mn physician may 2016

“The best estimate from autopsy studies is that there are 40,000 to 80,000 deaths a year from diagnostic error.”

Mark L. Graber, MD

In September 2015, the Commit-tee on Diagnostic Error in Health Care released a report, Improving

Diagnosis in Healthcare (hereafter known as “the committee’s report”) as a follow up to the Institute of Med-icine’s Quality Chasm Series. The report states, “It is likely that most

people will experience at least one di-agnostic error in their lifetime, some-times with devastating consequences.”

A study published in BMJ Quality and Safety in 2013 reviewed 25 years of medical malpractice claims for diagnostic errors and found that, “Di-agnostic errors appear to be the most common, most costly and most dan-gerous of medical mistakes.” Another study in Critical Care Medicine in 2012 found, “Significant discrepancies in

Prescribing medications to page 12

Diagnostic errors to page 10

Vo lum e X X X, N o. 2M a y 2016

What portion of the medicines that are prescribed end up in our water sup-ply? Consider that about 2.5 million

pounds of amoxicillin was sold in the U.S. in 2009. Eighty-six percent of amoxicillin is ex-creted unchanged in urine. Less than 2 percent of amoxicillin is removed by water-treatment facilities. That means that 2,100,000 pounds of amoxicillin enter the environment every year! As health care providers, we bear some respon-sibility for that.

Medicines are designed to affect living organisms—they kill unwanted bacteria and viruses, alter metabolism, or change hormon-al balances. They can have similar effects on other life forms when they enter our lakes and streams. We know that the presence of five parts per trillion of common contraceptive medica-tions can cause the collapse of fish populations and that low concentrations of antidepressants in water can alter fish reproductive behavior.

We can document DEET in 76 percent of sampled Minnesota lakes, amitriptyline in 28 percent of studied lakes, sulfonamides in sur-face water, and triclosan in treatment plant ef-fluent. Iopamidol, a radiopaque contrast agent, was found in 73 percent of the lakes in the 2013

Prescribing medications

Assessing the environmental impact

By Lowell J. Anderson, DSc, FAPhA

Diagnostic errorsAvoiding negative outcomes

By Ann Fiala, RN, BSN, CPHRM, CHC

Genetics and genomics is a fast-moving field. At the IM

Conference, medical professionals learn from and network

with international researchers and experts at the cutting edge.

“Very engaging and balanced subject

matter; there is something for all

attendees.” – 2015 Conference Attendee

ADVANCING CARE THROUGH GENOMICSHOSTED BY MAYO CLINIC CENTER FOR INDIVIDUALIZED MEDICINESUPPORTED BY THE SATTER FOUNDATION

INDIVIDUALIZINGMEDICINE 2016CONFERENCE

Oct. 5-6, 2016 / Rochester, MN

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Who should attend?

• Medical practitioners seeking to learn how to apply

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Why attend?

Discuss emerging topics in applied genomics:

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FEATURES

MAY 2016 MINNESOTA PHYSICIAN 3

MAY 2016 • VOLUME XXX, NUMBER 2

www.mppub.com

PUBLISHER Mike Starnes | [email protected]

EDITOR Lisa McGowan | [email protected]

ASSOCIATE EDITOR Richard Ericson | [email protected]

ADVERTISING DIRECTOR Stefani Pennaz | [email protected]

ART DIRECTOR Joe Pfahl | [email protected]

OFFICE ADMINISTRATOR Amanda Marlow | [email protected]

DEPARTMENTS

CAPSULES 4

MEDICUS 7

INTERVIEW 8

INFECTIOUS DISEASES 16Travel-associated mosquito-borne diseases

By Franny Dorr, MPH

PHARMACY 26Redesigning primary care

By Lara Kerwin, PharmD, and Heidi Le, PharmD

Diagnostic errors 1Avoiding negative outcomesBy Ann Fiala, RN, BSN, CPHRM, CHC

Prescribing medications 1 Assessing the environmental impactBy Lowell J. Anderson, DSc, FAPhA

Making MNsure work

Allison O’Toole, JD

MNsure

Provider burnout 20By Sara Poplau; Elizabeth Goelz, MD; and Mark Linzer, MD

Moving at the speed of 22 malpractice

By Gregory Alch, MA, EdD

What’s new in osteoporosis? 14By Yasmin Orandi, MD

Gestational diabetes 24 management By Lori Wilcox, MD, and Kim Plessel, MS, RDN, LD

SPECIAL FOCUS: PRACTICE MANAGEMENT

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.

Value - Based Purchasing:

A new way to pay for health care

Background and Focus: As initiatives driven by federal health care reform move forward, the term “Value-Based Purchasing” (VBP) is being applied to a wide spectrum of issues. But what does this mean? CMS is developing measurements, well over 150 to date, to define what “value” means in health care. It is proposed that these metrics will be used to create incentives that pay more for better care in every element of health care delivery. Hospitals, physician practices, home care, and long-term care will all be reimbursed by an emerging new math.

Objectives: We will explore the motivations behind this changing approach to purchasing health care. We will examine what is being measured and what value really means. We will discuss the arguments that claim VBP is a bad idea and those that believe it is the best solution. We will discuss how a collaborative, transpar-ent system, that integrates care teams, health information tech-nology and improved reimbursement methods will help achieve increased access to high-quality, cost-effective care for patients.

Please mail, call in, or fax your registration! mppub.com

Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub.com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable.

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Thursday, November 3, 2016 • 1:00-4:00 PMSymphony Ballroom, Downtown Minneapolis Hilton and Towers

FORTY-SIXTH SESSION

MINNESOTA HEALTH CARE ROUNDTABLE

PROFESSIONAL UPDATE: WOMEN’S HEALTH

CAPSULES

HCMC to Open New Clinic in North LoopHennepin County Medical Center (HCMC) has announced plans for a new clinic and pharmacy in the North Loop area of downtown Minneapolis.

“North Loop is the fastest growing residential neighborhood in Minneapolis and the people who live there have been asking for a local clinic and pharmacy to serve their health care needs,” said Jon Pryor, MD, MBA, chief executive officer of HCMC. “This new clinic will do that, and serve a broader need for several sought-after specialties for people who live and work in the area.”

The new clinic and phar-macy will occupy about 7,660 square feet on the first floor of the TractorWorks office building and is expected to open later this year. It will offer primary care, chiropractic services, and several specialty care services.

“This is an active neighbor-hood and this clinic will provide convenient access to primary care, chiropractic care, and acupuncture services that neighborhood resi-dents told us they want,” said Scott Wordelman, FACHE, senior vice

president of ambulatory care and support services at HCMC. “We will also offer allergy and dermatology specialty care by board-certified physicians, as well as additional specialties such as women’s health and sports medicine.”

Apple Valley Medical Clinic Adds Direct Primary Care ModelApple Valley Medical Clinic has announced it is now offer-ing Prima Care Direct, a health membership that allows patients to pay a monthly fee of $75 for unlimited primary care access.

“Many individuals are search-ing for a way to lower their health care costs without sacrificing access or quality,” said Victo-ria Champeau, chief executive officer of Minnesota Healthcare Network. “This innovative health care model is not based on in-surance. There are no copays or deductibles. The result is greater access to health care for patients, especially in areas related to pri-mary and preventive care.”

Care covered by PrimaCare Direct includes physician

services, throat cultures, casts and splints, blood pressure checks, cholesterol screenings, well child check-ups, nutritional counseling, Pap smears, lab, and X-ray services. “With PrimaCare Direct’s unlimited access to primary care, individuals with chronic conditions, such as dia-betes or asthma, are more likely to see a physician before their situation becomes acute,” said Champeau.

Study to Evaluate Cancer Prevention Tool in Rural AreasHealthPartners Institute and Essentia Health are launching a study to assess whether a clinical decision support tool for electron-ic medical records can increase preventive care for cancer in rural areas.

The tool, called the Cancer Prevention Wizard, identifies all eligible patients ages 11 to 80 who aren’t up to date on recommend-ed cancer prevention services. It then offers the provider recom-mendations for primary and secondary cancer prevention.

Researchers will conduct the study (Implementing Cancer Prevention Using Patient-Provider Clinical Decision Support) over five years. It will involve more than 150,000 patients who receive care at 30 Essentia Health clinics in northern Minnesota, north-western Wisconsin, and eastern North Dakota.

They will use a cluster-random ized trial design to compare three groups of clinics. In the first group, primary care providers will use the tool to iden-tify and offer prevention services. In the second, certified medical assistants will use the tool and discuss screening and prevention services with patients. In the third, patients will receive usual care with no cancer prevention recommendations from the tool.

“Nearly one in four Americans live in rural areas, and this study has the potential to improve their health and quality of life because research clearly shows that in general people in rural areas have higher rates of chronic illnesses than people who live in larger cities,” said Tom Elliot, MD, HealthPartners Institute research fellow and principal investigator of the study.

4 MINNESOTA PHYSICIAN MAY 2016

The team will assess wheth-er use of the tool leads to more patients receiving recommended cancer preventive services; wheth-er certified medical assistants have an effect on patients’ health outcomes; and if the tool results in higher short-term health costs but lower long-term costs com-pared to clinics that don’t use it.

“This tool will create a pa-tient’s risk profile for cancer and display it in one place so that the clinician and the patient can en-gage in a shared decision-making discussion to create a plan for primary prevention of cancer and cancer screening,” said Joe Bianco, MD, primary care provider at Essentia Health and co-investigator of the study. “The rapid collection of data creates efficiency for a busy clinician and how it displays this data for the patient will lead to better patient engagement.”

Sanford Health Buys Medical Center from City of TracySioux Falls-based Sanford Health has purchased Sanford Tracy Medical Center from the city of Tracy, Minn.

Previously, Sanford solely operated the facility while it was owned by the city. Now, under the new agreement that began March 31, the health system owns and will continue to operate the med-ical center building and grounds. Employees will not be affected, as they were already employees of Sanford Health. The purchase price was not released.

“This is a win-win situation for our town,” said Steve Ferraz-zano, mayor of Tracy and chair-man of the Sanford Tracy Med-ical Center board. “We’ll retain quality health care close to home, and the city will no longer have the financial responsibilities that come with owning a health care facility. This frees up taxpayer dollars for other projects.”

Improved Survival for Patients with Low-Grade Brain TumorNew research has shown that pa-tients with a low-grade brain tumor called glioma who received a com-bination of radiation therapy and a chemotherapy regimen have better

survival rates than those who only received radiation therapy.

“This is the first phase III trial to demonstrate conclusively a treatment related survival benefit for patients with grade 2 glioma,” said Jan Buckner, MD, chair of the department of oncology at Mayo Clinic and lead author of the study.

Researchers enrolled 251 patients with low-grade glioma into the trial between October 1998 and June 2002. The enroll-ees were considered to be at high risk due to being over the age of 40 or having a less-than-complete surgical removal of their tumor. They were randomized to one of two trials—one group received only radiation therapy and the other received radiation therapy and six cycles of procarbazine, lomustine, and vincristine (PCV) chemotherapy.

The results show that at a me-dian follow-up time of 11.9 years, 67 percent of the patients had tumor progression and 55 percent had died. Patients who received radiation therapy and PCV che-motherapy had a median survival time of 13.3 years, compared to 7.8 years for those who received only radiation therapy. The medi-an progression-free survival time was longer for the group that re-ceived a combination of therapies as well—10.4 years, compared to 4 years.

Ten year, progression-free survival rates and overall survival rates were better for the group that received radiation thera-py and PCV chemotherapy as well—51 percent compared to 21 percent, and 60 percent com-pared to 40 percent, respectively.

“Our results indicate that ini-tial radiation therapy followed by PCV is necessary to achieve longer survival in patients with grade 2 glioma and that salvage therapy at relapse after radiation therapy alone is less effective,” said Buck-ner. “It has also been hypothesized that other genetic alterations may be responsible for a small subset of patients whose glial brain tu-mors are chemotherapy-resistant. However, radiation therapy plus PCV appears to represent the most effective treatment identified to date for the majority of patients with grade 2 glioma.”

The clinical trial was conduct-ed by Radiation Therapy Oncology Group 9802. Full results were pub-lished in the April 7 issue of the New England Journal of Medicine.

Capsules to page 6 MAY 2016 MINNESOTA PHYSICIAN 5

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U of M Announces First Immigrant Physician ResidenciesThe University of Minnesota Pediatrics Residency Program has selected two immigrant physician candidates for residency positions through a grant from the Minne-sota Department of Health (MDH) as part of its International Medi-cal Graduate Assistance Program.

The program was established by the Minnesota Legislature in 2015. It was the first state-level ef-fort in the U.S. created to support pathways to licensure for immi-grant and refugee physicians to increase access to primary care and help eliminate health dispar-ities. MDH funds the program, which includes career naviga-tion, foundational skill building, clinical preparation, and residen-cy positions for immigrant and refugee physicians.

The University of Minnesota Pediatrics Residency Program was awarded a grant through MDH to fund one residency posi-tion for an immigrant physician,

but chose two due to the high qualifications of applicants—Hag-er Mohammed and Sahar Ahmed.

Mohammed and Ahmed both came from Sudan, where they worked as physicians. When they unexpectedly relocated to Minne-sota, they discovered major obsta-cles to becoming a doctor in the U.S. Many residency programs require U.S.-based clinical experi-ence and recent graduation from medical school. These require-ments disqualify most immigrant physicians. MDH estimates that there are between 250 and 400 immigrant physicians in Minne-sota facing these barriers.

MDH notes that studies suggest that increased diversi-ty in the health care workforce will lead to improved clinical outcomes for minorities and immigrant populations. Health disparities in Minnesota are some of the worst in the U.S., with poorer health outcomes and poorer general health for people of color and immigrant popula-tions than white Minnesotans. In addition, MDH projects a short-age of primary care providers in Minnesota in the next decade, as well as a growing population.

Fairview Health Services to Acquire UCareFairview Health Services and UCare have signed a letter of intent to combine their provider and payer operations. UCare will become a wholly owned subsidi-ary of Fairview under the agree-ment and Jim Eppel will remain in his position of president and CEO of the health insurance company. It will combine with PreferredOne, which came under Fairview’s sole ownership in Jan-uary, to form Fairview’s health insurance division. The two insurers are the fourth and fifth largest in Minnesota.

The organizations are finaliz-ing details of the transaction, in-cluding the new operational model and relationship between Fair-view, UCare, and PreferredOne, and hope to secure regulatory approval by mid-summer. Howev-er, they have agreed that Fairview will continue to collaborate with other health plan administrators and UCare will continue to do the same with other health care providers and systems. Workforce

reductions are not anticipated as a result of the change.

Medica and Altru Partner on New ACOMinneapolis-based health insurer Medica has announced it is col-laborating on a new accountable care organization (ACO) with Altru Health System, a Grand Forks-based system consisting of an acute care hospital, a specialty hospital, and more than 12 clinics in Grand Forks and the surround-ing area. The ACO, called Altru & You with Medica, is expected to be available to group purchasers in northwestern Minnesota and northeastern North Dakota in the third quarter of 2016.

The ACO includes access to care in more than 30 commu-nities and includes a network of more than 560 providers as well as access to telemedicine. It also includes access to experts at Mayo Clinic because Altru Health System is a member of the Mayo Clinic Care Network.

Capsules from page 5


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Scott Jensen, MD, president of Catalyst Medical Clinic, PA, in Watertown, has been named the 2016 Family Physician of the Year by the Minne-sota Academy of Family Physicians. Jensen has been a practicing family physician for more than 32 years and opened Catalyst Medical Clinic in 2001. He also teaches one day a month as a clinical associate professor at the University of Minnesota Family Medicine Residency program in St. Louis Park and serves as medical director of Pro Rehab, Inc., in Watertown. Jensen earned his medical degree at the University of Minnesota Medical School. He com-pleted both his residency and internship at Bethesda Hospital. Jensen has served as president of local Lions and Rotary clubs and multiple chambers of commerce and was elected to the District 110 school board where he served for 10 years, including three years as chairperson. He is now running for a state Senate position in Minnesota District 47.

Claudia Lucchinetti, MD, chair of the depart-ment of neurology and Eugene and Marcia Applebaum professor of neurosciences at Mayo Clinic, has received the 2016 John Dystel Prize for Multiple Sclerosis Research from the National MS society and the American Academy of Neurology for her contributions to understanding and treating MS. Lucchinetti is recognized as one of few world authorities in experimental and applied neuropathology research in the area of demyelinating and

inflammatory central nervous diseases, including MS, and has published more than 170 research papers on the topic. She earned her medical degree at Rush Medical College in Chicago, completed an internship at Rush Presbyterian St. Luke’s Medical Center, and completed a neurology residency and neuroimmunity fellowship at Mayo Graduate School of Medicine.

Sophia Vinogradov, MD, has been named the new head of the University of Minnesota Depart-ment of Psychiatry and will step into the posi-tion in August. Vinogradov is a schizophrenia researcher who most recently served as vice chair of the University of California–San Fran-cisco School of Medicine’s psychiatry depart-ment, where she was also a professor. Prior to that, she served as associate chief of staff for mental health at the San Francisco VA Medical Center. Vinogradov earned her medical degree at Wayne State University School of Medicine in Detroit. She completed a psychiatry residency at Stanford University School of Medicine, where she also served as chief resident, and completed a psychiatric neurosciences research fellowship at the Palo Alto VA Medical Center and Stanford University.

Glenn Shamdas, MD, oncologist at the Fargo VA Health Care System, has received the 2016 Dr. Byron D. Danielson Clinician of the Year Award. The Fargo VA Health Care System presents the award annually to recognize providers with outstanding clinical dedication that go above the call of duty to serve veterans. Shamdas earned his medical degree at the Malaga School of Medicine in Spain and completed an internal medicine residency at the University of North Dakota affiliated hospitals in Fargo. He also

completed a hematology/oncology fellowship at the University of Arizona. Shamdas has been with the health care system since 2003, where he also worked from 1992 to 1997. He is also a tradi-tional guardsman with the U.S. Air Force. MAY 2016 MINNESOTA PHYSICIAN 7

MEDICUS

Scott Jensen, MD

Claudia Lucchinetti, MD

Glenn Shamdas, MD

Sophia Vinogradov, MD

THE MUSIC OF ELLINGTON AND ELLA The Duke Ellington Orchestra and Patti Austin*Fri Jun 24 8pm First, you'll be treated to those unforgettable Ellington hits including Take the A Train, then Patti Austin sings her tribute to the First Lady of Song, Ella Fitzgerald.

THE NEW STANDARDSwith the Minnesota OrchestraSat Jul 2 8pmSarah Hicks, conductorChan Poling, piano / Steve Roehm, vibesJohn Munson, bass

You may have caught their holiday show or one of their gigs at the Dakota. Now you can be there for their first concert with the Minnesota Orchestra.

A BROADWAY ROMANCEA New York Cabaret*Sun Jul 10 7pmLaura Osnes and Santino Fontana, vocalsTed Sperling, music director and pianist

Join Minnesota’s own two-time Tony Award® nominee Laura Osnes (Grease) and Santino Fontana (Frozen)in this delightful tribute to love, Broadway-style.

VERDI’S OTELLOSat Jul 23 7:30pmAndrew Litton, conductorCarl Tanner, OtelloComplete cast list online

Shakespeare’s powerful tragedy inspired Verdi’s most glorious music.

LOUDON WAINWRIGHT III*Fri Jul 29 8pmSince his emergence in the late ’60s,Grammy-winner® Loudon Wainwright III has been entrancing audiences all over the world.

Andrew Litton /// Artistic Director

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All sales final. All artists, dates, programs, prices and times are subject to change.

PHOTOS Wainwright: Ross Haflin; Osnes: Nathan Johnson; artwork based on photos by George Heinrich and Travis Anderson

*Please note: The Minnesota Orchestra does not perform on this program.

MAY_MN Physician Ad.indd 1 5/3/16 3:09 PM

Making MNsure work

Allison O’Toole, JD

MNsure

Ms. O’Toole is CEO of MNsure, over-seeing an annual budget of nearly $50 million and more than 150 staff. She previously served as MNsure’s deputy director for external affairs and oversaw MNsure’s public-facing departments including Marketing and Communications, State and Federal Government Affairs, Navi-gator and Broker Relations, and was MNsure’s staff liaison to the board of directors. She was responsible for the implementation of the second phase of MNsure’s multi-million dol-lar marketing campaign, developed the strategic overhaul of the MNsure outreach and enrollment grants pro-gram, initiated the widely successful broker Lead Agency program, and helped lead MNsure’s efforts for greater public accountability and transparency.

Prior to her roles at MNsure, Ms. O’Toole was a director at Himle Rapp, a Minneapolis-based public affairs firm and state director for U.S. Senator Amy Klobuchar. She graduated from Franklin & Marshall College in Lancaster, PA, with a bachelor’s degree in government. She earned her Juris Doctor from William Mitchell College of Law.

What does MNsure do?

MNsure is a marketplace where Minnesotans can shop, compare, and choose health insur-ance coverage that meets their needs. MNsure is the only place where consumers can qualify for financial help, either through federal tax credits or through Minnesota’s two public health insurance programs, MinnesotaCare and Medical Assistance.

What are the biggest challenges that MNsure has faced?

It’s no secret that when MNsure launched in 2013 the result wasn’t pretty, and quite frankly, former leadership set expectations way too high. I’ve spent the past two years working to improve the consumer experience and level set with stakeholders about what MNsure is and what it can do. We’ve had external evaluators come in and show us where improvements are needed. We’ve ramped up relationship building with the broker community and communi-ty-based organizations. We’ve also worked to let the public know that MNsure is the place to shop and compare health insurance options.

We’ve done a good job turning the corner these past two years and the majority of Min-nesotans are now enrolling through MNsure with relative ease, but we cannot hide from our history. The good news is we are improving every day.

What strategies helped you to exceed your enrollment goals for 2016?

MNsure is laser focused on helping consum-ers find a health insurance plan that fits their needs at a price they can afford. That means providing increased market transparency. At its core, MNsure really acts like a consumer pro-tection agency, making sure Minnesotans are aware of all their health insurance options and the prices that go along with those options. In 2016, Minnesota saw large health insurance premium increases. While we still have some of the lowest rates in the Midwest, the in-creases were a shock for many Minnesotans.

What’s important to remember is that MNsure is the only place Minnesotans can access federal tax credits that can immediately lower those monthly premiums, or qualify for public programs. We do not want Minnesotans to leave money on the table. We’re encouraged that so many Minnesotans came to MNsure during this past open enrollment to com-pare plans and get financial help. In fact, 45

percent of MNsure’s current private plan enrollees are new for 2016. That’s the highest percentage of new enrollment nationwide. MNsure also saw the largest percentage of overall private enrollment growth nationwide. These statistics tell us that more Minnesotans are getting the message about the benefits of MNsure, and that’s great news for Minnesota.

What are the most common mispercep-tions about MNsure?

One of the biggest misperceptions about MN-sure is that we’re an insurance company and we set health insurance rates. Both of those things are simply not true. MNsure is the mar-ketplace you go to shop and compare health insurance products sold by private companies. Think of MNsure as a grocery store and the private insurance companies as the aisles. When Minnesotans come to MNsure they can walk up and down the aisles to check out insurance products from different companies, and see if they qualify for financial help while they’re at it.

MNsure enrolls consumers into health in-surance coverage, but once that transaction is complete, the consumer is left with insurance coverage from a private insurance company.

Why aren’t the choices available through MNsure increased to include the leading national insurance providers?

In order to sell health insurance products in Minnesota, an insurance company must meet very specific requirements that are regulated by the Minnesota Department of Commerce. The fact is that MNsure does not limit who can participate in the exchange and who cannot. If an insurance company is currently not par-ticipating in MNsure and would like to do so, they are more than welcome to go through the process of having products on the exchange, as long as they follow the state and federal laws that are required.

What can you tell us about the way MinnesotaCare affects MNsure?

MinnesotaCare is a public program that covers certain individuals who make too much money to qualify for Medical Assistance, but not enough to afford a private health insurance plan. Minnesota is one of only two states in the country to offer a program like this on the ex-change. MinnesotaCare offers great coverage, and we are happy that Minnesotans are getting coverage they need at a price they can afford.

INTERVIEW


What kind of data can you share about the savings MNsure members receive through Affordable Care Act subsidies?

Last year, Minnesotans saved nearly $50 mil-lion on their private health insurance premi-ums through tax credits available on MN-sure. That’s up from $30 million in 2014. This is real money that Minnesota families can keep in their pockets each month. These tax credits act like instant discounts off monthly health insurance premiums, which means Minnesotans see the benefit immediately and do not have to wait until tax time to collect.

Under what circumstances could someone purchase insurance through MNsure outside of the open enroll-ment period?

Just like when you want to make changes to your health insurance policy through an employer, MNsure allows enrollment changes if qualifying life events occur. These usually involve the loss of a job, mar-riage, birth of a child, or change in income. We require Minnesotans to verify that they are eligible for a special enrollment period. Minnesotans who are eligible for Medical Assistance or MinnesotaCare can enroll at any time during the year. There is no open enrollment for those two public programs.

What would you like patients to know about MNsure?

If you purchase health insurance coverage on your own, MNsure is the place to shop, compare, and get financial help like tax credits, low-cost, or no-cost plans. Visit us online, or in person, to find out what you might qualify for. The coverage you get through MNsure is no different than the coverage you purchase directly from an insurance company. In fact, it literally pays to shop on MNsure because you may find a better policy at a better price.

What would you like physicians to know about MNsure?

For your patients who are uninsured or who are not satisfied with their current health insurance plan, MNsure can offer a real solution for Minnesotans to find a plan that

fits their needs and budgets. We all do better when we have quality access to health care.

What do you see in the future for MNsure?

The Affordable Care Act is working in Minnesota. We just successfully completed our third open enrollment period and saw the largest percentage of enrollment growth nationwide. Additionally, a bipartisan task force created by the Minnesota State Legislature has recommended that Min-nesota stay the course with a state-based marketplace. The Minnesota Department of Health also recently announced that since 2013, Minnesota’s uninsured rate has been cut in half and is now the lowest it has ever been in state history. People are getting into coverage, they are saving money through MNsure, and they are getting the level of coverage they need.

I am encouraged by that news, but know there is still more work to be done. We are currently evaluating many of our operations and business practices, as well as identifying areas for IT improvement. Much progress has been made since the initial rollout and the proof of that is starting to show.

Minnesota’s uninsured rate … is now the lowest it has ever been in state history.


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18.5% of patients who under-went autopsy, 7.5% of them were diagnoses with impact on therapy and outcome.”

Countless stories of patient harm, delayed treatment, and death are shared on the Inter-net, in medical journals, and throughout our communities. Diagnostic error is a significant and complex problem facing the health care community. Solving it will require a change in culture and a paradigm shift from the old “physician knows best” model to one that includes a team-focused approach, a mission to eliminate all harm, and humility.

Preventing diagnostic errors

Because very little research exists in regard to diagnostic error, the committee’s report applied global principles of patient safety and performance improvement to identify rec-ommendations aimed at error reduction. Central to address-ing harm caused by missed

diagnosis is communication among all stakeholders—patients, families, consult-ing providers, and any other member of the health care team involved in the process.

The recommendations en-courage organizations to focus on eight goals:

1. Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families.

2. Enhance health care pro-fessional education and training in the diagnostic process.

3. Ensure that health infor-mation technologies sup-port patients and health care professionals in the diagnostic process.

4. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice.

5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance.

6. Develop a reporting environ-ment and medical liabil-ity system that facilitates improved diagnosis through learning from diagnostic errors and near misses.

7. Design a payment and care delivery environment that supports the diagnostic process.

8. Provide dedicated funding for research on the diagnos-tic process and diagnostic errors.

The importance of feedback

Several of the report’s recom-mendations and goals center on the principle of feedback. In 2008, Eta Berner, EdD (profes-sor at the University of Ala-bama and director of the UAB Center for Health Informatics for Patient Safety/Quality), and Mark L. Graber, MD (senior fellow at RTI International and professor emeritus of medicine at Stony Brook University), con-ducted a comprehensive review of the available literature that discussed diagnostic errors and how to reduce them and presented their findings in an article in the American Jour-nal of Medicine. According to Berner and Graber, “Feedback in general can serve to make the diagnostic error visible, and timely feedback can mitigate the harm that the initial misdi-agnosis might have caused.”

Over the years, health care has utilized feedback in a very linear fashion. Retrospective data (incident reports, autopsy

results, patient complaints, etc.) may be reviewed but very little was done to change the systems involved in creating the errors. Those systems are deeply em-bedded in health care culture and will require significant change. The committee’s report provides a framework to begin transforming current practic-es. Feedback is central to that framework.

Let’s take a look at the report’s goals that specifically focus on feedback.

Effective teamworkThe first goal to facilitate

teamwork among providers,

patients, and family members is key to achieving error reduc-tion. Few would argue about the value of effective teamwork among providers to enhance the diagnostic process. Provid-ers and other members of the health care team rely on one another to navigate the day-to-day management of caring for patients. But including patients and their family members is also essential to error reduc-tion. The Committee’s report states, “Supportive health care environments are places where patients and families feel com-fortable sharing their concerns about diagnostic errors and near misses and providing feedback on their experiences with diagnosis.” Patients are the key stakeholders in physicians arriving at the appropriate diagnosis and then treating it. Involving patients in the pro-cess and empowering them to take an active part in managing their own care creates engage-ment and provides an essential safety net to ensure errors are


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identified and addressed quick-ly. Additionally, when errors do occur, creating an environment where patient voices can be heard adds a human element to a complex system.

Some suggestions from the committee’s report to support patient and family feedback include:

• Utilize shared decision models: Moving beyond the traditional informed con-sent process to a model that evaluates patient values and preferences. This creates a partnership between health care providers and patients and enhances engagement.

• Make follow-up phone calls: Checking in with patients upon discharge shows a sense of caring, allows them to ask questions while under less stress, and encourages feedback.

• Implement teach-back ed-ucational methods: Eval-uating a patient’s level of comprehension establishes trust and partnership with their care providers. Ensur-ing that they understand follow-up expectations gives patients a sense of shared accountability.

• Provide patient portals for clinical notes and test results: Utilizing technology to create transparency and easy online access to medical records and test results, gives patients more control over their care. Empowered pa-tients are engaged patients.

• Establish solid disclosure policy and practices: Recog-nizing the value of disclosing errors to patients and fami-lies, while involving them in activities to prevent future occurrences, offers health care systems the opportuni-ty to learn from mistakes. Patients may have unknown information that offers solu-tions to complex problems.

• Form patient and family member advisory coun-cils: Involving patients and families in the development of new or the evaluation of old services fosters a

patient-centered approach to care and may assist in proactively identifying safety issues.

• Develop closed-loop communication systems: Including patients as mem-bers of the diagnostic team and establishing foolproof systems that funnel reports from consulting specialists to primary care providers may prevent lost, missed, or delayed diagnoses.

Learning from mistakesThe fourth goal focuses on

identifying, learning from, and reducing diagnostic errors and near misses in clinical practice. It’s important to focus on the changing systems and practices that led to any errors.

Berner and Graber have argued that, “Physicians in gen-eral underappreciate the like-lihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors.” By the na-ture of their training and con-ditioning over time, physicians have come to rely on memory and intuition to diagnose. While this method produces accurate results much of the time, it is not a reliable system and can lead to diagnostic error.

Physicians cannot learn from mistakes without reliable data that has been validated and vetted among peers and provides objective, measurable indicators of quality. Construc-tive feedback utilizing data helps clinicians assess how well they are performing in the diagnostic process, correct overconfidence, identify when remediation efforts are needed, and reduce the likelihood of repeated mistakes.

Here are some important techniques for ensuring con-structive feedback:

• Utilize decision support tools: Computerized software tools that utilize patient-specific symptoms can assist providers in differential diagnosis and treatment recommendations.

• Encourage consults and/or second opinions: Culture that supports peer-to-peer consults and case discussion lets providers explore diag-nosis and treatment options they may not otherwise have considered.

• Initiate morbidity and mortality rounds: Review of all deaths, expected or unexpected, provide forums to discuss and learn from actual patient cases.

• Initiate planned follow up and tracking of results: Integration of test tracking and documentation into the electronic health record decreases the number of lost or missed reports.

• Perform chart audits by using trigger tools: Pre-specified criteria utilizing electronic medical record flags (e.g., readmission to the emergency department within 72 hours or abnormal results without documented follow up) may identify patients

who have experienced diag-nostic miss or error.

• Review adverse events/per-forming root cause analyses (RCAs): Detailed analysis of adverse events can identi-fy system-level issues that require change and ongoing monitoring.

• Implement post-event and simulation debriefings: Immediate evaluation after a post adverse event or sim-ulated high-risk process can provide members of the care team actionable corrective measures.

• Develop robust, focused, and ongoing professional practice evaluation process-es: Incorporating diagnostic error measures into the provider credentialing and privileging process provides medical staff leadership with the information neces-sary to evaluate quality and ongoing membership.

Diagnostic errors to page 38

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MPCA lake study, including Lake Kabetogama, which is near Voyageurs National Park. Even though only an estimated 2.4 percent of the U.S. popu-lation uses cocaine, it is sur-prising that it is found in lakes across Minnesota. It is puzzling how some of these products, such as cocaine or iopamidol, get into lakes and streams, while for others it is less so.

How contamination occurs

Certainly medications that are “thrown out” contribute to these numbers. Those unused prescription medications that are out-of-date and thrown in the trash or flushed down the toilet may eventually end up in surface water or in the preload for water treatment plants. Much of what goes into treat-ment plants comes out the other side into ground water or as drinking water. We have gotten better about offering public “take-back” programs for

unused medicines in pharma-cies, municipal buildings, and through community organiza-tion programs. These are cum-bersome programs, however, in that they require staffing and reporting. Also, because many of them are episodic, it is difficult for consumers to have a dependable way to dispose of excess medicines, even if they understand the need.

The other source of water pollution is by active drug ingredients or metabolites that humans and animals excrete in urine and feces. The major-ity of all medications that are consumed by consumers are excreted in the urine in un-changed condition or as metab-olites. Even topical medications such as DEET can enter sew-age through bath water. Most

water treatment facilities are not designed to remove these products. The bottom line is that we know these products are there but do not know the full risk to the environment or humans. There are a number of efforts in Minnesota to more fully understand the effect of these products on the Minneso-ta environment.

Defining the risk

We do know that certain medicines entering the environ-ment can have serious effects. In Pakistan, 95 percent of the Gyps vulture population died from renal failure after feed-ing on the carcasses of cattle treated with diclofenac, an anti-inflammatory. This is an extreme example of the potency of some of the medicines that we routinely use, but it points to how dramatic the effect can be.

It should be accepted that all medicines are inherently hazardous. Hazard considers these inherent environmentally damaging characteristics in terms of:

• Persistence: The ability to resist degradation in the aquatic environment.

• Bioaccumulation: The accu-mulation of these chemicals in adipose tissue of aquatic organisms.

• Toxicity: The potential to poison aquatic organisms.

The challenge is to under-stand which products pose an environmental risk. “Risk” is different than “hazard.” Risk considers the degree of hazard of the product and the concen-tration in the environment. It considers how much of a prod-uct is used in a geographic area and how much it is diluted in the geographic water supply.

Classifying the risk

A program launched in Stock-holm, Sweden in 2005 found that 6 percent of pharmaceuti-

cals tested in its market posed a moderate environmental risk. Examples are medicines such as: benzoyl peroxide, ciproflox-acin, erythromycin, estradiol, ethinyl estradiol, ibuprofen, chlorhexidine, propranolol, mycophenolate mofetil, and terbinafin. The antitubercular product bedakilin (bedaquiline in the U.S.) was found to be “particularly hazardous.” The remaining 94 percent were of insignificant risk.

In 2004, the Stockholm County Council, LIF (Swedish Association of the Pharma-ceutical Industry), and other Swedish agencies collaborated to produce and support a risk classification of pharmaceuti-cals in the Swedish market. The results of this collaboration are published each year in a book-let, “Environmentally Classified Pharmaceuticals.” This booklet is intended as a reference for both consumers and practi-tioners. The 2014–2015 edition can be accessed in an English version (http://www.janusinfo.se/Global/Miljo_och_lakemedel/Miljobroschyr_2014_engelsk_webb.pdf). This document organizes medicines into thera-peutic categories and lists their risk to the Swedish aquatic environment. The risk is rated as “insignificant,” “low,” “mod-erate,” or “high.” It also pro-vides hazard values (0 to 3) for persistence, bioaccumulation, and toxicity of each product.

The Stockholm County Council also considers environ-mental factors in its medicines formulary called, “The Wise List.” The Wise List includes medicines recommended for the treatment of common dis-eases. The recommendations are based on scientific evidence regarding efficacy and safety, pharmaceutical suitability, cost-effectiveness, and environ-mental aspects. By considering environmental factors in the construction of the formulary they remove the necessity for the prescriber to consult yet another document or drop-down list. The “Wise List” is available in English at: http://www.janusinfo.se/In-English/The-Wise-List-2015-in-English/.


Prescribing medications from cover

Eighty-six percent of amoxicillin is excreted unchanged in urine.


What can we do?

There are opportunities for all practitioners involved in the medication-use continuum, as well as managed care organiza-tions, to make a difference.

Practitioners who prescribe medicines

• With each medicine pre-scribed, there is an opportu-nity to inform patients about the importance of proper disposal of unused medi-cines. Refer patients to the Rethink Recycling website, which lists the locations of take-back facilities (www.rethinkrecycling.com).

• Even though many health plans encourage a 90-day supply, restrict new pre-scriptions to no more than 30 days. Take advantage of starter packs for those plans that allow them.

• Absent an insurance bene-fit that allows starter pack prescriptions, encourage your patients to ask their

pharmacists to allow them to partially fill the Rx for a new medicine to see if it works for them.

• Prescribe antibiotics and opioids prudently.

• Be aware of those medicines that are documented as being potentially harmful to the environment, and consider prescribing alterna-tives when indicated. A good place to start is with those that the Swedish authorities have designated as “moder-ate risk” even though their risk assessments are based on Swedish use data.

• Remind patients to buy over-the-counter medicines in quantities that can be used before expiration.

Pharmacists who dispense and manage medicines

• Include a discussion about the appropriate disposal of unused medicines as part of the OBRA ’90 counseling program.

• Encourage starter packs when an insurance plan allows.

• Work with your municipal-ity to install an approved patient-accessible medi-cine disposal unit in the pharmacy.

• Refer patients to the Re-think Recycling website, which lists the locations of take-back facilities (www.rethinkrecycling.com).

Managed-care organizations• Institute polices that en-

courage, and do not penalize plan members, for using starter packs.

• Incorporate environmental risk considerations into the design of drug formularies and note those medicines with potential for envi-ronmental risk in the plan formulary.

• Reconsider the incentives for 90-day supplies of medicines and contracts with mail-order distributors

that automatically send out renewal prescriptions without properly monitoring current orders.

What is the state doing?

In Minnesota there are several agencies that are addressing the issues of pharmaceuticals in the Minnesota environment.

• The Minnesota Board of Pharmacy is proposing legislation that will allow the use of secure collection boxes in health facilities for consumers to dispose of unwanted medicines.

• The Minnesota Pollution Control Agency is conduct-ing ongoing studies and in 2013 published findings in a report, “Pharmaceuticals and Endocrine Active Chemicals in Minnesota Lakes” (https://www.pca.state.mn.us).

• The Minnesota Depart-ment of Health published the “Pharmaceutical Water-screening Values

Prescribing medications to page 36

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Osteoporosis is increasing in our population—and so is the discussion

about guidelines for prevention and treatment options. Accord-ing to the National Hospital Discharge Summary, 310,800 total hip replacements were performed among inpatients aged 45 and older in 2010, up from 138,700 in 2000. That’s an increase from 142.2 to 257.0 for every 100,000 persons. One in two women now get osteoporo-sis, along with one in four men.

Risk factors

We are learning more about the risk factors associated with osteoporosis, including the following:

• Diets low in calcium and vitamin D

• Physical inactivity

• Tobacco and alcohol use

• Being a woman

• Thin body frame or body mass index of 19 or less

• Advanced age

• Caucasian or Asian descent

• Family history

• Too much thyroid hormone in women

• Too little estrogen in women

• Low testosterone in men

• Eating disorders, such as anorexia or bulimia

• Secondary causes, including gastrectomy, weight-loss sur-gery, and conditions such as Crohn’s disease, celiac dis-ease, and Cushing’s disease

• Certain medications, includ-ing long-term use of corticosteroids, aro-matase inhibitors, selective serotonin reuptake inhib-itors, methotrexate, some anti-seizure medications, and proton pump inhibitors

• Excessive caffeine use

• Osteopenia

Screening guidelines

The U.S. Preventive Services Task Force recommends dual-energy X-ray absorptiome-try (DEXA) scans for women 65 years and older and for younger women with increased fracture risks, as determined by the World Health Organization’s Fracture Risk Assessment Tool (FRAX). FRAX is an algorithm based on probabilities that can help physicians determine the likelihood of someone break-ing a bone within the next 10 years. These probabilities are based on a person’s age, weight, height, alcohol consumption,

and history of osteoporosis, among other factors.

There are no guidelines for rescreening women who have a normal DEXA screen. Some suggest intervals of every four years, but insurance generally covers screening every two years, which is what I recommend to my patients. Routine screening for men is not suggested unless they have risk factors.

Current recommendations for patients with osteoporosis

Encouraging adequate amounts of calcium and vitamin D is still the recommended advice for those with osteoporosis. Most studies suggest 1200 mg of calcium and 800 interna-tional units of vitamin D daily for postmenopausal women with osteoporosis. Premeno-pausal women are encouraged to consume 1000 mg of calcium and 600 international units of vitamin D daily.

For men between the ages of 51 and 70, the recommended

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dietary allowance is 1000 mg of calcium daily, but after age 70, they should take in 1200 mg each day.

In the past, physicians have recommended that at least half of this intake for both men and women come from dietary sources, such as dairy products, broccoli, kale, canned salm-on, sardines, and soy, with the rest from calcium supplements such as calcium carbonate and calcium citrate. Calcium citrate is the recommended choice for patients taking proton pump in-hibitors or H2 blockers or who have achlorhydria.

Studies now indicate, how-ever, that prescribing calcium supplements should be done with care, as new cardiovas-cular risks are becoming more prevalent. These risks occur when the total calcium intake exceeds recommended amounts or supplements are given in large doses, bringing the total intake above 2000 mg per day. Some physicians believe it is wise to avoid doses greater than

500 mg of calcium at one time. Personally, I encourage calci-um to come from diet unless patients cannot tolerate milk or have a diet very low in calcium.

Our bodies need vitamin D to absorb calcium, but the amount of recommended vita-min D is controversial and un-der discussion by experts. For adults 19 to 70, the RDA is 600 international units each day, in-creasing to 800 units after age 71. The Institute of Medicine has defined the safe upper limit for vitamin D as 4000 units per day, although sometimes higher doses are required during initial treatment of vitamin D deficiency or when coexisting conditions require higher doses.

I always ask my patients whether they are taking

additional dietary supplements, such as multivitamins, that might contain vitamin D before I prescribe extra vitamin D. Too much of this vitamin,

especially if taken with calcium supplements, can lead to hypercalcemia, hypercalciuria, or kidney stones.

The goal is to get a patient’s vitamin D level above 30. In ad-dition to sunlight, good sources of vitamin D include oily fish, such as tuna and sardines, egg yolks, and fortified milk. The two most common forms of vitamin D supplements are er-gocalciferol and cholecalciferol. Cholecalciferol works more efficiently.

While calcium and vitamin D are critical to preventing and treating osteoporosis, I always

encourage my patients to make lifestyle changes that can de-crease their chances of break-ing a bone. This includes:

• Increasing the amount of exercise. A good balance of strength and cardiovascu-lar exercise, coupled with weight-bearing exercise, is best. Good weight-bearing ex-ercises are walking, jogging, tennis, and climbing stairs.

• Decreasing caffeine intake. I tell my patients to restrict their caffeine intake to no more than 2.5 cups of coffee or 5 cups of tea per day. A recent South Korean study reported that drinking cof-fee within these guidelines can actually reduce a per-son’s risk of osteoporosis.

• Drinking in moderation or not at all. That means fewer than four alcoholic drinks per day for men and fewer than two for women. Alcohol can interfere with the body’s ability to absorb calcium.

There are no guidelines for rescreening women who have a normal DEXA screen.


What’s new in osteoporosis? to page 34

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The current Zika disease outbreak affecting many Latin American and

Caribbean countries provides a timely opportunity to remind Minnesota medical providers of the many mosquito-borne diseases their patients may be at risk for when traveling (see Ta-ble 1). Mosquito-borne disease risk can vary considerably de-pending on geographic location, local mosquito ecology, time of year, and the patient’s length of stay and previous exposure to mosquito-borne viruses. Adding to these intricacies, worldwide mosquito-borne disease risk is expanding and changing, largely due to the unprecedent-ed scale of international travel and commerce. The changing landscape of risk is evident in the recent introductions of two mosquito-borne viruses to Latin America and the Caribbean islands—chikungunya virus in 2013 and Zika virus in 2015. The introduction of these viruses into regions of the world that were previously free of local transmission have had major

implications on local residents and communities, as well as vis-itors to the affected countries.

With the accessibility and speed of modern travel, it is increasingly important for Minnesota medical providers to become acquainted with inter-national and domestic disease risks for their traveling patients. A medical provider’s general un-derstanding of mosquito-borne disease risk is not only per-tinent for patients returning with symptoms; providers should also be prepared to give pre-travel advice to patients about their potential risks, or

point them to reliable resources for information. This article will provide helpful resources for medical providers to use when caring for a patient who is considering travel or returning with symptoms (see the recom-mended list of resources). This article will also highlight the mosquito-borne diseases in trav-eling residents most commonly reported to the Minnesota De-partment of Health (MDH).

Although there are many mosquito-borne diseases worldwide, there are some travel-associated diseases that are reported to MDH more often than others. These com-monly reported diseases include the ever-significant parasitic in-fection malaria, emerging viral diseases such as chikungunya and Zika, and re-emerging dis-eases such as dengue.

MalariaMalaria is the most commonly reported travel-associated mosquito-borne disease in Minnesota, with an average of 54 cases annually from 2010–2014. The vast major-ity of these cases occurred in foreign-born residents returning to their country of origin to visit friends and relatives. The most frequently reported countries of exposure in Minnesota’s malaria cases are Liberia and Nigeria. Notably, Minnesota has the largest Liberian pop-ulation in the world outside of the country itself. Globally, malaria remains a tremendous problem with an estimated 198 million clinical cases and 500,000 deaths in 2013 alone. Malaria is caused by several protozoan species in the genus Plasmodium. It is endemic in many tropical and subtropi-cal regions of the world, most notably throughout much of

Africa, India, parts of Southeast Asia, and much of northern South America. Malaria is transmitted to humans through bites of infected Anopheles genus mosquitoes. Incubation periods vary depending on the Plasmodium species, but most people develop symptoms within a month following a bite from an infected mosquito. Malaria is a serious febrile illness with many nonspecific symp-toms that may become severe, resulting in organ failure and cerebral malaria. Pre-exposure prophylaxis and post-infection treatment are available for traveling patients. Appropri-ate prophylaxis and treatment vary depending on location of travel and Plasmodium spe-cies circulating in the area. Malaria diagnosis is confirmed by microscopic examination (blood smear, typically available in-house) or PCR testing, which is available at many commercial laboratories or the MDH Public Health Laboratory.

ChikungunyaChikungunya virus has recently emerged as a commonly reported disease in Minnesota travelers. Prior to 2013, chiku-ngunya virus transmission was not recognized in the West-ern Hemisphere. Local virus transmission was first reported on the Caribbean island of St. Martin in December 2013 and very quickly spread through-out the Caribbean islands and Latin America. In 2014, Florida reported 12 locally acquired cases of infection with the virus, but following that small outbreak there has been no further local transmission reported in the United States. In 2014, there were 28 cases of travel-associated chikungunya disease reported to MDH, with the majority of cases reporting travel to the Caribbean islands. Chikungunya virus is trans-mitted to humans through the bites of infected Aedes aegypti and Aedes albopictus mosqui-toes—commonly referred to as the yellow fever and Asian tiger mosquitoes, respectively. In contrast to many other arboviruses, most people who are infected with chikungunya virus will develop symptoms,

Travel-associated mosquito-borne

diseasesWhat medical providers need to know

By Franny Dorr, MPH


usually within three to seven days of infection. The most common symptoms include fever and arthralgia, but may also include headache, joint swelling, rash, and myalgia. Severe illness and death are rare, but symptoms of arthral-gia may persist for several months following infection. Treatment for chikungunya disease is limited to support-ive care. Chikungunya can be diagnosed using serology or PCR testing, available through many commercial laboratories or at the Centers for Disease Control and Prevention (CDC) after consultation with an MDH epidemiologist.

ZikaMost recently, Zika virus has made its way into much of Latin America and the Carib-bean following its introduction to the region in the spring of 2015. Zika virus is transmit-ted primarily by Ae. aegypti and possibly by Ae. albopictus mosquitoes. Like chikungunya before it, the rapid spread of

the virus is primarily due to infected individuals traveling to areas with competent mos-quito vectors and previously unexposed populations. Local transmission of the virus is not expected to occur in Minnesota due to the lack of appropriate vector populations. Nearly 80 percent of Zika infections are asymptomatic. Symptoms of Zika disease are mild for most people and include fever, arthralgia, rash, and conjunc-tivitis. These symptoms typi-

cally develop within three to 14 days following infection, and may last up to a week. There is growing evidence that Zika infection in pregnant women may be linked to birth defects such as microcephaly, or spontaneous abortion. There

is also a possible link between Zika disease and Guillain-Barré syndrome. These reported links are still under investigation. Treatment for Zika disease is supportive, and laboratory testing is available at CDC after consultation with an MDH epi-demiologist. Medical providers should note the current CDC recommendation that pregnant women should not travel to countries and territories with active Zika virus transmission.

DengueDengue is one of the most frequently occurring mosquito-borne diseases worldwide. MDH has received an average of 11 case reports annually from 2010–2014, most of which were acquired in Latin

America. Dengue is not con-sidered endemic in the United States; however, outbreaks have occurred in warmer states, such as Texas and Hawaii, where appropriate mosquito vectors are found. Regions of the world with endemic den-gue include Africa, India and Southeast Asia, Latin America, and the Caribbean. Dengue virus is transmitted to humans through the bite of infected Ae. aegypti or Ae. albopictus mosquitoes. There are four distinct serotypes of dengue virus, and subsequent infec-tions with different serotypes are possible. Symptoms usu-ally occur within four to seven days of infection and may be mild, including fever (which typically lasts two to seven days), headache, arthralgia, and myalgia. Occasionally, symp-toms rapidly progress to a more severe disease, characterized by hemorrhage or shock. Risk for severe dengue is greatest during the post-febrile period of

Local transmission of the virus is not expected to occur in Minnesota due to the

lack of appropriate vector populations.

Travel-associated mosquito-borne diseases to page 18

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the illness. There is no specific treatment for dengue disease, only supportive care to manage symptoms. Until dengue can be ruled out, use of NSAIDS is not recommended due to increased risk of hemorrhage. Dengue infections can be diagnosed using serology or PCR testing, available at many commercial laboratories or at CDC after consultation with an MDH epidemiologist.

Other emerging diseases of interestThere are many other mosquito-borne diseases of interest to MDH that are not commonly seen in U.S. travelers. A few to keep in mind include Rift Valley Fever virus (occurs in many African countries and is transmitted by infected Aedes genus mosquitoes); Murray Valley encephalitis virus (a risk for trav-elers to Australia or Papua New Guinea, transmitted by infected Culex genus mosquitoes); yellow fever (occurs in many subtropical regions of South America and

Africa, primarily transmitted to humans by infected Ae. aegypti mosquitoes); and Japanese encephalitis (occurs in many parts of Asia, transmitted by infected Culex genus mosqui-toes). Vaccines are available for both yellow fever and Japanese encephalitis viruses.

For further information and assessment of mosquito-borne disease risk for travelers, CDC of-fers an excellent reference guide on health information and inter-national travel called the Yellow Book, as well as a frequently updated website on current trav-el health notices (see the recom-mended list of resources).

Local mosquito-borne disease riskWhen assessing patients with a history of travel during warmer months of the year, medical providers should also keep in mind that Minnesota has several endemic mosqui-to-borne diseases that should be considered. West Nile virus is endemic throughout Min-nesota and the U.S., and is the most frequently reported

mosquito-borne disease in Minnesota with an average of 36 cases annually from 2010–2014. Other endemic mosquito-borne viruses in Minnesota include La

Crosse encephalitis virus, which can cause neuroinvasive illness in children, and Jamestown Canyon virus. Less common

Travel-associated mosquito-borne diseases from page 17

CDC Website (Centers for Disease Control & Prevention):• Malaria — http://www.cdc.gov/malaria/

• Chikungunya — http://www.cdc.gov/chikungunya/index.html

• Zika — http://www.cdc.gov/zika/ — http://wwwnc.cdc.gov/travel/page/zika- travel- information

• Dengue — http://www.cdc.gov/dengue/Dengue Clinical Case Management Course — http://www.cdc.gov/dengue/training/cme.html

Yellow Book — http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014

Travel Health Notices — http://wwwnc.cdc.gov/travel/notices

Minnesota Department of Health: • Mosquito-Transmitted Diseases Website — http://www.

health.state.mn.us/divs/idepc/dtopics/mosquitoborne/

Metropolitan Mosquito Control District: http://www.mmcd.org/

Recommended resources for mosquito-borne diseases

All mosquito-borne diseases must be reported to the Minnesota Department of Health. Reports need to include demograph-ic, clinical, and laboratory information. To report cases, please download case report forms at www.health.state.mn.us/divs/ idepc/dtopics/reportable/forms/arboviralform.html or contact the vector-borne disease epidemiology staff at (651) 201-5414.

Reporting mosquito-borne diseases


Source: Minnesota Dept. of Health

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but possible mosquito-borne diseases in Minnesota include Western equine encephalitis and Eastern equine encephalitis. The risk for acquiring mosqui-to-borne diseases in Minnesota is highest during the months of July through September.

In general, mosquito-borne disease risk is much lower in the United States compared to abroad. This is true even in the southern states that have estab-lished mosquito vector popula-tions for many of the diseases discussed in this article. There are several reasons for this decreased risk, perhaps the most important being that buildings in the U.S. have much better structural integrity compared to most tropical and subtropical countries, including screened-in windows or air conditioning that protect people from mosqui-toes. Additionally, widespread access to the Internet, televi-sion, video games, etc., may lead to behavioral differences in U.S. residents, keeping them indoors more often than resi-dents of tropical and subtropical countries. Wetland drainage and

agricultural land use in the U.S. greatly diminishes the breeding habitat for many mosquitoes. In much of the country, cold winters greatly reduce mosquito activity and subsequent virus amplification and transmission for the majority of the year. Finally, there are hundreds of local mosquito control agencies throughout the country that play a large role in reducing mosquito-borne disease risk for the populations they serve. Locally, Minnesota has the Metropolitan Mosquito Control District (MMCD), which oper-ates within the seven-county

metropolitan area. MMCD maintains extensive surveil-lance and control of exotic mos-quito introductions, including the detection and elimination of seasonal introductions of Ae. albopictus.

What can medical providers do?MDH encourages medical providers to use the available resources on travel-related risks for not only mosquito-borne diseases, but for other dis-eases as well, as risks in Minnesota may be very dif-ferent than in other parts of

the world. Finally, report-ing laboratory-confirmed or clinically suspected cases of mosquito-borne diseases to MDH is important for contin-ued understanding of trends and changes in both locally endemic and travel-associ-ated mosquito-borne diseases (see the sidebar on reporting mosquito-borne diseases).

Franny Dorr, MPH, is an epidemi-ologist in the Vectorborne Diseases Unit at the Minnesota Department of Health.

Table 1. Quick- reference of common travel- associated mosquito- borne diseases

Disease Pathogen Type

Mosquito Vector Species

Key Symptoms Diagnostic Tests

Treatment

Malaria parasite, Plas-modium spp.

Anopheles genus spp.

fever, chills, sweats, headaches, myalgia, nausea, and vomiting

blood smear or PCR

Varies depend-ing on Plasmo-dium spp.

Chikungunya alphavirus Ae. aegypti, Ae. albopictus

fever, arthralgia, my-algia, rash

serology or PCR

supportive

Zika flavivirus Primarily Ae. aegypti, likely Ae. albopictus

fever, arthralgia, rash, conjunctivitis

serology or PCR

supportive

Dengue flavivirus, se-rotypes 1-4

Ae. aegypti, Ae. albopictus

fever, headache, myalgia

serology or PCR

supportive

Source: Minnesota Dept. of Health

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For many professionals in the health care industry, finding the right balance

between work schedules and home life can be challenging. Health care providers such as physicians, physician assis-tants, and nurse practitioners (commonly referred to as advanced practice providers) are not immune to this issue. In fact, stress and burnout are prevalent in the medical field and if left unaddressed, can affect quality of care. As recent studies have shown (Shanafelt, Mayo Clinic Proceedings, 2015), burnout is on an upward trend and now affects more than 50 percent of all physicians in the U.S. Research on Advanced Practice Providers (APPs) is still being conducted but is expected to show similar results to phy-sicians in terms of stress and burnout. This article will refer to the combination of physi-cians and APPs as “providers.”

Hennepin County Medical Center (HCMC), a safety net health care system, is tackling

this serious issue in a variety of ways. For the past 20 years, the authors have studied physician satisfaction, stress, and burnout and for the past six years have worked with HCMC executive leadership to better address the components and predictors of burnout, as well as the implica-tions for providers and patients. As a result, the Office of Profes-sional Worklife (OPW) and the Provider Wellness Committee (PWC) were launched at HCMC.

The research base

In the early 2000s, a team, including one of the authors, was formed to study physi-cian burnout in a randomized control trial called MEMO (Minimizing Error, Maximizing

Outcome), which was funded by the Agency for Healthcare Research and Quality (AHRQ). MEMO involved data collection from physicians, clinics, and patients and showed there are relationships between work conditions, physician reactions, and patient care. Per MEMO study results published in 2009, 50 percent of physicians needed more time for visits, 27 percent were burning out or burned out, and 30 percent were likely to leave their job within two years. There were strong rela-tionships between work condi-tions (specifically time pres-sure, work control, chaos, and culture) and physician satis-faction, burnout, and turnover, as well as links between work conditions and many patient outcomes in terms of chronic disease management and health maintenance activities.

The next step in the research was to see if altering work con-ditions affected providers and outcomes such as burnout and satisfaction, along with clinical outcomes such as diabetes and blood pressure management. The same team conducted a randomized control trial called Creating Healthy Work Places (HWP), also funded by AHRQ, involving medical providers, patients, and clinics. The hy-pothesis of the study was that workplace changes, prompted by feedback on clinician percep-tions and outcomes, would lead to a decrease in clinician stress and improved care for patients. The study used a survey tool called the Office and Work Life (OWL) measure, which assessed the work environment and care quality at baseline and up to 12 months later. Sites in the study were given worklife and clinical data about their practice and provider survey results that they could use to determine what sorts of interventions

would be best for them as a group. HWP identified inter-ventions that would be able to reduce provider burnout.

Establishing a committee

After seeing the power that HWP survey data could have on a practice (by leading to mean-ingful discussions between medical providers including physicians and APPs, staff, and leaders), one of the first steps HCMC undertook in 2013 was to establish the PWC. The PWC is composed of physicians and advanced practice providers, including nurse practitioners, psychologists, and dentists from nine clinical departments and three administration units. It meets once a month, has an approved charter, and reports directly to executive leader-ship on a quarterly basis. The membership of the PWC is a unique component of our provider wellness initiatives as it allows interaction between departments that may not nor-mally interact with one another. These monthly meetings are a chance to share experiences, discuss how policies impact dif-ferent work areas, review data, brainstorm solutions, and find ways to make HCMC the best place to work.

PWC members are not the only staff engaged in wellness on campus. There are departmental wellness champions — individ-uals who commit to spending time reviewing burnout survey data and working with depart-ment chiefs to implement im-provement strategies. Wellness champions also act as the face of wellness in their departments and are often the first ones to hear about frontline challenges. Wellness champions interface with the Provider Wellness Com-mittee when someone raises a wellness issue.

The survey

Once our leaders understood the root causes of physician and other health care provider stress and burnout, and what national burnout rates were, they wanted to learn what those figures looked like locally at HCMC. Our team developed a

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short, 10-item survey tool called the Mini Z (the “Z” stands for Zero Burnout Program). The Mini Z derives its questions from validated tools such as the OWL used in the MEMO and HWP studies. The tool is easy to use and provides enough preliminary data to “take the temperature” of a clinical setting. There are questions that address common burnout factors like: work control, work-place chaos, personal values alignment with leaders’ values, stress, teamwork, and time pressure due to the electronic health record (EHR).

The Mini Z survey was distributed in the fall of 2013 and 2014 to all HCMC provid-ers (physicians and APPs) who met certain criteria (0.5 full time equivalent [fte] or higher, and employed for more than six months). The response rate was excellent (60+ percent each year) and our analytics team was able to transfer the data into an easy-to-read format.

The data

After the first survey was dis-tributed and the data analysis complete, we hosted a half-day retreat with PWC members, leaders, department chiefs, and wellness champions to review the data, discuss possi-ble interventions, and plan for data distribution. The survey data showed trends at HCMC that were similar to colleagues across the country—burnout was present in about one-third of the respondents. Respon-dents reported too much electronic medical record work, excellent teamwork, but also challenges with chaotic work-places. Key provider wellness leaders held meetings with department chiefs and wellness champions to review survey data within their departments. These meetings were eye opening in terms of discussing real issues facing providers. They also showed how much chiefs cared about their faculty, through their engagement and concern about the data.

As a result of the data meet-ings, executive leadership sup-ported changes in departments

that were experiencing high rates of stress and/or burnout. These changes (sometimes in the form of standard quality improvement Plan-Do-Study-Act [PDSA] programs) were often small and inexpensive, but the response to them was

overwhelmingly positive. Sur-vey data the next year showed improvements in scores with burnout dropping from 33 to 27 percent, control over workload improving from 55 to 62 per-cent, time for documentation increasing from 49 to 59 per-cent, and six of the departments with the highest burnout rates showing substantive improve-ment in their burnout scores to some of the lowest reported at HCMC.

Noticing the results

The work the Provider Wellness Committee is doing is being noticed on campus. “With Dr. Linzer’s guidance, attention to provider wellness is starting to bear fruit. Similar to national trends, providers at HCMC are now employed by the health sys-tem. That makes provider well-ness a system concern,” said Brad Linzie, chief of pathology at HCMC. “The amazing work our providers do depends on staying in a healthy mental zone of focus. The Wellness Committee has helped teach reactive coping tactics like taking a time out and proactive strategies like changing the end of day schedule, which are now becoming sanctioned and supported.” The authors have noticed an increased aware-ness of provider wellness, a reduction in burnout, and more personal satisfaction. This is an integral part of the organiza-tional goal of improving patient outcomes and satisfaction.

The importance of wellness

After two years, we took provider wellness to the next level and created the Office of Professional Worklife. The OPW program focuses on offering wellness services that improve the work lives of all 600+

HCMC providers. The OPW recognizes that providers need to know that their workplace is supportive of work/life balance. This can be accomplished by implementing wellness initia-tives that redesign workflow in the clinics and improve com-munication between provider groups. The OPW includes the authors and other commit-ted leaders and the hope is to create a model of a supportive

organization with a positive work environment that pro-motes humanism in medicine and the highest quality care for patients. The topic of provider wellness is rapidly gaining traction nationally, and HCMC is thrilled to be involved in the front lines of this research and program development.

Dr. John K. Cumming, vice president of Medical Affairs and president of the medical staff at HCMC said, “I am in-vested in supporting our physicians and advanced practice providers. Provider health and wellness is critical to achieving excellent out-comes and patient experience. Through high-value initiatives such as the Provider Wellness Committee and the Provider Dining and Wellness Center (under construction), the Office of Professional Worklife is producing a strong impact on the health and wellness of our providers.”

Providers need to know that their workplace is supportive of work/

life balance.

Provider burnout to page 32

Your Link to Mental Health ResourcesYour Link to Mental Health Resources



I was privileged to give the keynote speech to the March 2016 Minnesota

Medical Group Management Association (MMGMA) confer-ence. The conference included executive directors, human resource directors, adminis-trators, and other health care professionals and I discussed the changing state of health care, the impact it is having on physicians (and other health care professionals), and the sub-sequent rise in burnout among physicians. Unfortunately, many heads nodded in agree-ment that this is a growing problem in many organizations. This problem will continue to worsen unless we act now to help those who are dedicated to healing others.

The changes

The last several years have seen accelerated change in health care. For example:

• Rising costs mean that smaller, independent phy-sician groups are being

bought or merged with larg-er health care organizations to stay alive and/or relevant.

• Decreased reimbursement, particularly from Medicare, is creating a vicious cycle of working harder and longer for the same (or less) pay, even after a buyout or merg-er with a larger entity.

• The enactment of digitized medical records have, how-ever inadvertently, made the doctor/patient interaction less patient centered and less personal, increasing the stress and frustration on both sides.

• ICD-10 coding, may offer more specificity, but it has turned out to be a lot more costly and time consuming than anticipated.

• All of this (and more) results in the increased pressure to do what has become a man-tra in many hospitals and clinics, “Do more with less.”

These issues are hardly new and, in fact, are becoming the new normal. So, what is the impact of these changes on physicians?

Increased expectations

In a large, independent, spe-cialty medical group in another state, physicians are very busy and dedicated to providing excellence in health care. Within their specialty, like the rest of health care, if mistakes are made, people can die.

Many of the shareholders, who are physicians and part-ners, offered their opinions on the problems they were facing in their daily practice. Complaints were at an all-time high, backbiting was prevalent, revenue (and thus income) was down for the second consecu-tive year despite being busier than ever, physicians distrusted administrators, and complaints of burnout were openly dis-cussed. When asked what had the biggest impact on their practice, one of the physicians summed up his experience in a sentence that spoke volumes, “I’m moving at the speed of malpractice.”

What does moving at the speed of malpractice look like?

• Increased pressure to see more patients, causing physicians to spend less time with each patient in order to maintain their tight schedule.

• With increased pressure to move quickly, physicians become stressed and pa-tients pick up on this, which affects the clinic visit. This negatively impacts the doctor/patient relationship, often culminating in patient complaints. Staff, can also be adversely affected by phy-sician stress leading to hurt feelings and hostility.

• When staff are preoccupied with the perception that they are being treated disrespectfully, mistakes are made. Communication between physicians and staff is rushed because of time constraints, often resulting in more misunderstandings or miscommunications. (This can happen with patients too.)

The Mayo Clinic study

The Mayo Clinic Study (Mayo Foundation for Medical Educa-tion and Research; Mayo Clinic Proceedings, December 2015) (http://dx.doi.org/10.1016/j.mayocp.2015.08.023) examined physician burnout and work/life balance (WLB) comparing the years 2011 and 2014. They found that over half of U.S. physicians experience at least one of the following indicators of professional burnout: 1) emotional exhaustion, 2) loss of meaning in their work, 3) feelings of ineffectiveness, 4) depersonalization (the tendency to view people as objects), and 5) compromised patient safety.

As a result of the burnout study, Mayo observed that the quality of care that physicians provide decreases and that phy-sician turnover increases—all of which combines to signifi-cantly and negatively impact the quality of the health-care delivery system.

Physician burnout increased from 45.5 percent in 2011 to 54.4 percent in 2014. While some specialties suffered more than others, all specialties saw at least a 10 percent increase. Compared to the general pop-ulation, physicians were at a burnout rate of 48.8 percent vs. 28.4 percent and for work/life balance satisfaction, physicians

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were at 36 percent vs. 61.3 per-cent for the general population. As you can see, physicians (and health care staff) are under a great amount of stress and pressure.

Hospital errors are now the third leading cause of death, behind heart disease and cancer, estimated between 220,000–450,000 deaths per year (Journal of Patient Safety, September 2013). While there are many factors contributing to these adverse events, the research specifically identifies the following as contributing factors: 1) increased production demands, 2) decreased staff, and 3) a shortage of physicians, which leads to fatigue and burnout. Not surprisingly, this mirrors much of the Mayo Clin-ic’s findings.

Helping the healers

Considering the problems shown in the Mayo study and in points already discussed, there are several recurrent themes.

1. Physicians care, sometimes too much. They practice medicine to help people and make a difference. When they experience a “system” that isn’t working well or effectively they become stressed and frustrated because their work is ham-pered by forces outside of their control.

2. Physicians are held to the highest standards, by the health care system, patients and their families, and themselves. When those standards are not attainable, stress and frustration rise, and can often affect staff, partners, and patients.

3. Physicians can become desensitized due to the pressure of having less time. This takes a toll on their self-esteem and sense of ef-fectiveness and they become increasingly disengaged.

4. The increased demand and pressure to earn their keep takes a toll on the physician and his or her family. They are absent from home more, miss out on raising their kids, and when they are home they are exhausted or finishing dictation.

5. Physicians often have poor stress management skills because this isn’t taught or emphasized in medical school.

There is an increased risk for burnout because of many factors. While many factors are out of their immediate control, many are not and can be effec-tively managed.

The paths for change

There are many things that can be done to curtail and minimize physician burnout. It is important to note, as the Mayo Clinic did in their study, that the most effective process includes interventions that hap-pen from both a systemic (what the administration can do) and individual perspective.

The systemic level1. Identify systemic concerns/

issues sooner. Physician complaints, even if they have merit, are often dismissed by administrators because of how physicians go about voicing their concerns. Their concerns are seen as being “negative,” and physicians are sent for executive coach-ing sessions without the administration fully review-ing the issue. Relatedly, if a physician is being identified as having issues or concerns, administrators need to act sooner rather than later and address the concerns before they become even more disruptive.

2. Develop an accountability process/procedure. Every organization should have a graduated process for addressing behavior issues in the workplace that apply to everyone. This helps with “fairness” concerns and decreases the possibility for others to claim discrimina-tion if they believe they are treated differently.

3. Leadership involvement. It is unrealistic to think that staff will report a physi-cian, who is often their boss, for inappropriate or

unprofessional behavior, despite rules that allow them to do just that. Lead-ership (the Board of Direc-tors, the administration, or human resources) must hold physicians accountable. When leadership doesn’t do this, morale drops and staff members go silent.

4. Training. It is important to train employees—physi-cians and staff alike—in key

workplace be-haviors, such as conflict management, professional boundaries, and dealing with difficult situations/people.

5. Developing a positive organi-zational culture. By engag-ing in steps 1–4, organiza-tions can work to positively shape their culture by show-ing care and commitment and by minimizing disrup-tive behaviors and attitudes.

When staff is happy and healthy that means that pa-tients and their families are happy too.

The individual levelIn addition to systemic

interventions, it is important to include interventions that hap-pen from an individual level, or what executive coaches can do with individuals. Physicians are sent for or seek executive coach-ing for a wide variety of issues and concerns, but more often than not, it is because they have maxed out their coping mecha-nisms. Here are some examples:

1. Define what you can control and what you can’t. When a coach sits down with a physician, the administra-tion has already filled the coach in on the problem, but it’s important to understand the physician’s perspective as well. There is overlap between the two sides, but it’s common to hear from

Physicians often have poor stress

management skills.

Moving at the speed of malpractice to page 30


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Gestational diabetes mellitus (GDM) is on the rise worldwide and

is now among the most com-mon medical complications of pregnancy (Poomalar, 2015). According to the Centers for Disease Control and Preven-tion, the prevalence of GDM in pregnant women is estimated as high as 9 percent. Data suggest this rise is linked to the coincid-ing increase in obesity (DeSis-to, Kim, & Sharma, 2014). In response, increased efforts in research and prevention are influencing today’s clinical management of GDM in the primary care setting, including pre-pregnancy counseling, early screening strategies, therapeu-tic management, and long-term follow up postpartum.

What is GDM?

Gestational diabetes is defined as any degree of glucose (carbo-hydrate) intolerance, with onset or first recognition during preg-nancy. The American Diabetes Association (ADA) suggests this definition encompasses

insulin or diet-only modifica-tions for treatment and whether the condition continues after pregnancy.

Among GDM risk factors are a body mass index (BMI) greater than 30, family or pre-vious history of GDM, known impaired glucose metabolism, polycystic ovary syndrome, and previous infant birth weight over 9 pounds. Other factors associated with glucose abnor-malities in pregnancy include excessive weight gain prior to pregnancy and excess saturated fat intake.

Significant health concerns

GDM is associated with

neonatal and fetal complica-tions. Women with GDM are at higher risk of gestational hypertension, preeclampsia, and cesarean delivery. Infant risks include macrosomia, neo-natal hypoglycemia, hyperbil-irubinemia, operative delivery, birth trauma, and respiratory distress syndrome.

The long-term impact of GDM is significant. The Amer-ican College of Obstetricians and Gynecologists (ACOG) projects that upwards of 50 per-cent of women with GDM will develop type 2 diabetes at some point in their lives. Children of women with GDM are at greater risk for diabetes, glucose intol-erance, and obesity (Metzger & Coustan, 1998).

Early screening strategy, diagnosis

ACOG recommends all preg-nant women who do not have preexisting diabetes be tested for GDM (see the sidebar). A two-step approach to testing is common in the U.S. The first step is performed by checking capillary or serum glucose one hour after ingesting 50 grams of carbohydrate. Depending on the results, a second diagnostic step includes a three-hour glu-cose test with ingestion of 100 grams of carbohydrate.

• Low-risk patients are screened at 24 to 28 weeks of gestation; if glucose levels meet or exceed screening thresholds greater than 135 or 140 mg/dL (based upon community prevalence rates of GDM), the patient under-goes diagnostic testing.

• High-risk women, those with a history of previous gestational diabetes, known impaired glucose metabo-lism, or obesity, are screened at 10 to 14 weeks. If glucose

levels are normal, she will be rescreened with a one-hour glucose test at 24 to 28 weeks. If the glucose is high, the patient will complete an early three-hour glucose tolerance test (GTT). If she passes threshold parame-ters, she will be rescreened at 24 to 28 weeks.

Alternative protocols have been used and promoted by other organizations. The Inter-national Association of Diabetes and Pregnancy Study Groups (IADPSG) suggest a one-step approach. At the first prenatal visit, a hemoglobin A1c or a fast-ing plasma glucose (FPG) test is performed for all or only high-risk women to identify undiag-nosed pregestational diabetes. Overt diabetes in pregnancy is indicated with an A1c >6.5 percent or FPG > 126 mg/dL. While the A1c may be a useful marker to help identify preges-tational diabetes, ACOG contin-ues to recommend the two-step approach due to lack of evidence that the one-step approach would lead to clinically signifi-cant improvements in maternal or newborn outcomes (Feldman, Tieu, & Yasumura, 2016).

Medical management during pregnancy

It is important to offer nutri-tional counseling as part of a multidisciplinary approach to medical management of gestational diabetes. Medical nutrition therapy, initiated within one week of diagnosis and with a minimum of three nutrition visits, results in decreased insulin use, improves likelihood of normal fetal and placental growth, and reduces risk of perinatal complications, especially when diagnosed and treated early. Registered dietitians and certified diabetes educators help patients achieve normoglycemia, prevent ketosis, and gain appropriate preg-nancy weight. Timely referrals allow women to quickly access resources and provide seam-less continuity of care. At our practice, for example, women receive education on gesta-tional diabetes that includes a carb-controlled meal plan, glu-cometer teaching, and exercise

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counseling. They also receive patient navigator services throughout their pregnancy to ensure glycemic control.

If a woman experiences persistently elevated glucose at any point of her pregnancy and/or excessive rate of fetal growth, she should be referred to a diabetes specialist for con-sideration of pharmacological therapy. Women requiring med-ication can also start weekly biophysical profiles at 32 weeks.

In the absence of a dietitian or certified diabetes educator, here are some useful recom-mendations from ACOG:

1. Practitioners should encour-age patients to consume adequate calories to promote appropriate weight gain with guidance from the Dietary Reference Intakes (DRI) for pregnant women, as re-search indicates that inad-equate weight gain during pregnancy is associated with an increased risk of preterm delivery, regardless of pre-pregnancy BMI levels. The USDA has created a use-ful app, “DRI Calculator for Healthcare Professionals.” In obese women, the Acade-my of Nutrition and Dietetics Evidence Analysis Library recommends that 70 percent of the DRI calculated en-ergy needs, or at least 1800 calories daily, will help slow weight, prevent ketonemia, and ketonuria. The general caloric needs of pregnant women increase by ~340 cal-ories in the second trimester and another ~110 calories in the third trimester. For obese women, the addition of 150 calories in the second and third trimesters will help meet their pregnancy needs while supporting ap-propriate weight gain.

2. The DRI recommends that pregnant women consume a minimum of 175 g of car-bohydrate daily to provide glucose for the fetal brain and to prevent ketosis. Carbohydrate intake affects post-meal blood glucose levels. Postprandial hy-perglycemia is associated with increased incidence

of large-for-gestational age infants and increased rate of cesarean deliveries. Studies show improved outcomes at carbohydrate intake of less than 45 percent of total energy intake.

3. ACOG recommends that carbohydrates be distrib-uted between three meals and two to three snacks to reduce postprandial glucose fluctuations. Due to pregnancy hormones, women with GDM often find it hardest to control their blood sugar in the morn-ing. Clinicians can consider recommending a general pattern of 15 to 30 grams of carbohydrate at breakfast and snacks with 45 to 60 grams of carbohydrate at lunch and dinner.

4. Useful apps primary care providers can recommend to patients include: Diabetes App by BHI Technologies; Glucose Buddy by Azu-mio; Diabetes Tracker by MyNetDiary; or Diabetes in Pregnancy by Coheso. Food and glucose diaries, whether electronic or paper, have been shown to be more effective in controlling GDM when practitioners request and review them.

Clinicians should also consider recommending a moderate exercise program that consists of physical exercise for 30 minutes per day to improve glycemic control (Blumer et al., 2013). If women are prescribed insulin, they should check their blood glucose prior to exercise. The ADA (2016) recommends consuming carbohydrates before exercise if blood sugar levels are below 100 mg/dL.

Considerations for delivery

According to ACOG, women with gestational diabetes with good

glycemic control and no other complications can be managed expectantly. Women on medi-cal therapy with good glycemic control do not require delivery before 39 weeks of gestation. Delivery at or after 37 weeks

should be considered for women with poor glycemic control.

Macrosomia is more com-mon in women with gestational diabetes, and shoulder dystocia is more likely at a given fetal weight in pregnancies compli-cated by diabetes. Ultrasound for estimated fetal weight (EFW) may be considered for those women in which macrosomia is expected. The accepted range of error in ultrasound EFW is 10 percent of the actual fetal

weight, which limits its useful-ness. It has been estimated that up to 588 cesarean deliveries for an EFW of 4,500 gm and up to 962 cesarean deliveries for an EFW of 4,000 gm would be needed to prevent a single case of permanent brachial plexus palsy. It is reasonable to discuss the option of scheduled cesarean delivery when the EFW is 4,500 gm or more.

Medical management postpartum

At a patient’s postpartum appointment at six to 12 weeks, it is recommended that all women with gestational diabe-tes complete a fasting glucose. They may also be tested with a 75 gm two-hour challenge test. If postpartum testing is normal, repeat testing is conducted at three-year intervals in concor-dance with ACOG and the ADA.

Clinician support of breastfeeding is also nota-ble. Research has indicated

Children of women with GDM are at greater risk for diabetes, glucose

intolerance, and obesity.

Gestational diabetes management to page 29

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PHARMACY


According to the Centers for Medicare & Medic-aid Services (CMS), the

total cost of health care in the United States in 2014 reached $3 trillion, with government programs and private payers spending at rates higher than ever before. Much of this cost is due to an increase in prescrip-tion medication utilization. Four out of every five health care visits result in a medica-tion being prescribed. Eighty percent of adults take prescrip-tion or over-the-counter med-ication, or other remedies on a weekly basis, and 30 percent of these adults take at least five medications. Medications are beneficial when appropriately taken as prescribed; however, they can also do significant damage if not used appropri-ately. The Institute of Medicine (IOM) estimates that hospital-izations caused by adverse drug events costs the health care sys-tem $3.5 billion annually. The health care system is undergo-ing major payment reform in an

attempt to address the rising to-tal cost of health care—shifting from an entirely fee-for-service world to a world that rewards high-quality care. Value-based payments are intended to both increase the quality of care provided and minimize the cost of care to whatever extent possible. Minnesota-based health systems and physician groups are responding to this call for change, recognizing the opportunity to revamp a system in need of repair. To begin the renovation, blueprints for the remodeling process have been outlined in the core objectives

set forth by the Institute for Healthcare Improvement (IHI) Triple Aim: to elevate the pa-tient experience, improve the health of the population, and reduce the per capita cost of health care. Safe and effective medication use should be at the forefront of this charge.

Reducing the cost of care In order to achieve these core objectives and sustain the results, health systems and phy-sician groups are redesigning the structure of primary care practice with a collaborative, team-based approach. As med-ication specialists, pharmacists are becoming an increasingly important member of a patient’s care team. How does the addi-tion of a pharmacist to a care team contribute to value-based care? Pharmacists have effec-tively managed high-risk patient populations by optimiz-ing medication use to improve clinical outcomes and reduce health care costs. For exam-ple, results from a prospective study published in 2008 in the Journal of the American Phar-macists Association showed a statistically significant total decrease in health expenditures over one year (from $11,965 to $8,197 per person) when incor-porating clinical pharmacy services to optimize patient care. A 2010 article in the Jour-nal of Managed Care Pharmacy studied cost savings by phar-macists in a health system. The results showcased a total cost savings of $2,913,850 ($86 per encounter), and the total cost of clinical pharmacy services was $2,258,302 ($67 per encoun-ter), for an estimated return on investment of $1.29 per $1 over 10 years.

Improving patient experience through team-based care Minnesota’s three pioneer accountable care organizations (ACOs)—Allina, Fairview, and Park Nicollet/HealthPart-ners—are paving a new path for payment, from volume to value. These ACOs are gaining headway by enlisting the help of pharmacists to provide direct care for patients through a consistent patient care process known as Comprehensive Med-ication Management (CMM) or Medication Therapy Manage-ment (MTM).

CMM is a value-added ser-vice delivered by pharmacists in Minnesota health systems to optimize medication use. Through this consistent care process model, pharmacists systematically “...determine that each medication is appropri-ate and effective for the med-ical condition, safe given the comorbidities and other med-ications being taken, and able to be taken by the patient as intended.” Pharmacists design and implement patient-driven care plans to achieve thera-peutic goals with appropriate follow-up to determine actual patient outcomes. According to Rae Ann Williams, MD, region-al medical director at Health-Partners, “[Medical] providers in my internal medicine clinic rely heavily on their pharma-cists to help titrate and monitor medications. It is one thing if patients are well controlled, but the literature would suggest that approximately 50 percent of the time patients’ medica-tion doses are not optimized for their chronic conditions for a variety of reasons. While physicians often address mul-tiple health concerns during an office visit, pharmacists can focus on titrating medications and following up on necessary dose adjustments, which allows us to expand our ability to care for more patients.” Effec-tively, CMM adds value to the care patients receive and also fosters cooperative relation-ships between pharmacists and providers.

Williams puts it this way, “You can care for patients yourself, but once you work

Redesigning primary care

The role of the pharmacist in value-based care

By Lara Kerwin, PharmD, and Heidi Le, PharmD

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with a pharmacist and appre-ciate their knowledge base, it is hard not to have them on your team and utilize them. There’s opportunity here. We, as phy-sicians, are very busy and may not have the ability to follow up with patients as quickly as they want, but if they partner with a pharmacist providing com-prehensive medication manage-ment, they can help optimize their medications and get them to goal.” Each member of the health care team should be leveraged to work to the top of his or her license. Pharmacists delivering comprehensive med-ication management in ambu-latory care settings can address and fulfill this need.

Caring for populationsWhile comprehensive medication management has an import-ant role in the value-based care model, generally, it is a resource-intensive process focusing on patients at the high-est risk for poor outcomes and does not broadly target a large population of patients. Because

of the improvement to quality and cost-savings seen by having a pharmacist in clinics, many

health systems are integrating pharmacists into care teams in non-dispensing roles. Pharma-cists are now taking on roles to manage population health. For instance, pharmacists in primary care clinics are leading quality improvement initia-tives. One example is a phar-macist evaluating all patients with diabetes within a clinic that are not on statin therapy and working with clinic-based quality improvement teams to resolve this population-based drug therapy problem. In this way, pharmacists are able to facilitate quality improvement

upon state quality metrics and national quality measures, such as from CMS.

On a larger scale in Minne-sota, health systems are joining forces with payers to broadly review medication utilization and identify gaps in care. Phar-macists like Amanda Brummel, PharmD, BCACP, director of Fairview Pharmacy Clinical Ambulatory Services (which em-ploys 25 pharmacists in primary care clinics across the health system), are championing these efforts. When system-payer collaborations come to fruition, it forms a partnership that helps eliminate the issue of each party working parallel to one another instead of in tandem. Brummel

notes, “We need to stop duplicat-ing efforts—it is better for every-one if we can all work together as a team.”

The role of community pharmacistsWith established CMM services happening in primary care clinics and population health management partnerships growing with payers, what is the role of community pharma-cists in value-based care of the future? Dan Rehrauer, PharmD, of HealthPartners suggests focusing on an overlooked asset of the pharmacist: accessibil-ity. One of the key barriers to providing high quality popula-tion-based care is underutiliz-ing key players on the health care team, such as pharmacists, who have frequent opportu-nities to impact and monitor the care of patients between primary care visits. In a climate where there is a shortage of pri-mary care providers and access to patients in a clinic setting is

Comprehensive medication management has an important role

in the value-based care model.

Redesigning primary care to page 28


limited, the opposite holds true with pharmacists in a com-munity-based setting. A phar-macist can be found on nearly every street corner and in every hospital, and they have the advanced training necessary to provide direct patient care and to care for Minnesota commu-nities. Rehrauer of HealthPart-ners discusses implications for community pharmacy involve-ment in the value-based care model, “Community pharmacy partnerships are still very much in their infancy. We can utilize the community setting to provide better care and decrease overall cost of care by focusing on population health. We just need to figure out how to use and pay for community pharmacies to roll out these services. People aren’t necessar-ily exploring this opportunity or thinking about it right now. This is beyond comprehensive medication management. Com-munity pharmacies can touch

big populations when CMM doesn’t.” In addition, pharma-cists may be able to evaluate and adjust medications for conditions such as high blood pressure and diabetes in-be-tween medical visits to more closely manage follow up and

facilitate improved health out-comes. Establishing relation-ships with untapped resources such as community pharmacies is one such example answering the IHI’s charge of restructur-ing primary care services.

Many health systems and physician groups in Minnesota are using pharmacists to drive progress toward improving the patient experience, managing population health matters, and

reducing total cost of care. Although progress is advanced in Minnesota, compared to other states, there is still work to be done to realize the full potential of each team member in value-based care. Rehrauer states, “While pharmacists are

a part of it, it is going to take a system as a whole, not an individual provider, to move forward.” In addition, Brummel stresses, “It will be necessary to take all of these interven-tions (CMM, population-based efforts, new partnerships, and team-based care) to tackle the health of the population.” Wil-liams concludes, “We are at a pivotal point in which we need to be forward thinking, be more

proactive than reactive, and touch more patients.”

Minnesota health systems and physician groups are align-ing their mission and visions for the future of value-based health care. At the forefront of achieving this goal is optimiz-ing medication use and prevent-ing adverse drug events, which can be facilitated by leveraging the skills of a pharmacist as an integral member of the care team. Now, it is up to pharma-cists and providers to come to the table, to open lines of communication, build collab-orative partnerships, and start the conversation.

Lara Kerwin, PharmD, is a phar-maceutical care leadership resident at the University of Minnesota and practices at Smiley’s Family Medicine Clinic. Heidi Le, PharmD, is a phar-maceutical care leadership resident at the University of Minnesota and practices at Broadway Family Medi-cine Clinic.

Pharmacists are becoming an increasingly important member

of a patient’s care team.

Redesigning primary care from page 27


that breastfeeding results in long-term improvements in glucose metabolism even after adjustment for maternal age, BMI, and use of insulin during pregnancy. Breastfeeding may also reduce the risk of type 2 diabetes in children (Academy of Nutrition and Dietetics Evi-dence Analysis Library, 2016).

Conclusion

With the increasing incidence of obesity and diabetes in pregnancy, health care provid-ers are uniquely positioned to advocate for holistic approaches to improve patient health. The ADA recommends that clini-cians consider three key themes for diabetes care including:

patient-centeredness; diabetes across the life span; and advo-cacy. Recommending a compre-hensive plan with a multi-dis-ciplinary approach will reduce health risks including blood pressure and lipid control, smoking prevention and ces-sation, weight management, physical activity, and healthy lifestyle choices. Improving coordination between clinical

teams will also help patients transition through different stages of their life span. The natural transition from gesta-tional diabetes to postpartum prevention of type 2 diabetes is an opportune time to make long-lasting lifestyle improve-ments for women and their children. Advocacy at multiple

levels of the health care system will help improve the societal determinants of obesity and diabetes that are at the root of these problems.

Lori Wilcox, MD, is an obstetri-cian/gynecologist who practices at Oakdale Obstetrics and Gynecology (a division of Premier ObGyn of Minnesota). Kim Plessel, MS, RDN, LD, is a registered dietitian and sees patients at Oakdale Obstetrics and Gynecology.

The prevalence of GDM in pregnant women is estimated as high as 9 percent.

Gestational diabetes management from page 25

Two out of four glucose values are high on the three-hour glucose test.

ABNORMAL VALUES:

• Fasting ≥ 95• 1 hr ≥ 180• 2 hr ≥ 155 • 3 hr ≥ 140

Diagnosis of GDM

Source: American College of Obstetrics and Gynecologists, Practice Bulletin No. 137, 2013

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physicians what it’s like to be in the “trenches” and how difficult it is to meet the needs of the health care system, the parent organi-zation, the clinic, and the patient in a fast-moving system. It’s important for the physician to determine and understand what is within his or her control and what is not.

2. Learn to manage your emotions so your emotions do not manage you. It’s im-portant to talk about stress management; self-manage-ment (managing yourself and not outcomes, which have many variables that are often outside of your con-trol); impulse control (just because you think or feel something, does not mean you should verbalize it); and “slowing down” so you can think before you speak.

3. Be in the present (mentally), not in the past or the future.

In short, the only time you have control over anything is in the present. Staying in the present enables you to think about what is helpful now. This is highly effective in minimizing stress, pressure, and anxiety.

4. Develop emotional intel-ligence in a high IQ envi-ronment. Physicians are, on the whole, a very bright bunch of people. That said, their intelligence may be more “narrowly” focused, often excluding the skill sets identified as necessary for working well with others. This has been called emo-tional intelligence (EI or EQ for short). Study after study has found that EQ is a more accurate predictor of

success in life (not just work) than IQ. Learning to read situations, have empathy, be flexible, know how you feel, and how it may impact others are indicators of your emotional intelligence. The BarOn EQ-i is a useful tool

to evaluate a physician’s emotional intelligence and determine where their skills lie and where they are lacking. Developing these “soft” skills makes you more communicative, a better team member, and a more effective leader.

5. Explore your underlying attitudes and beliefs that give rise to your behavior. A person cannot act against his or her belief system on a regular basis. Belief systems

are quietly and constantly running behind the scenes, dictating what you can or can’t do. It’s helpful to ex-plore your beliefs and keep what works for you, discard what doesn’t, and adopt new beliefs that fit who you are and your current situation.

Conclusion

As health care continues to evolve, the constant in all the change is physicians. We need to ensure we are helping our healers (and health care organizations) to stay healthy, so they may continue to heal all of us.

Gregory Alch, MA, EdD, is a licensed psychologist and organization con-sultant in practice for over 28 years. He is the founder and president of Method 44, an organization consult-ing group. He works extensively with health care organizations providing executive coaching, leadership devel-opment, team building, training, and other change initiatives.

EQ is a more accurate predictor of success in life (not just work) than IQ.

Moving at the speed of malpractice from page 23

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North Memorial is hiring MDs, NPs and PA-Cs.We are a fiercely independent, physician-led organization. Our physician leaders, including our CEO, and VPs see patients every week. Healing defines us. Not bureaucracy. We treat our patients and our employees better. We’re committed to ensuring our providers have fulfilling clinical work, competitive salary and benefits, and work-life balance. Interested applicants may contact:

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FAMILY PRACTICE PHYSICIANS:

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Do you know what it feels like to work with a sense of purpose? At Marathon Health, we’re on a mission to put “health” back in healthcare. We have partnered with Cargill’s turkey and cooked meats business in Albert Lea, MN and are looking for a part-time Family Practice Physician to work with employees and their families (newborns +). This is an onsite position, working either four hours per week or two days per month (total:16 hours per month) with a clinical team consisting of a Family Nurse Practitioner and a Medical Assistant. There are no on-call hours. Our intention is to provide the best patient care in a collaborative clinical community, and to give access to the workforce population in and around Albert Lea. Imagine – work could be the highlight of your day. For a more detailed job description and to apply online, please visit www.marathon-health.com.

Family Medicine

Minnesota and WisconsinWe are actively recruiting exceptional board-certifi ed family medicine physicians to join our primary care teams in the Twin Cities (Minneapolis-St Paul) and Central Minnesota/Sartell, as well as western Wisconsin: Amery, Osceola and New Richmond.

All of these positions are full-time working a 4 or 4.5 day, Monday – Friday clinic schedule. Our Minnesota opportunities are family medicine, no OB, outpatient and based in a large metropolitan area and surrounding suburbs.

Our Wisconsin opportunities offer with or without obstetrics options, and include hospital call and rounding responsibilities. These positions are based in beautiful growing rural communities offering you a more traditional practice, and all are within an hours’ drive of the Twin Cities and a major airport.

HealthPartners continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and benefi ts package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact [email protected], 952-883-5453, toll-free: 800-472-4695. EOE

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Services offered by the OPW include: one-on-one discussions about work-life; advocacy with leadership for ways to improve balance between work and life for providers; and partnering with the Provider Wellness Committee, wellness champi-ons, and department chiefs to ensure that the needs of provid-ers are heard and addressed. They hope that by elevating work/life balance to the level of this office that providers will know this is an important issue and that help is there. In 2016, the OPW will promote sustain-ability and self-preservation, create a more supportive tone in messaging from leadership, support more time for self-care, advocate for less EMR work at home, develop transparency in values among leadership, and promote engagement as a means to decrease burnout.

A place to recharge

One unique feature of the OPW is the Reset Room where providers can go for quiet time to recharge during the busy workday. It serves as an oasis for providers during stress-ful times. Providers work

very hard and are dedicated to delivering compassionate, high-quality care for those in need. Addressing issues before they cause burnout is critical to making sure that providers are practicing medicine in the best environment possible. The room includes soft lighting, a sound machine (with waves and a babbling brook) and comfort-able chairs for relaxation and rejuvenation.

A wellness center

The latest OPW initiative is the transition of a doctors’ dining room at the downtown loca-tion into the Provider Dining and Wellness Center. The new 24-hour Center will offer break-fast and lunch to the provid-

ers and will have a facelift to brighten the space and create areas for exercising and relax-ing. The Center will include a workout space, a shower and changing room, eating space, and meeting areas. Soft carpet and moveable tables will enable groups to sit on the floor to debrief challenging events.

Conclusion

We have been working with national partners to increase awareness and decrease pro-vider burnout. The American Medical Association, the Amer-ican College of Physicians, and the Association of Chiefs and Leaders in General Internal Medicine have all collaborated with us, spreading the word concerning the “Hennepin model” of addressing burnout issues. We are very happy to have these national organiza-tions as partners who can carry the message to other health care delivery systems nation-wide.

Sara Poplau is assistant director of the Office of Professional Worklife at HCMC. Elizabeth Goelz, MD, is the chair of the Provider Wellness Committee and a general internist at HCMC. Mark Linzer, MD, is director of the Office of Professional Worklife and a general internist at HCMC.

Addressing issues before they cause burnout is critical.

Provider burnout from page 21

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Lakewood Health System is seeking to expand the care team for its progressive and patient-focused clinics and hospital. Located in Staples, Minnesota, Lakewood is an independent, growing healthcare system with fi ve primary care clinics, a critical access hospital and senior living facilities. Practice consists of 14 family medicine physicians and 10 advanced practice clinicians, as well as a variety of on-staff specialists. Competitive salary and benefi ts. Relocation and sign-on bonus available.

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• Stopping the use of tobacco. While smoking has been connected to bone loss, it is difficult to separate smok-ing from other risk factors common to smokers, such as alcohol intake, small body mass, physical inactivity, and poor diets. Women who smoke also have an earlier menopause than nonsmokers.

• Making the home safe. Most falls take place in the kitchen, bath, or on steps. I encourage patients to assess the risk of falling and re-move any risk factors, such as throw rugs, dark hall-ways, or slippery floors.

• Increasing exposure to sun-light or ultraviolet light to 30 minutes per day, five days a week. Sunlight contributes to our body’s production of vitamin D.

New medications

Most physicians today recom-mend bisphosphonates, includ-ing alendronate (Fosamax) or ibandronate (Boniva) as a first-line medication for osteo-porosis. These medications are usually well tolerated and cost less than some of the newer pharmaceutical agents on the market today. I usually stop them after five years, as fewer patients are willing to take med-ications due to the risk of femur

fractures and jaw necrosis, both of which have had a lot of media coverage in recent years.

Other common osteoporosis medications include selective estrogen receptor modulators (SERMs) like raloxifene (Evis-ta) or newer SERMs such as lasofoxifene.

Teriparatide, marketed as Forteo, is an anabolic agent that treats osteoporosis and also stimulates bone formation. Other similar drugs are in clin-ical studies, as are drugs that communicate with the chem-ical that signals bone-eating cells (osteoclasts) to block that signal. Scientists believe there may be other ways to speak to osteoclasts through signaling mechanisms.

Osteoporosis in men

More attention is being given to osteoporosis in men, although guidelines for testing are less clear than they are for women. Bone density measurements are obtained infrequently in men. Therefore, the diagnosis

of osteoporosis is often made as a result of incidental osteo-penia seen on radiographs or by fracture or height loss. Routine screening is not yet widely recommended, but the Male Osteoporosis Risk Esti-mation Score (MORES) is a scoring algorithm to identify men at risk for osteoporosis and therefore candidates for DEXA screening.

Taking the time

I recommend that physicians take the extra time to address bone health during annual exams. We have a lot of health screenings to go over in a short time, and bone health can be overlooked, along with coun-seling for risk factors, calcium, and vitamin D, but prevention is much easier than managing osteoporosis or treating painful fractures.

Yasmin Orandi, MD, is a family medicine physician at the Apple Valley Medical Clinic.

What’s new in osteoporosis? from page 15

Prevention is much easier than managing osteoporosis.

www.olmstedmedicalcenter.org

Olmsted Medical Center, a 220-clinician 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:

Send CV to: Olmsted Medical CenterHuman Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

email: [email protected] • Phone: 507.529.6748 • Fax: 507.529.6622

ENTRochester

Southeast Clinic

General SurgeryHospital

Plastic SurgeryOMC Hospital –

Women’s Health Pavilion

PsychiatristRochester Southeast Clinic

Psychiatrist – Child & Adolescence

Rochester Southeast Clinic

Sleep MedicineRochester Northwest Clinic

UrologyHospital


Contact: Todd Bymark, [email protected](218) 546-3023 | www.cuyunamed.org

Cuyuna Regional Medical Center is seeking two full-time Family Medicine physicians for its Crosby Clinic. Located in the heart of the Cuyuna Lakes Area, CRMC’s Crosby clinic has recruited 22 New and dedicated, quality physicians & APC’s in the last 2 ½ years that, along with the required up-to-date technology, have developed CRMC into a regional resource for advanced diagnostic and therapeutic healthcare services. Our Family Medicine opportunity:• MD or DO• Board Certified/Eligble in Family Medicine, Internal Medicine or IM/Peds• Full-time position equaling 36 patient contact hours per week• Work 4.5 days a week.• 1 in 11 Peds call. (Majority of calls handled by phone consultation) • Practice supported by 14 FM colleagues, APC’s and over 35 multi-specialty physicians• Subspecialty providers—Internal Medicine, OB/GYN, Orthopedics, Urology, Surgery, Oncology, Pain Management and more• Competitive comp package, generous signing bonus, relocation and full benefits • New Residients are encouraged to apply

A physician-led organization, CRMC has grown by more than 40 percent in the past three years and is proudly offering some procedures that are not done elsewhere in the nation. The Medical Center’s unique brand of personalized care is characterized by a record of sustained strength and steady growth reflected by an ever-increasing range of services offered.

Family Medicine & Emergency Medicine Physicians

• ImmediateOpenings• Casualweekendoreveningshiftcoverage• Setyourownhours• Competitiverates• PaidMalpractice

Great Opportunities

763-682-5906|[email protected]

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Connecting your business to your market

in Minnesota Physician

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Surveillance for infectious dis-

eases is a core public health

function essential to prevention

and control efforts. Since early in its

creation in the 1880s, the Minneso-

ta Department of Health (MDH) has

mandated the reporting of selected

infectious disease cases by physicians,

laboratories, and other health care

professionals. The reasons for surveil-

lance are to assess the health of the

population, and measure the burden of

disease in Minnesota; i.e., how much

Lyme disease, tuberculosis, West Nile

virus disease, or other infectious dis-

ease is there in Minnesota? What are

the trends in these or other diseases

over time? Are the numbers increasing

or decreasing, and how are the char-

acteristics of the cases and patients

changing? What are the risk factors or

sources of exposure for the cases? This

information is used by MDH to inform

prevention and control measures, and

assess their effectiveness. In addition,

other governmental and private sourc-

es can analyze trends and allocate and

Political malpractice to page 18

Infectious disease to page 16

Vo lume X X IX , N o. 7

O c t ob e r 2015

What are patients and doctors to

make of the bevy of acronyms

that seem to increase daily?

HMO (health maintenance organization)

has been a commonplace set of initials,

as have HSAs (health savings accounts)

and PBM (pharmacy benefit manage-

ment). But now we have ACA (the Patient

Protection and Affordable Care Act),

which may be easily confused with ACOs

(Accountable Care Organizations), one of

the ACA’s means of cost control.

So how did it happen that all of us are

now subject to the ACA, its ACOs, and an

alphabet soup of other acronyms, e.g.,

EHRs (electronic health records); P4P

(typically pay for “value” performance,

aka payment reform); FFS pay (fee-

for-service); or a threatening IPAB (the

federal Independent Payment Advisory

Board)? Recently, huge health insurance

corporation mega-mergers have been fea-

tured in the news. Flying below the radar

are mini-mergers between ACOs (hospi-

tal/medical staff insurance corporations)

and HMOs. What happened, what’s going

on, and how do all these things work…or

not work?

Political

malpractice

A look at medical costs

By Robert W. Geist, MD

Infectious disease

The value of physician reports

By Richard Danila, PhD, MPH, and Ruth Lynfield, MD

My colleagues at Park Dental

and I see dozens of patients

every day. While our focus is

on their mouths, we occasionally en-

counter other health-related issues that

require the attention of a physician.

Our dentists and hygienists routinely

take each patient’s blood pressure, per-

form oral cancer screenings, and look

for any other symptoms that might be

indicative of a larger health issue. If we

encounter any concerning medical is-

sues our dentists instruct their patients

to visit their physicians.

One of our dentists, Joseph F.

Rinaldi III, DDS, recently shared a

story with me about just such an oc-

currence. Dr. Rinaldi was scheduled to

remove a patient’s molar. Prior to the

surgery, the patient’s blood pressure

Leveraging information technology to page 18

Forging new alliances to page 16

Vo lum e X X IX , N o. 1

A p r i l 2015

Electronic health record (EHR) sys-

tems have become commonplace

in Minnesota’s health care sys-

tem, with most clinics and all hospitals

transitioning from paper charts to EHRs.

Despite this high adoption rate, provid-

ers are struggling to optimize the tools

and capabilities to support patient care,

and to exchange clinical health informa-

tion with providers outside of their own

health system.

In 2007, the Minnesota Legislature

passed the 2015 Interoperable EHR

Mandate, which states that all hospitals

and health care providers must use an

interoperable electronic health record

(EHR) system by Jan. 1, 2015 (Minne-

sota Statute § 62J.495 Electronic Health

Record Technology). An important com-

ponent of this law is that providers not

only adopt the technology, but that they

use the tools available in their EHRs and

securely exchange relevant health infor-

Leveraging

information

technology

A look at EHR data

By Bob Johnson, MPP, and

Karen Soderberg, MS

Forging new

The benefits of medical/dental collaboration

By John E. Gulon, DDS

alliances

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.


Report” in 2015 (http://www.health.state.mn.us/divs/eh/risk/guidance/dwec/pharmwaterrept.pdf).

• The One Health MN Antibiotic Stewardship Collaborative is working with a range of public and private partners across human, animal, and environmental health to protect health and preserve antibiotics. The Collaborative mem-bers include the Minne-sota Department of Health, the Minnesota Department of Agriculture, the Minneso-ta Board of Animal Health, the Minnesota Pollution Control Agency, and the Minnesota Department of Human Services.

• The Grand Portage Indian Reservation Ecosystem Health Collaboration Group is a multidisciplinary group studying how the state of the

ecosystem affects the health of the Grand Portage tribe. Their focus is on emerging and unregulated chemicals and pharmaceuticals and determining how they inter-act with the ecology of the region, and in particular the food supply.

• The College of Pharmacy at the University of Minne-sota has a team looking to borrow from the Swedish, “Environmentally Classified Pharmaceuticals” and im-plement a similar document with Minnesota use and dilution data. This group will work with other profes-sional and consumer organi-zations, and managed care to raise public awareness of

individual activities that can make a difference.

Conclusion

All of these Minnesota groups are to be commended for addressing the issue of ground-water contamination. However, eventually the decision on using

and disposing of unwanted medicines is an individual one. Will the prescriber consider the actual prescription quan-tity needs of a patient and the best medicine with the least risk? Will the pharmacist be an information resource and advocate for optimal disposal? Will managed care implement rational drug benefit designs that do not encourage surplus and un-needed medicines?

And most of all, will the con-sumers of medicines under-stand that every pill, taken or not, may eventually contribute to the pollutant profile of our water supply?

Walleye laced with DEET and ethinyl estradiol is a bizarre food we probably shouldn’t try!

Lowell J. Anderson, DSc, FAPhA, is a pharmacist who formerly practiced in St. Paul. After leaving practice in 2006, he joined the faculty of the College of Pharmacy at the University of Minnesota. He is a professor in the department of Pharmaceutical Care and Health Systems and co-director of the Center for Leading Healthcare Change. He has served as president of the Minnesota Pharmacists Association, Minnesota Board of Pharmacy, and the American Pharmacists Association.

Prescribing medications from page 13

Restrict new prescriptions to no more than 30 days.

OPEN POSITIONS INCLUDE: �� Cardiology (EP & Noninvasive)�� Dermatology�� Endocrinology�� Emergency Medicine�� Family Medicine�� Geriatrics

�� Internal Medicine�� Neurology�� Ophthalmology�� Orthopedics�� Rheumatology�� Urgent Care

EOE/M/F/Vet/Disabled

Physician OpportunitiesEssentia Health delivers on its promise to be “Here With You” and is guided by the values of quality, hospitality, respect, justice, stewardship and teamwork.

PLEASE CONTACT800-882-7310 | www.essentiahealth.org/careers

Richfield Medical Group is looking for two Board Certified/Eligible Family Physicians / Internal Medicine. Our practice defines full time as 3.5 days per week, with no evenings, weekends, or hospital rounding. We enjoy a very vibrant, satisfying professional practice and are committed to providing exceptional patient care. As an independent primary care clinic, we maintain our autonomy and control our destiny.

For more information please contact: Carol Lucio: 612-767-4737 [email protected] or Jim LaRoy, MD: [email protected]

Interested in Exploring a New Practice Opportunity that Allows

Work / Life Balance?


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. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. 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

• Associate Chief of Staff, Primary Care

• Dermatologist

• Internal Medicine/ Family Practice

• Occupational Health/Compensation & Pension Physician

• Physician (Compensation & Pension)

• Physician (Pain Clinic)/Outpatient Primary Care

• Psychiatrist

Applicants must be BE/BC.

St. Cloud VAHealth Care SystemBrainerd | Montevideo | Alexandria

You focus on taking care of patients.We’ll take care of the rest.

To learn more, visit allinahealth.org/physicianjobs.

Send CV to: [email protected] ext. 108 • www.raiterclinic.com

417 Skyline Blvd. • Cloquet, MN 55720

Our independent, physician-owned clinic is seeking a BC/BE physician (with or without OB) for our clinic.

1:7 Calls. Competitive salary/benefits, with opportunity for ownership within 1 year. Paid malpractice, health and dental

insurance, 401(k), CME and more. Cloquet is an historic, vibrant community just 15 minutes from Duluth and 10 minutes from Jay Cooke State Park. Adjacent to the St. Louis River, Cloquet has hiking, biking and ATV trails; skiing; boating; fishing; parks; and the only white water rafting in Minnesota. Residents enjoy locally performed

plays, concerts and the arts; community festivals; dining and more.

Family Medicinewith or without OB

It’s your life. Live it well.

• Re-evaluate autopsy policies and procedures: Clarification and education concerning autopsy expectations may provide necessary data as it relates to diagnostic error and other adverse events.

Averting blameEffective feedback

should be actionable, timely, individualized, and non-punitive. A non-punitive culture helps foster an environment in which mistakes are viewed as opportunities for growth and improvement.

The fifth goal of es-tablishing a work system and culture that supports the diagnostic process and improvements in diagnostic performance is also very im-portant. Health care systems on the journey to becoming high-reliability organizations (HROs) are focused on failure. They seek to understand why

a process failed and look on failure as an opportunity to im-prove. In order to move toward becoming an HRO, an organi-zation’s culture must support reporting errors.

Although the benefits of a non-punitive environment

have been well-studied and acknowledged for quite some time, many health care work-ers are reluctant to admit fault out of fear of retribution. If the behaviors that perpetuate diag-nostic error are to be changed, it is essential to foster a culture

of open communication where health care professionals at all levels feel safe to discuss medi-cal errors.

Mark Chassin and Jerod Loeb, both with the Joint Com-mission, detail the necessary steps to achieve high-reliability

in their 2013 article, High- Reliability Health Care: Getting There from Here. For those organizations approaching high-reliability, “Close calls and unsafe conditions are routinely reported, leading to early prob-lem resolution before patients are harmed; results are routine-ly communicated.” In essence, feedback is a key component to cultural change.

Overcoming the fear of legal action

The sixth goal to develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diag-nostic errors and near misses involves national policy chang-es. In 2005, Congress passed The Patient Safety and Quality Improvement Act, which pro-vided some peer protections for specific types of information shared with a designated Pa-tient Safety Organization (PSO). Progress has been slow though and challenges remain concern-ing collection and meaningful aggregation of this data.

Organizations must feel safe to report diagnostic errors in order to extend learning beyond their own system. Fear of legal action impedes open shar-ing of information and stifles feedback on a larger scale. Extending the PSO network and

increasing the protections it offers provides a safer environ-ment for reporting errors and sharing lessons learned.

Because diagnostic error is the most common source of payments made by medical professional liability carriers,

it is mutually beneficial for organizations to work with their carriers to improve processes. Insurance com-panies have access to risk management expertise and data on potential and actu-al claims that could serve to enhance feedback.

Conclusion

Physicians are expected to practice medicine in an environment that is grow-ing increasingly complex

with expansive regulatory requirements, spanning from reimbursement requirements to the HIPAA Privacy and Security Rules to the implementation of electronic medical record systems. All of this complexity often results in high levels of stress. The responsibility for improving diagnostic error can-not lie solely on the shoulders of physicians. By implementing process improvement methodol-ogies that are team-focused and include structured feedback, organizations can positively impact diagnostic error rates.

Diagnostic error prevention represents the next movement in patient safety. It is imperative that we seize the moment and harness the sense of urgency explained in the committee’s re-port. As part of this effort, cur-rent feedback mechanisms need to be examined and enhanced to support process improve-ments. Health care providers and patients deserve nothing less than our full attention.

Ann Fiala, RN, BSN, CPHRM, CHC, is a senior claims consultant at Coverys. She has more than 30 years of health care experience with extensive expe-rience in medical staff credentialing, regulatory readiness, patient-centered care, utilization and case manage-ment, and data analytics.


Diagnostic errors from page 11

Diagnostic error prevention

represents the next movement in patient safety.

Maintenance of certification (MOC) means different things to different people. Currently much press has been given to the cyn-ical and the skeptical. To the cynical it simply represents an opportunity for the American Board of Medical Specialties (ABMS), and its specialty member boards, to gouge physicians by mandating allegedly expensive and irrelevant educational programs. To

the skeptical it foists an unproven pro-cess with the overly optimistic claim of improved patient outcomes. Both positions are untenable.

MOC is, first and foremost, a form of continuous professional development, which is a structured approach to education, learning, and practice improvement to ensure a phy-

The coming physician shortage to page 12

Maintenance of certification to page 10

Vo lum e x x V i i i , N o. 6S e p t e mb e r 2014

Health care has been at the center of federal and state politics for decades. No matter which way the political winds are blowing, health care in Minnesota and the rest of the country has been in a state of change for several years. While much of the atten-tion recently has focused on the Afford-able Care Act and the ever-changing envi-ronment in which it continues to operate, there are a number of fundamental issues that Minnesota will face in the coming years. One issue that has garnered signifi-cant attention recently is whether the state will have the workforce in place to meet the growing health care demands.There seems to be a general consen-

sus in Minnesota that the state will face a physician shortage in the very near future as more physicians reach the age of retirement and fewer new graduates and residents fill those gaps. Although the numbers vary based on who does the analysis, most people who have looked at the issue in recent years, including the Minnesota Medical Association and

The coming physician shortage

What are the issues?By Nate Mussell, JD

Maintenance of certificationIs MOC necessary for lifelong learning?By Jon Thomas, MD, MBA

Session or “unsession”? to page 12

Mild traumatic brain injury to page 10Mild traumatic brain injury (mTBI), or concussion, has been recognized

and documented in every civilization throughout history. The physical

effects of mTBI are documented on the walls of caves, in ancient scrip-

tures, and in historical text.

Session or

“unsession”?

Anything can happen

By H. Theodore Grindal, JD,

and Nate Mussell, JD

The 2014 Minnesota legislative session

gets underway on Feb. 25. Even-year

sessions are traditionally shorter—

often just a few months long—and most

often center on the bonding bill for capital

investment projects, although even-year

sessions have often bucked this trend in

recent years. The state’s biennial budget for

FY2014–15 was passed in the 2013 session,

but the Legislature is likely to pass a small

supplemental budget to address any pro-

jected surplus or shortfall. The upcoming

November elections, in which every member

of the House of Representatives and the

governor will be on the ballot, will prompt

legislators to focus on a few key accom-

plishments and try to adjourn quickly so

they can return to their districts and start

campaigning.

During his State of the State address last

year, Gov. Mark Dayton deemed the upcom-

ing session the “unsession,” and he is urging

the Legislature to focus on repealing unnec-

essary laws. However, the November budget

forecast, combined with the inevitable pol-

iticking during an election year, make the

prospect of an “unsession” rather unlikely.

Mild traumatic brain injury in the 21st century

By Ronald Tarrel, DO

Vo lum e x x V i i , N o. 10

J anu a r y 2014

The evolution of concussion

Th e I n d e p e n d e n t M e d i c a l B u s i n e s s N ews p a p e r

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The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. © 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G1553

T o rehabilitate a body, we start with the mind and soul.

If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a simple premise for you to consider: To recover physically, you need support mentally and emotionally. How positive and how determined someone is can make all the difference. We believe the most effective therapy treats your body, mind and soul. That’s our approach.

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NOVEMBER 2015 MINNESOTA PHYSICIAN 44

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Practice Leadership Assessment tool. Find out how our full suite of insurance services and risk management resources can help improve clinical, operational and financial

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mn physician may 2016

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