Minnesota Physician July 2014

Telemedicine is the practice of medicine using electronic communications, information

technology, or other means between a physician in one location and a patient in another location, with or without an intervening health care provider. It typ-ically involves secure videoconferenc-ing, or store-and-forward technology to

provide or support health care delivery by replicating the interaction of a tradi-tional encounter in person, between a provider and a patient. Generally, telemedicine is not an audio-only, telephone conversation, email/instant messaging conversation, or fax.

Physician leadership to page 12

Developing policy for telemedicine to page 10

Vo lum e x x V i i i , N o. 4J u l y 2014

There are profound changes occurring in our state, and in our country, that will affect physicians and their profession

for many years. It seems logical to assume that physicians would look toward physician leader-ship for guidance on how to shape and respond successfully to these changes.

What are the changes that physicians are ex-periencing, and how have these changes affected the profession? Economic realities—primarily declining payments and uncertainty regarding future payments from government programs—and administrative/regulatory burdens over the last few decades have produced a dramatic shift in our profession, from a primarily inde-pendent-practice model to an overwhelmingly employment-based model. This shift has created new realities and independent physicians have responded to these realities by:

• Forming alliances with hospital systems or accountable care organizations

• Forming larger groups in order to secure a patient base

• Solidifying their bargaining power

• Transitioning to a direct pay or concierge type of practice

• Continuing to practice as they always

Physician leadership There are more questions than answers

By Lyle Swenson, MD

Developing policy for telemedicine

New regulations and guidelines

By Jon Thomas, MD, MBA

GET READYFOR

ICD-10

Official CMS Industry Resources for the ICD-10 Transitionwww.cms.gov/ICD10

The ICD-10 transition will affect every part of your practice, from software upgrades, to patient

registration and referrals, to clinical documentation and billing.

CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to:

• Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

• Train Your Staff—Find options and resources to help your staff get ready for the transition

• Update Your Processes—Review your policies, procedures, forms, and templates

• Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

• Test Your Systems and Processes—Test within your practice and with your vendors and payers

STAY ON THE ROAD TO 10STEPS TO HELP YOU TRANSITION

Now is the time to get ready.www.cms.gov/ICD10

Minnesota_Physician_052814.indd 1 5/28/14 1:52 PM

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address 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 publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to re-place medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

Features

ProFessional uPdate: neurology

July 2014 MINNESOTA PhySIcIAN 3

July 2014 • Volume XXVIII, No. 4

Publisher Mike Starnes | [email protected]

senior editor Janet Cass | [email protected]

editor Lisa McGowan | [email protected]

Art director Alice Savitski | [email protected]

office AdministrAtor Amanda Marlow | [email protected]

Account executive Stacey Bush | [email protected]

Account executive Jan Ehrlich | [email protected]

Huntington’s disease 18By Martha A. Nance, MD, and Jessica Marsolek, LSW

mINNesota HealtH care rouNdtablePost-acute care 20By MPP staff

dePartmeNts

caPsules 4

medIcus 7

INterVIeW 8

PedIatrIcs 14School-based asthma action plansBy Barbara P. Yawn, MD, MSc; Dan Jensen, MPH; Lisa Klotzbach, RN, BAN, MA; and Erin Knoebel, MD

otolaryngology 16Cochlear implantationBy Colin Driscoll, MD

PublIc HealtH 28A look at e-cigarettesBy Barbara Schillo, PhD

surgery 30Making the inoperable, operableBy Meysam Kebriaei, MD

Donald E. Gehrig, MDInternal medicine

Developing policy for telemedicine 1New regulations and guidelinesBy Jon Thomas, MD, MBA

Physician leadership 1 There are more questions than answersBy Lyle Swenson, MD

Background and focus: As tools and techniques for treating chronic illness have expanded, so have methods and mechanisms of provider reim-bursement. More people now have access to care, and with this comes a heightened awareness of the impact of social determinants on health. The transition to rewarding physicians for maintaining a healthier population is slow but the promise is clear. Treating chronic illness remains an area of high-volume use and, improperly managed, quickly becomes an area of high cost.

Objectives: We will evaluate changes that health care re-form is bringing to chronic illness care. We will examine new community-based partnerships that are forming to address prevention, compliance, and better identification of risk. We will look at specific diseases and how workplace solutions, insurance companies, clinics, hospitals, long-term care facilities, and home care providers are working together to lower costs and improve outcomes.

MINNESOTA HEALTH CARE ROUNDTABLE

Please mail, call in, or fax your registration by 10/28/2014

Please send me ____ tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, Inc., 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone 612.728.8600 or fax 612.728.8601.

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42nd Session

capsules

4 Minnesota Physician JULY 2014

Minnesota’s Uninsured Rate Falls 40 Percentthe number of uninsured Minne-sotans fell by 180,500 people, or 40.6 percent, between sept. 30, 2013 and May 1, 2014, according to an analysis by the University of Minnesota’s state health access Data assistance center (shaD-ac). Prior to the start of Mnsure open enrollment, 445,000 people, or 8.2 percent of Minnesotans, did not have health insurance. one month after enrollment closed, those numbers fell to 264,500 people, or 4.9 percent of the population.

the decrease is attributed largely to more people becoming eligible for Medical assistance and Minnesotacare, and an increase in the private insurance market. according to shaDac, of those without health insur-ance, 67 percent of adults and 82 percent of children are eligible for public programs.

“Minnesota’s uninsured rate is now one of the lowest in the

country, thanks to the Medicaid expansion and all the outreach ef-forts to get people enrolled,” said Lucinda Jesson, human services commissioner, Minnesota Depart-ment of human services. “For most people, it’s easier to sign up for public programs than ever before. i’m delighted to see them getting the coverage they needed.”

in the report, shaDac used methodology comparable to that which the state has used to esti-mate health insurance coverage rates since the early 1990s.

“our findings are consistent with reports of early national im-pacts of the affordable care act (aca),” said Julie sonier, shaD-ac deputy director. “We know the aca’s impacts will vary by state, and our purpose in doing the analysis was to examine the im-pacts on Minnesota, in advance of the first state-level results from surveys, which are not expected until the end of this year at the earliest.”

Mnsure will be audited by a watchdog unit with the U.s. De-partment of health and human services to determine whether

it effectively screened enrollee eligibility.

“our understanding is that it’s part of a national audit request-ed by congress,” said Mnsure spokesman Joe campbell. “the oiG [office of inspector Gener-al] is currently wrapping up an audit of the federal exchange, the report’s due out in about a month. and so we expect this to be a sim-ilar type of evaluation that was done for the federal exchange.”

Minnesota Hospitals Rank Among Top Pediatric Hospitalsthree Minnesota hospitals have ranked on the Best children’s hospitals 2014–2015 list by U.s. news & World Report, an annual report that ranks the top 50 facili-ties in 10 pediatric specialties.

the Mayo clinic children’s center in Rochester increased its ranking in several pediatric specialties. it ranked 13th in can-cer; 13th in cardiology and heart surgery; 17th in gastroenterology

and Gi surgery; 25th in nephro- logy; 19th in neurology and neu-rosurgery; 31st in pulmonology; and 11th in urology. Minneapo-lis-based children’s hospital and clinics of Minnesota ranked 47th in cardiology and heart surgery, and 49th in pulmonology. and, st. Paul-based Gillette children’s specialty healthcare ranked 23rd in orthopedics.

“Finding care for a child with a life-threatening or rare con-dition is one of the most over-whelming experiences parents face,” said Ben harder, managing editor and director of health care analysis at U.s. news. “We hope the rankings and information in Best children’s hospitals help make a family’s search for the best care possible for their child a little easier.”

this year, the report’s method-ology had some changes. scor-ing weight assigned to infection prevention and to use of “best practices” was increased and the weight of hospital reputation was decreased, among other changes.

Five-sixths of the hospitals’ scores were based on patient

JULY 2014 Minnesota Physician 5Capsules to page 6

outcomes and the pediatric care resources available. U.s. news sent a clinical questionnaire to 183 pediatric hospitals to compile data for the report. the remain-ing one-sixth of the scores was based on an annual survey of 450 pediatric specialists and subspe-cialists within each specialty cat-egory over three years. Physicians were asked where they would send the sickest children in their specialty, setting aside location and expense.

Construction Begins On Affordable Housing for Veteransconstruction has started on a new, $17.2 million 58-unit affordable housing community for military veterans and their families at Fort snelling, which will be completed in 2015. the facility is part of an effort to end homelessness among veterans in Minnesota.

the project will renovate five historic buildings into 58 one-, two-, and three-bedroom apart-ments on the Fort snelling Upper Post. Residents will have access to on-site health care; social and support counseling and monitor-ing; academic support; and job training. the community also will feature an on-site business center, computer lab, courtyard, elevators, laundry facilities, and a community room. each unit will contain central air conditioning, vaulted ceilings, and walk-in closets.

“Minnesota’s heroes should never be homeless,” said Gov. Dayton. “our veterans risked their lives to protect our state, our country, and our freedoms. they have more than earned safe and affordable places to live.”

Minnesota housing commis-sioner Mary tingerthal co-chairs the Minnesota interagency council on homelessness, a coalition of 11 state agencies that has launched a plan to prevent and end homelessness by 2015. Minnesota already has the lowest homeless rate for veterans in the country. “With continued invest-ments, we could be the first state in the country to essentially end veteran and chronic homeless-ness,” she said.

commonBond communities, a st. Paul-based nonprofit that provides affordable housing and

supportive services in the Up-per Midwest, will develop and manage the new community. commonBond advantage ser-vices, the Department of Veterans affairs, and other providers will manage on-site support services.

“this new community at Fort snelling will be a model for addressing the growing need for permanent housing and services for military veterans,” said Paul Fate, president and ceo of com-monBond communities.

New Funding for Regenerative Medicine ResearchGov. Mark Dayton has signed legislation that will provide about $50 million for regenerative med-icine research in Minnesota over the next decade.

house majority leader and registered nurse Rep. erin Murphy (DFL–st. Paul) spear-headed the initiative, inspired by a meeting with Jakub tolar, MD, PhD, director of the University of Minnesota stem cell institute. senate Majority Leader Katie sieben (DFL–newport) authored the companion bill in the senate.

Despite legislative support, Murphy didn’t expect to gain much in funding for regenerative medicine research this session.

“We were going to have an op-portunity to talk about the issue, but we probably wouldn’t be able to do a very robust funding pro-posal. i was wrong about that,” Murphy said. “i’m excited about this piece of legislation. i’m still pretty amazed that it got done.”

andre terzic, MD, PhD, di-rector of Mayo clinic’s center for Regenerative Medicine, testified before a senate committee in March. While excited about the funding, terzic said the signifi-cance of the bill is broader than money.

“the dollars are always sig-nificant but i think what is even more critical is the commitment at the state level to, in essence, single out this new and evolving medicine,” he said. “For us, that is a major achievement.”

the legislation provides $4.35 million in funds in 2015. according to tolar, a committee of experts will analyze proposals

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based on how they affect commu-nities, if jobs will be created, and whether they have potential for industrial or clinical applications. tolar emphasized that any re-search done with the funds must occur in Minnesota. “there has to be a palpable benefit for people who live in this state,” he said.

a five-member board that includes a representative from the University of Minnesota, Mayo clinic, and the private sector; possibly a patient; and one other member, will decide which projects to fund. Representatives from the University of Minnesota and Mayo clinic will work together to establish partnership de-tails and create a plan for the new research. to begin, tolar expects they will be able to fund three or four proposals.

Allina Closes United Hospital 7th Floor allina health has closed the sev-enth floor of United hospital in st. Paul. the health care organi-

zation says the decision is only one part of its overall plan to cut $100 million in costs over the next 18 months, after weak first-quar-ter financial results.

Previously, allina treated epilepsy patients on the seventh floor. those patients will move to the fourth floor, where other neurology patients are treated, according to allina spokesman David Kanihan.

“it doesn’t make sense to have [an] entire floor of operations if we can handle overflow another way,” said Kanihan.

Job cuts are not a major part of the plan to cut costs, according to Kanihan. “there will be no net decrease in (workers), but a focus on new areas,” he said. “this means we are not looking at staff reductions as a significant part of the $100 million in savings.”

Kanihan said that the larg-est issue leading to the cuts was weak patient care revenue. Vol-ume declines came as expenses increased because of acquisitions and investments.

in addition, decreased patient

revenue resulted from the health care system’s issues determining if patients were insured through Mnsure. “the first few months of the year have been financially challenging for us,” Kanihan says. “i wouldn’t put it all on the slow start of Mnsure.”

allina’s operating income in the first quarter of 2014 was $449,000, a significant drop from last year’s first-quarter results of $22.3 million. its first-quarter revenue in 2014 was $844 million, up from $810 million during the same time period last year; how-ever this quarter’s expenses also increased to about $843 million, up from $788 million last year. Kanihan noted that despite the challenges, the health care sys-tem’s financial performance had shown improvement in april.

PrairieCare Expand-ing to Brooklyn ParkPrairiecare has announced its official plans for a new child and adolescent psychiatric hospital in Brooklyn Park. the

72,000-square-foot facility will have 50 inpatient beds with the capacity to treat more than 1,500 patients annually. once complete, the hospital will employ 280 peo-ple and will be the largest facility of its kind in Minnesota.

“there are hundreds of youth in the twin cities in psychiat-ric emergencies who wait for hours in emergency departments or have to travel tremendous distances to get the care they need,” said Prairiecare ceo Joel oberstar, MD.

“the addition of these beds will greatly increase patients’ access to high quality, compas-sionate mental health care.”

the facility will treat children and teens with mental health issues including depression, anxiety, autism, and aDhD. the average stay will be seven to 10 days and the hospital will not serve the criminal justice system, according to officials.

the $20 million project was approved in February and is expected to open in the fall of 2015.

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JULY 2014 Minnesota Physician 7

Tina A. Ayeni, MD, has joined Minnesota oncology’s gynecologic oncology/surgery group. she earned a medical degree from Mayo clinic college of Medicine, completed an ob-gyn residency at Duke University Med-ical center, Durham, n.c., and completed a fellowship in gynecologic oncology at the Mayo Graduate school of Medical education. Previously, she held the position of assistant professor in the department of gynecologic oncology and reproductive medicine at the

University of texas MD anderson cancer center, houston.

Charles Fazio, MD, MS, has joined healthPartners as its health plan medical director. Previously, Fazio served as senior vice president and chief medical officer at Medica, and in clinical and administrative leadership roles at Mille Lacs health system, st. Joseph’s Medical center, central Minnesota Group health Plan, and the institute for clinical systems improvement. Fazio earned his medical degree from Georgetown University, Washington, D.c., and his master’s in administrative medicine from the University of Wisconsin–Madison.

Gary S. Francis, MD, FACC, FAHA, FACP, a professor in the University of Minnesota Department of Medicine cardiovascular Di-vision and interim director of the university’s heart Failure and transplant section, re-cently has received two awards. honored by the heart Failure society of america with its lifetime achievement award, Francis also was selected by the american college of cardiolo-gy to receive its distinguished teacher award for 2014. he earned a medical degree from creighton University school of Medicine, omaha; served an internal medicine residen-

cy with the U.s. navy; and completed a cardiology fellowship at naval Regional Medical center UcsD, san Diego. he is board-cer-tified in internal medicine, cardiovascular disease, advanced heart failure, and transplant cardiology.

Deepak Kademani, DMD, MD, FACS, board-certified in oral and maxillofacial surgery, has joined north Memorial health care as the fellowship director of the oral/head and neck oncologic surgery and re-constructive surgery program. Kademani completed dental and medical degrees and a residency in oral and maxillofacial surgery at the University of Pennsylvania, Philadel-phia, and completed a fellowship in head and neck surgery at Legacy emanuel hospital in Portland, ore. he is also an associate profes-sor at the University of Minnesota school of Dentistry.

Thomas Malloy, MD, board-certified in gastroenterology/hepatology, has joined es-sentia health–Duluth clinic. Malloy earned his medical degree from the Medical college of Wisconsin in Milwaukee, served a residen-cy in internal medicine at University of Mich-igan hospitals in ann arbor, and completed a fellowship in gastroenterology-hepatology at the University of iowa hospitals and clin-ics in iowa city.

Medicus

“The last internist”

Donald E. Gehrig, MD

Internal medicine

Donald Gehrig, MD, has been in solo, independent, general internal medicine practice in St. Paul, for the last 15 years. He began his career in 1980 in a small

group practice in St. Paul, and then spent several years

in a large, managed-care practice. Since January 2012,

Dr. Gehrig has stopped accepting Medicare and Medicaid patients, along with major non-Medicare

carriers. He now practices a direct pay model of care.

Somewhere along the line we went from being doctors to being providers. How did this happen?

This was an unintended occurrence, in my view. The terminology has inadvertently trivialized what it means to become and be a practicing physician, and not merely someone providing prescription refills or durable medical product reauthorizations.

I guess I’d call that latter stuff “provisional medicine,” rather than the practice of medicine. Indeed, the last 30 years of improved preventive therapies for the many cardiovascular diseases has stabilized the health and care for patients for very long stretches. This has made it easier for physicians to be perceived as merely providers of predictable, repetitive, and unchanging things like prescriptions and recurrent services.

As you see it, are there any negative repercussions related to physicians being viewed as providers?

Yes there are, unfortunately. Our making routine, what previously wasn’t, has fostered a wisdom and knowledge trap that yields a false sense of compla- cency about how incredibly complex and sneaky disease and organ function disorders can present, in confusing and subtle ways. Policymakers have fallen into the oversimplification trap of “provisional med-icine.” They have equated family medicine doctors with internists and pediatricians. They have assumed that any of these quite-differently trained primary care doctors are interchangeable with advanced allied nursing or physician assistant professionals on the front lines of care.

There are huge differences in educational rigor, du-ration of training, and experience in medical prac-tice curriculum among these different practitioners. Physicians know the difference, but the political policymakers mistakenly assume that there are little to no differences. In the face of the clinical unknown, physicians have extensively more training at “knowing what you know,” but also a great deal more reveren-tial attention about what we don’t or can’t know when faced with a key clinical decision. This makes a huge difference!

What do you have to say to people who claim physicians must be part of a big health system to survive?

Poppycock! I am proof that this is not the case. However, the younger, newly-arrived, heavily-in- debted physicians, have little choice in our price-fixed, heavy-handed, government-managed, cartel-con-

trolled, and contrived, third-party payer system.

New doctors must first choose a procedure-domin- ated subspecialty. If they can’t or don’t, and precari-ously choose a primary care specialty, they must sub-mit their futures to indentured status, as the current price-fixed system—not market forces—has destroyed most viable practices. This underlying, unfair, unseen, and opaque price fixing of our fees for two genera-tions has destroyed the viable medical market for

independent practice. This is especially true for doc-tors who practice nonpro-cedural care, i.e., primary care medicine (internal medicine, family practice, and pediatrics), because

our operating margins are so very low. Our evolved third-party payment system rewards the “do-do-do” largess of big, multispecialty clinic operations, often dwarfing and overshadowing the basic unit of care—that of one patient choosing one personal physician.

What advice can you give to those who are just beginning their careers in medicine?

Simply put: Don’t, unless you can get someone else to pay for your education. Medicine is simply no longer a viable profession. That is a hard reality for someone like me, who dearly loves what it means to be a phy-sician. Our professionalism will remain a false front for political grandstanding and manipulation until patients can directly choose their physicians, and personally own and choose more affordable health insurance policies (i.e., physicians only working for and getting paid by their patients directly). Doctors should only have “contracts” with patients, not insur-ance payers, whether they are government created or private carrier derived. True, ethical health care, in my opinion, is a two-party affair, not a third-party one, like the one under which we now try to survive.

What can you tell us about the role of phy-sician mentoring and how it is changing?

Physician mentoring has been practically elimi-nated as the control of graduate medical education has come under government-fostered, nonmedical systems of “care.” Independent and appropriately sovereign professional medical hospital staffs no lon-ger exist at almost all medical training centers. The beginning of the end occurred with the shortsighted and draconian price fixing of diagnosis-related group codes (DRGs) in October 1983, and ended the avail-ability of physician teacher, mentor, or role model. Shortly thereafter, all physician fees came under third-party price-fixing mechanisms, too, and care became volume driven, not patient-care driven.

IntervIew

Physicians have … a great deal more reverential attention about

what we don’t or can’t know when faced with a key clinical decision.

8 MINNeSOTa PHYSIcIaN JULY 2014

Medical students and residents got displaced and put in the background of medical edu-cation centers, while exposure to possible physician mentors from the real world of the practice of medicine dried up overnight. There was simply no affordable time to give back. This is a hidden, but overt, consequence of faulty political maneuvers, once again.

Why do some people say the prac-tice of medicine, as a profession, is dead?

I think medicine has already died, or at least, its functional life has been widely suspended. Most of my colleagues in the big factory clinics are nothing more than mere factory workers and computer keypunchers, who try to manufacture clinical outcomes and their attendant codes, and maximize reim-bursement for their non-physician bosses. It’s a sad evolution, and a sad reality for this widespread, faux clinical, third-party, non-oath-taking, nonprofessional “industry.”

A law was recently passed in Minnesota, which allows advanced practice nurses to operate clinics independently. What issues does this development pose?

Let me ask a question about what I believe to be a politically contrived and reactive pro-

cess. Would the Minnesota Board of Medical Practice allow me to “independently” hang a shingle for such a practice, if I presented with a relatively superficial and foreshortened level of training and education?

It’s a sad commentary of our evolved, demon-ized, and trivialized status, as a mere “pro-vider,” that gets the political apologists and supporters for this sort of “provision” to exist at all. a hundred years ago, our american medical education system needed the Flexner Report, which cleaned up and extended our medical education curriculum to appropriate, replicable, and trustworthy levels.

The current absence of available numbers of primary care doctors is not a result of the failure of that system. It is rather the result of heavy-handed, short-sighted price fixing of our worth by decades of duplicitous, “well-mean-ing,” bipartisan politicians, who are trying to hide the unsustainable nature of LBJ’s 1960s, “ponzi’d” mess of our predicted-to-fail, unsus-tainable, modern Medicare system. The future of hopeful, well-trained medical students is jeopardized. These students are economically denied the possibility of choosing and surviv-ing in any clinical, non-procedural specialties, so they seek residencies in the better-reim-bursed, procedural/surgical ones.

As our system of health care delivery becomes increasingly complex and focuses on populations vs. individuals, what are we at risk of losing?

Quite simply, we have already lost the core unit of purpose, the patient/physician alliance. Nowhere in the aca (affordable care act) or past national legislation has that primordial and sacred trust been properly recognized, protected, preserved, or promoted.

Why do you call yourself “the last internist?”

I admit it is a bit of hyperbole, but unfortu-nately, in this land of giant, multibillion dollar behemoths of “managed care,” not-for-profit (chuckle, chuckle), “too big to fail,” manufac-turing clinics of widgets of outcome, which have little to do with what that next unique patient truly needs or wants, I am quite liter-ally, one of a very few remaining practicing in-ternist physicians, not providers, left! and that is not a good thing for our coming boomer tsunami, who are fast approaching their last few decades of medically complicated, diverse, individually unique, and should-be private medical lives.

JULY 2014 MINNeSOTa PHYSIcIaN 9

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10 Minnesota Physician July 2014

Developing policy for telemedicine from cover

the pharmacy statutes in most states require a physical exam for prescribing purposes, which prior to current technol-ogy had to be done in person.

the state and federal regulatory community has traditionally recognized this in-person phys-ical exam as sine qua non. even-tually, once this initial hands-on exam took place, a physician could then provide follow-up care by phone, email, or other means. no one in the regulatory community today can conceive

of an initial meeting occurring solely by phone. however, there are situations today and in the future where it could be ac-ceptable to initiate a physician/patient relationship through secure videoconferencing and

the use of technology. once the relationship is established, other means of communication could be used to provide con-tinuity of care, i.e., via phone, email, text, etc.

twenty years ago, when the Federation of state Medical Boards’ (FsMB) first telemed-

icine policy was adopted by its house of Delegates, technology was limited. the FsMB actually promoted a telemedicine regis-tration pathway for licensure at that time, recognizing that only a small number of people could

practice telemedicine because of technological limitations. With the increased capabilities of the internet and new technology, telemedicine is now open to anyone with a computer or smartphone. the FsMB expects physicians to ultimately set the stan-dards of how telemedi-cine should be used in the practice of medicine. We don’t explicitly define where and when it may

be appropriate to use telemedi-cine. We believe that telemedi-cine should be held to the same standards as a face-to-face medical encounter.

State medical boardsFounded in 1912, the FsMB is a leader in medical regulation through effective policy and standards in support of the state medical board’s protection of the public. the state of Min-nesota has been an active mem-ber of the Federation and has contributed greatly to its success. i have been fortunate to be one of six Min-nesotans to have served as chair of the board of directors of the FsMB since 1912. as chair, i appoint-ed the state Medical Boards’ appropriate Regulation of tele-medicine (sMaRt) Workgroup to develop model guidelines for use by state medical boards in evaluating the appropriateness of care as related to the use of telemedicine.

the vanguard of health care is clearly concerned about the future of health care costs and access. the looming demo-graphic bulge of senior citizens hitting Medicare age, the addi-tion of new health insurance en-rollees as a result of the afford-

able care act, the increasing burden of chronic illness and disease management, and pro-jected shortages of physicians all make for very scary head-lines. Politicians, policy wonks, and health care entrepreneurs have been promoting the idea of telemedicine as a solution to the expected crisis by increasing ac-cess and decreasing the cost of access. Venture capitalists and industry are pouring money into telemedicine start-ups. the thought is simply that a tele-medicine physician in one state will be able to treat a patient in another state. Unfortunately, it isn’t that simple. companies have already run afoul of many state laws regulating medicine, or what we call medical practice acts.

Medical practice actsthere is a little-known and poorly understood fact regard-ing medical practice and its relationship to state medical boards. the practice of medi-cine is, by and large, a self-reg-ulated profession. the actual practice of medicine, which is how we interact with and treat patients, is regulated at the state level by the medical board ac-cording to the 10th amendment to the U.s. constitution. the

10th amendment simply states, “the powers not delega- ted to the United states by the constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.” as a result, con-stitutional law grants police power to the states, which allows each state to regulate the practice of medicine. a state’s medical practice act defines the structure and composition of the medical board and how members are appointed, which is typically by the governor. By design, most gubernatorial ap-

Telemedicine should be held to

the same standards as a face-to-face

medical encounter.

July 2014 Minnesota Physician 11

pointees to the medical boards are physicians. Generally, this means that practicing physi-cians regulate practicing physi-cians, although public members are being appointed in greater numbers.

Medical practice acts are not prescriptive. By design, they do not define how diseases should be treated, which surgery should be done for a spe-cific problem, or which technology should be used. a physician who is alleged to have delivered below-standard care will be judged by his peers in relationship to the community standard, regardless of the technology used. one of the problems in telemedicine is that many entrepreneurs are developing business models that simply do not meet the standard of care. these entrepreneurs are frustrated that there are no clear guidelines in medi-cal practice acts that explic-itly allow or prohibit certain activities. they see the lack of clear and explicit guidelines as barriers to widespread adoption of new technologies.

the question remains whether a physician wanting to deliver his or her services to po-tentially every state would need to be licensed in every state. to streamline this barrier to wide-spread adoption, telemedicine companies have been lobbying congress for a single national license. the FsMB’s response to national licensure, is that this violates the 10th amendment and isn’t best for patient protec-tion. currently, only 6 percent of physicians in the U.s. have three or more licenses. nation-alizing an entire licensing sys-tem and creating a new federal bureaucracy for a small number of entrepreneurial physicians so they can deploy services to all of the U.s. seems fraught with unintended consequences in the name of convenience and profit. currently, the practice of medicine occurs where the pa-tient is located. some think that it should be defined where the physician is located. the FsMB strongly believes that licensure should remain with the loca-tion of the patient, otherwise telemedicine providers would flock to the state with the least

patient protections.

The future of telemedicinethe FsMB came out with its first telemedicine policy in 1996. at that time, telemedicine was expensive and limited. today,

telemedicine is relatively sim-ple to deploy. technology has made it possible for patients to connect with their physicians anytime and anywhere. Patients are driving this because of con-venience, but they can mistake convenience for quality. clearly not every encounter is appropri-ate for telemedicine. however, as we learn more we begin to understand the limitations.

in april 2014, the FsMB came out with the first compre-hensive telemedicine policy to address some of the concerns that we have discussed. the goal of the policy was not to hamstring the process. there are many integrated, managed care organizations around the country that have deployed telemedicine in very innovative ways without running afoul of state laws or policy. in addition, the idea that telemedicine will allow delivery of specialized ser-vices in states across the coun-try may be overblown. i believe that most telemedicine will be provided in the state where both the patient and physician reside. certainly telemedicine has the potential to allow new and innovative ways of interacting with patients. however, i don’t see that it will necessarily and automatically result in reduced cost or increased access. Mak-ing it easier to access physicians may mean more encounters, not necessarily fewer, which drives utilization and cost. in addi-tion, a busy specialist in high demand isn’t going to have more time just because of technology. But telemedicine will provide services where there is a short-age of medical specialties.

the new policy of the FsMB breaks new ground for regula-tors in several ways:

• you can start a physi-cian/patient relationship through telemedicine.

• telemedicine should be viewed as a tool and not a separate specialty. Physi-cians should determine how best to use and deploy telemedicine.

• standards of care should be the same as for face-to-face physician-patient encounters.

• audio-only telephonic

interaction generally is not telemedicine.

it is important to understand telemedicine and the issues surrounding it. Patients seem intrigued by the technology and the seemingly instant access

to their physicians that it promises. specialties in short supply in a particu-lar region are going to provide their services through telemedicine. We are just starting to scratch the surface and it is important that physicians understand all the

issues surrounding telemed-icine, even if they don’t have plans to implement the technol-ogy anytime soon.

Jon Thomas, MD, MBA, is a member and past chair of the board of directors of the Federation of State Medical Boards and member and past president of the Minnesota Board of Medical Practice.

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have, with expectations of earning less and spending more time on nonclinical responsibilities

it is not surprising that a 2012 Physicians Foundation survey (www.physiciansfound ation.org), one of the largest and most comprehensive physician surveys ever undertaken in the United states, found that 84 percent of physicians re-sponding to the survey thought that their profession was in decline. a majority, 58 percent, would not recommend medicine as a career for their children or other young people. eighty-two percent of respondents thought that doctors have little ability to change the health care system, and 92 percent were unsure how they will fit into the health care system in five years. surprisingly, 60 percent of respondents stated that they would retire today if they had the means.

With these frightening statis-tics, there is an obvious need for

physician leadership to speak for physicians and to improve the fortunes of our country’s, and our state’s, physicians.

Necessary leadership qualitiesWhat should we look for in our physician leaders, and what makes an effective leader? in part, this will be determined by the nature of the organization. in this case, let’s consider a group of physicians. there are qualities that are desirable in all leaders, regardless of their af-filiation. to lead effectively, one must have courage, conviction, and skills. one also must have the trust of the organization’s members, and be able to repre-sent the members by speaking and writing effectively, and advocating on behalf of the best interest of the members in that organization.

there are additional quali-ties that are specifically rele-vant to a physician leader. all physicians take an oath based on the hippocratic oath, and it is widely believed that this com-

mitment is especially important for physician leaders. i suspect that most physicians also want their leaders to have the same education, training, and clini-cal experience that they did, to ensure that leaders understand the needs of the practicing physician.

other qualities, though not unique to medicine, are import-ant for our physician leaders. they should have an inclusive spirit, which will allow them to embrace all physicians. even if representing only a certain segment of the profession, they must guard against the potentially divisive nature of specialty affiliation; political ideology; geographic location; and employed, independent, or academic status. Physicians

spend their professional lives in many different arenas, and they must balance the needs of other health-related organizations with which they may be affiliated, with their commitments to their fellow physicians and their profession. We also expect our physician leaders to be proac-tive, rather than reactive, so they can identify and act on the issues of most importance to physicians, and not merely wait for problems to arise before attempting to solve them.

Who are our physician leaders, and where do we see them promoting the interests of physicians? one can hardly go a day without media attention focusing on medical issues. however, we rarely see the me-dia reach out to our physician leaders, other than for a quick sound bite. the media tends to use these sound bites when creating a story rather than gaining a true understanding of the physician perspective on a particular issue. We seldom see physician leaders reaching out to the media, whether it is local

12 Minnesota Physician July 2014

To lead effectively, one must have

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or national television, print media, or internet-based media. Physicians rely to some extent on medical journals for advo-cacy within the profession, and these journals are sometimes accessed by the media. But within the medical literature, physicians are primarily in-volved with scientific reporting. Policy articles, surprisingly, are most commonly authored by nonphysicians or nonpracticing physicians, and our physician leaders have generally not used journals to advocate for the profession.

in the past, members of local, state, and national physi-cian organizations have played an important role in nurtur-ing, guiding, choosing, and advancing prospective leaders. Unfortunately, these organiza-tions are losing the support of practicing physicians, which decreases the pool of potential leaders.

the leaders who do emerge carry less clout, as the orga-nizations lose members and influence. For example, the

american Medical association now draws membership from a small percentage of the nation’s practicing physicians (most recently 15 percent) and the Minnesota Medical association (MMa) counts fewer than half of the state’s practicing physi-cians as members. at the state level, most nonmembers have very little understanding of the role and efforts of the MMa, much less aspire to become leaders in the organization. Many MMa members are em-ployed by large organizations and receive their membership as part of a dues arrangement involving the entire group. they may not have made a conscious choice to join, and may not place much importance on their membership, making physicians less likely to take on a leader-ship position in the traditional way.

Leadership development neededWith increasing health care costs felt by individuals, em-ployers, and government pro-

grams; growth in an increasing-ly powerful profit-driven health care industry; and a domi-nant—some would say oppres-sive—regulatory role of govern-ment, the ability of practicing physicians to guide health care policy has diminished. as stated previously, there are many eco-nomic, administrative, and reg-ulatory issues that have made the practice of medicine less re-warding and less enjoyable than in the past. the response of physicians to these changes has not empowered them, nor has it allowed the development of effective new leaders. instead, physicians have retreated into defensive positions, focusing on their individual situations. if physicians worked to strengthen their organizations, this would create leaders that could effec-tively present their profession’s message to the appropriate policymakers.

What does this say about our current physician leadership? have physicians not provided the appropriate environment and nurturing for prospective

leaders? have we lacked a clear vision and understanding of the importance of leaders? have we failed to make clear the expec-tations we have for our leaders? have we chosen the wrong lead-ers? have physicians stopped believing that leadership makes any difference to the profes-sion? have physicians given up on having any substantial role in formulating health policy that affects physicians?

these questions need to be addressed by physicians and physician organizations if they are to have any success in reversing the destructive trends that have adversely affected physicians. successful physi-cian leadership should allow physicians to focus on providing the best care for their patients, while valuing and rewarding them reasonably and fairly.

lyle Swenson, MD, is a board-cer-tified interventional cardiologist who practices at East Metro Cardiol- ogy, Maplewood, and has hospital privileges at HealthEast hospitals in St. Paul. He is a past president of the Minnesota Medical Association.

July 2014 Minnesota Physician 13

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Pediatrics

health care occurs in many places beyond our offices, hospitals,

and emergency departments. For children and adolescents, schools are one of the most important places they may need support for health problems. traditionally, schools have been the site of mass immuni-zation and health screenings. But school nurses also care for children with acute and chronic health issues that range from nausea and vomiting, to asthma exacerbations. this care often requires prescription therapy, and individualized plans and orders for each child.

the southeast Minnesota Beacon program involves 11 counties that are working to improve health care and health-delivery systems. the Beacon program has worked to address the lack of asthma action plans required in schools to support care of asthma “at-tacks” and other acute asthma problems. Without an asthma

action plan, a school often has no recourse but to call a child’s parents to address asthma exacerbations. in our research, it quickly became apparent that completion of an asthma action

plan for the medical record does little to support health

care delivery in the schools, since less than 25 percent of those plans actually made it into the schools.

the southeast Minnesota Beacon program developed a

working team of parents, school nurses, public health profes-sionals, physicians, and nurses to identify barriers to getting useful asthma action plans into the schools and in the hands of the school nurses. Working with a community team is not a new concept; it has been used in other similar programs. the major barriers are shown in the sidebar on page 15.

Creation of a standardized formatit would be ideal to use one asthma action plan across all health systems and clinics so that the schools can expect a uniform format. the southeast Minnesota Beacon collaborative was unable to achieve this goal. We were, however, able to de-velop a standardized format for the student demographic and the clinical material in the plan.

each health system’s plan has the demographic or iden-tifying information at the top of the plan (e.g., child’s name, child’s birth date, parents’ names, and usual asthma med-ications), but the exact arrange-ment of this material varies by health system. the main body of the school asthma action plan is laid out in a standard

green (doing oK), yellow (some problems), and red (immediate action required) zones format. this section is only a slight modification of the asthma action plans found online from the Minnesota Department of health and the american Lung association.

More important, exactly the same terminology is used to describe the symptoms of each zone and when to seek emer-gency assistance. For example, “a child who is unable to speak in full sentences, or refuses to lie down or is unable to walk comfortably due to breathing problems, should result in a call to 911 for emergency sup-port” is used across the board. the health care systems have developed electronic versions of the school asthma action plans, with drop-down boxes to facilitate consistency and ease of completion.

Health action plan accessibilityafter a student’s health action plan is completed, it needs to be made accessible to his or her school. the Beacon team worked with a local public health department, olmsted county Public health services, to develop electronic access to student health action plans. Differences between the health systems workflows and health action plans, as well as 41 school districts using different information systems without resources to support additional electronic infrastructure, significantly influenced the decision to develop a centrally supported and secure web-based portal. “Kids-e-health” is housed and supported by olmsted county Public health service’s information system, called Ph-Doc.

the school portal makes student health action plans securely accessible to students’ school nurses. to access the plans, schools must enroll in the portal and register their school nurses with assigned us-ernames and secure passwords. the nurses can access the portal only from their school computers, and can access only

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their school’s students’ health action plans. non-enrolled iP addresses are not allowed through the firewall, and students are linked to specific schools and school districts.

When a student has a new asthma action plan written or updated that includes parental/guardian consent, the health care system makes the new plans available for upload into the school portal. alerts are sent to the appropriate users managing the portal.

school nurses receive non-Phi (protected health infor-mation) emails, letting them know that new and/or updated student health action plans are available in the portal. they then can log in to view, print, or save their students’ new and/or updated plans. the portal gives nurses a snapshot of the prevalence of asthma in their schools, listing all the students in that school with asthma action plans. this knowledge informs the school nurse’s plan for asthma intervention.

Using the information appropriatelyGetting student health action plan information to the schools is not enough; it does not com-plete the circle of care. Parents and health care professionals need to understand the usabil-ity of the information: Was the

data sufficient, is it being used frequently (frequent asthma at-tacks), and is more information needed?

the school portal provides a way for school nurses to com-municate information about their students’ symptoms and medication/equipment needs back to the health care system and parents. For example, a school nurse can use an elec-tronic form within the portal to notify a student’s health pro-vider and parent/guardian if the student required an unplanned intervention for asthma symp-toms, or if the student needed a spacer for his or her inhaler at school. this mechanism of electronic, secure communi-cation facilitates the sharing of information that health professionals outside of the school seldom have access to otherwise—information related to asthma control and exacer-bations during school hours. the school-to-clinic and school-to-parent system of informa-tion sharing would appear to facilitate improved access to information and potentially improved asthma care and outcomes. this portion of the program has not been tested yet, however, so it must remain a suggestion.

the transfer of information from the health care system to the school system is not perfect.

1. Lack of a standardized plan that was easy to use in an urgent or emergency situation, such as during an asthma “attack”

2. Failure of the plans to clearly list medications in an actionable manner allowing nurses to dispense

a. School nurses, like nurses in the hospital, office, or emergency department, require drugs with name, doses, and exact adminis-tration instructions.

i. “Albuterol 2 puffs prn”—is not adequate.

ii. “Albuterol 2 puffs every 15 minutes for up to three doses “—is adequate.

b. Medication names must match the medication sent to the schools.

c. School policies require new orders at the beginning of each academic school year.

i. Updating every student’s health action plan in August or September is not practical for office practices.

ii. This is an ongoing issue that likely will be faced in each school district, since school nurses are required to comply with school policies.

3. School policies require parent/guardian consent to allow:

a. Medication dispensing to a child

b. Communication with a child’s physician or medical office

c. Self-carry by a child

Barriers to asthma action plans for schools

a major issue is the inability to include into the portal the required parent/guardian con-sent signatures along with the student health action plans. the schools must obtain separate

parental/guardian permission to treat the child and share medical information with non-school-based health profession-als. But the overall program has worked sufficiently well enough

School-based asthma action plans to page 38

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“…I heard the birds singing, a fish jumping, a loon calling, and all the things I never heard for a long time. I can hear my pastor’s sermon. I can hear most people on the phone, even my grandchil-dren. My wife no longer needs to be my ears!” — A grandfather

We have come to expect comments like this from our patients at

the Mayo Clinic, but they still strike me as remarkable. The emotional letters and stories are a thrill to read. They impress on all of us involved in the co-chlear implant process the great impact this device can have on individuals and families.

The pioneers of cochlear im-plant (CI) technology—Graeme Clark, Ingeborg Hochmair, and Blake S. Wilson—were present-ed the 2013 Lasker~DeBakey Clinical Medical Research Award, often a precursor to the Nobel Prize. This under-scores the profound impact this unique device has had on hu-mankind. The cochlear implant

is a remarkable feat, linking technology to human physiol-ogy, and restoring hearing—a valuable “sense.”

Today, most people have heard of cochlear implants, because they have been rou-tinely implanted for 30 years. However, as the devices have matured, the surgical technique improved, and outcomes as-sessed, this technology is being applied to new populations. It has applicability in patients with single-sided deafness, those with substantial residual

hearing or disabling tinni-tus, and even in patients with neurofibromatosis type 2 and bilateral acoustic neuromas. The candidate age range now extends from children as young as 6 months to adults of any age. There is not an age beyond which hearing is unimportant; in fact, quite the opposite is true.

Single-sided deafness“I just woke up and there was no hearing in my ear.”

Sudden unilateral sensori-neural hearing loss (single-sid-ed deafness) is a fairly common clinical situation. Despite prompt treatment with steroids, many patients do not recover useful hearing. Some patients adapt fairly well, but many struggle with hearing, particu-larly with hearing in environ-ments with background noise, such as restaurants, stores, places of worship, outdoors, and at social gatherings. In fact, in most places where we are talking and listening, there is background noise.

Traditionally, we have pro-vided devices—contralateral routing of signal (cros) hearing aids, or bone-anchored hearing aids—that route sound from the poor-hearing ear around to the good ear. Unfortunately, this does not restore the ad-vantages of binaural hearing, sound localization, and im-proved hearing in noise.

A CI is the only method to restore the binaural advantage. Why have we not previously im-planted this patient population? A CI can restore nearly normal hearing in terms of sensitivity (volume), but the clarity is not commensurate with normal

hearing. It was presumed that the relatively “poor” sound quality of a CI would actually interfere with the better-hear-ing ear; some early experiences supported this. However, the technology has improved and our understanding of who may best benefit and the optimal timing for implantation has changed the landscape.

I have been shocked at how much benefit some of our single-sided deafness patients report. Not everyone with sin-gle-sided deafness will need or desire implantation, but those who have been recently deaf-ened, adapt poorly to the loss, or have intrusive tinnitus may benefit. This experience has also led us to reconsider options for children born with unilat-eral hearing loss. We know that there are educational challeng-es that result from unilateral hearing loss. Could a CI elimi-nate that burden?

Patients with acoustic neuromasNeurofibromatosis type 2, characterized by bilateral acoustic neuromas, can be mild or very severe, resulting in a reduced life expectancy. But in all cases, the hearing is highly threatened, and the majority of patients lose useful hearing. Traditionally, we have used auditory brainstem implants (ABI) to restore some hearing. Rarely do these devices result in hearing that would allow for talking on a telephone or car-rying on conversations without lip reading. About 10 percent of the time, they provide no useful sound. It was thought that a CI would not be effective because of the affect of acoustic neuroma tumor on the auditory nerve.

It turns out, however, that even when the tumor is still in place, the CI can drive a useful signal down the auditory nerve. Because we can take advantage of the tonotopic layout of the cochlea, the sound quality is far superior to an ABI. We now treat many acoustic neuromas with stereotactic radiosurgery. This commonly leads to com-plete hearing loss, but the

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CI can be effective in this sce-nario, also. our 1,000th patient to receive an implant at Mayo Clinic suffers from this disease. He, his family, and friends were not proficient in American Sign Language, and were reduced to writing and reading for com-munication. It was an effective but cumbersome strategy. Just a month after implantation, he reported voices sound-ing “fairly normal” and he is already talking on the phone. His mother reported that he is hearing speech well. Ten years ago, nobody thought this degree of hearing restoration would be possible in this clinical situa-tion.

Potential candidates“I can hear with my hearing aids—but struggle! When should I have a CI?”

We believe the FDA audio-metric criteria to qualify for a CI are overly conservative, par-ticularly the stringent Medicare guidelines. These guidelines

have prevented patients from taking advantage of a CI. As we gained experience with out-comes, it has become clear that

many hearing aid users would perform better with a CI than their hearing aid. Today, the majority of adults we implant have considerable residual hearing, and can communicate quite well in quiet environ-ments. A number of studies underway—or recently com-pleted—provide the evidence to support expanding the criteria. We have extensive outcomes data that allows us to predict who will be better after surgery and by how much, on average. Patients continue to wear their contralateral hearing aids, although many contact us about getting a second implant.

“Can I wear a hearing aid and

CI in the same ear?”

yes, the concept of a hybrid device—a CI combined with a hearing aid—has come to

fruition. Most people lose more hearing in the mid and high tones, and have better preserva-tion of the low frequencies. This residual hearing is inadequate for understanding speech, but provides considerable benefit. Music appreciation, access to some sound when the implant is off (e.g., sleeping, showering) and improved sound quality are some benefits reported by patients.

The high frequencies are fortunately located at the basal end of the cochlea. The hybrid device is a very thin, flexible electrode that is implanted part way into the cochlea, to electri-cally stimulate this region. The

preserved low frequencies are augmented with conventional amplification, if needed. We can reliably place these electrodes and preserve the hearing at the time of surgery, but some patients lose their hearing during the first year, for reasons that are not yet clear. Work is underway to better understand and treat this delayed hear-ing loss. Minimizing cochlear trauma during device insertion also results in better spiral ganglion survival and CI-alone performance. Preservation of intracochlear structure may also allow for the application of not-yet-discovered therapies in the future. The hybrid con-cept is the ultimate “win-win:” absent high frequencies are restored with electrical stimula-tion through the implant, while the person preserves native low-frequency hearing.

As a surgeon, I am less involved in the progress of the external components my audi-

There is not an age beyond which hearing is unimportant; in fact, quite the opposite is true.

Cochlear implantation to page 36

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“there’s nothing you can do for a person with huntington’s

disease.” that statement is no longer true. twenty-one years after the discovery of the ge-netic abnormality that causes huntington’s disease (hD), there is much that physicians can do to help today’s patients and families. and a global hD research community is working collaboratively to develop dis-ease-modifying treatments for the patients of tomorrow.

the core features of hD include a disturbance of vol-untary movement (incoordina-tion); involuntary movements

such as chorea or dystonia; progressive cognitive impair-ment (dementia); mood and behavioral disturbances; and an apparent bioenergetic defect that leads to weight loss. al-though medications to improve coordination or dementia do not yet exist (the cholinergic

drugs used in alzheimer’s disease have not been shown to help), medications are com-monly used to reduce chorea and ease common psychiatric symptoms such as depression, irritability, obsessiveness, anxiety, and paranoia. Physi-cal exercise helps people with hD to maintain their strength and stamina. careful attention to food textures and eating style forestalls choking due to dysphagia. attention to the home environment and appro-priate adaptive equipment can help patients avoid injury due to involuntary movements, and optimize independence. and there is a way to minimize or prevent weight loss, which most patients enjoy: eat more!

an exciting advance in hD management was the FDa ap-proval in 2008 of tetrabenazine (Xenazine), a dopamine deple-tor, as a specific treatment for chorea in hD. although not all hD patients need treatment for their chorea, this drug provides a helpful option for those who do.

the psychiatric and be-havioral features of hD are generally relieved with stan-dard doses of typically-used antidepressants, antipsychotics, anxiolytics, and mood stabiliz-ers; there is not a specific drug to use or avoid using because of the diagnosis of hD. For pa-tients with treatment-resistant behavioral symptoms, careful attention to the environment, daily routines, and reducing or avoiding stress-producing interactions can help. Families should be reassured that as the disease progresses, disturbing behaviors often subside.

accurate information and proactive preparation for the future can make all the differ-ence for a family. the genetic aspects of the disease are

still often misunderstood; the sidebar on page 19 outlines the genetic features of hD, as well as the applications of genetic testing. the shoulson-Fahn total Functional capacity scale, a 13-point, five-stage scale, helps a patient and doctor to know where he or she is on the inexorable course of the disease, and what challenges may be on the horizon (see the sidebar on page 34).

Highly-developed support systemexcellent care for hD families is complicated, and benefits from a team approach. For-tunately, the Upper Midwest has among the most highly-de-veloped hD care and support systems of any region in the country:

• the hD center at hen-nepin county Medical center—which includes a research arm at struthers Parkinson’s center (Park nicollet clinic/Methodist hospital)—was founded in 1978. it is one of 21 huntington’s Disease so-ciety of america (hDsa) centers of excellence. the center includes two neurologists, a research nurse, and specialists in neuropsychology, psychol-ogy, genetic counseling, social services, physical therapy, speech pathology, occupational therapy, and nutritional therapy.

• Good samaritan society specialty care commu-nity, Robbinsdale, has a 32-bed long-term care unit specifically for people with hD, one of only a hand-ful of such units in the country.

• adult group homes spe-cializing in hD care have been developed in three communities in central Minnesota.

• hD center of excellence neurologists provide con-sultative support for tanya harlow, MD, a movement disorders specialist in Fargo, n.D., and Michael Kruer, MD, who is estab-lishing an hD program in

Professional UPdate: neUrology

Huntington’s diseaseHelp for today, hope for tomorrow

By Martha A. Nance, MD, and Jessica Marsolek, LSW

sioux Falls, s.D.

• the Minnesota chapter of hDsa has provided support groups, a hotline, in-service training for care facilities, fundraising and advocacy events, and an annual education day for patients and families for many years. the chap-ter has won numerous awards over the last 15 years from the national parent organization for its programs, newsletter, and fundraising activities. smaller independent sup-port groups are active in the sioux Falls and Fargo areas; these lay groups are supported by a network of experienced social work-ers: nina Ross and Jessica Marsolek in Minnesota, and eileen Kruger in the Dakotas.

• the University of Minne-sota Molecular Diagnos-tic Laboratory (Bharat thyagarajan, MD, associ-ate medical director) has performed the hD gene molecular analysis (“gene test”) for 20 years, provid-ing a local alternative to national reference labora-tories, where personalized attention to unusual cases is hard to obtain.

• the huntington’s Dis-ease youth organization (hDyo) was cofounded in 2012 by apple Valley, Minn. native B. J. Viau,

with the goal of creating a kid-friendly web presence, where children and young adults can go for infor-mation and support about hD. the website has been translated into nine lan-guages, gets 300,000 hits per month, and conducts youth-focused hD events in europe and the U.s.

highly-skilled care, educa-tion, and support are available for people with hD from diag-nosis to death. Genetically at-risk family members (any child of an affected person has a 50 percent chance of carrying the disease-causing gene) can ob-tain detailed information about their reproductive and genetic testing options from genetic counselors at the hDsa center of excellence (carol Ludowese, Ms, cGc), the University of Minnesota (Matt Bower, Ms, cGc), or at sanford health sioux Falls (Lior Borovik, Ms).

Looking aheadWhat about hope for tomorrow? there is much excitement in the hD research community. twenty years of intensive bench research is bearing fruit, bring-ing new insights into the patho-physiology of hD, and novel therapeutic avenues for clini-cal researchers. For example, gene silencing and gene repair techniques are being studied intensively in hD animal mod-els, as this autosomal dominant disease is an ideal one in which to model these approaches.

Modulation of caspases, sirtuin 1, histone deacetylase, phos-phodiesterase 10a, intracellular metal transport, and immune system function are among many approaches currently under study in laboratories or clinics nationwide.

two large, long-term ob-servational studies in the U.s.

(PReDict-hD and PhaRos) have shown that clinical, neu-ropsychological, and radio-logical changes are detectable in hD gene carriers as much as 10 years before the age of expected clinical diagnosis. as disease-modifying treatments are developed, we likely will


• HDisanautosomaldominantdisease(onecopyoftheabnormalgenecausesthedisease)causedbyamutationintheHTTgene.EveryonehastwocopiesoftheHTTgene;mostpeoplewithHDhaveonenormalcopyandonecopywithamutation.

• Malesandfemalesareequallylikelytoinherittheabnormalgene.

• TheonlymutationthatcausesHDisa“CAGrepeatexpansion”atasinglelocationintheHTTgene.

• CAGrepeatnumbersof10to35arenormal;≥36isnotnormalandcancauseHD.

• LargerCAGrepeatnumbersareassociatedwithloweronsetages.

• Repeatnumbersintheabnormalrangeoftenchangeastheypassfromparenttochild(“meioticinstability”);thus,aparentwhocarriesanHDgenewith43CAGrepeatsmayhaveachildwhohas46repeats.Therepeatnumbercangetsmaller,but,moreoften,increasesinsize.

• LargeincreasesinCAGrepeatnumberaremorecommonwhentheaffectedparentismale—thisexplainswhymostchildrenwithjuvenileonsetHD(about5percentto10percentofallpeoplewithHD)haveanaffectedfather.

• Repeatnumbersof36to39areabnormalandcanleadtoHD,butsometimesdonotcausediseasesymptomsinanormallifetime;thisphenomenoniscalled“reducedpenetrance.”

• CAGrepeatnumbersof28to35havebeenreportedintheparent(usuallythefather)ofindividualswitha“newmutation”(nofamilyhistoryofHD);thisissometimesreferredtoasthe“intermediaterange.”

• AnalysisoftheCAGrepeatnumbersintheHTTgene(theHDgenetest)canbedonetoconfirmtheclinicaldiagnosisofHD,forprenatalorpre-implantationtestingofafetusorembryo,andfor“presymptomatictesting”inhealthyindividualsknowntobeatrisk(childrenofaffectedparents).Presymptomatictestingshouldbeprecededbyadetaileddiscussionofitspotentialrisksandbenefits,implications,andlimitations.

Clinical genetics of Huntington’s disease

Huntington’s disease to page 34

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M i n n e s o t a h e a l t h c a r e r o u n d t a b l e

Post-acute careFixing cracks in

the system

MR. STARNES: Today, we are discussing the topic of post-acute care. Like so many other topics in health care, this one will be defined 10 different ways by 10 different people, all of whom may work in the field. This is a good starting point for problems to arise, and there are many problems. There is also significant motivation to address them. How significant? If we look only at CMS spending in this area, some estimates put it at more than $62 billion in 2012. This is a figure that commands attention and one that is project-ed to grow. Let’s get started with the defi-nition of some terms. What is meant by the term “post-acute care?”

DR. KORANNE: I would define it as includ-ing community-based services which not only have to do with medical care, but are essential to keeping our neighbors in the community: hospice, palliative care services, faith community nursing, home health services, custodial services, county services, adult day care programs, and other social services in the community can all be under this broad umbrella.

MS. THURLOW: It’s not just facility-based, and includes community-based service providers. And it’s not necessarily post-hos-pitalization, but can also be prehospital-ization. It’s not about fixing cracks in the system, it really is about building a system, and that starts with the definition. I would use the more expansive definition, looking more broadly to facilities but also commu-nity providers, as well as informal caregiv-ers and family members.

MS. KLEFSAAS: We want to allow customers choice for the setting that they prefer. We’ve talked about the setting but not about the time frame of post-acute care. Is it a 30-day time frame? Ninety days? What are we including in the post-acute definition, and who should be involved in those conver-sations? How do we balance the voices of preferred networks and customer choice?

MS. SIMONSON: From my perspective working with the Area Agency on Aging in the community, the older adult—primarily someone who needs post-acute care—is at home at some point in their post-acute stay. We need to think about post-acute care in all its settings. Home is often where post-acute care takes place.

DR. FREDERICK: I would rather call it transi-tions of care across the continuum of care, because whether you’re a senior or not, you’re going to be dealing with different levels of disease and different needs of care. If it involves a hospital stay, there will be transitions in/transitions out.

MS. BOSTON: When you look at it from a policy perspective, we’re really looking at it as admission to a nursing home. I like the fact that at the national and state levels, you’re seeing a change in terms. They’re using “care transitions.” People understand that better than “post-acute care.”

MR. STARNES: Now that we have a sense of the waterfront covered by this term, let’s look at what it has to offer, or the value proposi-tion that post-acute care brings to the health-care delivery system. That might help us define it. Sharon, from Presbyterian Homes’ point of view, what is the value proposition for post-acute care?

MS. KLEFSAAS: We bring value to reducing costs and providing efficient care, but hav-ing great outcomes too. We have regulatory components that have added value in terms of assessment, protocols for treating differ-ent diagnoses in our care centers, etc. Our cost model is less than the hospital system. When we look at bundled payments, total cost of care, the cost of the episode, we are a vital player in that and a great partner to acute-care systems and other providers be-cause we are one piece of that total episode of care.

DR. KORANNE: The framework that a lot of health care systems are starting to use is the Triple Aim. It should be the para-digm that we should embrace for quality, cost, and the member’s experience of care. At HealthEast, we’ve added a fourth di-mension, employee engagement. Those of you working in institutional post-acute care facilities realize that’s the challenge we face now and in the future. I don’t just mean LPNs and RNs. I also mean physical therapists, social workers, chaplains, nurse practitioners, PAs, physicians, and many others.

MR. STARNES: If we look at post-acute care as the way we treat patients when they come out of an acute facility, where is the value that post-acute care brings to the organization?

MS. BOSTON: Preadmission screening is a federal requirement before someone goes into a nursing home. They have to meet a level of care and the federal government requires the state of Minnesota to screen to determine whether that person is men-tally ill or might need special services in the nursing home. In working with nursing homes over the years on an initiative called Return To Community, we have learned that the critical point at which that person is going to avoid hospital readmission is at about the three-day mark. Are meals being delivered? Did home care arrive? Did they see the physician? Did their medications get filled? Were they compliant with med-ication? When I think of post-acute care I think about it from hospital care transi-tions to nursing home, to home, and the array of services that must be delivered at that critical point. Because if they’re not delivered, that person will return to the nursing home or hospital. That’s a systemic expense. When I think of the value

About the RoundtableMinnesota Physician Publishing’s

forty-first Minnesota Health Care Round- table examined the topic of post-acute care.

Six panelists and our moderator met on April 17, 2014, to discuss this topic. The next roundtable, on Oct. 30, 2014, will

address treating chronic illness.

20 MINNEsOTA PHysICIAN July 2014


proposition for post-acute care, I think of the great potential for partnerships. We’re trying to incentivize that in all the payment structures. It’s not there yet, but it’s getting there.

MR. STARNES: If we can create an equa-tion that demonstrates this value, what evidence do we need in that equation to make it meaningful?

MS. THURLOW: Aging services of Minnesota has partnered with our national organization, LeadingAge, to help primarily nursing home providers benchmark with other providers in the state on CMs quality measures. The most robust data we have is rehospital-ization data. We have that for nursing homes and across all long-term care providers, assisted living, and home care. Rehospitalization is important, but it is not the only quality metric. We’re working on benchmarking costs of certain episodes of care and commu-nicating that to our other partners.

MS. SIMONSON: We have to consider extending the definition of value to include non-medical home and com-munity-based services. They are part of the continuum of post-acute care. That’s where we have an opportunity to assign value to home-delivered meals, home modifications, and consultations about care options or how to pay for care.

MS. KLEFSAAS: Infrastructure to support obtaining that data is lacking, especially in many post-acute settings. Care centers for example: We’re not giv-en funding, as hospitals were, for com-puter technology and system upgrades. But it’s intuitive that we know the value of a meal delivered to someone’s home might make the difference in their care. To quantify that, we’re at the tip of the iceberg of what we need to do.

MR. STARNES: Let’s assume we have that equation. What will different stake-holder groups gain from hearing this message? Why do we need the public to hear this message?

MS. SIMONSON: Often, political will stems from the public. To have a policy framework that supports a comprehen-sive post-acute model in our country, the public must understand the im-portance of care and the breadth of that care. Not only for older people or someone labeled post-acute, but also for their family. We haven’t talked much about what post-acute means for families. What are the roles of family caregivers in helping to make certain

that someone’s recovery proceeds well? We have a political and public process here, driving policymakers to think about a comprehensive long-term care benefit and financing mechanisms.

DR. KORANNE: Part of the discussion needs to be burden versus benefit of the continuum before and after the hospital, and how we can reduce over-all societal burden. The public needs to hear it. The payer? The revolution has begun: There is experimentation happening in CMs, several sNFs in the Twin Cities are experimenting. DHs is striking its own path. In this day of high-deductible plans, Medicare Ad-vantage, dual eligible plans, it’s import-ant to have very simple messaging to the end customer so that decision-mak-ing can become easier.

MS. KLEFSAAS: There’s a lag behind the sustainable financial payment model to support programs through the federal government and our state fund pilot initiatives. When we talk about the value of our payers know-ing that, they need to know early on the value of these programs through evidence-based information and out-comes, so that they can more quick-ly support the efforts. some pilots had wonderful models of care with evidence-based outcomes that were fantastic at maintaining people in the community, but when funding ended the program died because there wasn’t an insurance payer, governmental provider, or state funding behind that program to sustain it. The more we can publicize the work that we’re doing and the outcomes, maybe the more quickly we’ll get that support.

MS. THURLOW: We see hospital systems leading the charge and experimenting. Much of the experimentation has been metro-based. We haven’t seen much robust experimentation in rural Min-nesota. What works in the Twin Cities might not work as well in Warroad, where you have a different array of services, a different work force.

MR. STARNES: What do legislators need to hear, and how they could help?

MS. KLEFSAAS: There’s work being done to eliminate requirements for the three-day hospital stay for Medicare payment for patients going from acute care to a skilled nursing facility. state and federal governments could support creative waivers for certain programs or exclusions from regulatory require-

Krista Boston, JD, directs consumer assistance programs for the Minnesota Board on Aging and for Minneso-ta Department of Human Services’ Aging and Adult Services Division. Her 18-plus years of policy and legislative work includes advocating for and building access systems, including the award-winning website www.minnesotahelp.info, which contains the Long-term Care Choices Navigator. Boston manages Senior Link-Age Line and directs the Minnesota Help Network, the statewide Aging and Disability Resource Center initiative that supports the Disability Linkage Line.

John P. Frederick, MD, is executive vice president and chief medical officer of PreferredOne, a health insur-ance provider based in Golden Valley. He has served in this capacity since October 2000, in addition to serving on numerous committees, task forces, and boards of physician/clinic groups and health plans in the Twin Cities. Board-certified in family medicine, he earned a medical degree from, and completed a residency in family medicine at, the University of Minnesota. His experience includes active medical practice, medical teaching, practice management, medical care manage-ment, and quality management.

Sharon Klefsaas is vice president, operations, for Presbyterian Homes and Services (PHS). In this capacity, she oversees operations for 45 senior communities in Minnesota, Wisconsin, and Iowa, which provide a total of more than 12,000 units devoted to senior care. PHS senior communities include stand-alone independent living, assisted living, enhanced assisted living, memory care, long-term care, and short-term rehabilitation mod-els. Klefsaas is currently directing a new franchise model for short-term rehabilitation services with Allina Health Systems on Allina’s West Health Campus in Plymouth.

Rahul Koranne, MD, MBA, FACP, is vice president and executive medical director, HealthEast Care System community and post-acute services. Board-certified in internal medicine and geriatrics, he oversees and pro-vides strategic direction to all inpatient and outpatient programs at Bethesda Hospital, St. Paul. Koranne’s work as physician lead on the transformation of HealthEast’s care navigation strategy resulted in that system being the first in the nation to have certified Level II transition coaches and the first in the Twin Cities to use care coaches, shown to reduce post-discharge hospital readmission.

Dawn Simonson, MPA, is the executive director of the Metropolitan Area Agency on Aging, Inc., a nonprofit organization that helps older adults maintain their inde-pendence. The Agency provides resources for long-term services and supports; offers information and assistance to help older adults make decisions about services and housing options; and works with community partners to improve quality of life for older adults and family care-givers. Simonson’s 20-plus years’ experience in the field of aging includes work in many different sectors.

Kari Thurlow, JD, is senior vice president, advocacy, at the nonprofit organization Aging Services of Minnesota, the state’s largest trade association of elder care pro-viders. This organization works with more than 50,000 caregivers statewide that serve more than 125,000 elders each year in settings across the care spectrum, including private homes, congregate housing, assisted living, and care centers. Thurlow collaborates with a wide range of advocacy groups, external partners, and policymakers to accomplish common public policy objectives.

about the ModeratorMike Starnes has been the publisher at Minnesota Physician Publishing since 1986. His duties include the production of MedFax, Minnesota Physician, Em-ployee Benefits Planner, and Minnesota Health Care News; directing the Minnesota Health Care Consumer Association; and hosting the Minnesota Health Care Roundtable.

July 2014 MINNEsOTA PHysICIAN 21

M i n n e s o t a h e a l t h c a r e r o u n d t a b l e sponsored by


on average, boomers have about $50,000 in savings.

Krista Boston, JD

ments that might be a barrier. Looking at the payment structure, for example, how much more we pay for two physicians for a hospital visit versus a visit in a care cen-ter. Where should incentives be aligned to support post-acute care settings? Get to our legislators with those messages, and make them aware of the barriers we face. We have a responsibility in the provider net-work to offer solutions, not just to complain to our legislators.

MS. THURLOW: Public-policy makers have to be aware that the older adults services continuum is grossly underfunded. It seems counterintuitive that if you invest a little bit of money on that side of the equation, you save money in the long run. I don’t know that policymakers get that.

MS. BOSTON: Post-acute care providers un-derstand. A lot of innovations are part of a long-term care reform agenda that is trying to redesign the system for the impending baby boom. Many people have their first episode of long-term care need in their 60s. We need to prepare for it; it could essentially bankrupt our state budget if we don’t.

MS. KLEFSAAS: I’d be interested in what Dr. Frederick would say about this in terms of insurance products that are available, bar-riers that need to be removed so that you can be more creative in what you cover, and how plans are constructed. Could we de-velop plans that incent customers to make those choices, just like we have with health insurance policies: If you use the nurse triage line, there’s no cost. If you go to the emergency room, it’s $150. Could we apply those same concepts to this post-acute care arena when we have data to support what pathways are most cost-effective, and have the best outcomes and experience for our

customers? Could we also align our insur-ance products to give our customers choice, and say, hey, if you want to stay in the hospital for 10 days and pay for it yourself, that’s an option, but here’s a less expensive one. Is it possible to align insurance prod-ucts with choices and changes we’re seeing in the model of the community?

DR. FREDERICK: yes. The biggest concern is that at this point, we haven’t got a well-de-fined product. This discussion is about how can we do it better. At some point, the whole system’s got to be accountable. The way health care is paid for these days is in-centive-based, so we have to have some way of defining the most effective system for an individual.

MR. STARNES: What are obstacles to deliver-ing post-acute care?

MS. KLEFSAAS: One barrier is the sharing of electronic medical record information. We’re making progress slowly on finding ways, if not to fully integrate our electronic medical records, to sharing information and having it available when transitioning from acute care to the next post-acute care setting. We talk about having person-to-per-son contact between the acute care provider and the post-acute care provider, and what value that brings to the patient in under-standing the handoff, understanding their responsibility, what their outcomes are likely to be, what their choices are. It’s the elephant in the room that if you are a large provider, a large health care system, you have more leverage, more dollars to invest in collaborative arrangements with post-acute providers. How will that develop in the future? How narrow will our networks be in the future? If you’re a small provider, how will you be able to compete against

larger organiza-tions that have more resources? Those are challenges statewide.

DR. KORANNE: An- other obstacle involves transitions. About 10 years ago, I was a primary care doc and geriatrician in star-buck, Minn., and I saw Mrs. Johnson in the primary care clin-ics. Then she fell and

broke her hip, so I followed her in the crit-ical access hospital, and then transitioned her into the TCU. Then, I made a house call to see her. Life was easy; I was the care co-ordinator and the primary care physician.

Now, systems are going toward health care home or medical home, where the primary care physician and system know the patient. We need to connect with the patient’s pri-mary care physician. ACOs nationwide have talked about primary care as the basement where the ACO will be built. Population health concepts could get lost if physicians only see patients in nursing homes or as-sisted living or make house calls, but don’t connect with the health care home. Let’s not duplicate and look at payment models as spurring us to create something new.

MR. STARNES: Does the quality of hospital discharge information create a problem?

MS. SIMONSON: It does. The process of helping to educate the patient, identifying the family caregiver, preparing that care-giver to implement the discharge plan once someone is home: All are critical to the discharge planning process and the success of the person once they’re home. And to the critical 48 hours once the person is home, when it is important to see the discharge plan in action. Whether it’s getting medica-tions in place, figuring out wound care, the reality that might hit when the discharge plan places a fairly large burden on the family caregiver and realizing that the caregiver has mild cognitive impairment. Discharge planning is critical but it’s not just what happens in the hospital, it’s what happens with that consumer, their family caregiver, and those critical hours at home short term, and then long term.

DR. FREDERICK: Dollars are limited and all of these things cost money. My experience has been that the best way to define success is to say who’s doing the best job of getting the best outcomes. I’m not sure if there are good methods in place to be able to de-fine measurable outcomes, but I feel very strongly that we need to have those met-rics before we can start saying somebody’s successful.

MS. BOSTON: For figuring long-term care costs, there’s a great financial calculator online that Dr. Robert Kane at the Univer-sity of Minnesota put together. Minnesota




home is often where post-acute care takes place.

Dawn Simonson, MPA

is the No. 1 state in terms of long-term care insurance policies per capita. Nationally, on average, boomers have about $50,000 in savings. The daily rate for a nursing home, assisted living, or 24-hour care means you’ll go through that money in six or seven months. you need a lot of assets to suc-cessfully live at home and avoid going onto Medicaid, which isn’t necessarily fun. We all have an obligation to talk to our friends and family and plan ourselves for our fu-ture, and soon.

MS. KLEFSAAS: When we’re talking about access to health care and having finances to pay for it, how can we make this easier for older adults to understand, and reduce the number of people we send into that independent housing setting? After services have ended, how many individuals are going to have to call that person to see how the care was? No wonder our seniors are confused. What can we do, as a system of providers, to help streamline that and make it more understandable?

MS. THURLOW: We talk about access prob-lems like it’s going to happen in the future. In nursing homes, we are seeing it already throughout the state, not because we have a shortage of beds, but because of a shortage of workers. There are open beds out there, but if you can’t staff them, you can’t admit residents to use them. It’s not just nursing homes that need to think about access. Think about community-based services. If you want to hone in on where access issues lie, especially in post-acute care, look at the Gaps Analysis, a study DHs does every few years. Do you know what the No. 1 gap is for long-term care in the state? Transpor-tation. Particularly in rural Minnesota, if your patient can’t get the transportation to go to the follow-up doctor visit, we have a broken system. We have gaps in mental health, gaps in adult day services. Those types of services are going to be critical to post-acute care. so going back to the very first question, I would say that transporta-tion, adult day, mental health, all of those things should be part of the definition of post-acute care.

MR. STARNES: Let’s say that someone leaves one facility for another facility before they’re able to go home. This could lead to several layers of care being provided. Improving coordination of care along that continuum becomes a different challenge because the

person at step four may be so far removed from hospital discharge that they may not know it occurred. Are there tools that are available or could be created to improve this care coordi-nation?

DR. KORANNE: Care co-ordination; case man-agement; the new CMs regulations emerging around paying for tele-phonic or non-in-per-son services that nurse practitioners, PAs, and physicians provide— that model of connectivity to primary care as part of the neighborhood—are part of what we’re trying to build statewide. start-ing in 2008, there was health care home legislation, and a lot of the major systems and smaller clinics have been certified as health care homes. If that is going to be the framework, then, thinking about a hub and spoke model, as the knowledge cen-ter where everything needs to connect. If everybody starts making different visits, it could get disjointed and confusing, not just for the patient and the family, but it would be difficult for a payer to say, “Who’s creating what value and how do I distribute that value?” so we have to think about how to connect case management in the hospi-tal, in the various post-acute care settings. We need to continue to use that framework of primary care now and in the foreseeable future.

MR. STARNES: What can be gained by patient and caregiver sharing goals for post-acute care? Are we trying to work with the patient to determine an achievable personal goal?

MS. SIMONSON: We have some wonderful pilot work and integration into some health care systems around helping the patient identify life goals and thinking about how that connects when someone has an acute incident or is in care transition. Patient activation, health care coaching, transition coaching can be key to helping the con-sumer make the best use of the health care team and molding the care plan around those patient goals. I wanted, too, to com-ment on the framework centrality of primary care. The health care home can be

a really strong model to work from, but in today’s definition of the requirements of a clinical health care home in particu-lar, there is a very light requirement for a health care home’s knowledge and connec-tion to the system of long-term services and supports. so we have to think about mak-ing that a more meaningful requirement, if indeed the locus of coordination for care is going to exist in the clinical health care home.

MS. KLEFSAAS: Many of us in senior health care and housing offer that whole range of services within our continuum. Because we’re often working with the same team members that move across our system, we’ve got the same medical records, so there’s the opportunity for coordination of care. The handoff of information face-to-face between your own team members as individuals move across your continuum of care, maybe going from acute care for an episode, to TCU, and then transitioning back home is beneficial.

MS. BOSTON: With our Return to Commu-nity Initiative, we target about 2,000 people a year that should have transitioned out of the nursing home like their peers, but did not. We target them to see if we can assist them and if they still want to move home. On entry into the facility when they get their Minimum Data set assessment, or MDs, they answer yes, I would like to move home. But when we talk to them at 60 days, 28 percent of them say no, I like it here. People’s opinions and ideas evolve.




incent long-term care facilities via a payment add-on for preventing readmission.

Sharon Klefsaas

MR. STARNES: One challenge we haven’t delved into much concerns costs and reim-bursements. What are three reimbursement challenges to maximizing the benefits of post-acute care?

DR. FREDERICK: Data can be defined in dollars and cents or by quality measures. Ultimately, the outcome has to be for a pop-ulation of patients. For that population, we need to see who is doing the best job and getting the best outcomes, and be able to validate that this is working. Remuneration for services should be tied to those outcome measurements, which we don’t have. so the next step is, we’ve got to get them.

MS. BOSTON: When it comes to collect-ing data about services we deliver, senior LinkAge Line is considered a national model. We have an immense amount of information about who we serve, especially in our care transitions model. Dr. Freder-ick is right: We should not be paying for something that does not deliver the highest quality and doesn’t meet people’s needs. The state is moving in that direction. you’ll see that in the next 10 to 20 years.

MS. THURLOW: Getting to a shared defini-tion will eventually lead to metrics. Regard-ing reimbursement, we’re acting as though payment has changed, but it hasn’t. We’re still in a fee-for-service model. We need to have data, and we need to make sure it’s not just hospitals and docs that are part of that shared risk-reward payment, but that it includes the broad continuum of post-

acute care providers as well.

MR. STARNES: Sharon, we have a diversity of providers and industry sectors delivering care. Who should have ownership of the care? How does that factor into getting the right data?

MS. KLEFSAAS: We have to continue to allow our customers to have the choice of networks and to make sure we don’t lose that as we look at broader health care re-form. We have to allow smaller providers of different kinds of post-acute care to par-ticipate in the way health care is reformed, because all of them play a role in the services we make available to the broader community. We are still being paid in the old fee-for-service model, but maybe there are shorter-term solutions to how we incent our care facilities. Just like hospitals are pe-nalized for readmission, maybe we should incent long-term care facilities via a pay-ment add-on for preventing readmission. Look at other resources to align incentives of post-acute care providers.

MR. STARNES: What roles can ACOs play in getting the most from post-acute care? Can an ACO help identify who needs post-acute care?

MS. THURLOW: sure. Is an ACO required to do that? Not necessarily. I have nothing against ACOs, but I don’t think it’s the only model that can provide care coordination and effective placement. Other experiments in the state that are not necessarily ACOs provide coordination effectively.

DR. KORANNE: Right now in Minnesota, we are looking at “accountable communities for health,” so we are leapfrogging over the system ACO and looking at communities. I don’t put too much emphasis on the term. However, the payment mechanism and system must think strategically about post-acute care. Recent reports say about

33 percent of Medicare spending is in post-acute care. Most chronic diseases are in elders, and most elders will be or are on Medicare or a state-run program, so ACOs, ACHs, total cost of care, some acronym like that must think about post-acute care.

MR. STARNES: We know there needs to be a reimbursement model to better incent post-acute care. Are there examples of how post-acute care providers could benefit financially from reduced readmissions?

DR. FREDERICK: I want my doctor to be ac-countable for the care he’s delivered to me. To be able to say they’re doing it right, you have to have well-accepted outcome mea-surements. How do you know who’s doing a good job? I’m going to cite my experience 10 years ago on a panel to improve diabe-tes care in Minnesota. We came up with measurements on how many diabetics were being effectively managed. some of it was process measures, but there also were lab results that showed who was doing the best job. The first year we reported that informa-tion to the provider systems, overall optimal management of diabetics was 6.7 percent. We told the docs, “Here are your numbers. We’ll measure this next year, and then let’s talk about it and see what you’ve been doing.” The next year, the number was 9.6 percent. They must have done something better. Now, instead of 6.7 percent, the numbers of the best clinics are sometimes over 70 percent of patients being optimally managed for diabetic care. Those are what I would call accountable organizations. They’ve taken the data in front of them, applied it, and they’re getting better results. To translate that to this situation, we have to figure out what optimal care is for this group of patients, say, “This is the standard of care,” and then measure outcomes and let both the delivery systems involved, and the patients who are consumers of this care, know. Organizations need to be finan-cially rewarded for what they do. Payment’s going to come from a pool of dollars. More dollars go to ACOs that are doing the best job; fewer, to ones that aren’t. you’ve got measurable outcomes; you know who’s do-ing the best job. Reward them for it.




it’s important to have very simple messaging to the end customer.

Rahul Koranne MD, MBA, FACP

MR. STARNES: What’s a model for getting that pool of dollars into the right place?

MS. KLEFSAAS: Key ingredients are: All caregivers have to align on care practices, what we expect outcomes to be, and in how many days we expect those outcomes to take place. We’ve talked about needing to have an electronic medical record and shar-ing information to get outcomes. We have to be willing to share risks with our provid-ers in post-acute care. Whether it’s shared risk or shared savings, how do all providers share risks so that we each can sustain our business line but provide the outcomes we’re looking for in the most cost-effective way? Where to go from there? Medication error rate, development of pressure ulcers, falls, readmission rates; there’s a range of metrics that we need to make transparent, revisit, and adjust our protocols to make sure we are getting the outcomes we want.

MS. THURLOW: Minnesota has a nursing home report card at minnesotahelp.info. My team has been charged with developing a home- and community-based services report card to go to the Legislature this August. The initial services that will be displayed on that report card are registered housing with services, adult foster care, and possibly another service yet to be deter-mined. Ultimately, about 20 different home- and community-based services will be on it. What those measures will be requires consensus from providers, consumers, and state policymakers.

In talking about metrics that help inform a payment system, there’s a great template from Boston-area ACOs. They got together with post-acute providers, agreed upon a definition, and discussed what standards to have as collaborators, including appropri-ate metrics for rehospitalization and med management. Those metrics look different from report cards we have today, which are consumer facing and tell you what services are available. Helpful information, but I’m not sure it gets us to where we want to go in terms of aligning payment incentives with outcomes we desire to improve care, lower costs, and improve consumer satisfaction. That’s the conversation we need to have. It’s a collaborative effort. It’s not just payers making decisions about metrics, and it’s not just hospitals and docs making decisions about which metrics work. They may not be the same.

DR. FREDERICK: If a provider is at 30 percent and they go to 50 percent, that’s good. But I’d rather go to someone who improved from 70 percent to 71 percent. It doesn’t have to be improvement that you measure. you can measure absolute outcomes.

DR. KORANNE: surgical metrics and falls are metrics every hospital agrees upon, and those can be used in a variety of ways. They can be consumer facing or they can be pay-for-performance, they can be included in ACO. We need to have metrics and we need to pay for those metrics, but there’s a step before that. Unless we get organized around metrics, the ACOs don’t know what to start collecting and pay for. We need to empower post-acute care providers to start developing metrics that make the most

sense to them, that line up with consumers’ needs, and with governmental and the com-mercial payers. sNFs need to propose met-rics. Then we can debate: Is falls the right metric? Is facility pressure ulcers the right metric? Is readmission the right metric?

MS. BOSTON: There’s a big difference between what we need for transparency purposes and the limited amount of infor-mation that a consumer wants to look at during a long-term care crisis. We need to deliver them relevant, transparent informa-tion about a provider as quickly as possible, because a lot of times, these are very quick decisions that represent a different set of metrics than what the state would use to make payments. These projects will defi-nitely align. There is a pilot effort right now, called PIP—Payment Incentive Program—to make payments for home- and communi-

ty-based services providers. There isn’t yet a pool of money to make payments based on achieving metrics goals.

MR. STARNES: Medicare has been working since 2006 on its post-acute care payment reform demonstration project, and there’s plenty of data from that. Even though pay-ments vary substantially for similar patients in different post-acute care settings, there is little evidence that payments translate into significant benefits to patients. There is little empirical evidence regarding outcome differences across post-acute care settings, so differences in quality are difficult to notice. Let’s talk about what a patient might find helpful.

MS. BOSTON: With the Return to Commu-nity Initiative, we’ve been gathering data about the caregiver experience. Eighty-five percent of caregivers interviewed by Dr. Robert Kane at the University of Minnesota school of Public Health Center on Aging and Dr. Greg Arling at Indiana University Center for Aging Research said, “I just want information.” We have to deliver informa-tion at the literacy level and decision-mak-ing level they can handle. Most of our society has an eighth-grade literacy level. Much of what we are communicating, peo-ple aren’t going to use anyway. so they’re struggling. If there’s anything we can do systemically beyond reporting on quality measures that consumers care about, it is to translate our material in a way they can understand.




looking at consumer satisfaction data is going to be critical.

Kari Thurlow, JD

MS. SIMONSON: We have to think about what choice means in Greater Minne- sota. For an older adult, there may not be a choice, or their choice is focused on what’s closest to their home community or to where their daughter lives so she’ll be able to visit once a week. What meaningful choice is may depend on where you live and on the availability of care.

MS. THURLOW: Intuitively, we know that the No.1 question is, what are my options as close to home as possible? How often can my daughter visit me? How often can I see my grandchildren? It may not be the No. 1 quality-ranked post-acute provider, but you know what? Post-acute providers who might rank in the middle of our report cards, their consumer satisfaction data is out of sight because consumers are happy with their care. It might reflect the fact that we have, overall, really good quality in Min-nesota, but it also reflects that it’s meeting their needs. Looking at consumer satisfac-tion data is going to be critical.

MS. BOSTON: We asked, how would you make a decision about moving? The two things people said: Can my grandkids come to play on a playground nearby, and, will a facility take my dog? We have to meet these people where they are, and that’s a challenge.

MR. STARNES: Any time there are new models in health care, we hope we’re not repeating the same mistakes that occasioned a need for new models. In creating an ideal

model for post-acute care delivery, what do we want to avoid? To start with, is it a conflict for an acute care facility to own a post-acute care facility?

MS. KLEFSAAS: I don’t think so. Lots of communities in Minnesota and across the country have that. There are pros and cons to that relationship. some disadvantages of being connected may be that you have a

conceptual model of services of physicians operating in a hospital, and they tend to apply that same kind of thinking—ordering pre-scriptions, services, and labs—when the patient moves to skilled nursing or a transitional care unit.

so you might actually have a higher cost of care because of the practices that you’re seeing. On the benefit side, not having to be transported to another location is a benefit. sometimes, sharing the medical record when the two communities are connected to each other is a benefit. sharing staff, ac-cess to lab, X-ray, those ancillary services, is very convenient. If you can manage the cost of those services in the reimbursement model we have in skilled nursing homes through the Medicare system, where it’s an all-inclusive payment, that’s your challenge: to manage all those services within that daily per diem. Duplication of service costs could arise.

It’s all about collaboration and working that out. It’s about negotiating payment for those services at a rate that is covered and reasonable under our reimbursement pay-ment on the skilled services side. so there are pros and cons, but I don’t think it’s a conflict.

DR. KORANNE: Is it a conflict for one part of the continuum to align with another part of the continuum? Employment or having

the same ownership is one way of aligning. Collaboration is another way of aligning. In our system, we are starting to think about not duplicating services or core competen-cies; that would be the easiest and the best way to reduce social burden. Our last few years of work has been to develop a part-nership with post-acute care providers, who know their business best. For a primary care clinic or a hospital to say, “yeah, but we can do it better,” would be foolhardy. The only way to succeed is to align core competencies of each part of the continu-um. Honor the value that each part of the continuum brings. Because we talked about bundles of money, outside the health care continuum lies another continuum, where there is some money and lots of duplication, and those are social services. We have to get our act together, but authentic engagement, community conversation, and not duplicat-ing services are the guiding principles.

MS. THURLOW: Keeping the patient at the center of this is key. some past mistakes have been that we would direct the patient where to go; we need to reverse that. Mrs. Johnson may not want to spend a gazillion hours trying to figure out her options and she may take risks we are not comfortable with. But, it’s still her choice.

MS. SIMONSON: Vertical development in silos was a mistake. We have to think about this horizontally, across communities for accountable care. Part of that is complicated by many sectors’ duplication, relation-ships not in place, perhaps not knowing the work of other sectors. This is complex. We have to embrace the complexity. ACO mod-els today encourage more vertical building. Complex issues require complexity in terms of approach.

MS. BOSTON: A mistake I would not want to repeat is people not getting enough infor-mation about the financial impact of their long-term care choice. Everybody thinks Medicare pays for it all. They don’t under-stand that if you end up in a post-acute facility or a nursing home, you’ve got about 20 days of Medicare paying, and then either you’re picking up the bulk of the payment or you’re spending down to Medicaid very fast, and that means the state’s picking up the payment, and that’s all of us. They don’t meet with the billing office to hear, “Here’s your financial situation. Let’s do some




let patients make decisions based on outcomes and cost.

John P. Frederick, MD

planning.” If that could happen, it would change things for people. It would be more transparent.

MS. KLEFSAAS: The consumer needs to take responsibility, too, for self-management of care, for making reasonable choices aligned with recommended treatment. I would hate to see the sort of pushdown that some of us experienced in the past, where patients are discharged too soon from a hospital system because of pressure that hospitals received. Those of us in long-term care and other settings took those patients when they shouldn’t have been with us yet, because they were discharged sooner than they were ready. That maybe led to a readmission. I would hope we don’t push that same expe-rience down to the next level in transitional care, where, through pressures, we feel we have to discharge people sooner from tran-sitional care or from a home care program before they’re ready, before social and family systems are in place to support them.

MR. STARNES: Let’s think about the role that the physician can have in improving care co-ordination through the medical home model.

DR. FREDERICK: I don’t think it’ll work. To be accountable, you have to be able to show that you’re doing the job and let patients make decisions based on outcomes and cost.

DR. KORANNE: The primary providers in post-acute care settings, sNFs, are learning from the health home ambulatory model. The Optage model, the HealthEast Medical Care for seniors model, the Allina model, and the Fairview Transitions model are still using the health care home concept, but are integrated in post-acute care facilities. sit-ting in a primary care clinic and coordinat-ing in the nursing home absolutely would not work. But the nurse practitioner or geriatrician seeing a patient in a post-acute care setting is the only way to go. That’s the model we are using. It has to be at different levels, and that’s also something that we are doing at HealthEast, learning as we go with our partner, post-acute care facilities. It’s not just the front line at the bedside with Mrs. Johnson, it’s also at that policy level with administrators and the DONs of the skilled nursing facility.

MR. STARNES: One more thing from a provider perspective that we touched on briefly: the role of mental health in the post-acute setting. How are we using it now? How can using it better improve overall outcomes?

DR. KORANNE: Everybody in the room probably agrees this is something that needs a lot of work. Not just in the state but also nationally. We are starting to look at our Medicare shared savings data from a Health-East perspective, but it could be easily generalizable. For the Medicare population, adding a mental health diagnosis—I don’t mean full-blown schizophrenia—I mean depression that happens after a cardiac procedure, seasonal variation in mood, stuff like that, has a superadditive effect on diabetes, hy-pertension, hip fracture treatment. I think the journey has begun to start thinking about it, but the system is in very rudimen-tary phases and from a sNF perspective, we have psychologists that might come with a month-out appointment for somebody that just came from the hospital. Lots of work needs to be done, and we need to get together on it.

MS. BOSTON: I was at a meeting where we were discussing this very issue in terms of preadmission screening. Because, if you have a mental illness diagnosis, then you get referred for the OBRA level II, which could result in an assessment from the county. Who should get that assessment? The county assessor in the room said, “Well, someone with anxiety or depression isn’t meeting that level for us to do a full as-sessment.” Of course, the two moms in the room that have autistic kids with anxiety diagnosis said, “you do need to do that if they have anxiety, and if they’re in a nurs-ing home, they may need special services and the nursing home may not be aware of it.” It was very interesting to me that autism was seen as “mental illness lite” and wasn’t quite worthy of full assessment. I under-stand they have resource limitations, but how do we get to a place where somebody that has those basic needs can get consul-tation and assessment? Maybe by the time they’re discharged, they haven’t even had any consultation.

MR. STARNES: One last question: What must be done to clearly show that post-acute care is realizing its best potential?

MS. SIMONSON: Coming to consensus on a definition. As an Area Agency on Aging, we advocate for a definition that includes care in an institution as well as care at home.

DR. KORANNE: What needs to be done is to have a louder community conversation and to let post-acute care facilities come into their own and share expertise from acute care.

MS. THURLOW: What steps can be taken to ensure post-acute care realizes its full value? Move toward a consensus definition. Agree upon standards and metrics. It’s not just a conversation on one side of the continuum, it has to be all of us working together. Progress toward an interoperable health care exchange. Information exchange is vital to get to where we need to be.

MS. BOSTON: For post-acute care to come into its own, I look forward to seeing the baby boomers hit that system and how it responds.

DR. FREDERICK: Triple-A. It needs to be applied here like it is everywhere else in the health care system.

MS. KLEFSAAS: The patient-centered ap-proach. Listen to what patients say and adapt our models to keep them at the center of it.


Doctors have long helped patients quit tobacco. Asking about tobacco use

and making referrals to proven cessation services can be very important in improving long-term health. But the world of tobacco is constantly changing, as manufacturers evolve in the hopes of keeping customers addicted and buying. One new product that has received a lot of attention recently is the elec-tronic cigarette, or “e-cigarette.”

ClearWay Minnesota is a leading tobacco control non-profit in our state, conducting research and providing free tobacco cessation programs to Minnesotans through QUITPLAN Services. We have received many questions about e-cigarettes, and we know health care providers have been receiving them too. Understand-ing what is known—and what isn’t known—about e-cigarettes will help you give your patients the best possible advice, and to point those who smoke to tools that are proven to help them quit. With your help, more Min-

nesotans will leave tobacco be-hind, embrace healthier living, and avoid devastating health problems down the road.

What are e-cigarettes?Unlike conventional cigarettes that burn tobacco, e-cigarettes

use a battery to heat and va-porize a solution for inhaling.

E-cigarettes are designed to mimic the experience of smok-ing a cigarette. Although they do not contain leaf tobacco, the vast majority do contain nicotine, the addictive chemical present in tobacco.

There is not yet conclusive

scientific evidence on e-ciga-rette use and its possible health effects. However, the majority of health organizations, including Mayo Clinic and the Campaign for Tobacco-Free Kids, are concerned about their prolifer-ation and growing popularity in Minnesota and across the United States.

Advocates for e-cigarettes say they are harmless, but there simply isn’t sufficient evidence to support this claim. Initial studies have confirmed the presence of heavy metals and carcinogens in the vapor. Further, studies have found that e-cigarettes contain varying levels of addictive nicotine. Since there is no regulation or ingredient disclosure, there is no guarantee that there is con-sistency in how much nicotine each e-cigarette contains.

E-cigarettes are unregu-lated products. No long-term studies have been conducted on them, so the lasting health effects on their users and on others exposed to the vapor are completely unknown. This aspect should be of concern to anyone who uses e-cigarettes or is considering using them.

MarketingThe way in which e-cigarettes are marketed is also troubling. Often they are promoted not as alternatives to smoking, but as supplements to help smokers get around smoking bans. This worries many tobacco control experts, since we have seen that concurrent use of multi-ple tobacco products (such as cigarettes and chewing tobacco) can complicate nicotine addic-tion and make quitting more difficult. And unlike nicotine replacement therapy such as patches and gum, e-cigarettes are not an evidence-based medication, and no established treatment protocols exist for using them to move smokers off of cigarettes.

E-cigarette marketing also emphasizes their similarity to conventional cigarettes. The system for delivering nicotine—inhalation—is the same, and so is the glamorous and sexual-ized imagery used to promote them. Tobacco advertising has been heavily restricted in the United States for decades, but e-cigarettes are not subject to the same regulations. Media commentators have noted the similarity between e-cigarette ads and vintage tobacco pro-motions, with their celebrity endorsements and air of style and sophistication.

The tobacco industry, for its part, clearly sees e-cigarettes as the wave of the future. The three largest tobacco com-panies—Philip Morris, R.J. Reynolds, and Lorillard—have bought up manufacturers of the devices and are investing sig-nificant resources in developing their own lines of e-cigarettes.

E-cigarettes and youthPerhaps the area of greatest concern around e-cigarettes is their potential appeal to youth. Because of internal documents revealed during the Minne- sota tobacco trial in the 1990s, we have detailed information about how the tobacco indus-try has marketed directly to youth. E-cigarette makers are following the same playbook—using sexualized advertising as mentioned above, making product use as normal a part of our society as possible, and in-troducing sweet flavorings into

Public HealtH

A look at e-cigarettes

Long-term health effects are unknown

By Barbara Schillo, PhD

The three largest tobacco companies are investing significant resources in developing

their own lines of e-cigarettes.

28 MINNESOTA PHySICIAN JULY 2014

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the nicotine cartridges. E-cig-arettes have candy flavors such as chocolate, bubble gum, and fruit punch, and research shows that flavored tobacco products have strong appeal for children and teens.

E-cigarette use by kids has risen; in fact, recent CDC research indicates that use by middle-school and high-school students increased between 2011 and 2012, and that 76 percent of these young users also smoked conventional ciga-rettes. There is serious concern among experts that the combi-nation of addictive nicotine, a smoking-like delivery system, youth-appealing advertising, and kid-friendly flavors could result not just in increased use of e-cigarettes, but in individu-als using both e-cigarettes and other tobacco products.

E-cigarettes and cessationWe have all heard anecdotal stories of people who have used e-cigarettes to quit smoking. But the U.S. Food and Drug Administration (FDA) has not approved e-cigarettes as an ef-fective method to help smokers quit. There is no evidence prov-ing that they are effective cessa-tion tools, and no best practices or treatment protocols exist for their use to help patients quit.

At the same time, we do know what has been scientif-ically proven to help smokers stop using tobacco. Several medications, including nicotine replacement therapy (NRT) and prescription medications, have been approved as safe for use by the FDA. Studies show that medication, when used in com-bination with counseling, is the most effective cessation treat-ment option available. (NRT and counseling are available at no cost to Minnesotans through QUITPLAN Services.)

Anything that prolongs a smoking addiction or directs smokers away from proven methods for quitting smoking is of legitimate concern to health practitioners. The FDA has proposed initial regulations on e-cigarettes, and has called for new research to inform further ones. The University of Min-nesota has also announced its intention to conduct a study on the health impacts of e-ciga-

rette use and exposure. But for now, there remain too many unknowns. Simply put, until science suggests otherwise, tobacco users who want to quit should explore proven options like those offered by QUIT-PLAN Services.

Policy developmentsIn Minnesota, e-cigarettes are taxed as a tobacco product, and it is illegal to sell them to minors. E-cigarette use does not meet the current definition of “smoking” under Minnesota’s Clean Indoor Air Act. However, this spring, Gov. Mark Dayton signed a bill prohibiting the use of e-cigarettes in several public workplaces, including hospi-tals and clinics, most govern-ment-owned buildings (in-cluding correctional facilities), University of Minnesota and Minnesota State Colleges and University buildings (including dorm rooms), and daycares during operating hours.

Many local communities and some major businesses have also taken action to limit the use of e-cigarettes and to ensure that indoor air remains clean and healthy.

• Duluth, Hermantown, Ely, and Mankato ban the use of e-cigarettes anywhere smoking is prohibited, including bars and restau-rants. They also prohibit the sampling of e-ciga-rettes in retail stores and require e-cigarette sellers to get a tobacco license.

• Beltrami County includes e-cigarettes in its county indoor air law, requires e-cigarette vendors to get a tobacco license, and has limits on sampling in stores.

• Hennepin County bans the use of e-cigarettes on county property.

• Housing and redevelop-ment authorities in St. Cloud, Eveleth, and Worth-ington include e-cigarettes in their smoke-free hous-ing policies.

• Hennepin County Tech-nical College and Bemidji State University ban the use of e-cigarettes on their campuses.

• Rock County requires that all e-cigarettes be sold from behind the counter in a locked case in retail stores, and prohibits sam-pling.

• Scott County includes e-cigarettes in its smoke-free work place policy.

• Target Field, Mall of Amer-ica, Target Center, and the Minnesota Zoo all prohibit e-cigarette use.

Both state and local bodies of government have taken policy steps to address the concerns residents have about e-ciga-rettes.

Barbara Schillo, PhD, is a vice pres-ident at ClearWay Minnesota in Min-neapolis, where she leads research and cessation programs and coordi-nates efforts to translate knowledge into effective initiatives that reduce tobacco use in Minnesota.

• AfactsheetandvideofromClearWayMinnesota,anindependentnonprofitworkingtoreducetobacco’sharmthroughoutthestate:www.clearwaymn.org/e-cigarettes/

• Freequittinghelp,phonecounselingandmedicationsforMinnesotatobaccousers:www.quitplan.com

• TheU.S.DepartmentofHealthandHumanServices’PublicHealthServiceClinicalPracticeGuidelinefortreatingtobaccouseandde-pendence:http://bphc.hrsa.gov/buckets/treatingtobacco.pdf

• InformationandlinksfromtheMinnesotaDepartmentofHealth’sOfficeofTobaccoPreventionandControl:www.health.state.mn.us/divs/hpcd/tpc/facts/ecigarettes.html

• Acommentone-cigarettesfromMayoClinic:www.mayoclinic.org/electronic-cigarettes/expert-answers/FAQ-20057776

Resources for information on e-cigarettes

JULY 2014 MINNESOTA PHySICIAN 29

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according to the epilepsy Foundation of Minnesota, more than

2.2 million americans live with epilepsy. in Minnesota alone, that includes approximately 60,000 individuals—among them, one-year-old Jack. in 2012, when Jack was just a few weeks old, his parents noticed he was having uncontrolla-ble “episodes” for no obvious reason. his body would fre-quently tense up and appear as though he was either laughing or crying.

after several months of visiting various doctors and specialists, Jack arrived at chil-dren’s hospital and clinics of Minnesota, home to one of the largest and most well-respected pediatric epilepsy programs in the country, particularly for children with complex epilepsy.

Weighing open surgeryan MRi revealed that Jack had an 8-millimeter by 10-millime-ter hypothalamic hamartoma, a benign tumor located in the

hypothalamus—a small, but critical and difficult to reach area of the brain. the tumor was causing Jack to suffer from rare gelastic and dacrystic seizures, which in Jack’s case could occur up to 15 times a day. While traditional treat-ments to address his seizures were initially explored, includ-ing medication, nerve stimu-lation, and dietary changes, Jack had no respite. therefore a fourth option, typically consid-ered when medication fails to control the seizures, was ulti-mately discussed: surgery.

typical epilepsy surgery, or

craniotomy, requires making a relatively large incision in the child’s scalp. then, de-pending on the depth of the targeted lesion that is causing the seizures, an incision has to be made inside the child’s brain so the lesion can be taken out. Finally, all of the surgical incisions need to be closed. although a major procedure, the benefits of epilepsy surgery can clearly outweigh the risks. in fact, some research indicates that for many patients, the odds that epilepsy surgery can pro-vide complete seizure control is up to 70 percent—dramatically improving a child’s and their

families’ overall quality of life.

indeed, Jack was an excel-lent surgical candidate. how-ever, because of his young age, the fragility of his brain, and the fact that the lesion was small and deeply-seated, the potential risks of performing a craniotomy on Jack—such as significant blood loss and neurological injury—far out-weighed the benefit.

A new window into the brain gives hopein october 2013, children’s acquired Visualase, a new, minimally invasive laser that uses MRi mapping and precise thermal destruction to ablate undesirable tissue in the brain. the procedure itself requires making a 3-millimeter pin-hole in the skull and under the guidance of an MRi-cath-eter system, threading a laser directly to the active lesion site. Laser ablation takes place while a patient is in an MRi scanner,

Surgery

Making the inoperable, operable

Breaking new ground in pediatric epilepsy treatment

By Meysam Kebriaei, MD

Making the inoperable, operable to page 32

Are Your Kids Ready?Minnesota’s Immunization Law

MMR

MMR

MMR

MMR

Varicella

Varicella

Varicella

Varicella

Early childhood programs & Child care

Birth through 4 years

For Kindergarten

Age: 5 through 6 years

For 1st through 6th grade

Age: 7 through 11 yearsFor 7th through 12th

grade

Age: 12 years and older

Immunization Requirements

IC# 141-3830 (3/2014)

Use this chart as a guide to determine which vaccines are required to enroll in child care, early child-hood programs, and school (public or private).Find the child’s age/grade level and look to see if your child had the number of shots shown by the checkmarks under each vaccine. Children birth to age 2 may not have received all doses. Look at the table on the back, it shows the age when doses are due.

To enroll in child care, early childhood programs, and school in Minnesota, children must show they’ve had these immunizations or file a legal exemption.Parents may file a medical exemption signed by a health care provider or a conscientious objection signed by a parent/guardian and notarized.

Exemptions

Hepatitis B

Hepatitis B

Hepatitis B

Hepatitis B (Hep B)

Hepatitis A (Hep A)

Hib

Meningococcal at 7th grade & at age 16

Influenza Annually for all children age 6 months and older

Pneumococcal

Human papillomavirus At age 11 -12 years

Immunizations recommended but not required:

For copies of your child’s vaccination records, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 1-800-657-3970.

Looking for Records?

RotavirusFor infants

DTaP/DT

tetanus and diphtheria containing doses

Tdapat 7th grade

DTaP

Polio

Polio

Polio

Polio

Minnesota Department of Health, Immunization Program


Are Your Patients Ready? Minnesota’s New Immunization Law Goes into Effect 9/1/14

There are important changes that apply to children entering school, child care, and early childhood programs. This means you likely have patients who will need to get caught up on some of their immunizations between now and the end of the summer. For vaccines that are required or recommended, please use this chart (legal exemptions are available).

Call in patients who need vaccines. Use the Minnesota Immunization Information Connection (MIIC) to identify and call in children who still need to get their shots. For more information or technical assistance, contact your MIIC regional coordinator:

www.health.state.mn.us/divs/idepc/immunize/registry/map.html.

Are Your Kids Ready?Minnesota’s Immunization Law

MMR

MMR

MMR

MMR

Varicella

Varicella

Varicella

Varicella

Early childhood programs & Child care

Birth through 4 years

For Kindergarten

Age: 5 through 6 years

For 1st through 6th grade

Age: 7 through 11 yearsFor 7th through 12th

grade

Age: 12 years and older

Immunization Requirements

IC# 141-3830 (3/2014)

Use this chart as a guide to determine which vaccines are required to enroll in child care, early child-hood programs, and school (public or private).Find the child’s age/grade level and look to see if your child had the number of shots shown by the checkmarks under each vaccine. Children birth to age 2 may not have received all doses. Look at the table on the back, it shows the age when doses are due.

To enroll in child care, early childhood programs, and school in Minnesota, children must show they’ve had these immunizations or file a legal exemption.Parents may file a medical exemption signed by a health care provider or a conscientious objection signed by a parent/guardian and notarized.

Exemptions

Hepatitis B

Hepatitis B

Hepatitis B

Hepatitis B (Hep B)

Hepatitis A (Hep A)

Hib

Meningococcal at 7th grade & at age 16

Influenza Annually for all children age 6 months and older

Pneumococcal

Human papillomavirus At age 11 -12 years


For copies of your child’s vaccination records, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 1-800-657-3970.

Looking for Records?

RotavirusFor infants

DTaP/DT

tetanus and diphtheria containing doses

Tdapat 7th grade

DTaP

Polio

Polio

Polio

Polio

Minnesota Department of Health, Immunization Program

Check marks represent number of doses

We are specialists in Apple devices (including iPads and iPhones) and software. We also support Windows and Windows to Apple integration. We are certified through the Apple Consultants Network serving individ-uals and businesses inquiring about moving to Apple, or how to improve existing systems.

Services include:

612-643-0643www.perfecteden.com

Rapid service and reasonable ratesProviding service throughout the metro area and remote service connection throughout Minnesota

Computer Problems?

•On-sitetraining–inyourclinic,hospitalorathome

•GroupWorkshops

•ExpeditedComputerRepairs

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•Networkconnectivityissues

Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.

Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefi t package, paid malpractice and a commitment to providing exceptional patient-centered care.

Apply online at healthpartners.com/careers orcontact [email protected]. Call Diane at 952-883-5453; toll-free:800-472-4695 x3. EOE

healthpartners.com© 2014 NAS(Media: delete copyright notice)

MN Physician4" x 5.25"4-color

Renville County Hospital & Clinics is looking for a BC/BE Family Medicine Physician. RCHC is

25-bed Critical Access Hospital with three clinics committed to quality, evidence-based care and

exceptional patient satisfaction. Current call is 1:4.

Excellent compensation. Enhanced physician benefits with PERA retirement benefit

included with this position.

Contact: Lynette Bernardy611 East Fairview Avenue, Renville, MN 56277

[email protected]: (320) 523-1261 • Toll-free: (800) 916-1836

BC/BE Family Medicine Physician

We’re located in a beautiful, family-oriented community just 90 miles west of Minneapolis/St. Paul. Recreational facilities include five golf courses, hunting, fishing, several relaxing lakes and Minnesota River within minutes.

Plus! We’re building a new medical center (projected completion 2015)!


Emergency Room Physicians

Looking for leisure work hours?

• Immediate openings

• Casual weekend or eveningshift coverage

• Choose from 12 or 24 hourshifts

• Competitive rates• Paid malpractice

Attention Physicians

763-682-5906 • 1-800-876-7171

F-763-684-0243

[email protected]

• Set your own hours

• No contract

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Great Emergency Department in Southern Minnesota

and uses light energy to heat and destroy lesions in the brain. Guided by real-time thermal MRI images, surgeons are able to pinpoint the exact target area without damaging the healthy surrounding tissue. While the technology has historically been used to address various neurosurgery cases in adults, we are using the laser to treat children.

A thriving little boyIn January 2014, neurosur-geons used the new, minimally invasive technology to address the lesion that was causing Jack’s seizures. Stabilizing his head with a frame, surgeons used X, Y, and Z coordinates to determine the exact target area deep within Jack’s small brain. After passing a catheter di-rectly to the site, a second MRI confirmed that surgeons were in the right area. The laser then heated and destroyed the lesion, and real-time monitoring data

ensured that no surrounding nerves or tissue were damaged or destroyed in the process.

Immediately following the procedure, Jack’s seizures ceased. In addition, because the minimally invasive technique only required a 3-millimeter burr hole and incision that was literally sewn together with a single stitch, it meant that Jack could be discharged the very next day. Today, Jack remains seizure-free.

How laser ablation fits into current approachesThe contrast between conven-tional epilepsy surgery and laser ablation is mainly in the amount of surgical injury a child has to go through to have an epileptic lesion removed. That can be profound in a child, especially for younger children like Jack, where the head is still typically bigger in proportion to the body.

As far as the downsides, to date, not many have been found. The biggest worry, and

the hypothesized problem with the approach, is that the laser simply cannot ablate enough tissue to affect a cure of some epilepsy syndromes. Postoper-ative swelling is another poten-tial concern—yet to a far lesser degree than with major invasive surgery of the brain. To address possible swelling concerns, pa-tients undergoing laser ablation are monitored overnight in the hospital before going home.

The take-home We have successfully used the laser ablation procedure to treat both epilepsy patients and those with brain tumors. The results have been nothing less than great. For example, nearly eight months after using the laser, one 14-year-old patient, who previously had to have fre-quent open surgeries when her medications did not alleviate her chronic epileptic seizures, is now seizure-free.

Aside from epilepsy, we also use the laser to treat brain tumors, such as that of a 7-year-

old patient who had previously undergone 17 different surger-ies. After each invasive brain surgery, however, the child’s tumor grew back. Yet after two separate minimally invasive laser ablation procedures, not only has the child’s peach-sized brain tumor shrunk 40 percent, but three months after the surgery, it shows no signs of growing back.

Laser ablation does not nec-essarily open surgical epilepsy techniques to a brand-new col-lection of patients. Traditional treatment methods for epilepsy likely always will have their place. What laser ablation does do, however, is offer pediatric neurosurgeons and a handful of their patients access to new, minimally invasive options that did not exist just five years ago—ultimately providing the potential to render the term “inoperable” brain tumors and lesions obsolete.

Meysam Kebriaei, MD, is a pe-diatric neurosurgeon at Children’s Hospitals and Clinics of Minnesota.

32 MInneSoTA PhYSIcIAn JULY 2014

Making the inoperable, operable from page 30

BC/BE Family Practice Physician

No phone calls please. Submit Cover Letter and Resume to [email protected].

CLOSING DATE: Open until filled.1213 E. Franklin Avenue, Minneapolis, MN 55404

Immediate opening at dynamic urban clinic serving the Native American community. We are passionate about our work and about providing exceptional care. We are

looking for a physician who will be a good fit for our clinic and for the community we serve. This is a full-time position (80 hours per pay period), with health and dental benefits.

We are a NHSC and IHS loan repayment site.

Must be licensed to practice in Minnesota and have current

board certification or eligibility.

Clinic hours are Monday thru Friday 9am-5pm and Saturdays 10am-2pm.

Sioux Falls VA Health Care System

Sioux Falls VA HCS, SD

Applicants can apply online at www.USAJOBS.gov

Sioux Falls VA HCS(605) 333-6852

www.siouxfalls.va.gov

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

Primary Care (Family Practice or Internal Medicine)

Psychiatrist

Endocrinology

Pulmonologist

Oncologist

Cardiologist (part time)

Urgent Care

We have part-time and on-call

positions available at a variety of Twin

Cities’ metro area HealthPartners

Clinics. We are seeking BC/BE full-

range family medicine and internal

medicine pediatric (Med-Peds)

physicians. We offer a competitive

salary and paid malpractice.

For consideration, apply online at

healthpartners.com/careers and

follow the Search Physician Careers link

to view our Urgent Care opportunities.

For more information, please contact

[email protected]

or call Diane at: 952-883-5453;

toll-free: 1-800-472-4695 x3. EOE

healthpar tners .com© 2014 NAS(Media: delete copyright notice)

MN Physician4" x 5.25"4-color


In the U.S. Air Force, the power of being a physician reaches new heights. Work on the most time-sensitive cases. See medical advances as they happen. Be a hero to heroes. And do it all at 30,000 feet.

- Family Physician- Flight Surgeon- Internist- Pediatrician- Psychiatrist- General Surgeon- Neurological Surgeon- Trauma Surgeon

We’re looking for you

1-800-588-5260

Olmsted Medical Center, a 160-clincian multi-specialty

clinic with 10 outlying branch clinics and a 61 bed hospital,

continues to experience significant growth.

Olmsted Medical Center provides an excellent

opportunity to practice quality medicine in a family

oriented atmosphere.

The Rochester community provides numerous cultural,

educational, and recreational opportunities.

Olmsted Medical Center offers a competitive salary

and comprehensive benefit package.

Opportunities available in the following specialties:

Child PsychiatristRochester SE Clinic

Dermatology Rochester Southeast Clinic

Family Medicine Byron Clinic

Pine Island Clinic

General SurgeryCall Only – Rochester Hospital

Send CV to: Olmsted Medical Center Administration/Clinician

Recruitment102 Elton Hills Drive NW

Rochester, MN 55901

email: [email protected]: 507.529.6748

Fax: 507.529.6622

www.olmstedmedicalcenter.org

BC/BE Family PracticeMankato Clinic is seeking a Family Practice provider to work at Madelia Hospital & Clinic in an inpatient/ outpatient/ Emergency Department practice. Madelia Hospital is a 25-bed, acute care, Critical Access Hospital that has received the JCAHO Gold Seal of Approval. Primary health services available in-clude medical/surgical, Level 4 Trauma, 24/7 Emergency Room, 24-hour Lab, Physical Therapy, diagnostic imaging with a 16 slice CT, digital mammography and more.

Madelia Hospital & Clinic offers a sign-on bonus of $75,000 and an additional $50,000 bonus to live in the community.

Contact Dennis Davito for more information at (507) 389-8654 or by email at [email protected]

Apply online at www.mankatoclinic.com

Mankato Clinic employment features:• Excellent first year guarantee and

production bonus opportunity• Competitive Benefit Package with

401(k) and profit sharing• Shareholder opportunity in your

second year• Generous CME allowance

use quantitative MRI analysis and computerized cognitive tasks, rather than the clinical exam, to evaluate their effects. Unlike Alzheimer’s disease and Parkinson’s disease, we have the ability through genetic testing to identify with certainty who will develop HD, as early as we want. Clinical trials in the “pre-symptomatic” HD population are beginning—with cautious attention to the critical ethical, legal, and social implications of this work.

HD clinical researchers have organized into large consor-tia to facilitate our work. The Huntington Study Group, a consortium of HD clinical re-

search centers in the U.S., has performed about 20 observational and experi-mental trials over the last two decades. Members of the Minnesota HD com-munity, working through the Center of Excellence, have participated in about a dozen of these trials.

Another observational study, Enroll-HD, has gone global and plans to enroll 20,000 HD patients and family members from around the world. The study will collect samples and data in a uniform fashion for data-min-ing analyses, compare aspects of HD care around the world, and facilitate access to biolog-

ical specimens for HD bench researchers.

The annual meeting of the Huntington Study Group will take place in Minneapolis in November. Although the meet-ing is restricted to the HSG membership, an associated

Clinical Research Symposium on Nov. 8 is open to interested health professionals and to the public. There also will be a one-day CME course on HD for physicians on Nov. 7. Physicians attending either of these events will be convinced that there is never “nothing I can do” for someone with HD.

Martha A. Nance, MD, is a neurologist and geneticist, and has been the director of the HD Center of Excellence at Hennepin County Medical Center since 1991. Jessica Marsolek, LSW, is the state social worker with the Minnesota Chapter of the Huntington’s Disease Society of America.

• Abilitytowork:3-normal;2-mildimpairment;1-volunteerwork;0-unable

• Abilitytomanagemoney:3-normal;2-mildimpairment;1-simplepur-chaseonly;0-unable

• Abilitytodohouseholdchores:2-normal;1-someimpairment;0-unable

• Abilitytodoactivitiesofdailyliving:3-normal;2-mildimpairment;1-moderate-severeimpairmentbutparticipates;0-unable

• Abletolive:2-home;1-someprofessionalassistance;0-long-termcare

Stage1:11to13points;Stage2:7to10points;Stage3:3to6points;Stage4:1to2points;Stage5:0points

The Shoulson-Fahn Total Functional Capacity ScaleHuntington’s disease from page 19

“ThePhysician’sGuidetotheManagementofHuntington’sDisease,Thirdedition,”waspublishedbytheHuntington’sDiseaseSocietyofAmerica(HDSA)in2011andisdownloadablefromtheHDSAwebsite.Itisanexcellentresourceforphysicians,otherhealthprofessionals,andfamilies.AvarietyofotherusefulonlineandprintresourcesarealsoavailablethroughtheHDSAwebsite.Findmoreinformationat:

Huntington’sDiseaseSocietyofAmerica:www.hdsa.org

Huntington’sDiseaseYouthOrganization:en.hdyo.org

MinnesotaChapter,Huntington’sDiseaseSocietyofAmerica:www.hdsa.org/mnchap

More information about Huntington’s disease

34 MINNESoTA PHySICIAN JULY 2014

Think about what you really want in a career.

We’ve got you covered from both sides...

The Left Side Your Analytical, Pragmatic Side

*Company Paid Malpractice Insurance *Comprehensive Healthcare Benefits + 401(k) Plan

*Consistent & Predictable Work Schedule *Freedom from the Hassles of Managed Care;

No Insurance or Billing Issues

The Right Side Your Creative, Spontaneous Side

*Generous Paid Time Off & Holidays *Professional Satisfaction Treating Diverse & Clinically Interesting Cases

*Collaborate with an Experienced Treatment Team of Healthcare Professionals and Security Staff

*CME Paid Days Off & Reimbursement

We are also seeking a Primary Care Physician to serve as our STATEWIDE MEDICAL DIRECTOR based out of our Regional Office in St. Paul.

MHM Services, in conjuction with Centurion of Minnesota is proud to be the provider of healthcare services to the Minnesota Department of Corrections. We currently have excellent Full Time, Part Time & Per Diem

PRIMARY CARE and PSYCHIATRIST opportunities available throughout Minnesota, including the following locations:

Lino Lakes * Shakopee * Oak Park Heights * Stillwater Faribault * Moose Lake * Red Wing * Rush City * St. Cloud

For more information, please contact: Tracy Glynn· 877.616.9675· [email protected]

www.mhm-services.com | Equal Opportunity Employer

Please contact or fax CV to:

Joel Sagedahl, M.D.5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

www.NWFPC.com

Join the top ranked clinic

in the Twin CitiesA leading national consumermagazine recently recognizedour clinic for providing the bestcare in the Twin Cities based on quality and cost. We are currently seeking new physicianassociates in the areas of:

• Family Practice

• Urgent Care

We are independent physician-owned and operated primaryclinic with three locations in theNW Minneapolis suburbs. Work-ing here you will be part of anaward winning team with partner-ship opportunities in just 2 years. We offer competitive salary andbenefits. Please call to learn howyou can contribute to our innova-tive new approaches to improvinghealth care delivery.


Here to care

At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 12 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel.

Make a difference. Join our award-winning team.

Madalyn Dosch, Physician Recruitment ServicesToll-free: 1-800-248-4921 Fax: 612-262-4163 [email protected]

allinahealth.org/careers

13273 0414 ©2014 ALLINA HEALTH SYSTEM ® A TRADEMARK OF ALLINA HEALTH SYSTEM

EOE/AA

3.5x4.75_AD_MN_Medicine.indd 1

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

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position

may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction

Program. Possible recruitment bonus. EEO Employer.

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information:Visit www.USAJobs.gov or contact

Nola Mattson, [email protected] Resources

4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

• Dermatologist• Geriatrician/ Hospice/

Palliative Care• Internal Medicine/

Family Practice

Applicants must be BE/BC.

• Medical Director- Extended Care & Rehab (Geriatrics)

• Ophthalmologist• Psychiatrist

ology colleagues manage, but the advances have been remark-able. Performance with a CI has consistently improved over the years. Some of this involves improved internal devices and surgical technique, but enhancements in the external device electronics have played a big role.

Sound processing strate-gies, algorithms for managing background noise, connectiv-ity with phones, FM systems and other devices, and remote controls have all enhanced the functionality. Some devices will now allow for data logging—it will be possible to know in what types of environments a child is listening, what programs they use, and how many hours the device is on.

Keeping devices on children can be a challenge in some families. But a child cannot be expected to learn speech and language without exposure, and

this tool will help us better un-derstand why some children do not progress as well as others, and perhaps help us develop interventions to improve out-comes.

Age is not a factorThe final boundary I’ll com-ment on is age. It is not uncom-mon to hear, “I’m too old to do something like this.” I would argue that, since our lives revolve around communicating with others, hearing becomes increasingly important as we age. We have published out-comes in patients over age 80, and they are quite favorable. Performance is similar to a matched cohort of younger adults, although it may take a little longer to reach maximal performance. Complications from this one-hour outpatient

operation are rare.

At the other end of the age spectrum are the young children. We know that early implantation results in the best speech outcomes, but how

young is young enough? Below the age of 6 months, we can-not be confident we know the hearing thresholds, but around this time we can consider im-plantation. When we are highly confident a child meets implant criteria, we can proceed with bilateral simultaneous implan-tation at 6 months. The data suggests that these children gain language skills faster. But it is not clear if their ultimate performance is better than a child implanted at 1 year.

Having a CI can change a child’s life. This is what can

happen:

“My daughter became a mem-ber of the high school marching band in the drum line. As I sat there and watched, I was moved to tears. If not for the cochlear implants she would not have been able to participate. She’s joined the speech team and is learning tuba … She has friends who ask “What is it with those things on your head?” She has adapted so well no one realizes she is hard of hearing.” —A mom

Today’s cochlear implant recipients are, as a whole, quite dissimilar to those being im-planted in the 1980s. They are younger and older, have more residual hearing, may have tumors involving the hearing nerve, and may even have nor-mal hearing in the nonimplan- ted ear. What an evolution!

Colin Driscoll, MD, is a professor and chair of the department of oto-laryngology—head and neck surgery, at the Mayo Clinic, Rochester.

As the devices have matured, the surgical tech-nique improved, and outcomes assessed, this

technology is being applied to new populations.

Cochlear implantation from page 17

36 MInneSoTA PHySICIAn JULY 2014

Physician Practice Opportunities

www.averamarshall.org

Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassion-ate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.Currently we are seeking to add the following specialists:

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/

For more information, contact Dave Dertien,Physician Recruiter, at 605-322-7691 • [email protected]

• GeneralSurgery• RadiationOncology• InternalMedicine

• Pediatrics• FamilyPractice

Avera Marshall Regional • Medical Center300 S. Bruce St. • Marshall, MN 56258

Psychiatrist

Unique Practice – Unique Psychiatrist Needed!HealthPartners Medical Group is a top Upper Midwest multispecialty group practice based in Minneapolis/St. Paul, Minnesota. We have a unique metropolitan-based outpatient position available for a talented, bilingual BC/BE psychiatrist interested in a non-conventional practice.

This full-time position combines cross-cultural psychiatric medicine with community mental health. Receiving practice support from both HealthPartners Center for International Health and from the Ramsey County Mental Health Center, 0.5 FTE of the position will provide psychiatric care to an international refugee patient population utilizing an integrated holistic/primary care model. The other 0.5 FTE of the position will work as part of a multidisciplinary team to provide care to individuals with serious mental illness, chemical health diffi culties and/or co-occurring medical problems.

This exciting practice is full-time, but qualifi ed candidates interested in part-time outpatient opportunities in Cross-Cultural Psychiatric Medicine or Community Mental Health are encouraged to apply. In addition to a competitive salary and benefi ts package, there are opportunities for an academic faculty appointment at the University of Minnesota, teaching involvement in the Global Health Pathway (globalhealth.umn.edu) and further development of best practice programming at Ramsey County Mental Health Center. For consideration, please forward your CV and cover letter to [email protected], apply online at healthpartners.com/careers, or call Lori at (800) 472-4695 x1. EOE

© 2014 NAS(Media: delete copyright notice)

Minnesota Physician4" x 5.25"B&W

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

Stevens Community Medical Center’s Starbuck Clinic is looking for a family medicine physician. Enjoy the beautiful

area lakes, quiet atmosphere and all that West Central Minnesota has to offer. Starbuck Clinic is home to Staff

Care’s 2013 Country Doctor of the Year. Dr. Bösl and Greg Rapp, PA provide full clinic services in the picturesque

town of Starbuck, MN on Lake Minnewaska. Dr. Bösl would like to transition into retirement. If you would enjoy the

serenity of a rural lake community plus the comfort of an independent practice, this is your opportunity!

Family Medicine

www.scmcinc.orgVisit us on Facebook and Twitter.

Morris locationJohn Rau, CEO320.589.7655

[email protected]

Starbuck locationDr. Robert Bösl320.239.3939

[email protected]

For more information, contact John Rau, CEO or Dr. Robert Bösl.

THE STRENGTH TO HEAL

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.

© 2010. Paid for by the United States Army. All rights reserved.

and stand by those who stand up for me.

To learn more, call 1-855-276-9579 or visitwww.healthcare.goarmy.com/q955.


The perfect matchof career and lifestyle.

www.acmc.com |

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

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

Internal Medicine

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

• Psychiatry• Pulmonary/

Critical Care• Rheumatology• Urgent Care

For more inFormaTion:

Kari Lenz, Physician Recruitment | [email protected] | (320) 231-6366

that it soon will be expanded to include action plans for anaphy-laxis (EpiPen) therapy.

Additional usesA similar system could share other important health-related information between the child’s school-based and non-school-based health professionals.

The types of health action plans that can be developed and shared are numerous, ranging from asthma and anaphylaxis

to seizures, diabetes, and behavioral issues. Electronic transfer of student health data assures that what is developed in the office is accessible in the school. Use of standardized templates with drop-down boxes assures that the orders and action steps are useable by the school nurses or other personnel.

While completion of the plans requires time and a sys-tem to assure successful trans-fer of the information to the

schools, failure to share infor-mation and medication orders can put children with chronic conditions at significant risk for delayed or inappropriate care. Reimbursement for this im-portant service is not currently available, but may be a possibil-ity with pay-for-performance or Accountable Care Organization payment plans.

Barbara P. Yawn, MD, MSc, is a family physician and the director of research at the Olmsted Medical Cen-

ter. Dan Jensen, MPH, is the asso-ciate director at the Olmsted County Public Health Services. He led the school portal development portion of the program. Lisa Klotzbach, RN, BAN, MA, works for the Olmsted County Public Health Services. She led the school portal implementation work of the program. Erin Knoebel, MD, is a pediatrician in the com-munity pediatrics department at the Mayo Clinic, Rochester. She and Dr. Yawn co-chaired the school asthma action plan for the Southeast Minne-sota Beacon program.

For more information about asthma action plans, visit:

• MinnesotaDepartmentofHealth:www.health.state.mn.us/asthma/ActionPlan.html

• TheAmericanLungAssociation:www.lung.org/lung-disease/asthma/taking-control-of-asthma/create-an-asthma-management-plan.html

Beaconisacommunity-basedprogramthatspotlightsavarietyof“bestpractice”approachestoimprovinghealthandhealthcaredeliveryintheUnitedStates.TheBeaconcommunitiesareaseriesofmedicalpracticeandresearchcoalitionsfocusingonspecifichealthconditionsintheirareas,anddevelopingefficientsystemsbasedontheirexpertise.FormoreinformationabouttheSoutheastMinnesotaBeaconprogram,visit:

• www.semnbeacon.wordpress.com/

• www.health.state.mn.us/e-health/summit/s2011beacon.pdf

Asthma action plans and the Beacon program

38 MinnEsOTA PhysiCiAn JULY 2014

School-based asthma action plans from page 15

6444 Xerxes Ave South • Edina, MN 55423 • (952) 831-422214050 Nicollet Ave South • Suite 114 • Burnsville, MN 55337 • (952) 303-5895611 East Fairview Ave • Olivia, MN 56277 • (320) 523-1085

www.audiologyconcepts.com

We believe in the delivery of hearing healthcare based on a medical model, not the purchase of a gizmo online or from a big box retail store. Our patients receive doctoral level assessments to address not only hearing loss but lifestyle, cognitive abilities and budget. We thank our referring physicians for their continued referrals, belief in this medical model and ongoing support.

—Dr. Paula Schwartz

Paula Schwartz, Au.D., Doctor of Audiology

Jason Leyendecker, Au.D., Doctor of Audiology

Courtney Stone, Au.D., Doctor of Audiology

Rebecca Thiesse, Au.D., Doctor of Audiology

X Physician endorsed X Edina, Burnsville & Olivia X Pediatric testing (Burnsville) X Auditory Processing Disorder testing (Burnsville) X Audiological assessments X Hearing technologies X Tinnitus treatment through the Tinnitus and Hyperacusis Clinic (Edina)

Alcohol is more harmful to an unborn baby than cocaine, marijuana or heroin.Drinking during pregnancy can cause Fetal Alcohol Spectrum Disorders (FASD) which permanently harm the way your baby learns and behaves.

- ZERO ALCOHOL FOR NINE MONTHS.

At MMIC, we believe patients get the best care when doctors, staff and administrators are humming the same tune. So we put our energy into creating risk solutions that help everyone feel confi dent and supported. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care.

To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.

The more weget together, thehappier and healthier we’ll be.

MnPhy POMM.indd 3 4/15/2013 1:22:59 PM

Minnesota Physician July 2014

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