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MetroDoctors The Journal of the Hennepin and Ramsey Medical Societies September/October 2006 1

C O N T E N T SV O L U M E 8 , N O . 5 S E P T E M B E R / O C T O B E R 2 0 0 6

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2 FEATUREMedicare 646: Quality Demonstration in the Upper Midwest

7 Why Should Health Care OrganizationsApply Lean Thinking Principles?

10 COLLEAGUE INTERVIEWNick Meyer, M.D.

13 Courage Center: A Leader in Rehabilitation, Policy and Reform

14 Classied Ad/Volunteer Opportunity

16 Ten Days in Haiti

20 Minnesota Immunization Information Connection

21 HMS and RMS Resolutions Being Submittedto MMA House of Delegates

24 Members in the News

Index to Advertisers

RAMSEY MEDICAL SOCIETY

25 Presidents Message26 Introducing New Employees for Dakota County Smoke Free Partnership/

Doreen Hines Recognized for 25 Years of Service

27 RCMS, Inc. Becomes Minnesota Physician Services, Inc./RMS Staff to Expand/New Board Member/Second Hand Smoke Speakers

28 In Memoriam/New Members/Senior Physicians

HENNEPIN MEDICAL SOCIETY

29 Chairs Report30 HMS In Action/Sue Schettle Departs HMS31 New Members/In Memoriam/Senior Physicians Association32 HMS Alliance

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

Doctors

On the cover: Haiti is richin history, culture and oppor-tunities to volunteer. Articlebegins on page 16. Photo byJames A. Rhode, M.D.

2 September/October 2006 MetroDoctors The Journal of the Hennepin and Ramsey Medical Societies

F E A T U R E S T O R Y

T

Quality Demonstration

In the Upper Midwest

Medicare 646

BY JEANNE RIPLEY, MBA

THE MEDICARE MODERNIZATION ACT (MMA) of 2003 promised major health carechanges through highly visible programs such as prescription drug coverage and Health Sav-ings Accounts. However, the most dramatic changes may come from the MMAs Health CareQuality Demonstration Program (The Section 646 Demonstration). Unlike CMSs traditionalapproach to demonstration RFPs that dictate desired form and function, this demonstrationwill allow for creative, innovative models that fundamentally change the way providers arerewarded for doing the right thing for Medicare beneciaries.

A coalition of providers in seven Upper Midwest states is working to develop a uniqueresponse to this demonstration. It is well known that the states in the MMA Region 25(Medicare Advantage) and Region 19 (PDP), plus Wisconsin, produce the highest quality,lowest cost care in the nation. This demonstration proposal will be designed to leverage thatrecord and showcase exciting quality improvement, care coordination, and data exchangeinitiatives that are underway across the region. This is regionalization at its best, says DaveDurenberger, former U.S. Senator from Minnesota and chair of the National Institute ofHealth Policy, and a model that holds promise for the modernization of Medicare.

At a March working group meeting of the Coalition, members received afrmationfrom CMS leaders and national experts encouraging the Coalition to submit a one-of-a-kindproposal and offering to help us along the way. Barry Straub, Chief Medical Ofcer for CMShad this to say:

You have the experience and intelligent people to pull this off. With that baseline and yourcombination of integrated health systems, health plans, academic centers, medical groups and yourdemonstrated ability to collaborate yours is a perfect testing ground. We want to be very, veryencouraging to you to come with a completed application by the deadlineThis is the most excitingconcept I have seen in my years at CMS.

Framework for the DemonstrationThe Upper Midwest Demonstration Project: Providing Health Care of Value in the UpperMidwest will build on the concept of a medical home for Medicare patients and will validatethe tools that providers and facilities along the entire continuum of care need to ensure thatall beneciaries are receiving the most effective, appropriate care available. Academic healthcenters, large integrated delivery systems, and both rural and urban small physician groupshave agreed to join the effort and see huge benets in sharing best practices and creating aregion-wide vehicle for exchanging clinical information.

This demonstration

proposal

will...showcase

exciting quality

improvement, care

coordination, and

data exchange

initiatives that are

underway across

the region.


(Continued on page 4)

Coalition members will use their collective inuence to re-shape Medicare payment poli-cies in a way that will reward them for delivering quality care and empower providers to take the time and effort to appropriately care for seniors. The Coalition does not intend to create new initiatives, but will disseminate current practices and will create a national showcase for existing quality improvement activities in the Upper Midwest. Through the power of collective advocacy, the group will advocate for Medicare payment policies and regulations that support Upper Midwest models of practice and quality improvement.

The potential for signicant health system redesign and Medicare policy change grows exponentially as the Coalition grows. The regional scope of this demo is its hallmark, taking advantage of the regional infrastructure created by the MMA 2003 legislation.

If you consider better health care for beneciaries the Holy Grail, and the sustainability of the Trust Fund an imperative, you cannot ignore this coalition, says Durenberger. We want to go from good to great and the providers who have joined this effort know how to do it. All they need to succeed is permission from CMS to do it their way a way that has already shown great results and provides value to beneciaries and Medicare and get rewarded for it.

GoalsThe goals of the Coalitions proposal include: More effective quality improvement efforts through widespread dissemination of tools

and data, and more equitable Medicare payment for high quality efcient care throughout the Upper Midwest.

A national showcase for the Best of the Upper Midwest. Quality-based health care at the lowest cost to Medicare. Given this track record, the innovative methods and care delivery models that are the heart of our success should inform all discussions and deci-sions about the future Medicare program nationwide.

Inuence Medicare policies by demonstrating to CMS how the Upper Midwest models for value-based health care can, and should, be replicated nationwide and become the foundation for future Medicare policies.

Designing the Demonstration ProposalCoalition workgroups will focus on the following areas:1. Clinical approaches to optimal care delivery and methods for signicant provider engage-

ment across the entire region.

...this

demonstration will

allow for creative,

innovative models

that fundamentally

change the way

providers are

rewarded for doing

the right thing for

Medicare

beneciaries.


Medicare 646

(Continued from page 3)

2. Financial models that support and re-ward providers for their efforts toward the established clinical goals. This group is also tasked with developing a research design and comparison population.

3. Technology and information exchange systems that will support the demonstra-tion and provide useful and appropriate real-time information to providers and beneciaries.

4. Organizational structure and Gover-nance for the Coalition that will be ap-propriately sized and staffed to support the work of the demonstration without being overly cumbersome or costly.

Membership in the Coalition The Coalition currently includes the follow-ing members: Allina Hospital & Clinics, Minneapolis,

MN Avera Health, Sioux Falls, SD Billings Clinic, Billings, MT Fairview Health Services, Minneapolis,

MN HealthEast, St. Paul, MN MeritCare Health System, Fargo, ND St. Marys Duluth Clinic Health Sys-

tem, Duluth, MN The University of Wisconsin Medical

Foundation, Madison, WI

Membership requires two commitments:1. A personal commitment from organiza-

tional leaders to actively participate in thoughtful ways and to assign nancial and staff resources as needed to the Coalitions efforts.

2. An organizational commitment to par-ticipate at one of the following levels:

Cornerstone Member ($25,000):are voting members and can identify one individual as an organizational repre-sentative on the Executive Committee

which oversees the overall policy and high-level design of the demonstration, budget decisions and sets the agenda for Coalition member meetings. Cor-nerstone members also participate in the Steering Committee, which will oversee the day-to-day development of the demonstration through the work-ing groups. Cornerstone members can appoint representatives to serve on the three working groups (Clinical, Data/IT and Finance).

Premier Member: all are voting mem-bers and can participate in the Steering Committee, which oversees the day-to-day development of the demonstration through the working groups. Premier members can appoint representatives to serve on the three working groups (Clinical, Data/IT and Finance).

Large Health System ($15,000)Medium Sized Provider Groups($7,500)Small Physician Practices ($2,500)*Note: these fees may be modied based on other in-kind contribu-tions.

In addition, there are non-voting mem-bers who support the efforts of the Coalition in a variety of ways. They receive special briengs on the efforts of the Coalition and are identied in public documents as Con-tributors. As requested, Contributors may serve on working groups of the Coalition or assist in the advocacy efforts of the group. Organizations that may become vendors of the Coalition or of the voting members of the Coalition are not eligible for membership.

Signicant Contributor ($10,000)Supporting Contributor ($7,500) Associate Contributor ($3,000)

In total, there are different levels of membership for provider organizations. All voting member organizations must include employment of, or close collaboration with,


physicians. Each voting member organiza-tion will have one vote.

The financial contributions notedabove will support project managementservices, workgroup facilitation, externalsubject expertise as needed, data purchaseand management, legal expertise as needed,and, ultimately, preparation and submissionof the full RFP response. The contributionsof staff time will support the developmentof the design of the demonstration.

The Coalition has engaged HallelandHealth Consulting to serve as the facilitatorsand Project Managers during the develop-ment and submission of the RFP response.The consultants at Halleland have signi-cant experience in this area having workedwith multiple CMS demonstration efforts,developing RFP responses, facilitating large,multi-stakeholder efforts and successfullymeeting time and budget constraints.

Community BriengThere will be an opportunity to learn moreabout the overall plan for the demonstrationat a community brieng that will be held inMinneapolis on August 31. Letters of sup-port for the proposed demonstration willbe accepted for inclusion in the submissionuntil September 22.

Jeanne Ripley, MBA, is vice president of Hal-leland Health Consulting and has experiencewith multiple CMS demonstration efforts, de-veloping RFP responses, and facilitating large,multi-stakeholder efforts.

For further information, please contactJeanne Ripley at (612) 204-4178 or by e-mailat [email protected]. Dave Durenberger [email protected] or (651) 962-4137is available to share his policy perspective on thiseffort as well.

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Why Should Health Care OrganizationsApply Lean Thinking Principles?

MOST OF US EXPERIENCE anxiety whenwe think about the prospect of our own or aloved ones hospitalization and understand-ably so. Our health care system provides therecommended care just 55 percent of the time,resulting in an estimated 98,000 deaths peryear from medical errors.

These statistics, coupled with a varietyof other problems including access-to-caredifculties, long wait times, lack of care coor-dination among providers, missing informa-tion, and staff shortages make the processof seeking and receiving health care downrightmaddening. If health care organizations are toimprove, those of us who work in the eld mustcollaborate to improve care and reduce costs.

The challenge, says Donald M. Ber-wich, M.D., the president and CEO of theInstitute of Healthcare Improvement, is torevolutionize our expectations of health care:to design a continuous ow of work for clini-cians and a seamless experience of care forpatients.

The question is, how do we do that?

Achieving our goalsMany health care organizations have missionstatements that dene their expectations ofhealth care. Typically, these statements men-tion the importance of satisfying patient needswith high-quality and safe care at reasonablecosts. Health care organizations, then, under-stand that patients value these things. So whydont they offer these things?

Perhaps were taking the wrong approach.To improve quality, increase safety, and reducecosts, we must strive to: a) dene a performance

management approach; b) develop strategiesfor performance improvement; c) foster aculture of continuous improvement; and d)include people, processes, and technology, asillustrated in the diagram below.

world. If Toyota wanted to compete, it neededto work smartly. With that goal in mind, thecompany developed a culture of empower-ment. Employees followed a continuousimprovement philosophy, and worked tire-lessly to drive inefciencies out of processes.The result included minimized manufacturingtime, fewer defects, and reduced costs. Thisimproved the companys nancial performanceand satised its customers.

Today, the ideas Toyota implemented areused by companies around the world underthe moniker Lean Thinking a set of man-agement principles, tools, and best practicesdesigned to identify and eliminate waste in allprocesses. It is important to note that LeanThinking is neither a head-count-reductionstrategy nor a cost-cutting strategy; instead,it is a tool designed to help an organizationachieve operational excellence. To be Lean isto provide what is needed, when it is needed,with the minimum amount of materials, equip-ment, labor and space.

The ve principles ofLean ThinkingThere are ve principles of Lean Thinking:

1. Dene value from the patient perspective.Health care consumers have different values.A 50-year-old female with breast cancer mayvalue seeing the most experienced oncologist.An elderly man on a xed income may valuereasonable costs. A busy mother may value anofce visit with little waiting time. It is criti-cal for health care organizations to understandtheir patients values and act on them. VirginiaMason Medical Center in Seattle, Washington,did. When the organization determined thatcancer patients, who were burdened withBY JANICE AHLSTROM,

RN,BSN,CPHIMSAND MICHAEL T. PYNCH, CMA,CPA

Available toolsAs health care organizations strive to reachtheir goals, thereby satisfying an increasinglyinformed consumer, they will likely compare anumber of quality improvement tools, includ-ing Total Quality Management (TQM), SixSigma, Lean Thinking, Balanced Scorecard,and ISO 9000, to name just a few. Which ofthese tools a health care provider uses is notimportant; all will work if applied properly.But in this article we will focus on one tool inparticular: Lean Thinking.

What is Lean Thinking?Many aspects of Lean Thinking have beenaround for centuries. The Venetians under-stood ow production, and by 1400 couldbuild an entire ship in a single day. The FrenchArmy understood the need for interchangeableparts by 1789.

More recently, Toyota benefited fromeven more aspects of Lean Thinking. AfterWorld War II, Japanese manufacturers wereat a considerable disadvantage to the rest of the

Technology

People

Continuous ImprovementProcess

DeneStrategy

Measureand Monitor

ExecuteImprovement

Projects

IdentifyImprovementOpportunities

DenePerformance

Metrics


8 September/October 2006 MetroDoctors The Journal of the Hennepin and Ramsey Med i cal Societies

fatigue, valued simplicity, it stopped forcingthem to navigate lengthy distances withinthe facility; instead, it brought services to thepatients.

Without understanding its patients val-ues, Virginia Mason Medical Center could nothave known what impact those improvementswould have nor can you.

2. Identify the entire value stream for eachservice or product. A patients value streamincludes all of the actions, both value-addedand non-value-added, required to bring thepatient from admission through dischargeand even follow-up. The outpatient surgeryvalue stream, for example, consists of thecomponents depicted in boxes in the diagrambelow. Each component may have manysub-processes, each of which may have manyactivities and tasks. As complex as this seems,if you identify the value stream in this way,you can understand the role each departmentplays and the impact each department has onthe others. Documenting a value stream, then,creates an understanding, shared across the or-ganization, of what is necessary to improve theorganizations services.

There are seven types of waste:

1) Overproduction. Examples: Lab reportsprinted when not needed or medications givenearly to suit the staff schedule.

2) Unnecessary processing. Examples: Writ-ing orders manually, then providing them tosomeone for data entry. Redundant capture ofinformation upon admission.

3) Transportation. Examples: Standard proce-dures requiring that patients be moved withinthe facility.

4) Waiting. Examples: Patient lines at registra-tion or staff waiting for bed assignments.

5) Excess inventory or work. Examples: Or-dering more supplies because no one can ndthe mobile supply cart or outdated pharmacysupplies in the medication refrigerator.

6) Excess effort or motion. Examples: Walkingto get equipment, medication, supplies, or ac-cess to information systems.

7) Defects and errors. Examples: Filing docu-ments in the wrong chart, medication errors,or illegible handwriting.

4. Let the patient pull the service or product.An organization must deliver products as soonas the customer wants them not before andnot after. Within health care organizations,this means providing access to specialty ser-vices within the appropriate time frame: Refer-ring patients too soon could have a negative nancial impact, while referring them too latecould result in decreased patient satisfaction(and patients could go elsewhere). It also meanshaving the appropriate amount of staff assignedto each shift: Having too many employees as-signed to a shift could have a negative nancialimpact, while having too few could lead to

patient safety concerns (and again, patientscould go elsewhere).

5. Pursue perfection through high-per-formance teams. Perfection means thateveryone is continuously striving to improve.The key words here are continuously andeveryone. Settling on past successes is notacceptable. And, it must also be understoodthat quality is everyones job. (At Walt Disney,for example, an executive was once asked howmany individuals worked in janitorial servicesto keep the grounds so immaculate; the ex-ecutive responded that everyone working atDisney was expected to pick up litter.) Indeed,implementing a continuous improvementprocess and motivating the entire workforceto pursue perfection is at the heart of LeanThinking. Moreover, the employees who willhave the most signi cant impact are not theorganizations leaders, but its staffso theymust understand what process improvementis, how it bene ts the organization and itscustomers, and whats in it for them. LeanThinking must be embedded in the entireorganization, from the recruitment process,through employee orientation, and even dur-ing performance reviews.

Who uses Lean Thinking?Many manufacturing organizations use LeanThinking to improve business processes andshop floor operations, but the approachsproblem-solving strategies are now embracedby organizations across a wide spectrum ofindustries.

In fact, Lean Thinking can produce signif-icant results in virtually any setting, includingthe health care industry. There are many barri-ers to implementation in health care, however.In many cases, minimal staf ng and limitedtraining prevent smaller facilities from embrac-ing Lean Thinking. But as more information

Value Stream: Outpatient Surgery

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3. Make value-creating activities flow byeliminating waste. One Japanese word thathas found its way into the American lexiconis muda, which means waste. Waste is ev-erything in the value stream that does not addvalue in and of itself, i.e., that doesnt help meetpatient requirements, or that patients would notpay us to do. As an example, look at Figure 1,which shows the components of a visit to theemergency room. The lighter areas representvalue-added activities. The darker areas repre-sent a particular type of waste waiting time.But there are other types of waste, and they canbe grouped into the following categories.

Pt inwaitingroom

19min

13min

18min

5min

3min

3min

48min

68min

3min

16min

Triage andRegistration

PatientRoomed

MD SeesPatient

MD orderswritten, RNin to draw

labsPatient at CT

ScanTotal = 94 min

Total=196 minWaiting for

attending MDcallback

Waiting fordiagnostic

results

Pt waitingin ED Rm

chart in rack

18 2 6 8 2 1 40 7 2 1 7

Lean Thinking Principles

(Con tin ued from page 7)

Figure 1


about Lean Thinking becomes available, more resources will undoubtedly be earmarked for the approach. Indeed, over the past ve years as quality, safety, and cost concerns have required health care organizations to do more with less, Lean Thinking has been used more and more within the health care industry.

It is worth noting that in many cases, health care organizations are looking outside their industry for Lean Thinking consultants. Thats because in order to achieve breakthrough results, health care organizations need to lever-age examples from other industries that have experienced similar problems.

What can Lean Thinking do for you?Lean thinking can do nothing if it is not: a) embraced by the organization; and b) used to motivate individuals to achieve higher levels of performance via behavioral changes. But if you do apply it properly, Lean Thinking can have signicant results. Consider the example of one health system in the Midwest. The health system struggled to determine where to begin process improvement. Ultimately, it gave em-ployees the task of identifying waste, develop-ing creative solutions to reduce the waste, and ensuring that what they did was best for the patient. Moreover, it promised its employees that there would be no widespread layoffs, and staff would only be reduced through normal attrition and turnover. Today, the health system attributes the millions of dollars it has saved by implementing a continuous improvement program to a Lean Thinking approach.

Striving to be LeanMany organizations claim that they dont have the resources to implement Lean Thinking; they are only making excuses. Other organi-zations claim that they have already done ev-erything they can to improve processes; they are kidding themselves. Using the Lean Thinking approach as part of a continuous improvement process is not an event. Continuous improve-ment is an organizational philosophy which must be deeply embedded in the culture of your organization and used continuously.

The continuous improvement journey is yours to begin; now its up to you to take the rst step.

Janice S. Ahlstrom is a director in Wipis health care practice. She has 25 years of experience in the health care eld, where she has helped a variety of organizations dene business practices and tech-nology strategies, enact operational performance improvements, and leverage lean principles for process improvement. In particular, Ahlstrom strives to help organizations in both the inpatient acute care and ambulatory medical practice envi-ronments use of electronic order communication systems, results reporting systems, and electronic medical records (EMRs) to improve performance. If you would like information about developing a continuous improvement approach within your organization, please contact Ms. Ahlstrom at (414) 431-9352 or [email protected].

Michael T. Pynch is a director in Wipis con-sulting practice. He works with a wide range of

Ten Clues That You May Benet From Lean Thinking

Patients have communicated that they are unhappy with wait times. Patients have a difcult time navigating your facility. Youre planning to build or renovate a facility. Equipment and supplies are never where theyre supposed to be. There are always scheduling issues. Physicians believe that they could work more efciently with better support. Copying, ling, and processing paperwork is a full-time job. There are always too many or too few nurses available. There is signicant turnover. The organization is not doing well nancially.

Five Considerations When Implementing Lean Thinking

1) Those who fear change will be skeptical. It is important for the organizations leadership to explain the objectives, the phases of change, and the expected results.

2 ) Facilities that receive cost-based reimbursement may nd that costs diminish through the application of Lean Thinkingbut this may result in a decrease in reimbursement amounts in some areas of the organization.

3) Improving processes may require minimizing handoffs. Consider this carefully. In some cases, handoffs are necessary to gain oversight and segregate duties, which will ensure proper internal controls.

4) When selecting a consulting rm, make sure youre comfortable with the consultants as individuals as well as their approach. The approach should include training your staff in Lean Thinking principles, and providing the staff with tools that will help them improve independently in the future.

5) Every member of your leadership team must embrace the philosophy of Lean Thinking. If the leaders of the organization do not believe in the approach, it will be impossible for them to motivate others.

companies to assist them in achieving their per-formance objectives through strategic planning, process improvement, and performance manage-ment. If you would like information on develop-ing a continuous improvement approach within your organization, please contact Mr. Pynch at (715) 858-6630 or [email protected].

Wipi assists health care organizations with strategic planning, performance management, technology, organizational transformation, and nancial solutions. Wipi strives to help you and your organization continuously improve and cultivate performance improvement skills in your employees. Please visit Wipi online at www.wipi.com.

This article is reprinted with permission from Wipi.


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

AQ

Nick Meyer, M.D.

Born and raised in White Bear Lake, Nick Meyer attended the U.S.Military Academy at West Point upon graduating from high school.After two years, he transferred out in pursuit of a non-military medicalcareer. He subsequently graduated from the University of Minnesotafor his undergraduate and medical school degrees. He then completedan orthopaedic residency at the Medical College of Wisconsin, and ahand surgery fellowship at the University of Minnesota. Dr. Meyerhas been practicing with St. Croix Orthopaedics for two and a halfyears. He lives in Stillwater with his wife (Karen) and two daughters(Ellie and Sonia).

What is the Military Family Support League (MFSL)?

The MFSLs mission is to assist families of military personnel throughlogistical, technical, nancial, emotional, and moral support, or anymeans necessary, through the creation and organization of a network ofindividuals interested in the well being of our servicemen and womenas well as their invaluable families. The MFSL is made up of a core of10 individuals who have volunteered their time to spearhead this effortand assist in the organization and networking of individuals interestedin helping this cause.

How did you become involved in the MFSL?

The Military Family Support League (MFSL) was founded in 2004by a chance encounter of a retired Colonel and West Point graduate, aWest Point attendee (myself ), and a retired Army reservist/doctor. Theretired Colonel, Curt Newcomb, unfortunately had an encounter witha pocketknife, which led to a laceration of his hand and subsequently aninfection. He was referred to me, Nick Meyer (the West Point attendee,who left after two years at West Point to pursue a medical career), to treathis hand infection. The anesthesiologist involved in his care, Dr. PeterBoosalis (the retired reservist/doctor), came into the picture during hissurgical treatment. During this series of encounters, we began talkingand determined that a need existed for families of military personnel.This need consisted of monetary, logistical, and moral support for manyfacets of their lives, now that loved ones and often heads of householdswere deployed for long periods of time. This core group has expanded toan extremely involved and dedicated nucleus consisting of approximately10 primary members organizing events and providing services to thosein need, along with a network of interested businesses and individuals

providing services and donations to assist in our efforts. Now, two yearslater, we are trying to make a difference by helping military families inthis time of need.

Were you involved in such activities prior to this meetingwith the patient that prompted this group?

I was not involved in any similar activities prior to this chance encounter.I, like most Americans, have often wanted to assist our country andthe military personnel in some way, but never knew how. Unlike otherwar times, Americans are not being asked to ration, work, or otherwisesacrice for the current military effort overseas. In this regard, manyordinary citizens want to help, but dont know how. While attemptingto minimize the use of oil products, conserve energy, and donate bloodare all worthy means of supporting our country and the military indi-rectly, we felt that a more direct role in assisting our military would beappropriate. For those deployed overseas or in other parts of the countryaway from their families, the last thing they want or need to worry aboutis their family. Thus our involvement: We want to assure those soldiersthat their families back home are being cared for appropriately whilethey are not available.

What attracted you to medicine versus West Point?

While I received an incredible education and experience at West Point,I had a yearning for a career as a doctor. My sister, a pediatrician, wascompleting medical school at the time and further solidied my desireto attend medical school. Unfortunately, I was forced to make a hugedecision at the age of 20: Complete my West Point education and at-tend medical school through the military, or transfer out of West Pointand pursue medical school outside of the military. Unfortunately, witha service commitment from West Point of ve years, and a two for onecommitment for medical school (eight additional years of service) to be



started after completion of residency, I would have been at least 45 years old before my military commitment would have been fullled. I wasnt ready to commit to a relative career as a military doctor at that time. Thus, I had an incredible two-year experience at West Point, which has been invaluable.

How do you and Dr. Boosalis nd the time in your busy practice to devote enough time to this activity?

Unfortunately, sometimes we dont nd enough time to devote to this organization. Fortunately, we have found some incredible individuals in the form of Curt and Sheila Newcomb, Julie Kink, and others who have been the backbone of this organization. As far as nding time to devote to this activity, it is simple: There are limited hours in the day, and priorities to be made. This is an incredibly worthwhile and deserv-ing cause that is well worth my time. I only wish I had more time and energy to devote to the MFSL.

Who is eligible for support from MFSL?

Candidates for support are any family with a member deployed for service, killed in duty, or simply in need of support. As a small organi-zation, we are trying to primarily help members in the St. Croix River Valley, but are attempting to help any military family members in need. All support is provided on a case-by-case basis and is reviewed promptly by the members of the MFSL.

What are some of the things you do for families?

Thus far, our involvement has been in two primary arenas: Helping individuals/families in need, and organizing group events to show our appreciation and support. Our individual actions have included help-ing with dog walking, providing school supplies, distributing phone cards, buying airfare to visit family, and bending the ears of those in the military chain of command to assure that the soldiers can travel safely (and inexpensively) back from leave. Our group activities have included a paddleboat ride down the St. Croix River, a spring get-together at the Stillwater Armory for family and children, hosting a reception at the Stillwater Veterans Memorial on Memorial Day, as well as a Mid-Winter Blast in Stillwater. The group events could not be made possible without the overwhelming support of local businesses and individuals, including the Water Street Inn, St. Croix Boat and Packet Company, and the local medical community.

The core group has expanded to an extremely involved and dedi-cated team, along with a network of interested businesses and individuals providing services and donations to assist in the efforts. They share the responsibility of planning events and elding inquiries from families in need, while raising donations to assist in the effort. This past January, thanks in large part to the local medical community, the St. Croix Valley Military Family Support League hosted a Mid-Winter Blast for military families. Here kids took a crack at a piata, jumped around in an inat-able bouncer, or danced with the DJ, while their parents got massages, sampled hors doeuvres and sandwiches, and enjoyed the company of others who share the same situation: families with loved ones deployed

on active duty. They came away with the knowledge that the community cares.

MFSL also connects military families in need of such help as snow removal, lawn care, child care, home maintenance or banking services, with those who can provide that help free or at a reduced cost.

Do you know of any similar programs throughout the metro area or is this just in the Stillwater area? Are there any similar groups in other parts of the country?

While we are not a part of any other groups, there are many similar grass-roots organizations that have popped up throughout the country with similar goals in mind. Fortunately, by remaining small and focused in our geographic area, we are better able to serve the needs of the individuals in need. However, our smaller size has made it more difcult to get the word out, both for those interested in helping our cause as well as those in need of our services.

Are there any other retired or still active military physi-cians in the area doing any other activities similar or complementary to the MFSL activities?

We are not aware of any other similar organizations in the area; although I am certain that many retired or still active military physicians are contributing in their own way. The military (each branch being differ-ent) usually has a Family Readiness group that helps families in the transition during deployment or other potentially unsettling events. Our organization works separate from this group and hopes to ll the gaps that may not be lled by these military Family Readiness groups.

How can other physicians and businesses help MFSL? Do you have any suggestions for other physicians who want to get involved but are not in the Stillwater area? What is the time commitment and the amount of money commit-ment to a physician who wants to get involved or to those who want to help out with the cause? Are contributions from individuals tax deductible?

Individual or business involvement in the MFSL can vary tremendously. The easiest means of assistance is obviously monetary, and all donations are tax deductible (our paperwork as a tax-exempt charity is currently in process). Other individuals have made themselves available to assist in whatever they do best (or at least with mediocrity) ranging from handyman work to babysitting to plumbing or tax help. Businesses have helped and can help by providing services at a reduced rate (or free), supplying gift cards or certicates for prizes during our events, providing facilities for events, or monetary support. Essentially, each individual or business can choose how to help. No minimum requirement exists. For physicians or other individuals interested in becoming involved, it may only require an hour or two per month of time commitment. As well, donations from $50 to $1,000 are not uncommon, and thus we welcome any monetary assistance (but, again, there is no minimum or


requirement). Monetary contributions should be tax deductible, but asalways you should check with your tax consultant.

As is often said, imitation is the sincerest form of attery. We wouldnd great pleasure in other groups springing up throughout the metroarea and across the Midwest to similarly support our military and theirfamilies. Thus, for those physicians not in the St. Croix River Valleybut desiring to help in some similar way, I would recommend talkingto others in your community and organizing a mirror group. All it takesis a desire to help, and a willingness to contribute.

In the past four years, more and more wives, husbands, children,and other loved ones have found themselves alone, often confrontedwith challenges that they may not be prepared to face. Many Ameri-cans feel unsure how to contribute to the military and their families inneed. Whether or not you agree with the military involvement overseas,whether you consider yourself a Democrat or Republican, and whetheryou know someone in the military or not, the reality in 2006 and manyyears to come is simple: Our military is stretched thin leaving manyfamilies in need without their head of household available.

If you or someone you know may be able to assist in any way, nomatter how large or small, the MFSL is waiting to hear from you. Thegoal is to provide assistance to military families in need, often at a lowercost and potentially on shorter notice. The MFSL is currently developing

a database of individuals, organizations, and businesses interested in help-ing these families. Please contact the MFSL at 1-866-949-8721 extension123 to discuss your potential contributions to military families in need.It could be a service to provide, a monetary donation, help with events,purchase of phone cards, plane fare and many other possibilities.

What type of support is needed after the person serving inthe military returns home from Iraq?

The rst need is, of course, when the soldier leaves for Iraq or elsewhere.When the head of household leaves, this creates a void as now wivesor fathers become single parents at home. When a soldier returns fromdeployment, however, the tide changes in the other direction. Thesemen (and women) often have to re-acclimate themselves to their homelife and the previously single spouse has to become reacquainted withworking as a team. While this is usually a joyous occasion, it can benearly as stressful as the initial deployment. Some of the greatest helpcomes in the most simple ways during these times: Acknowledging andthanking the soldier for their service (I have heard several commentsfrom Vietnam-era veterans who have applauded our organization andlamented the fact that the public opinion upon their return home wasvery negative), providing baby-sitting services so that the couples can getreacquainted, and continuing with other general services as describedpreviously.

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S

BY JAN MALCOLM, CEO

Since Courage Cen-ter opened its doors almost 80 years ago, it has been a voice and resource for per-sons with disabilities. The organizations earliest role was as an educator and ad-vocate. Gradually, it added rehabilitation services, including a transitional inpatient care unit licensed as a skilled nursing facility. Long a respected provider in the disability commu-nity, Courage Center is now helping to lead the larger discussion on health care reform.

We share a common interest with the rest of the medical community. We are all striving to remove barriers to maximal health and inde-pendence for everyone along the continuum of conditions and degrees of physical functioning. To fulll this shared mission requires a shift in thinking.

What is a disability? The World Health Organization makes an important distinction between limitation in physical function and disability. A physical limitation, which includes anything from vision impairment to back pain to arthritis, is something we all experience in one form or another at some stage of life. Dis-ability, on the other hand, is a social construct that creates an attitudinal barrier. It often prevents us from seeing beyond the limitation in order to recognize a persons abilities.

One in ve Americans has a physical limi-tation affecting the ability to see, hear, talk, walk, climb stairs, lift or carry, or perform activities of daily living. At Courage Center,

all of our services aim to reduce, if not remove, the barriers such limitations create.

Chronic health conditions frequently lim-it a persons activity. In fact, the ve conditions causing the most physical limitations in the United States are heart disease, back problems, arthritis, asthma and diabetes. Courage Center and the larger medical community are deliver-ing services to many of the same individuals, just at different points along the continuum of care.

A Comprehensive Rehabilitation ResourceThe most common perception of Cour-age Center is that it provides rehabilitation services for people with spinal cord injuries and traumatic brain injuries. While we are nationally known for our work in these areas, the organization offers much more. We serve a broad and diverse array of conditions, the largest categories being vision impairment, cerebral palsy, stroke, back pain and arthritis. Thirty-ve percent of our current participants are older adults, and 24 percent are senior citi-zens. The percent of our participants over age 75 has nearly doubled since 1998.

Courage Center services are equally diverse, in keeping with our holistic treatment philoso-phy and changing client demographics. We offer vocational counseling and have

received a presidential award for our suc-cess in helping people with disabilities re-enter the workforce.

Our driver assessment and training pro-gram is geared to meet a range of abilities, ages and needs, from behind-the-wheel instruction to preparation for the state road test.

Our state-of-the-art transitional inpatient unit prepares participants for independent

living after a median stay of only three months.

We are a leading resource for assistive technology applications that increase a persons independence.

Our chronic pain rehabilitation program helps patients who have undergone stan-dard medical treatment but continue to experience limitations due to chronic pain.

We weave health, wellness and tness into our therapy regimen, with new or expanded fitness centers at all of our locations.Courage Center strives to be a one-stop

resource for virtually every aspect of rehabilita-tion and community reintegration. We have the services and the capacity to address all the critical needs of a person with a chronic neurologic or musculoskeletal condition.

Expanding Our Continuum of CareIn order to provide a full range of clinical re-habilitation services, Courage Center has an expanding medical team. Dr. Jacalyn Kawiecki, our medical director, is board certied in physi-cal medicine and rehabilitation. She oversees clinical services at all of our sites Golden Valley, Burnsville, St. Croix, Forest Lake, and both camps.

Courage Center is building outpatient practices as well and is well positioned as a resource for therapy and physician services re-quired throughout the rehabilitation process. Following are two examples of our clinical expertise.


Courage Center:A Leader in Rehabilitation, Policy and Reform


Transitional Inpatient Servicesat Courage CenterGiven medical advances in trauma care tech-niques, neonatal intensive care, and coma care,there is a greater need for transitional rehabili-tation services than ever before. Fortunately,access to these services has increased. At ourtransitional rehabilitation facility in GoldenValley, known as the Courage Residence, ourcapacity to accept participants has doubled inthe past ve years as our average length of stayhas declined. In 2001, participants stayed anaverage of 11.5 months, and we had a waitinglist. Today, the median length of stay is threemonths, and we are able to admit most refer-rals immediately. About 100 people with severedisabilities enter our inpatient program everyyear. An average of 85 percent are dischargedto a more independent living setting.

The increased number of individualswith severe disabilities has created a demandfor more complex services. Specically, peoplewith disabilities are living longer, thus creat-ing a new kind of client, the person with along-term or life-long disability. These clientshave needs that differ from the older adultwho acquires a disability. More clients withcognitive as well as physical disabilities areentering rehabilitation, challenging currentknowledge, techniques, and practices. Aspeople move through acute care systems veryrapidly, they enter rehabilitation units andcommunity-based settings with more medicalcomplications as they continue to recover.

Our transitional rehabilitation unit hasbeen responsive to these changes. Four yearsago, we opened a completely remodeled facil-ity, which addresses the more complex needs oftodays client. Like a skilled nursing facility, ourtransitional residence offers physical therapy,occupational therapy, and speech therapy,along with medical monitoring. Where wediffer is in our continuum of additionaltherapeutic and independent living supportservices. We offer aquatic therapy, an adaptivetness center, a variety of assistive technol-ogy applications, and access to chemical andmental health specialists. Our holistic approachinvolves therapeutic recreation specialists andcomplementary therapies, drivers assessmentand training, vocational counseling and skills

training, and even tutoring for high school-age participants. To fully support participantsneeds, the transitional residence averages 5.3staff hours per patient day, higher than thenorm for a typical skilled nursing facility.

For every client who enters our transitionalrehabilitation facility, our goal is to help maxi-mize that persons ability to live independently.We measure outcomes in four areas: functionalmobility, including self-care and self-transfer;ability to move to a more independent livingsetting; progress toward establishing and realiz-ing vocational or avocational goals; and qualityof life, including a sense of well-being, chemi-cal health, emotional adjustment, and familialinteractions. Our targeted case management ser-vice creates a customized transition plan thataddresses housing, health care, transportationand medical equipment needs.

Chronic PainRehabilitation ProgramFor 25 years the Chronic Pain RehabilitationProgram has been a valued service in thiscommunity. Originally located at AbbottNorthwestern Hospital, this multidisci-plinary residential model is now offered atCourage Center. The only other such modelin the region is at the Mayo Clinic. MatthewMonsein, M.D., serves as the programs medi-cal director.

Typically, clients of the program are highhealth care users who have failed standardmedical treatment. In addition to their physi-cal problems, these patients are frequently de-pressed, deconditioned, dependent on narcoticanalgesics, and have poor coping skills.

The focused atmosphere of our chronicpain rehabilitation program has proved to bemore conducive to implementing change inour clients lives. Individuals who have com-pleted the program showed improvements inseveral areas. Nearly half returned to work; 69percent reduced or discontinued opioids; 35percent showed reduced health care utilization;75 percent increased their physical activity; and62 percent experienced a reduction in pain. Animpressive 84 percent reported a decrease indepressive symptoms. Research supports thePain Programs multidisciplinary approach asproviding the best opportunity for these indi-viduals to improve their health and well-being,and to return to a functional lifestyle.

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Policy from a CommunityPerspectiveIn addition to its role as a provider of clinicalservices, Courage Center has a long historyof shaping public policy. From urging formerGovernor Floyd B. Olson to provide bettertransportation for persons with disabilities,to advocating for legislation to remove archi-tectural barriers to public buildings, CourageCenter has participated on many fronts. In thepast decade, our role in policy discussions hasbecome more formally ingrained throughoutthe organization. And we have moved beyondarguing for coverage expansions for the medicalservices our clients need to taking a broaderview of the whole health and human servicescontinuum. In fact, there is strong overlap be-tween the concerns of the people we serve andthe issues people throughout our communityhave around affordable housing, transportation,access to health care and job opportunities.

Courage Center has put a stake in theground for the entire community. In helping todene what comprehensive chronic care shouldlook like, we are applying what we know at a

tactical, patient care level to a larger, commu-nity perspective.

The Minnesota Consortium for Citizenswith Disabilities is a coalition of more than40 groups, and Courage Center is a leader ofthat effort. John Tschida, our vice president ofpublic affairs and research, has served as co-chair of the consortium for ve years, and ourorganization provides ongoing staff support.

The Healthy Minnesotans Steering Com-mittee is a group comprised of doctors, busi-ness leaders, labor and consumer groups, andhealth plan and hospital representatives. I serveon that committee, which addresses broadpolicy issues related to health and health care.I will bring Courage Centers perspective, andthat of the people we serve, to the table.

Advocating for ChangeOur current health system makes it difcultfor an organization like Courage Center tothrive. When reimbursements dont supportthe breadth or intensity of services neededfor people with chronic conditions, CourageCenter gets squeezed out of what we considera critical component of peoples health and re-

covery. Unless we can change the system, werenot going to be able to pursue our mission aswell as we know we can.

The medical community is well awarethat the current system often doesnt do wellby people with complex needs. Somehow, weneed to break the stalemate on reform. If wedont, many of our most vulnerable citizens willbe underserved, and the providers that care forthem will continue to be nancially penalized.

From the beginning, advocacy has been ascentral to Courage Center as the rehabilitationservices we provide. We recognize the necessityof shifting the emphasis in the overall systemfrom acute to chronic care. Fortunately, theissue of health care reform is back on thetable, and people from every sector are com-ing together. Now is the time for us to deneour vision for a better system and engage thecommunity in nding a new way.

Jan Malcolm is CEO of Courage Center. Shewas Commissioner of Health for Minnesota from1999 to 2003, and, prior to joining CourageCenter, served as senior program ofcer for theRobert Wood Johnson Foundation.

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Ten Days in Haiti

BY JAMES A. RHODE, M.D.

MOST AMERICANS know little about Haiti, not recognizing it as the second oldest republic in the western hemisphere.

Haiti rst came to the attention of Eu-ropeans when Christopher Columbus visited the island of Hispaniola in December 1492.Through the 1600s it was a Spanish colony. Then, in the 18th century, the French made Haiti her most successful colony bringing in hundreds of thousands of African slaves to pro-duce thousands of shiploads of goods each year. At the beginning of the American Revolution, Haiti was out producing the 13 colonies. This ended with a slave rebellion and departure of many of the French.

As a former slave colony, Haiti was not popular among slave owning countries such as the U.S. For much of their history the Haititan people have had to struggle against powerful North American and European countries that were expected to invade at any time. This has left them with even less resources needed for education, economic development, infrastruc-ture building and health care.

With a population of eight million in an area one quarter the size of Cuba (11 million), Haiti struggles to nd answers to its social and economic problems. Many NGOs (Non-Gov-ernment Organizations) from the U.S. and Canada provide assistance, and hundreds of thousands of Haitians working abroad send money back home. Support from the U.S., United Nations and World Bank ebbs and ows with the political whims of the sponsor-ing countries.

My interest in Haiti began a few years ago with family friends working at the Hospital Al-bert Schweitzer, at Deschappeles in the Artibo-

nite River Valley. Then in 2004, a patient of mine presented to our ofce for travel shots. Conversation revealed he was traveling with an organization, Heal-ing Hands for Haiti, to lm a documentary of its work with the dis-abled in that country. As I have had 30 years of caring for physi-cally disabled patients at Courage Center Resi-dence in Golden Valley, I was soon in discussion with Al Ingersoll of Winkley Prosthetics and Orthotics. Al was the leader of the Minnesota Healing Hands for Haiti teams 2005 trip to Haiti. The teams include rehab physicians, physical, occupational, and speech therapists, nurses and other volunteers. Permanent staff in Port-au-Prince keeps the clinic going between visits of a dozen American and Canadian teams. They also provide a comfortable guest house for 20 or more volunteers.

During my st trip with the Minnesota team, in January 2005, I spent most of my time at the Clinic Kay Kapab in Port-au-Prince. The time in clinic was spent assisting Dr. Steve Fish-er, physiatrist at Hennepin County Medical Center and Regions Hospital, in evaluating 15-25 patients per day. Steve and Mark Kroll, an orthotist, were the rst two Minnesotans involved in Healing Hands for Haiti, joining teams from other states in 1999 and 2000. They have since organized a Minnesota team and have been back to Haiti each January. After this trip, I made it known that I was interested in returning to Haiti with other teams and was

invited to join the Jan Groves team from Salt Lake City.

The trip scheduled for August 2005 was canceled due to security issues. I waited until May after several other teams had restored the routine and proven that Healing Hands for Haiti could work safely. I was again asked to join Jan Groves team. Highlights of this extraordinary trip follow.

Four members of our team, including two nurses from United Hospital in St. Paul, a 19-year-old college student from Florida and myself, arrived in Port-au-Prince on the afternoon of May 18th. We were very happy to be met and led through customs by our leader Jan Groves. Each team member uses their two 50 pound luggage allotments to bring donated equipment and medications in plastic tubs and hockey bags. All ones clothes and personal items have to come as carry on.

Our first evening was spent getting acquainted and organizing the medications we had brought. The next morning was our rst outreach clinic in Laogane. We had more


than four large bags full of medications. These were mostly antibiotics, NSAIDs, heart meds, antihelmitics, vitamins, and skin creams. Half of the assortment was set aside for the outreach clinics and the rest sent to the central pharmacy at Kay Kapab. Over $3,000 of medications had come from MAPS, an organization that re-ceives donated drugs from the pharmaceutical industry. These were paid for by a grant from the Hennepin Medical Foundations Chairs Fund.

The next morning four team members (nurse Steph Becker from St. Paul, translator James Taylor a bilingual Canadian, a student from Utah, and myself, a family physician) traveled 90 minutes to a church in Laogone. We found the Pentecostal Church on a narrow side street in this city of 120,000. The church-yard was lled with 50 or so patients. We un-loaded our bags of drugs and set up shop in the sanctuary. With very little medical care in Laogone, a couple of nurses see patients in the church periodically. They had told parishioners that on this day an American doctor would be there for free consultations and medications. This was the rst for Laogone.

I soon learned how much I depended on lab, x-rays and scanners for diagnoses. In the front half of the church patients were inter-viewed, vital signs taken, and given a number. The brief records were in English but only Kreyol (Africanized French) was spoken. Thus, the translators were critical. We soon split into two teams with Steph seeing one line of patients and me the second. A Haitian architect served as our second translator. By noon the single lines had become crowds around the doctor and nurse teams and medical care became a spectator sport. The complaints were sore eyes, poor vision, headaches, chest pain, abdominal discomfort, joints and muscle pain, weakness, dizziness, rashes and diarrhea in infants. We had to call it quits at 4 p.m. to return to Port-au-Prince leaving another 30-40 patients still waiting to be seen. By then, we had seen 100 patients in seven hours but had hopefully done some good with our limited time and resources.

The high point of the third day was visit-ing the Wings of Hope Orphanage next to the Baptist Mission. This is one of thousands of orphanages in Haiti, but all the children and adults at Wings of Hope are all physically or

mentally disabled. We visited with Sonni, a cerebral palsy disabled adult who, as a child, had been a piece of the furniture and did not walk. Children from St. Josephs Boys Home for Street Urchins, took on Wings of Hope and Sonni as their project and taught him to walk, and then to dance. For years he has been a member of their dance troupe that we see perform during visits to St. Josephs.

Most Americans that work in Haiti hear about the work of Dr. Paul Farmer in the Cen-tral Plateau east of Port-au-Prince. As a medical student at Harvard in the early 80s, Paul started a clinic at Cange, a small village. While work-ing on a doctorate in anthropology, he spent much of his time in the small village, learning the language, culture, history and medical

problems. Paul also completed an infectious disease fellowship at Harvard. With friends and other volunteers, he started Partners In Health that has since been involved in work in Peru, Russia and Rawanda (www.PIH.org). It has attracted support from the Gates Foundation and Bono.

Sunday we left Port-au-Prince early traveling in a small SUV. Our four travelers included Cadet, a Healing Hands for Haiti project manager, Dr. Dave Ryser, Director of the Rehab Unit at LDS Hospital in Salt Lake City, James Taylor, translator and staff member of BIC (Bank Information Center) and myself. BIC is an NGO that monitors the activities of large development banks such as the World Bank and USAID. The three of us from the U.S. had hoped we would take the longer route around the mountain range but instead our driver (a plumber by trade) who spoke no English took us on the road over the

mountains. We had been told this national road was hard on the passengers and harder on the vehicle. The trip usually took 3-6 hours to cover 35 miles.

After three hours in the Nissan Xtera, we stopped at the Lake Pellagree dam. This dam, built with U.S. aid in the 1950s, caused thousands of farmers to be displaced from their fertile land. Many ended up in the village of Cange. After replacing a at tire with a tire only slightly better, we arrived at the Zanmi Las-anti (Partners In Health) compound. Abruptly along the dusty and unpaved road we came to a cement wall with a green metal gate. After a brief interview by the private security guards (universal practice in Haiti) we were allowed to enter.

It was noon on Sunday and several clin-ics were busily seeing patients. The hospital wards were clean and airy. PIH has a larger budget then the Haitian Ministry of Health. Most of the work is medical as only two oper-ating rooms are needed for a few dozen cases a month. Larger facilities are assigned to the work of infectious disease. Rehab does have a small therapy room and two PT techs trained in PAP by Healing Hands. They shared with us their need for more equipment and more referrals from the doctors at the Partners In Health hospital. We noted the need to network with the doctors and will try to schedule a visit to promote more use of rehab services.

Back in our Xtera for a 45 minute trip to the rst of four clinic visits. We arrived in Thomonde and found a small town with neatly laid out unpaved streets. The Dispensaire de Thomonde has several doctors, thousands of charts, laboratory, provides obstetrics and has a dozen or so inpatient beds. The tech helps treat stroke patients and other acute rehab problems. After a clinic tour we were driven across the village to a construction site. The beautiful new clinic is much larger then the current one with room for more inpatients. Next to it is a large community education building and the third structure is a bank, FonKoze (Shoulder to Shoulder) that makes micro loans and issues international money transfers from relatives working abroad. Probably the largest source of aid in Haiti is the diaspora living and working in North America and Europe. We see a sign



Haiti


that speaks of Crushing the Cycle of Poverty. Thus the clinic is one part of bringing progress to this remote community.

The next morning we are off to the second clinic on our tour, the Centre de Sante de Las-cahobas. Amazingly the road from Mirebalas to Lascahobas is paved and the town appears more commercial and successful. The clinic is large and busy as Monday was maternal and child health day. Thus, the clinic waiting areas were full of young families as well as the more elderly. Our guide this time was a young Hai-tian physician with a red T-shirt that carried the message: Zanmi Lasanti Where health and social justice meet. We were introduced to other doctors from Haiti and Cuba.

Though we were impressed by the labs, wards and x-ray, the high point of this tour was in the storeroom for medications. Large shelves contain many boxes of antibiotics, antihyper-tensives and parasite medications. What sur-prised us was the cabinet that contained ve or six HIV/AIDS antiretroviral drugs was in good supply. PIH receives drugs manufactured in In-dia that are generic versions of more expensive drugs developed in the U.S. and Europe. The clinic treats over 300 AIDS patients at the cost of $300 per patient per year for medications. Pregnant women are screened and, if HIV posi-tive, are watched closely and treated during the last trimester and for at least the rst year after delivery. The newborns are bottle fed, and the families are provided with bottles, sterilizing equipment, water and brushes to minimize the risk of bacterial diarrhea. Total cost of caring for an AIDS patient including visits, hospital-izations, nutrition, social work and follow-up averages $3,000 per patient per year. Many HIV positive patients are being followed for changes in their CD4 levels. The availability of treatment has lowered the stigma of this disease and prevention is a large part of the effort. For a country with a child mortatlity rate of 130per 1,000 in the rst ve years of life, this level of medical care is amazing.

Our third clinic visit was another hour further over difcult terrain including several shallow river crossings and ending at the Do-minican border town of Belladere. We found a government hospital that has had management taken over by PIH. Considering the funding

that Farmer and his team have available, it is not surprising that PIH is better able to pro-vide support for a remote hospital. But even Zanmi Lasanti has limitations. On our tour of the Belladere Hospital we met Dr. David Kuwayama, a native of Wisconsin, graduate of Harvard Medical and fourth year surgical resident at Johns Hopkins. He was completing a year as the surgeon at this frontier hospital and has gained experience by doing a lot of cases. Most of the 500 or so cases he had done in his year were hernia repairs (without mesh) and other elective procedures. Not as much trauma as he expected. Running a remote surgery department does not go easily when the satellite connection with Cange fails, and sterile gowns are unavailable for a week at a time. Patients traveling long distances for elec-

hundreds of AIDS patients were being man-aged and thousands of HIV patients were being monitored. The operating suite gets less use because of its nearness to Cange, but obstetrics and radiology are busy.

Back at Cange, and the central PIH hos-pital, we got another tour and now knew more questions to ask. The clinics and hospitals are monitoring 7,000 HIV positive patients and treating 2,000 AIDS patients. At dinner time we met doctors from the U.S., Cuba, and other parts of Haiti.

Day seven was our return trip to Port-au-Prince, but this time we took the longer route through the Artibonite Valley. This allowed us to stop at the Hospital Albert Schweitzer in Deschappeles. A parking lot full of cars prepared us for a busy organization. Started by Larry Mellon, a rancher and heir to banking and oil millions, the hospital has been a xture in central Haiti for 50 years.

Hospital Albert Schweitzer is a multi-specialty organization that now has all four of its major departments headed by Haitian physicians. Near a main highway, it gets lots of trauma cases as well as the infectious and nutritional diseases. Though the buildings are showing their age, there is no question that the care here is excellent. Interestingly, one of the waiting areas at one time was a parking lot forhorses, just like the clinic we had seen the day before. The effort is to treat only the local people due to limited resourses, but city folk from Port-au-Prince try to pass as farmers from the valley. The resources and efciency here surpass the University Hospital in Port-au-Prince, which though larger, lacks the constant addition of dozens of American and European volunteer physicians.

After four days in the mountains of Haiti, we headed back to Port-au-Prince. After one night at the guest house (including a warm shower and an hour in the swimming pool) I

tive surgery wait in the hospital for days. We noted that the wards do not have lights in the ceilings and a single battery operated bulb in the corner, which is all the illumination labor and delivery gets. David met Paul Farmer dur-ing medical school at Harvard, and despite the shortcomings has received invaluable clinical experience. He was not aware of the Healing Hands for Haiti clinic in Port-au-Prince that can make a state of the art prosthetic for his amputee patients.

Our third day of travel in the Central Plateau started as usual with a difcult drive up a mountainous road to reach the fourth clinic on our tour. Very few vehicles attempt this trip and when we arrived at the Centre de Sante Saint-Michel, we were at one of the most remote of the PIH clinics. In fact, until two years ago there was only an occasional outreach clinic visit from a Tennessee medical team. However their visits led to partnering with PIH in funding a clinic. Now there is a two-story building with an operating room, x-ray, well stocked pharmacy, satellite dish and lots of patient education space. Again,


was off to the next outreach clinic. My guide was Gina Duncan, a Haitian nurse who has been involved with Healing Hands for Haiti from the beginning and is the director of op-erations. Our destination was a small school at the plantation owned and operated by her mother-in-law, Mommy Duncan. Haiti does not have a functioning public school system or many of the government run social services. Most schools and orphanages are privately run and supported.

Several other team members had gone up to the plantation the afternoon before, and had set up the clinic that morning. As usual, pa-tients were waiting patiently for the American doctor to arrive. This time we had two nurses from St. Paul, Steph, who worked with me at Laogone, and Erin Bell. Both had taken a month off from their jobs at United Hospital in 2005 to work in Sri Lanka on the Tsunami disaster. They then went online looking for an organization they could volunteer with and found Healing Hands for Haiti. They were quite prepared for the type of medical problems we encountered in Haiti. Learning from our experience in Laogone, they had streamlined our pharmacy by counting out and labeling a number of drugs ahead of time. Each had a station and I moved back and forth consulting with the nurse and patient through translators. This time, one of our translators was Sheila, a 19-year-old college student from Florida. Born of Haitian parents she had learned the Kreole language well enough to be a certied transla-tor for Florida courts. But until now she had never visited Haiti.

Over the next several hours we saw 80 patients. The clinic patients were similar to those seen in Laogane with perhaps less diar-rhea and dehydration. As I consulted with each patient I took a picture for future reference. This gave us a record of the number, gender, age, and somewhat the illnesses of our clinic populations.

Our nal outreach clinic was held the next day at another school in a village near the Dominican border. This was a village that had no regular source of medical care and we were the rst outreach clinic. One would ex-pect horrendous medical problems, but most seemed healthy with good teeth and little obesity. Occasional untreated hypertension was noted. The school appeared well built but had limited equipment and supplies. Children peered in thru ventilation windows, as again medical care was provided with a minimum of privacy. Benches worked better then chairs as then the patient could lie down for an ab-dominal exam if needed.

The next and last day in Haiti, I had set aside for visiting several hospitals in Port-au-Prince. As a member of the Healing Hands for Haiti committee assigned the task of building a rehab hospital, we needed to familiarize ourselves with existing and planned hospital facilities. The rst hospital was a medium-sized institution that caters to the middle and upper economic classes. Most hospitals are private and provide quite varied services. This hospital had a new wing for private patients, with air conditioned single rooms and private bathrooms. What they lacked were the more highly qualied staff.

The second hospital visited was the new home for St. Damiens Childrens Hospital. This is a two-story structure under con-struct ion for three years. When completed it will have 66,000 square feet of space and start with 100 beds that can be expanded to 140. Emergency, intensive care, newborn nursery, oncology, surgery, radi-ology with CT scanner,

and rehabilitation are planned. The site also contains a water tower, two generators, hous-ing for volunteers, a nursing dormitory and a chapel. The beautifully built campus is walled in and also contains a clinic for HIV/AIDS and TB out-patient care. It should open this fall and equipment is already being moved in.

The last hospital visited was that of the Foundation Bernard Mevs, a busy general hos-pital built and run by two surgeons twin brothers Marlon and Jerry Bitar, born and edu-cated in Haiti but residency trained in France. They have another hospital in the elite section of town but this is their pride and joy. Near Cite Soleil it has many trauma and medical emergencies. Gunshot wounds are taken to the operating room rather than being stabilized in the ER. Healing Hands for Haiti has arranged many operations for disabled children and a few weeks before our visit, had brought in a neurosurgical team from Miami to operate on 21 hydrocephalic children. These procedures were performed in two days at the Mevs facil-ity. Extra beds had to be brought in and then removed. Two of the children remained in the pediatric ward. They do elective surgery such as gastric bypass on Haitians living in the U.S. They can perform the procedures cheaper in Haiti and still make a prot that supports their hospital.

The work of Healing Hands for Haiti International Foundation has an evolving and ever-expanding group of projects. We have plans to develop a clinic in Gonaives, a city north of Port-au-Prince by 3-4 hours, that was struck by a hurricane two years ago with over 2,000 dead. The hospital was badly damaged, as was most of the city, and much remains to be done to rebuild. The Minnesota team of Healing Hands for Haiti will return to Haiti in mid January 2007 and can be accessed through their Web site www.healinghandsforhaiti.org or by contacting Sue Kodadek at [email protected].

Haiti is rich in history, culture and oppor-tunities to volunteer. Many Minnesota organi-zations have projects in this island country. Any physician, health care professional or support volunteer can nd innumerable opportunities to contribute to the health and well being of people in Haiti and other countries.


H

Minnesota ImmunizationInformation Connection

HENNEPIN MEDICAL Society (HMS)and Ramsey Medical Society (RMS) havejoined forces to assist metro-area hospitalsin the electronic access of immunization dataand TB status on physicians who are on theirrespective medical staffs.

As you may know, the Joint Commissionon Accreditation of Healthcare Organizations(JCAHO) and other regulatory bodies requirethat hospitals inquire as to the immune statusof their health care workers. What we have dis-

also as a tool to better equip our metro-areahospitals with an important tool in knowingthe immune status and TB status of their physi-cians.

HMS and RMS identied an existingdatabase called the Minnesota ImmunizationInformation Connection (MIIC) which existsnow to capture patient-specic immunizationinformation. Working under our suggestion,this database is going through enhancement bythose who administer MIIC, the MN Depart-ment of Health, in order to meet our needs asit relates to additional security, adding a sectionrelated to TB status, and the ability for medicalstaff coordinators to run adhoc reports basedon a multitude of criteria. HMS and RMS areputting forward seed money to get the projectoff the ground, and will begin to raise fundsfrom various hospitals that have already pro-vided their endorsement of the project.

We have identied four hospitals thatwill be test-piloting the electronic access tothe data and will provide the MetropolitanHospital Physician Leadership committee witha report back on how it works later this sum-mer. Our plan is to offer this data to metro-areahospitals rst, then move outside of the metroarea to ease the data collection burden for thosehospitals as well. Look for an additional articleon the progress of the immunization databaseproject in a future edition of MetroDoctors.

To learn more, call Sue Schettle at (612)623-2889, or e-mail her at [email protected].

covered is that all hospitals ask for the immunestatus of their physicians, but from hospital tohospital, what they do with the informationvaries greatly.

There was a need identied through ourMet

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