 2.2


Victoza® (liraglutide [rDNA origin] injection)Rx OnlyBRIEF SUMMARY. Please consult package insert for full prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treat-ment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions].

INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve gly-cemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied.CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiv-ing liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a compara-tor-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have sub-sequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most fre-quently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consis-tent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calci-tonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evalua-tion. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other poten-tially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medica-tions known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing con-clusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer.Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial

All Victoza® N = 497 Glimepiride N = 248Adverse Event Term (%) (%)Nausea 28.4 8.5Diarrhea 17.1 8.9Vomiting 10.9 3.6Constipation 9.9 4.8Upper Respiratory Tract Infection 9.5 5.6Headache 9.1 9.3Influenza 7.4 3.6Urinary Tract Infection 6.0 4.0Dizziness 5.8 5.2Sinusitis 5.6 6.0Nasopharyngitis 5.2 5.2Back Pain 5.0 4.4Hypertension 3.0 6.0

Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials

Add-on to Metformin TrialAll Victoza® +

Metformin N = 724Placebo +

Metformin N = 121Glimepiride +

Metformin N = 242Adverse Event Term (%) (%) (%)Nausea 15.2 4.1 3.3Diarrhea 10.9 4.1 3.7Headache 9.0 6.6 9.5Vomiting 6.5 0.8 0.4

Add-on to Glimepiride TrialAll Victoza® +

Glimepiride N = 695Placebo + Glimepiride

N = 114Rosiglitazone +

Glimepiride N = 231Adverse Event Term (%) (%) (%)Nausea 7.5 1.8 2.6Diarrhea 7.2 1.8 2.2

evaluate how these technologiesaffect their work:• If you are committed to deliv-ering the highest quality carewithout sacrificing profitabil-ity, cost efficiencies are apriority. Telehealth has beenshown to reduce the costof health care and increaseefficiency through better man-agement of chronic diseases,shared health professionalstaffing, reduced travel times,and fewer or shorter hospitalstays.

• If you want to coordinatecare plans with other pro-viders and caregivers moreefficiently, a unified commu-nications platform can offerthe ability to streamlinecommunications. This tele-health technology allowsphysicians to engage, and addmid-meeting, multiple com-plementary providers in dis-cussions about care plans;“right-size” communicationsby using the most efficientmode of communication forany given interaction; reserve

in-person office visits for onlythose matters requiring physi-cal examination or in-depthdiscussion; and document oreven record conversations forfuture recall.

• If you want to increase youraccessibility and availability,improved access is importantto your practice and to yourpatients’ well-being. Tele-health improves access topatients in distant locationsor who are too ill or finan-cially stressed to travel, whileenabling physicians and otherhealth care professionals toexpand their reach, beyondtheir own facilities.

• If you believe that consumer-driven health care is not a“movement” but a new indus-try status quo, you’ll be inter-ested in how great patientdemand is for telehealth.Patients’ expectations are ris-

ing, due to their desire to con-nect with health care pro-viders whenever and howeverit’s convenient for them. Thistrend of accessibility stemsfrom other activities such asonline banking, online shop-ping, and online meetings,making health care the latestfrontier to address true“accessibility” as other indus-tries have.Additionally, a growing

body of data indicates that tele-health may be a solution to sev-eral distressing medical trends.The American Medical Associa-tion has reported that up to 70percent of doctor office visitsand 40 percent of emergencyroom visits are unnecessary,and the American Academy ofFamily Physicians has predictedthe shortage of family doctorswill reach 40,000 in the next 10years, as medical schools sendabout half the needed numberof graduates into primary caremedicine. Both of these chal-lenges—and hundreds more—can be effectively met with tele-health collaboration and com-munication tools that enableright-place, right-time provider-patient interactions.

A past with challenges;a future with great promise

Despite its potential as a caredelivery model, telehealth hashistorically failed to reachbroad adoption for two primaryreasons—the challenge of reim-bursement and the cost ofimplementation.

Most health insurers,including the federal govern-ment through Medicare, do notcover the cost of a virtual visitvia telehealth. There are someexceptions, but in general reim-bursement models have made itdifficult to deliver telehealthunder a traditional fee-for-serv-ice approach. Newer deliverymodels such as accountablecare organizations encouragethe use of telehealth to bettermanage overall cost and out-

comes, even if an individualdoctor-patient interaction isnot directly reimbursed. Weare already starting to see shiftsby the largest health insurers;WellPoint, UnitedHealth, andAetna have all announcedchanges to providers’ rewardand compensation models tomore strongly incentivize quali-ty and efficient primary care.

Also, the implementationcost of traditional telehealthsolutions has been prohibitive—dedicated networks wereneeded, with expensive andspecialized equipment thatconnected a single location toanother single location in apoint-to-point fashion. As anexample, a dedicated, physicalconnection between a clinic anda hospital required significantcapital expenditures on the partof health care systems, andcould be implemented in just afew locations.

Despite these obstacles,adoption of telehealth is experi-encing something of a boom inthe state. MN CommunityMeasurement, a Minneapolis-based health care-quality group,says that approximately 13 per-cent of medical clinics surveyedin the state—152 out of 1,198—reported offering electronic vis-its in 2010. That number nearlydoubled in 2011 as 334 clinicsof 1,313 surveyed—25 percentof the total—said their clinic ororganization offered e-visits.We anticipate that in years tocome, these numbers will con-tinue to climb as more versatile,dynamic, and cost-effective tele-health solutions penetrate themarketplace.

Physicians and patients,unified

A unified communications sys-tem can overcome some of thegreatest challenges facing tele-health and the medical profes-sion. As a set of real-time andnon-real-time services andproducts, unified communica-tions provides a consistent userinterface and user experienceacross multiple devices andmedia types—for both providersand patients.

Over the past few years, theadvent of cloud computing—theuse of remote servers hosted on


Telehealth from page 20

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Physicians must ultimately place a valueon the role effective communication plays

in fulfilling their duties to patients.

the Internet to store and man-age data, rather than a localserver or PC—has had a revolu-tionary effect on the affordabil-ity and functionality of tele-health. Cloud-based unifiedcommunications can be eco-nomically accessible to growinghealth care organizations,allowing easier start-up andimplementation, as well as con-tinuing to drive cost efficienciesonce implemented.

A comprehensive and com-pliant unified communicationssystem can improve communi-cations through its variouscapabilities: webcam videocon-ferencing; secure file transferssuch as a pdf of a patient recordor treatment protocol; VoIPtelephony (communicationsservices transported over theInternet); secure email that isHIPAA compliant; secure screensharing; and text messaging.Because all of these communi-cation interfaces are facilitatedsecurely via the cloud, a unifiedcommunications suite doesn’trequire the expensive, dedicatedinfrastructure typically associ-ated with telehealth or telemed-

icine solutions.Both providers and patients

save time and money when theyhave flexibility to connect out-side of an office visit, which ispossible with a comprehensiveunified communications suite’swide range of remote applica-tions. Interactions betweenprovider and patient ultimatelyare more efficient when theright tool is used to relay infor-mation—for example, usingemail to communicate drugindications—and both partiesare saved a resource-intensiveoffice visit. Certain unifiedcommunications platformsquickly authenticate and auto-matically validate patients’identification, greatly shorten-ing session times. Further effi-ciencies are made possiblebeing able to switch communi-cation modes mid-interaction,enabling parties to escalatefrom an online chat to a phone

conversation or video sessionwithout interruption.

Time and cost efficienciesare real objectives on the opera-tional side of medicine, but it’simportant to understand thatreputable telehealth services aredesigned with patient care atthe forefront. Shortened waittimes, more streamlined consul-tations and a low barrier toentry are worth nothing ifpatients don’t receive qualitycare. Quality is in the eye ofthe beholder (in this case, thepatient), and quality improve-ment may take many forms—faster and easier access to care;clarification of a lab resultdelivered from the provider’sportal without the need for afollow-on appointment; or theability to include a loved one oroutside caregiver in a virtualdoctor visit to help coordinatecare, communications, andfollow-up. Unified communica-

tions is a telehealth win–winthat marries high-quality careto efficiency and effectivenessin care delivery.

The future is connectedhealth care

Just as the smartphone hasemerged as a multipurposesolution to consumers’ demandfor integrated media, productiv-ity, and communications tools,unified communicationsanswers the health care indus-try’s need for integrated caredelivery tools that deliver healthcare at the right time, in theright way, and at lower cost. Forphysicians for whom telehealthhas seemed too costly or com-plicated to integrate into theirpractices, unified communica-tions is within reach … andwith it, so are their patients.

David Hemler is CEO of Bloomington-based Revation Systems, Inc.


A growing body of data indicatesthat telehealth may be a solution toseveral distressing medical trends.

Delivering care thatmakes patients feelknown and understoodAt Essentia Health, we have a supportive group of 750physicians across 55 medical specialties. Located in largeand small communities across Minnesota, Wisconsin, NorthDakota and Idaho, Essentia Health is emerging as a leader inhigh-quality, cost-e�ective, patient-centered care. EOE/AA

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EssentiaHealth.org/Careers800.342.1388 ext 63165


Children are not smalladults—one of the mainpoints of pediatric ortho-

pedic surgeon Robert Campbell’stestimony to the U.S. Senate in2007 when he stated, “Childrendeserve access to devices thatare safe, effective, and madejust for them. Yet today manydevices are not made with theseconsiderations in mind, andsome necessary devices are notmade at all.”

Children not only are muchsmaller in size; they are continu-ally growing, are more active,have a wide range of cognitiveand maturity levels, and havedifferent body structures andfunctions than adults. As aresult, pediatric medicaldevices—used to diagnose andtreat diseases and medical con-ditions of children—are oftenborrowed from adult applica-tions and jury-rigged to fit chil-dren and function properly—ifthey exist at all.

The main reason the marketlacks pediatric devices is thatthe financial return on invest-ment is often minimal or nonex-istent. Children under the age of

10 constitute less than 13 per-cent of the U.S. population, sothe pediatric medical devicemarket is a very small fractionof the size of the adult medicaldevice market.

As neonatologist AndreaLampland, MD, of Associates inNewborn Medicine, St. Paul, hassaid, “Little people equals littlefunds.” This leads to large gapsin the availability of appropri-ately designed pediatric medicaldevices, leaving many children’sclinical needs either unmet orunderserved. A few years ago,I concluded that attacking thegaps in the pediatric deviceproducts portfolio required anentirely new business approach.DesignWise Medical wasfounded to do just that.

Filling gaps in the pediatricproducts portfolio

After working for more than20 years developing medicaldevices in small start-ups andlarger medical device compa-nies, I wanted to refocus mybackground and experience onclinical needs that were eitherunmet or unaddressed by thefor-profit medical device indus-try. Recognizing and experienc-ing the gap in the resourcescommitted to developing adultmedical devices versus children’sdevices, I founded DesignWiseMedical with the philosophythat children’s medical needsshould receive the same level ofattention and applicable technol-ogy as adult medical needs.

In its first three and a halfyears of operation, DesignWiseMedical has initiated develop-ment programs for nine newpediatric medical products anddevices based on clinical needsidentified by clinicians as well asparents. The solutions developedwill have a positive impact onchildren’s health care outcomesand quality of life; specific proj-ects are targeting children withrare lung diseases that requiresupplemental oxygen therapy;those with type 1 diabetes; andthose who require intravenousaccess. These projects haveresulted from the efforts of morethan 240 volunteers (includingabout 160 higher education stu-dents) who are passionate aboutchildren. They have collectivelydonated more than 25,000 hoursof their time in the last threeand a half years.

By founding DesignWiseMedical as a 501(c)(3) nonprofitcorporation, we have avoidedbecoming just another entry inthe large field of medical devicestartup companies looking forventure capital and promisingquick profits. Instead, we aim tocapitalize on the broad appeal of

our mission and purpose andwill seek initial funding in theform of charitable contributionsfrom individuals, grants fromfoundations, and sponsorshipsfrom like-minded companies.

As DesignWise commercial-izes and introduces productsinto the medical device market-place, we will develop sources ofearned income through technol-ogy licensing or other revenue-sharing agreements with for-profit partners in the medicaldevice industry.

A volunteer-drivendevelopment process

Only by changing the dynamicsof the pediatric medical devicedevelopment process canDesignWise Medical be effective.The overarching philosophydriving our mission is that byfacilitating the collaboration ofvolunteer and philanthropicresources, we can develop pedi-atric medical devices at a frac-tion of the cost of the traditionalapproach employed by the for-profit industry, thereby remov-ing the main barrier keepingappropriate medical devicesfrom the children that needthem.

DesignWise Medical uses athree-step process in fulfillingits mission:1) Identify unmet and under-

served pediatric medicaldevice needs

2) Develop solutions to thoseneeds

3) Deliver the solutions to themarketplace and to childrenin need

Identifying medical needsrequires engaging clinicians,children’s hospitals, parentgroups, and disease foundations.

Developing solutions isachieved by employing anunpaid volunteer network ofactive and retired professionalsfrom a variety of disciplines, aswell as students and universitypartners. Additionally, by spon-soring student projects in a vari-ety of areas (e.g., marketing,business, engineering, biomed-ical, design, regulatory affairs,clinical), DesignWise Medicalis able to help provide real-world, project-based learningopportunities to colleges anduniversities.

Pediatricmedical devices

Local company aims to close a product gap

By Bradley F. Slaker, BSME, MBA


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For example, in early 2011we took 18 senior industrialdesign students from theUniversity of Wisconsin–Stout,in teams of three, to GilletteChildren’s Hospital in St. Paulfor an entire shift of shadowing,observing, and interviewing theclinicians, nurses, and parentswithin the Pediatric IntensiveCare Unit and other areas of thehospital. Our purpose was touncover and document unmetand underserved needs for chil-dren’s medical devices and prod-ucts. From this master list ofidentified pediatric needs, eachstudent initially developed 50design concepts addressingsome of those needs. The stu-dents then consolidated theireffort down to three needs anddesign concepts for those threeneeds.

Following a mid-semestercritique from industry profes-sionals, each student focused thefinal six weeks of the semesteron developing one main conceptaddressing one main identifiedneed. In mid-May, the semesterended with each student con-ducting a design review on theirfinal product and a senior showthat showcased the work theydid during the project. The finaldeliverables were a fully func-tional or scale-model prototypeof their design, along with prod-uct packaging and marketingmaterials. We are currently eval-uating the output of the stu-dents’ work for possible continu-ation as product developmentprojects within DesignWise.

Gillette Children’s was afantastic partner on this projectand was extremely accommodat-ing to our company and the stu-dents from UW–Stout. We arerefining the needs-discoveryprocess based on what welearned from this pilot projectand are planning to conduct fur-ther semester-long projects likethis on an annual basis.

Delivery of these solutionswill likely involve strategic part-nerships with established med-ical device companies. Takingcharge of a product thatDesignWise Medical has devel-oped and which has alreadyreceived FDA marketing clear-ance, the strategic partner candeliver the product to the mar-

ketplace and into the hands ofthe caregivers and children thatneed them. These partnershipseventually will provideDesignWise Medical with sus-tainable earned income and rev-enue sources.

First device in prototype stage

The Overnight Pediatric OxygenDelivery (OPOD) system is thefirst product developed byDesignWise Medical. The OPODprovides a noncontact methodof delivering supplementalovernight oxygen to infants andyoung children who havechronic lung conditions. Thesechildren do not need supplemen-tal oxygen for life support, butwithout it they may not developnormally and may develop pul-monary hypertension. TheOPOD, a hemispherical hoodplaced over the child’s head, pro-vides an alternative to cannulaand facemasks, which are notwell tolerated by young children.

The OPOD was inspired bya parent I met at a NationalInstitutes of Health conference.The parent described the diffi-culty of delivering overnightoxygen to her son, who has arare lung disease called NEHI(neuroendocrine cell hyperplasiaof infancy). Her son pulled thetaped nasal cannula off his faceso frequently that his parentshad to fasten the oxygen tubingto a teddy bear that he wouldhold closely, and then had totake turns watching over himall night.

We will be targeting respira-tory and/or sleep products com-panies as potential distributionpartners for the OPOD by eitherselling or licensing the rights tothe product. The earned incomefrom this product will be used tofund our next round of projects.

Collaboration and sponsorships

DesignWise Medical has spon-sored 30 student projects to datethat have spanned various disci-plines, including engineering,regulatory affairs, intellectualproperty, marketing, and busi-ness. We have developed part-nerships with eight local collegesand universities and will beexpanding to other regionalinstitutions as needed. In addi-tion to formal student projects,

various opportunities are avail-able for student group projects,internships, and volunteering.

Sponsorship opportunitiesare available for individuals,organizations, and educationalinstitutions that want to specifi-cally support the development offuture professionals throughproject-based learning opportu-nities. Sponsorship opportuni-ties include sponsoring a studentproject or supporting a studentinternship.

Benefits to stakeholders

DesignWise Medical also offersbenefits to our many stakehold-ers. First and foremost are thechildren, parents, and familiesthat will benefit from the prod-ucts we develop. Children willreceive products developedspecifically for their uniqueneeds while pediatric clinicianswill have the appropriate toolsto help them deliver the careneeded. Children’s hospitals andhealth-care clinic partners willbenefit by having a very visible,tangible way of showing theircommitment to continuousimprovement and innovation in

children’s health care.Students and volunteers

gain valuable experience andmentorship opportunities thathelp prepare future profession-als with real-world, project-based learning opportunities.Medical-device industry spon-sors and partners will be ableto demonstrate to stakeholderstheir commitment to children’smedical devices in a way thatdoesn’t detract from their strate-gic plans.

It is our hope that the pres-ence of this unique companywill help in a small way to diver-sify and strengthen our region’sleadership in the medical deviceand health care industries.

Bradley F. Slaker, BSME, MBA, hasmore than 20 years’ experience in thefor-profit medical device industry and isfounder and CEO of DesignWise Medical,a nonprofit pediatric medical device com-pany based in Minneapolis. For more infor-mation, visit www.designwisemedical.org.


Spectacular Fall Getaways. Relaxing, romantic vacations on Lake

Superior’s shore. Enjoy fabulous lakeside dining, a great wine list,

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For years the complexityand cost of health careexchange have forced pro-

viders to stick to obsolete, inse-cure, expensive, error-prone, andtime-consuming, paper-drivenworkflows involving printers,couriers, and fax machines. To-day with the Direct Project, wefinally have the secure healthInternet our patients and pro-viders deserve, and secure healthcommunications are available toproviders of all shapes and sizesand their patients.

Years ago, the Office of theNational Coordinator for HealthCare IT (ONC) of the U.S.Department of Health andHuman Services had a visionthat medical records could beshared across disparate pro-viders electronically. As a meansto reach that goal, the ONC,through its Nationwide HealthInformation Network (NwHIN,formerly NHIN), created NwHINConnect open-source software tosupport secure electronic healthinformation exchange. NwHINConnect was built on Web serv-ices and designed to meet usecases such as querying a health

network for the records of anunconscious patient presentingin an ER. But adoption ofConnect has been hampered bytechnical and legal complexities;providers often cannot affordthe products and maintenanceassociated with the technicalintricacies of these workflows,and the legal framework isexpensive and risky.

The HITECH stimulus act,part of the 2009 economic stim-ulus bill, also aimed to enhanceelectronic communicationamong providers by offeringincentives and introducing aframework for “meaningful use”of electronic health records(EHR) systems. However, it soonbecame apparent that smallerproviders—the ones with thegreatest need for stimulus and

for modernization—would bethe least able to participate inthese transactions, due to finan-cial and operational constraints.

At the same time, WhiteHouse chief technology officerAneesh Chopra was listeningto a primary care doctor’s frus-trations with not being ableto securely send patient datato a referring physician. DanBlumenthal, then national coor-dinator for the ONC’s HealthInformation Technology, wantedphysicians to be able to commu-nicate protected health informa-tion (PHI) easily and electroni-cally, instead of continuing thewidespread use of paper-drivenworkflows (e.g., those involvingprinters, copiers, couriers, andfax machines).

In response to the issuesraised by Chopra and Blumen-thal, as well as the ONC andproviders, Ability Network (thenVisionShare, Inc.) proposed aprotocol to facilitate simpletransactions available toproviders. The Minneapolis-based communications companyis the largest secure health infor-mation network in the nation,

NwHIN Direct, an extensionof the NwHIN, was announcedat the 2010 HIMSS (HealthInformation and ManagementSystems Society) conference bythe director of the Office ofStandards and Interoperability.Below is a brief look at howDirect has evolved since thenand what the advances in itsdevelopment mean for healthcare providers.

Developing a federal standard

The Direct standard was devel-oped using the concept of opengovernance, adopted from theworld of open source software.This model involves the opencollaboration of groups of stake-holders. The process of definingthe requirements, as well as thedevelopment of reference imple-mentations, is collaborative and

open to interested parties thatwant to contribute or simply tomonitor the process.

Open governance as ameans of developing federalstandards was a rousing success.Industry partners teamed upwith health care colleagues andorganizations to form commit-tees, and a federal standardwent from inception to realitywithin a year.

The first transaction on thenetwork, in early 2011, was animmunization message sentfrom Hennepin County MedicalCenter to the MinnesotaDepartment of Health’s immu-nization registry. Since that his-toric milestone, Ability has beennamed as the first health dataintermediary in Minnesota, wascertified as a health informationservice provider (HISP, a termfor a provider of Direct services)in Rhode Island, and became theHISP for the Wisconsin HealthInformation Network and forthe Delaware Health Inform-ation Network. The companyalso helped providers takeadvantage of the Minnesotae-Health grant initiative.

One of the reasons for thesuccess of the federal standardwas the charter given to theindustry participants and gov-ernment interests in developingit. They adhered to tenets like“Keep it simple; think big, butstart small” and “Design for thelittle guy so that all participantscan adopt the standard and notjust the best resourced.” Theirapproach resulted in a standardthat reused proven, understoodtechnologies where possible inorder to reduce complexity—and, thus, cost.

Performance, scalability, andease of adoption are all well-known quantities with Direct.Direct is literally “secure email”;it is based on email’s proven,30-year-old transport technology(Simple Mail Transport Protocol,or SMTP), underlying a proven,25-year-old security framework(x.509 Public Key Infrastructure,or PKI) with another proven,30-year-old directory service(Domain Name System, or DNS)for certificate discovery.

Uses of Direct include trans-actions such as:• Physician-to-specialist (inwhich a primary care physi-

Getting connectedDirect offers a simple, secure, and open

communication protocol for all

By McLain Causey


Ridgeview Medical Center and Clinics have a well-earned reputation for clinical excellence and compassionate care. Patients say the Ridgeview experience is remarkably different from what they have encountered elsewhere. One of the few remaining independent health care systems in Minnesota, Ridgeview responds to local and community needs through innovative care, cutting-edge service and partnerships with the best specialists.

Ridgeview is recruiting a full-time Internal Medicine Physician to join its Outpatient Clinic and Hospitalist practices. Seeking a candidate that is board certified or board eligible in Internal Medicine for a practice model that is approximately 80-90 percent outpatient-based medicine at Ridgeview Chaska Clinic at Two Twelve Medical Center,with scheduled shift work as a Hospitalist at Ridgeview Medical Center.Forward curriculum vitae and letter of interest to: Human Resources,Ridgeview Medical Center, 500 South Maple St., Waconia, MN 55387,or email: [email protected].

www.ridgeviewmedical.orgEOE/AA

Internal Medicine Physician

cian sends clinical data toreferring physicians).

• Provider-to-provider (in whicha hospital sends a dischargesummary to a patient’s homehealth agency).

• Clinic-to lab-to clinic (in whicha clinic sends an order to alab, which returns a lab reportto the clinic).

Direct and meaningful use

Direct messaging can also sat-isfy the federal government’sEHR meaningful use objectivessuch as these, for stage 1 (whichsets the baseline for electronicdata capture and informationsharing):• Exchange clinical informa-tion: Capability to exchangekey clinical information (suchas problem list, medicationlist, medication allergies,diagnostic test results, etc.)among providers of care andpatient-authorized entitieselectronically.

• Structured lab data into elec-tronic health record (EHR):Incorporate clinical lab-testresults into certified EHR tech-nology as structured data.

• Electronic copy to patients:Provide patients with an elec-tronic copy of their healthinformation (including diag-nostic test results, problem list,medication lists, medicationallergies, discharge summary,procedures) upon request (seeDirect and Patient Engage-ment, below).

• Discharge instructions:Provide patients with an elec-tronic copy of their dischargeinstructions at time of dis-charge, upon request.

• Clinical summaries topatient: Provide clinical sum-maries for each office visit.

• Send patient reminders: Sendreminders to patients perpatient preference for preven-tive/follow-up care.

• Provide patient access:Provide patients with timelyelectronic access to theirhealth information (includinglab results, problem lists,medication lists, medicationallergies) within four businessdays of the information beingavailable to the eligible profes-sional.

• Provide patient education:

Use certified EHR technologyto identify patient-specific edu-cation resources and providethose resources to the patient,if appropriate.

• Summary of care: Providersreceiving a patient from onesetting of care and referring toanother setting of care shouldprovide a summary of carerecord for each transition ofcare or referral.

• Immunization registry:Capability to submit electronicdata to immunization regis-tries and actual submission inaccordance with applicablelaw and practice.

• Report to public health:Capability to submit electronicdata on reportable (as requiredby state or local law) lab re-sults to public health agenciesand actual submission inaccordance with applicablelaw and practice.

• Syndromic surveillance:Capability to submit electronicsyndromic surveillance data topublic health agencies andactual submission in accor-dance with applicable law andpractice.

• Report clinical quality meas-ures to CMS: Provide aggre-gate numerator, denominator,and exclusions through attesta-tion electronically (pendingCMS readiness).

Direct and patient engagement

A number of the stage 1, Direct-compliant meaningful-use meas-ures listed above involve engag-ing with patients via electronictechnology. One way to do so isthrough a personal health record(PHR). The PHR is the patient-facing version of an EHR: anelectronic repository of clinicalinformation for patient use.

Many health system EHRsoffer PHRs to patients. If a prac-tice or hospital does not have aPHR of its own, there are otheroptions, such as MicrosoftHealthVault, a PHR that is freefor patient use and costsproviders nothing. Microsoft isan Ability partner that has beenengaged in Direct projects.

As an example, using theHealthVault PHR to satisfy apatient-engagement meaningful-use measure through Direct, aprovider could do the following:

1) Ask the patient if he or shewould like to receive his orher medical records electroni-cally using a free PHR prod-uct and a secure messagingstandard.

2) If the patient consents, ask forhis or her email address.

3) Send a Direct message [email protected] with the patient’s emailaddress in the subject field.

4) HealthVault will create aDirect address for the patientand send him or her a link toa Web page to activate theaddress and a HealthVaultPHR account for free.

5) The provider sends a Continu-ity of Care Document—a stan-dard electronic, structuredmedical record—to thepatient’s HealthVault account.The records are imported intothe appropriate sections ofthe PHR, and the patient canrespond to the message withquestions.Using a PHR with patients

establishes a bidirectional com-munication channel betweenpatient and provider that is as

easy to use as email, but secureenough to transmit PHI legally.

Expanding health carecommunication

By creating a federal standardfor electronic exchanges throughopen-source collaboration, theDirect messaging system hasexpanded the conversation inhealth care in several ways:• It provides a simplified (andthus cost-effective) means ofextending secure digital com-munications to previously dis-enfranchised entities such aspatients and smaller providers.

• It replaces costly and ineffi-cient paper-driven workflows.

• It simplifies connectivityamong disparate health infor-mation systems.

Direct can truly be thefuture of health care communi-cation.

McLain Causey, a product manager atAbility Network in Minneapolis, has abackground in computer science andindustry experience in cybersecurity andhealth care technologies.


Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional part-time or full-time BC/BE

family medicine physicians to join our primary care team in Sartell,

MN. This is an out-patient only opportunity and does not include

labor and delivery or hospital call and rounding. Our current primary

care team includes family medicine, adult medicine, OB/GYN and

pediatrics. Previous electronic medical record experience is preferred

but not required. We use the Epic electronic medical record system

at all of our clinics and admitting hospitals.

Our HealthPartners Central Minnesota Clinics – Sartell moved

into a new primary care clinic in the summer 2010. We offer a

competitive salary, an excellent benefit package, a rewarding practice

and a commitment to providing exceptional patient-centered care.

St Cloud/Sartell, MN is located just one hour north of the Twin

Cities and offers a dynamic lifestyle in a growing community with a

traditional appeal.

For more information, please contact [email protected] or call Diane at 800-472-4695 x3. EOE

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h e a l t h p a r t n e r s . c o m


If you’re a physician inMinnesota, you know thatthe U.S. Office of the

National Coordinator and theMinnesota Office of HealthInformation Technology havemandated that electronic healthrecords (EHR) systems beinstalled in a variety of health-care provider organizations.Minnesota’s state implementa-tion plans call for all healthcare providers and hospitals tohave an interoperable EHR sys-tem by 2015. Essentially, thismeans that no matter what typeof EHR system your facilityin-stalls, it must be able toex-change information witheveryone else’s EHR. This isnot an easy task, and a newtechnology industry has evolvedto provide the services neededto make it happen.

In Minnesota, the nonprofitCommunity Health InformationCollaborative (CHIC) is leadingthe way toward EHR interoper-ability through its state-certifiedhealth information exchangecalled HIE-Bridge. HIE-Bridgegives health providers access toauthorized patient information

through a secure Web-basedinformation exchange platform.Providers from different healthcare systems can exchange clini-cal documents electronically,using a Continuity of CareDocument—a snapshot patientsummary containing the perti-nent clinical, demographic, andadministrative data for a specificpatient. Nearly 200 healthorganizations in Minnesota andWisconsin now use the HIE-Bridge system, and CHIC andits technology partners are bol-stering the infrastructurerequired to expand its healthinformation exchange services

Evolution of a healthinformation exchange

Duluth-based CHIC was devel-oped under a federal Office ofRural Health Policy–Network

Development grant in 1997. Itis now a self-sustaining organi-zation financed by dues from itsmore than 170 members, whichrepresent the entire health spec-trum—hospitals, clinics, long-term care facilities, tribal healthfacilities, higher education insti-tutions, and public healthdepartments in Minnesota.

This unique partnershipallows CHIC members to maxi-mize the health care servicesthey can provide. By coordinat-ing health information technol-ogy, CHIC provides its membersstrictly controlled access topatient health care recordsamong care facilities; sendsMedicare claims efficiently andquickly; recruits and trains usersfor the state’s immunization reg-istry; administers telecommuni-cations services applications formembers; and coordinates emer-gency preparedness for healthcare partners under a contractwith the Minnesota Departmentof Health Office of EmergencyPreparedness.

Beginning in 2004, CHICassisted in developing the speci-fications and technical architec-tural design of the NationwideHealth Information NetworkExchange (NwHIN), a set ofstandards, services, and policiesthat enable secure health infor-mation exchange over theInternet. We were also closelyinvolved in developing policiesand procedures for joining theexchange.

As an outgrowth of thiswork, in 2010 CHIC contractedwith the Social SecurityAdministration to exchangeDisability Determination patientrecords electronically. CHICdeveloped an extensive Continu-ity of Care Document that metSocial Security’s requirements,and the project went live inSeptember 2011. The stream-lined electronic work flow for anold process has improved theturnaround time for decisions

regarding disability insuranceand decreased the time it takesfor providers to receive pay-ments under this same program.

Additionally, in the Dulutharea CHIC has implemented aVeterans Administration pro-gram called the Virtual LifetimeElectronic Record (VLER). Theprogram is designed to build acomplete electronic healthrecord for all service persons,both active and retired, that willcontain information from theprivate provider’s records as wellas the Veterans Health Infor-mation Systems and TechnologyArchitecture (VistA) system.Thus, no matter where servicepeople are stationed or whereveterans receive their care, all oftheir patient information will beavailable for their treatment.

HIE operations

CHIC is currently working onexpanding its electronic infor-mation exchange system to pro-vide a greater breadth of ser-vices. To that end, we havejoined forces with Emdeon, atechnology company that is alsocertified as a health data inter-mediary through the state’sHealth Information ExchangeService Provider certificationprocess. The HIE-Bridge servicehas been certified through thissame process as a health infor-mation organization—the onlyone in the state to date. [Moreon the state’s certificationprocess for health informationexchange is available atwww.health.state.mn.us/e-health/hie.html.]

Data that is exchangedthrough the HIE-Bridge is en-crypted before it is moved acrossthe Internet and decrypted justafter it is dropped off at theother end. At no time is anyinformation available for read-ing while traversing the Internet.Also, all users requesting infor-mation must adhere to aMilitary Level 3 Authorization/Authentication process everytime they enter into the HIE-Bridge system. No informationis ever released from HIE-Bridgeunless a signed patient release isattested to or it is an emergency.

CHIC’s existing HIE-Bridgenetwork is currently implemen-

Bridge-buildingAdvancing health information exchange

in Minnesota

By Cheryl Stephens, PhD


Sioux Falls VA Health Care System“A Hospital for Heroes”

Working with and for America’s Veterans is a privilege and wepride ourselves on the quality of care we provide. In return foryour commitment to quality health care for our nation’s Veterans,the VA offers an incomparable benefits package.They all cometogether at the Sioux Falls VA Health Care System.

www.siouxfalls.va.gov

To be a part of our proud tradition, contact:

Human Resources Mgmt. ServiceP O Box 5046Sioux Falls SD 57117605-333-6852

• Orthopedic Surgeon

• Emergency DepartmentPhysician

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• Urologist

• Psychiatrist

• Radiologist

• Cardiologist

• Pulmonologist

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BRIDGE to page 32


www.lrhc.org

Practice Well. Live Well.Lake Region Healthcare is located in a magnificent, rural,and family-friendly setting in Minnesota lakes countrywhere we aim to be the state’s preeminent regional healthcare partner.

Our award winning patient care and uncommon medicalspecialties set us apart from other regional health caregroups. Lake Region’s physicians and their families alsoenjoy an unmatched quality of professional and personal life.

Current opportunities including competitive salary andbenefit packages available for BE/BC physicians are:

• Dermatologist• Family Medicine• Emergency Medicine

• Hospitalist• Internal Medicine• Pediatrics

712 Cascade St. S., Fergus Falls, MN736-8000 • (800) 439-6424

Lake Region Healthcare is an Equal Opportunity Employer. EOE

For more information contactBarb Miller, Physician [email protected] • (218) 736-8227

Emergency Medicine

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For more information contact Tina Dalton or Mike Coulter at800-458-5003, email:[email protected] visit our website at

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Connecting your business to your market

Connecting your business to your market

By Robert Sweet, MD“I have prostate cancer

… and I want a robotic

prostatectomy ” This is

a common presenting“chief complaint” heard

nowadays in urologists’

offices across the state

and across the country

If you perform robotic prostatectomy, it

can be a plus in marketing your practice

If you don’t, you either try to convince your

patient that robotic prostatectomy isn’t all

it’s cracked up to be, or you refer him to

someone who does itTo date, removing the

aid of a robot is thapplicatii

figure, given the rela-tively recent adoption

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clinical applicationsThe rapid growth in

this field promisesto permanently alter

the way surgical proce-

dures—especially mini-

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and taughtThe currentTh

Volume XXI, No.7October 2007


B edside manner may be

viewed as a “soft” skill these

days, and advances in medi-

cine continue to heighten the

emphasis on clinical and technical

expertise But as medicine shifts its

focus to become more patient cen-

tered, patient experience is fast gain-

ing ground as a key measure of qual-

ity In 2004, for example, the U S

Medical Licensing Examination

added a national skills test on per-

sonal interaction and communica-

tion that medical students must pass

to be eligible for licensure And this

year, the National Committee for

Quality Assurance (NCQA) added

“shared decision-making” as one of

seven measures to assess patient

experienceShared decision-making involves

systematic interaction with pa

to arrive at an infobased on th

Talk it outShared decision-making improves

the patient experienceBy Marcus Thygeson, MD,

and Karen Kraemer, RN, CMC

Lending ahandRobotic surgerymakes inroads into the

OR and beyond

Volume XXI, No.8November 2007


Bringing a newmedical deviceto marketThe challengesof picking a winnerBy Curt Miller

in Minnesota Physician

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The perfect matchof career and lifestyle.

Affiliated Community Medical Centers is a physician owned multi-specialty group with 11 affiliate sites located in western andsouthwestern Minnesota. ACMC is the perfect match for healthcare providerswho are looking for an exceptional practice opportunity and a high quality of life.Current opportunities available for BE/BC physicians in the following specialties:

• ENT• Family Medicine• General Surgery• Geriatrician/• Outpatient Internal

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ted with a provider directory;a federated record locator serv-ice (RLS) that serves as an elec-tronic “card catalogue” forpatient records; and a consentmanagement system that meetsthe requirements of Minnesota’scurrent RLS legislation. To meetthe long-term requirements forMinnesota and its health careproviders, this platform will beexpanded with laboratory direc-tories and record locator infor-mation from Emdeon, alongwith directories for the Directmessaging program, which fa-cilitates sending secure, encrypt-ed messages over the Internet.

CHIC and Emdeon haveagreed to collaborate to deliverbest-in-class services forstatewide shared services,including both short- and long-term technical infrastructuresand core HIE services, so thatexchange members canexchange health informationacross their organizationalboundaries. The short-termstatewide shared HIE serviceswill use technologies based onfederal specifications already

implemented in certain healthcare provider organizations. Wewill augment these services withcore HIE services to addressobvious, immediate needsaround message exchanges, aswell as laboratory services.

We anticipate that the needfor more robust and query-basedforms of health informationexchange will result in a naturalprogression of certain initial usecases from a reliance on Direct-based message “pushes” (e.g.,sending clinical informationbetween two known entities,e.g., from a specialist to aprimary care provider) toexchange-based messages,queries, and “pulls” (e.g., query-ing for information about apatient, and responding withinformation on the locationand/or the content of a patient’srecords). For other use cases(such as primary-to-specialistcare referrals), evolution mayinvolve not so much a change inthe electronic transport mecha-nism but, rather, better integra-tion with existing workflows oradoption of higher-level stan-dards of interoperability.

The intention is for HIE-Bridge to provide an evolvingand “right-sized” technologyplatform at the times and places,and in the most appropriatemanner, needed to ensure effec-tive and sustainable health infor-mation exchange in Minnesotaand with surrounding states.

Future directions

Much has been done to helphospitals and clinics move to theelectronic age with health infor-mation technologies. Incentiveprograms such as REACH(Regional Extension AssistanceCenter for Health InformationTechnology), Meaningful Usedollars, and eHealth Connect-ivity grants have all focused onthese specific health care pro-viders. These initiatives havehelped advance the use of elec-tronic health records and healthinformation exchange inMinnesota.

In the coming year, we hopeto target another important seg-ment of the continuum of carefor patients, particularly thevulnerable population residingin long-term care facilities

throughout Minnesota. We havecommitments from AgingServices of Minnesota and CareProviders of Minnesota to worktogether on outreach and imple-mentation efforts with thenumerous facilities around thestate—virtually all of whom aremembers of one of these twoagencies. We anticipate thatintegrating long-term carefacilities into HIE-Bridge willimprove patient care, with moretimely and complete informa-tion. We also anticipateimproved information flow dur-ing transitions of care betweenthese facilities and hospitals.

CHIC’s history of providingrelevant technology servicesto its members, through closecollaboration in a trust-basedenvironment, provides the basisfor our vision for health infor-mation exchange. Along withour participating developersApeniMED and Emdeon, we willcontinue working toward achiev-ing that vision.

Cheryl Stephens, PhD, is presidentand CEO of the Community HealthInformation Collaborative.


Bridge from page 30

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Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference.

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and stand by those who stand up for me.


Rice Memorial Hospital has an out-standing opportunity for the rightperson to serve as its Chief MedicalOfficer (CMO).Reporting directly to the CEO, thissenior executive will be responsible forleading the medical staff in the plan-ning, facilitating and implementing ofprograms to enhance physician effec-tiveness, quality of practice, clinicalintegration and patient satisfaction.The CMO will be line administrator forphysician services within the Emergency Department and is expectedto provide direct patient care at least four shifts per month in theEmergency Room.The position requires an MD or DO with a license to practice medicinein the State of Minnesota; as well as a minimum of seven years ofclinical experience and at least two years of physician leadershipexperience. An MBA or Masters degree in public health is desirable.Located in the lakes region two hours west of the Twin Cities, RiceMemorial Hospital is the state’s largest municipal hospital, providinga vast array of services to the residents of west central Minnesota,including high-tech diagnostics, rehabilitation, long-term care, DME,mental health, dialysis, radiation oncology and hospice. Rice recentlycompleted a $52 million building and renovation project.

Chief Medical OfficerCandidates submit a coverletter and resume to:Michael Schramm, CEORice Memorial Hospital301 SW Becker AvenueWillmar, MN 56201

Rice provides a competi-tive salary and generousbenefit package. To learnmore see our website atwww.ricehospital.com

The Northwest Wisconsin Region of Mayo Clinic HealthSystem has more than 300 physicians representing a widerange of medical specialties in a community healthcaresetting. We are a respected and financially secure organiza-tion with strong emphasis on high quality care and patientsatisfaction. A Mayo One emergency medical helicopter isbased in Eau Claire, offering surrounding communitiesaccess to the area’s only verified Level II trauma center.Our current opportunities include:Dermatology OncologyEmergency Medicine Orthopedic Surgery –

General, Sports, & TraumaEndocrinology Palliative CareFamily Medicine PathologyGeneral Surgery PM & RHospitalist Psychiatry – AdultInternal Medicine RheumatologyNeurology Urology

If you wish to learn more or to express interest in thisposition, please contact:

Cyndi Edwards/Christie Blink by phone (800-573-2580);email [email protected] [email protected]

Urgent Care

We have part-time and on-call positions available at a variety of Twin Cities’ metro areaHealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicineand internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.

For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link toview our Urgent Care opportunities.For more information, pleasecontact [email protected] or call Diane at: 952-883-5453; toll-free:1-800-472-4695 x3. EOE

©

h e a l t h p a r t n e r s . c o m

Two BC/BE Orthopaedic Surgeonswanted to join four orthopaedic sur-geons at Sanford Bemidji OrthopaedicsClinic in Bemidji, Minnesota. Part ofan 85-physician, multi-specialty grouppractice and 118 bed acute care hospi-tal. 1:6 call anticipated. Competitivecompensation/benefits package, paidmalpractice, relocation assistance andmore. Sanford Health of NorthernMinnesota has 1,450+employees andis part of Sanford Health system basedin Fargo, ND and Sioux Falls, SD.

Bemidji, Minnesota, located in north-western Minnesota, is a beautifulresort community offering exceptionalschools, a state university, and year-round cultural activity as well as greataccess to the outdoors for year-roundrecreation activity. To learn moreabout this excellent practiceopportunity contact:

Kathie Lee,Director Physician PlacementPhone: 701-280-4887Fax: 701-280-4136Email: [email protected]

AA/EOE

OrthopaedicSurgery

OpportunityLive in Beautiful

MinnesotaResort Community


Minnesota is a greatplace to live and work,especially for members

of the health care industry.Health care professionals andmedical industry employeesalike can take enormous pride inour state’s history of contribu-tions to medical science. Theenvironment that exists inMinnesota has supported thedevelopment of high-knowledgecontent and life-supporting med-ical technology in collaborationwith world-class health caredelivery and reimbursement sys-tems, leading to many medical“firsts” in our state.

The uniqueness of ourMinnesota environment has cre-ated an “economic ecosystem”that has become the envy ofmuch of the world. The state'smedical device industry has ben-efited from and contributed toadvancing this collaborative andhighly entrepreneurial environ-ment. Minnesota is home to over400 medical technology compa-nies that produce final productsand 600 supporting companiesthat provide everything fromlegal services to high-technology

components and special testingcapabilities.

More than 250,000 people inMinnesota are either directly orindirectly employed by the med-ical technology industry, makingour state home to the mostdensely concentrated medicaltechnology cluster per capita inthe United States. According toresearch published by manage-ment and technology consultantKelvin Willoughby, PhD, inJanuary 2009, Minnesota is 3.35times more concentrated inmedical technology than thecountry as a whole.

This highly concentratedindustry has helped to improveand save patients’ lives world-wide, created thousands of high-paying jobs, and supported ourvibrant social communitythrough charitable giving andother community involvement.

It is an integral part of our eco-nomic health and local culture.

Unfortunately, today thenational and local medical de-vice industries are being pres-sured by a variety of factors. Forexample, last year the U.S.Department of Trade reportedthat in 2008 the U.S. importedmore medical devices than weexported. Medical devices havebeen a dominant industry forour country, a source of wealth,and an offset to our burdensometrade deficit. We have yet to seewhether this trend of increasedimports will continue or not.

The forces hampering thelevel of growth in the medicaldevice industry are both internaland external. This situation is acause for concern but also pro-vides a challenge for our com-munity to overcome. Five issuesare key to understanding themedical device industry todayand determining how to retainour state’s leadership positionwithin it: collaboration, regula-tion, investment, technologycommercialization, and globalpressures.

Collaboration

As an engineer and senior man-ager at a large medical devicecompany in a prior life, and nowas the president and CEO ofLifeScience Alley, I’m most con-cerned about the breakdown inthe culture of collaborationamong different segments in thehealth care environment. When Istarted my career, more than 30years ago, the day-to-day inter-action among health care deliv-ery, reimbursement, and medicaldevice industry professionalswas the key to success in identi-fying and implementing systemsolutions. One need only recallthe story of physician WaltLillehei and electrical engineerEarl Bakken inventing the pace-maker, which ignited the cre-ation of the medical deviceindustry in Minnesota, to under-stand the need for and benefitsof this type of collaboration.

In my opinion, collaborationamong stakeholders is the rea-son that Minnesota is the mostdensely concentrated medicalproducts industry community inthe U.S. When the differentmembers of the health careecosystem work together, clini-cal need is internalized andinvention occurs. As a result, allmembers of the ecosystem bene-fit—especially the patients.

However, in this era ofhealth care reform and mount-ing cost pressures in the healthcare system, many constituentshave taken to blaming other sec-tors for the issues the industryfaces. There are reimbursementpeople who feel that all medicaldevice products add to health-care system costs, and devicepeople who feel that the onlytrue cost-reduction possibilitiesare device-driven. The realitylikely lies somewhere in the mid-dle, but these concerns cannotbe addressed successfully with-out collaboration in good faithamong all parties.

In addition, productive col-laboration in the U.S. is increas-ingly complicated by a pervasivefear of conflict of interest. In aneffort to avoid the appearance ofinappropriate relationshipsbetween clinicians and devicemakers, companies functioningas a “middleman” are meetingwith doctors and health careprofessionals, interpreting theirneeds, and then communicatingthose needs to medical devicemanufacturers. Unfortunately,increasing the distance betweenclinicians at the point-of-careand technology/therapy produc-ers only hampers the ability tobring about novel, and muchneeded, solutions to patients.

Regulation

One of the most publicizedissues facing the medical prod-ucts industry today is the unpre-dictable nature of the regulatoryapproval cycle. No one is advo-cating for a lack of oversight andregulation of the industry, as weall value the safety of the pa-tients whose lives we endeavorto improve and save. The con-cern within industry is theunpredictable nature of require-ments and uncertain timelinesfor approval or disapproval.

Re-igniting the sparkTaking stock of the medical device industry

By Dale Wahlstrom


In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Central Lakes Medical Clinic, a 30-physician multispecialty group,and Cuyuna Regional Medical Center, a critical access hospital offering superb new facilities with the latest medical technologies.Outdoor activities abound, and with the Twin Cities metropolitan area just a short drive away, you can experience the perfect balance of recreational and cultural activities.

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SPARK to page 36


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The Food and Drug Admin-istration (FDA) has taken note ofthe situation and is makingefforts to improve the process.One of its initiatives, launchedin August 2011, is called theStrategic Plan for RegulatoryScience. The agency recognizesthe limitations of clinical studiesand traditional bench-testing toidentify product performanceconcerns. The regulatory sciencestrategic plan seeks to applyadvanced predictive modelingand testing as a tool to help theFDA assess new products, withgoals of better predicting chron-ic product performance and pro-viding faster approval cycles.

We recognize that industryand academia can play a role inthis process, which is whyLifeScience Alley has signed amemorandum of understandingto work with the FDA on im-proving regulatory science.Through this project, industryand academic stakeholders willwork to form a center of excel-lence in Minnesota focused onregulatory science as applied tomedical devices.

Investment

The uncertainty in achieving aregulatory decision is causingentrepreneurs to hold back onstarting new companies; largecompanies to reduce their re-search and development invest-ments; and the venture capitalcommunity to reduce or stopinvesting in medical technology.

The BioBusiness Alliance ofMinnesota, a strategic affiliate ofLifeScience Alley, provides sup-port to start-up companies. Wehave supported 272 companiesin the start-up stage over thepast three years. This year, forthe first time, we have seenthree company business planswith no intention to release theirproducts in the U.S. We havealso received anecdotal inputfrom some members that theyare moving their design, clinicaltesting, and product approvalefforts offshore to avoid some ofthe uncertainties of the commer-cialization process.

The good news is that thecommunity shares our concernover the dearth of funding avail-able to promising start-up com-panies. In 2011, the BioBusinessAlliance of Minnesota created

the Minnesota Angel Network(MNAN) to accelerate thegrowth of early-stage companiesthrough multidisciplinary educa-tion and connections to inves-tors, strategic alliances, and bus-iness resources. In the fourthquarter of 2011 alone, MNANattracted 50 individual accre-dited angel investors and 20self-identified accredited angelfunds/angel networks as directmembers. MNAN invited 24companies to participate in theprocess, certifying six of themby year’s end.

Technology commercialization

While Minnesota still has athriving entrepreneurial commu-nity, our academic and businesscommunities have struggled totransfer world-leading researchseamlessly into the private sec-tor for commercialization.

Leaders from business andfrom the University of Minne-sota have been working on thisissue. In a very promising break-through, the university recentlyannounced a philosophical andpractical change in how it han-dles the transfer of intellectualproperty from industry-fundedresearch. The new system,dubbed MN-IP, provides a sim-pler and more business-friendlyframework for transferring re-search into the private sector.There is still work to be done,but the necessary parties arehaving the right conversationfor sustained improvement.

Global pressures

Many countries have begun toappreciate the value of the med-ical device industry and aremaking large investments indeveloping their own industries.Medical technology has attrac-tive attributes: It is clean, aver-age wages are significantly high-er than for other industries, andit adds value to people’s livesand to society. As a knowledge-based economic sector, it is notdependent on local, naturalresources and therefore is“portable.”

While other industrializednations are doing their best toentice U.S. companies to estab-lish operations overseas, manyof those countries are not ableto provide the one resourcewithout which Minnesota’s

device industry would perish:our interconnected industryecosystem. Beginning with thetransition of highly skilled main-frame computing engineers andscientists into medical techno-logy disciplines, we have built afull-spectrum ecosystem with allof the service providers neces-sary to support our medicalproduct manufacturers righthere in Minnesota. It is possibleto find entrepreneurial physi-cians, IP attorneys, regulatoryand reimbursement specialists,contract manufacturers, productmarketing firms, clinical studylocations, and world-class healthcare facilities all within the TwinCities alone.

Despite the strength of oursupporting community, estab-lishing operations in countrieslike Japan and China is still anattractive option for many of ourcompanies. However, we have anopportunity to engage with thesecountries in a way that can bemutually beneficial. Our localmedical device community canopen up business opportunitiesin other countries while retain-ing operations at home.

Continuing innovation

As a state, we have the ecosys-tem, the talent, the knowledge,and the resources to continueleading the world in medicaldevice and health care deliveryinnovation. However, it willrequire us to work together forthe benefit of all stakeholdersand, most importantly, for thepatients.

The good news is that thesediscussions are already takingplace and are beginning to occurmore frequently. Medical officersof device companies are meetingwith medical officers of reim-bursement companies andhealth care institutions. Givenour history of innovation andour community’s deep under-standing of the interactionbetween health care delivery andmedical products, Minnesota isuniquely positioned to helpguide and set the course to keepthe device industry centered inthe United States.

Dale Wahlstrom is president and CEOfor LifeScience Alley and the BioBusinessAlliance of Minnesota. In 2006 he retiredfrom Medtronic, after 24 years.


Spark from page 34

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Home visitation programs.Another effective family-levelyouth violence intervention ishome visitation programs. Theseprograms involve weekly tomonthly visits by nurses duringpregnancy, continuing for thefirst two years of a child’s life.The nurses provide parentinginformation, emotional support,counseling, and linkage to socialservices. Long-term follow-up inrandomized controlled studiesconducted by Olds and col-leagues indicates that childrenwho are visited have lower ratesof offending as teenagers, lessantisocial behavior, and less sub-stance use than those not receiv-ing home visitation. The successof this model is a powerful illus-tration that an intervention dur-ing the first two years of achild’s life can have an enduring

effect on development. Physi-cians should refer high-risk fam-ilies for home visitation.

Programs in Minnesota arefunded through the MinnesotaDepartment of Health, with localpublic health departmentschoosing how to implementtheir programs (see www.health.state.mn.us/divs/fh/mch/fhv).

Safe firearm storage

A case-control study of firearmsconducted by Grossman and col-leagues, published in the Journalof the American Medical Asso-ciation in 2005, found that safestorage practices—specifically,keeping firearms stored

unloaded, in a locked place; andstoring ammunition locked andin a separate location—each hada protective effect against unin-tentional firearm shootings andsuicide attempts among childrenand adolescents. Thus, these arethe evidence-based storage prac-tices to convey to gun-owningfamilies.

In a study reported inPediatrics in 2000, Grossman etal. found that brief counselingand providing written informa-tion on household firearm risksor firearm removal, safe storage,and storage device coupons inthe office setting did not lead tostatistically significant changes

in gun ownership or storage atthree-month follow-up. In a sub-sequent primary care-basedstudy in Pediatrics in 2009,Barkin and colleagues foundthat brief motivational inter-viewing and offering cable lockswere significantly associatedwith using cable locks for saferfirearm storage at six monthfollow-up. In both studies,24 percent of families were gunowners.

Project ChildSafe (www.projectchildsafe.org) is anorganization that works withlaw enforcement to distributecable gunlocks. Medical prac-tices may be able to obtain gun-locks by working with their locallaw enforcement offices.

As child and adolescenthealth care providers incorpo-rate youth violence preventioncounseling into their clinicalencounters with youth and fami-lies, think LAKES—a handful ofevidence-based youth violenceprevention recommendations.

Iris Wagman Borowsky, MD, PhD, isan associate professor in the Departmentof Pediatrics at the University of MinnesotaMedical School, Minneapolis.

Violence from page 11


Family-levelinterventions areamong the mostpromising youthviolence preventionapproaches knownto date.

Boynton Health Service

Welcome to Boynton Health ServiceGynecologist/Clinical Supervisor

176093

A Diverse and Vital Health Service

You wouldn’t give a 4-year-old a drink, so why would you give one to an unborn child?

As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy.

Share 049: Zero Alcohol For Nine Months.

www.mofas.org

Documents

Minnesota Physician April 2012