telemedicine - the future is now

MetroDoctors The Journal of the Twin Cities Medical Society March/April 2013 1

V O L U M E 1 5 , N O . 2 M A R C H / A P R I L 2 0 1 3

CONTENTS

Page 25

Page 13

On the cover: Telemedicine is becoming a widely uti-lized form of care delivery. Articles begin on page 6.

Page 28

Page 5

2 Index to Advertisers

3 IN THIS ISSUE Telemedicine: Are You Ready to Take the Plunge? By Peter Dehnel, M.D.

4 PRESIDENT’S MESSAGE By Edwin N. Bogonko, M.D.

TCMS: Vibrant and Strong—Yesterday and Today

5 TCMS IN ACTION By Sue Schettle, CEO

TELEMEDICINE 6 • Colleague Interview: A Conversation With Douglas A. Smith, M.D.

10 • Telemedicine: A Rising Star in Health Care Delivery By Zoi Hills, Mary DeVany, and Stuart Speedy, M.D.

12 • Telehealth Technology—Real Time Versus Store and Forward By Scott Colesworthy

15 • Telestroke Offers Life-Saving Therapy By Paul Schanfield, M.D.

17 • Radiology: Telemedicine has Enabled Sub-specialization and Access to Images By John A. Eklund, M.D., Ph.D. and Steve Fischer

19 • Telepsychiatry: Expanding Access to Care Across the State By Joel V. Oberstar, M.D. and Todd Archbold, LSW, MBA

21 • Minnesota Collaborative Psychiatric Consultation Service

22 • Telemedicine: Emerging Technolgy, Emerging Risks By Robert S. Thompson, RT, JD, MBA, LLM, CPCU, RPLU

25 2012 Shotwell Award Recipient Senator Linda Berglin

26 TCMS Annual Meeting

27 First A Physician Award

28 Member Profile: Kacey Justensen, M.D.

29 In Memoriam

30 New Members

Career Opportunities

32 LUMINARY OF TWIN CITIES MEDICINE Laurence A. Savett, M.D.

33 2013 MMA Annual Meeting

2 March/April 2013 MetroDoctors The Journal of the Twin Cities Medical Society

Physician Co-editor Lee H. Beecher, M.D.Physician Co-editor Peter J. Dehnel, M.D.Physician Co-editor Gregory A. Plotnikoff, M.D., MTSPhysician Co-editor Marvin S. Segal, M.D.Physician Co-editor Richard R. Sturgeon, M.D.Physician Co-editor Charles G. Terzian, M.D.Managing Editor Nancy K. BauerAssistant Editor Katie R. Snow

TCMS CEO Sue A. SchettleProduction Manager Sheila A. HatcherAdvertising Representative Betsy PierreCover Design by Outside Line Studio

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: [email protected].

For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood CircleMonticello, MN 55362 phone: (763) 295-5420fax: (763) 295-2550 e-mail: [email protected]

MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS.

Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Katie Snow at (612) 362-3704.

March/AprilIndex to Advertisers

TCMS Officers

President: Edwin N. Bogonko, M.D.President-elect: Lisa R. Mattson, M.D.Secretary: Carolyn McClain, M.D.Treasurer: Kenneth N. Kephart, M.D.Past President: Peter J. Dehnel, M.D.

TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer(612) [email protected]

Jennifer J. Anderson, Project Director(612) [email protected]

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors(612) [email protected]

Andrea Farina, Executive Assistant(612) [email protected]

Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota(612) [email protected]

Katie R. Snow, Project Coordinator(612) [email protected]

Kristine Stevens, Project Coordinator(612) [email protected]

For a complete list of TCMS Board of Directors go to www.metrodoctors.com.

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

DoctorsAdvanced Dermatology Care.........................24

Billing Buddies MN .........................................13

Classified Ad .......................................................11

Crutchfield Dermatology .................................. 2

DMG Financial Group ...................................16

Fairview Health Services .................................31

Great Plains Telehealth ....................................18

Gundersen Lutheran Medical Center .........30

Healthcare Billing Resources, Inc. ...............29

Kathy Madore..................... Inside Front Cover

Lockridge Grindal Nauen P.L.L.P. ...............14

Minnesota Epilepsy Group, PA ...................... 9

MMIC ................................Outside Back Cover

Neighborhood Health Source .......................31

Newman Long Term Care ..............................20

Saint Therese .......................................................24

University of Minnesota CME .....................23

Uptown Dermatology & SkinSpa ................21

Winona Health ..................................................31

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I N T H I S I S S U E . . .

By Peter Dehnel, M.D.Member, MetroDoctors Editorial Board

Telemedicine: Are You Ready to Take the Plunge?

DIVING INTO YOUR FAVORITE MINNESOTA LAKE is not a highly sought after activity at this time of year. Even when the ice has been thoroughly cleared from the lake, most people that I know would still prefer to wait until there have been a string of 85 degree days and the water temperature is considerably north of 65 degrees. July is a much more “acceptable” and “reliable” time to do this very same activity, even though it may be the very same lake that you are considering. The only difference is time and “water temperature development.” By way of analogy we come to the current issue of MetroDoc-tors which is focusing on the topic of telemedicine. Telemedicine in some form has been around for over three decades. If you include telephone care as a related form of electronically-based, non face-to-face care, it has been utilized since the late 1880s. It is a care delivery method of proven value in many venues, not the least of which is in the military, where facilitated “remote” triage and management of wounded soldiers is a well-developed enhancement of care. The University of Arkansas has an extensive program in telemedicine, which began 20 years ago as a way to help manage high-risk pregnancies across the state of Arkansas. Physicians and clinics in Georgia can participate in a variety of telemedicine opportunities through the Georgia Partnership for Telehealth. Since its inception, this partnership has since expanded to include the neighboring states of Florida and Alabama. There is substantial support for telemedicine at the fed-eral level. There are 12 federally-sponsored regional centers for telemedicine and telehealth across the country, of which our own center is known as gpTRAC — the Great Plains Telehealth Resource and Assistance Center. The University of Arkansas has secured literally hundreds of millions of grant dollars to expand telemedicine services across the state of Arkansas, much of which has gone into the expansion of high-speed internet connection. There continues to be substantial sources of grant funds available for groups to expand this very developed form of care delivery from both private and public sources. This form of care delivery continues to expand within Min-nesota, of course. Our patients are seeing more opportunities for convenient online assessment and treatment for a variety of acute

care conditions. Larger health care systems are exploring the opportunities available for opti-mizing management of their pa-tients in medical home programs. Accountable care organizations are recognizing this form of care delivery to help improve quality of care while holding down their costs of care delivery. The oppor-tunities within this “space” are limitless — even NASA utilizes telemedicine applications within the space program. If you are not particularly familiar with telemedicine, this current issue of MetroDoctors will allow you to “dip your toe into the water.” The articles are intended to display the range of opportunities available to clinicians and their clinics within this state. Included is some basic information just to ensure that all readers have a good and reliable foundation of this topic. At the other end of the care continuum, provid-ing for out state management of potentially devastating acute neurologic events through telestroke management is a huge care enhancement, as described by Dr. Schanfield. Dr. Doug Smith’s perspectives and experience in the development of new care delivery models is very pertinent to this topic. Telemental health care is one of the most developed areas in telemedicine nationally, and PrairieCare’s insights will assist in a better understanding of this needed expansion. Finally, we fully acknowledge that there are many medicolegal land mines and pitfalls in this form of care delivery. MMIC’s perspectives are thoroughly acknowledged and appreciated in this regard — we have much work to do. So where are you personally in terms of embracing the con-cept of a “telemedicine opportunity” for your practice or hospital system? Are you ready to take a plunge into this care delivery format? Or, are you perhaps waiting for the “waters” to warm up a bit before you feel it is safe and reliable? The Twin Cities Medical Society has convened an ongoing work group to see how we, as a medical society, can more effectively expand telemedicine within the region. Your participation is encouraged and always welcomed.


President’s Message

TCMS: Vibrant and Strong — Yesterday and Today

EDWIN N. BOGONKO, M.D.

METRODOCTORS SEEKS TO KEEP YOU ABREAST with what’s going on at the medical society, as well as introduce to you new paradigms of care. Our focus this month is telemedicine as we seek ways to have TCMS play a role in improving access to care including specialized opinions to doctors, especially in rural Minnesota. However, I wish to bring your attention much closer, toTCMS and your stake in it. It is easy to forget that our beloved society has achieved so much the last several years. We did

great work with metro area counties creating a smoke-free Minnesota and continue to engage with communi-ties, businesses and schools as key partners of the Twin Cities Obesity Prevention Coalition. More recently, our most celebrated achievements have come through our signature award winning program — Honoring Choices Minnesota. Not only has it earned nationwide recognition, it has become the subject of books and new programs being designed that show best practices on how to approach advanced care planning through community engagement. Equally, through our vibrant legislative and policy committee, we continue to engage our elected leaders at the capitol in an effort to ensure that they understand our positions on key issues that affect Minnesotans, always advocating for the principle of protecting and preserving our practices as well as something we all hold dear — the doctor-patient relationship. In 2013, we look to strengthen the foundation for the future of TCMS including engaging medical stu-dents with our “lunch and learn” program. We have more medical students participating in medical society activities than ever before — we applaud their enthusiasm. Please recognize their efforts and interest for they are the future representatives of what is best about organized medicine. As the largest component society of the MMA, it is my hope that we will continue to take our place in it and make our presence count even as the MMA grapples with difficult yet necessary changes to make it work better for all Minnesota physicians. We will look to collaborate around issues of health disparity and work with MMA’s Minority and Cross Cultural Affairs committee to aid the cause of immigrant physicians who make the grade but are misplaced and have no path to practice — yet could be working to serve their communities here. Also, TCMS through its East and West Metro Foundations, has a presence in many programs in the metro area as we support both physicians and public health efforts. Since we merged the two medical societ-ies, we’ve accrued several advantages of improving efficiency and optimizing how we deliver services. This year we plan to extend that process to our foundations. We will engage the leadership of our two foundations around merging their operations to achieve much needed synergy even as we continue to perfect our union. I believe it’s the right thing to do. Please join me and TCMS leadership in cementing our long-term strategy around five key pillars — public health, public policy, increasing outreach to our members to enhance engagement, practice improvement, and providing good stewardship of the resources you have entrusted us. It may be easy to be passive about health care these days — nothing seems to pan out as promised and patients continue to see transfer of financial risk to them by employers as well as insurers. As physicians, we continue to be caught in the middle. The challenge of our time is the reality of ever decreasing resources to meet the demands of the care we provide our patients. With the passing election, it is clear Obamacare is here to stay. The pressure on our time and ever-rising expectations of our roles — some yet to be defined — will no doubt mount. What part will

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TCMS IN ACTIONSUE A. SCHETTLE, CEO

The TCMS Annual Board dinner was held on January 14, 2013 at the Town and Country Club. We had a jammed packed agenda and yet finished on time! I want to convey my sincere thanks to Peter Dehnel, M.D. for his leadership as the 2012 TCMS president and I look forward to working with our new presi-dent, Edwin Bogonko, M.D. Based on the results of the recent TCMS membership survey, the TCMS Legislative and Policy Committee will be working on four key areas as the 2013 Legislative Session begins. 1) Support funding for graduate medical education through the Medical Edu-cation and Research Costs (MERC) program; 2) Oppose legislation nega-tively impacting physician practice and the practice of medicine; 3) Oppose further cuts to physician reimbursement in state public health care programs; and 4) Support an increase in the price of tobacco and more funding for public health programs. Twin Cities Medical Society is exploring the opportunity to serve as a convener and coordinator for tele-medicine resources in the metro area. We have had some preliminary meetings with key stakeholders and are on a steep learning curve as we work to uncover whether this role is desirable and need-ed. Contact [email protected] if you would like more information.

Honoring Choices MinnesotaKent Wilson, M.D., Ken Kephart, M.D. and I met recently with Minneso-ta Commissioner of Health, Edward Eh-linger, M.D., Commissioner of Human Services, Lucinda Jesson and Lieutenant Governor Yvonne Prettner-Solon to discuss aligning the Honoring Choices Minnesota initiative with their Own Your Future Program. OYF works to

raise awareness among Minnesotans of the importance of planning now so they have personal and financial options to meet future long-term care needs; and increases the number of Minnesotans who have taken action to address and provide for their long-term needs.

NE Florida hosted Honoring Choices Minnesota staff at a recent meeting convened by the Community Hospice of Northeast Florida. They, too, are in-terested in learning about the Honoring Choices Minnesota model. Leaders of Honoring Choices Min-nesota attended the National Summit on Advance Illness Care in Washing-ton DC in late January. Kent Wilson, M.D., medical director, Honoring Choices Minnesota provided open-ing remarks at the public engagement portion of the conference. Many of our video clips were featured throughout the two day conference.

Twin Cities Obesity Prevention CoalitionThe Twin Cities Obesity Prevention Co-alition is kicking off its final year with a plan of action that will have us engaging with over 120 metro communities, host-ing informative webinars for local policy makers and supporting communities in passing healthy eating active living resolutions that benefit all residents. In addition, we are actively engaged in finding additional funding to continue the project into 2014. For more infor-mation, contact Jennifer Anderson at [email protected].

The Honoring Choices Minnesota model is growing in leaps and bounds. Many presentations are occurring in Minnesota and in other parts of the country.

I recently hosted the executive director and physician president of the Richmond, Virginia Academy of Medicine who were on a quest to learn more about Honoring Choices Minne-sota. TCMS physicians Stefan Pom-renke, M.D., Kent Wilson, M.D., Ken Kephart, M.D. and Edwin Bogonko, M.D. also joined in on the day-long meeting.

Commissioner Edward Ehlinger, M.D., Kent Wilson, M.D., Lieutenant Governor Yvonne Prettner-Solon, Ken Kephart, M.D. and Commissioner Lucinda Jesson.

Front: Deb Love and Edwin Bogonko, M.D.Back: Kent Wilson, M.D., Richard Szucs, M.D., Sue Schettle and Stefan Pomrenke, M.D.


Colleague Interview: A Conversation With Douglas A. Smith, M.D.

Convenience is a big selling point for retail clinics. Comment on providing primary care services for patients without an appointment. What is the im-pact of retail clinics on patient’s use of ERs — now and the future?

Retail clinics were developed due to access issues for patients who wished to see their primary doctors. Unfortunately this problem has not changed over the past nearly 15 years and continues to be dealt with in a variety of ways. Primary care services can certainly be provided without ap-pointments; in fact the whole appointment mentality can become a barrier to service rather than an asset. As retail clinics evolve and develop more close associations with clinics/physicians, I would expect to see the addition of primary care services work as an extension of the “parent” clinic. Certain essential primary care services, particularly preventive services, do not need physician supervision — merely need labs, procedures and/or education. I believe that the impact of retail clinics on ER visits will not change. In general there is little change in the ER usage with the retail clinics as they are still a small fraction of the medical service delivery system. Currently there are over 1,400 retail clinics in the country and 38 states that have retail clinics, still a tiny fraction of the total health care delivery system.

Most of the care in retail clinics is provided by nurse practitioners on protocol and supervised by physi-cians. Is this situation similar to or different from the clinical decision-making, supervision, and phy-sician participation in most primary care clinics?

The use of mid-level providers (NPs and PAs) for delivering care in the retail clinics was an intentional choice based on two issues:1. The cost of these providers is substantially less than using a

physician and, more importantly,2. NPs and PAs follow protocols! There is a big difference behind using “evidence-based guide-lines” for development of clinical decision-making trees and rigid practice protocols for delivery of care. The whole issue of evidence-based guidelines could be debated as they are for the most part “expert guidelines” rather than evidence based. The development of clinical decision tools is to assist rather than direct the treating physician when dealing with issues and diagnoses that they see infrequently or even frequently, but where the recommendations are changing rapidly. The development of clinical practice protocols in the retail clinic setting is to specifically direct and limit the deviation in treatment and care. As a family physician with over 20 years of practice experience,

Douglas A. Smith, M.D. is the medical founder of MinuteClinic and origi-nator of the retail clinic model and currently is the chief medical officer

of Consult A Doctor, a start-up telemedicine company. Dr. Smith received his medical degree at the University of Minnesota and completed a family practice residency at Methodist Hospital/University of Minnesota. He is a board member of NewBridge Wellness Clinic and a consultant at Gehrsen Lehrman Group on Retail Clinics. In addition, Dr. Smith serves as a physician advisor to Integrity Medical Services, Sedwick James physician consultant, and is the medical direc-tor of RTW Inc. Dr. Smith can be reached at: (612) 889-2675, or [email protected].

Medical Care OrganizationsTelemedicine



I absolutely believe in the “gestalt” of an experienced physician and value the additional ease of accessing clinical guidelines, but still have the ability to tailor specific therapies for individual patients based on a number of factors — physical, emotional, sociological, etc. That level of deviation cannot occur in a retail clinic where the care is being delivered more as a “cookie cutter” approach due to the limited diagnoses and problems being treated. I do not believe, nor do I think that it will happen, that medical care will be delivered at the physician level as “cookbook” medicine.

Are there data on patient access, care quality, and cost of the services of retail clinics in comparison with traditional independent practice or health plan clinics? (Such as: comparative patient satisfaction, relative use of antibiotic and opioid prescriptions, and timely referral to specialists or inpatient care.)

Good questions. There have been several surveys both internal and external on many of these areas. Patient satisfaction tends to cluster around 90 percent believing the quality of the care received was “excellent” and nearly all would recommend the service to family/friends. A landmark study for MinuteClinic published in the Annals of Internal Medicine found that MinuteClinic patients received care for sore throats that followed guidelines 99 percent of the time. A recent MN Community Measurement study found that MinuteClinic treatment followed guidelines for colds 93 percent of the time, as compared to 87 percent for the overall clinic average. The Agency for HeathCare Research and Quality (AHRQ) has other statistics for both cost and quality elucidated if the reader is interested. However, even given the above data, I would NOT suggest that the care delivered in the retail setting was better than that in a clinic setting, but it is certainly more controlled and consistent. Just to clarify, there are NO controlled substances prescribed in the retail clinic setting. Again, if and when these clinics become more of an extension of existing health systems, that may change but for now, no controlled substances.

The rise of time efficient, protocol driven medicine is likely to change workforce requirements. At the same time, we may be over-educating many of our health care professionals and graduating far too many trapped in heavy debt. If you were to engineer a time-efficient and cost-efficient educational path to serve in MinuteClinics and other representations of the new medicine, what would you most want to see?

Well, no one has yet approached me to become the Czar of medicine, still waiting for that, so maybe I can become the Czar of medical education! The skill sets needed for delivery of protocol driven diagnostic and treatment care requires a fundamental knowledge of basic

medical care. Because the emphasis is less on ill-defined symptom complexes (see “House”) and more on identification of outliers and triage of them to more appropriate care settings as well as rigid treatment guidelines, the need for extended post-education training is certainly less. To date, these roles have been filled by physician extenders, but going forward, the reintegration of a general practice model where there is a shortened post-medical school training schedule would make some sense. Not that this was the intent of the question, but I will use this opportunity to give some thoughts on the widespread use of PAs and NPs in clinics and how I believe that they are best used. Physicians are trained to be primarily diagnosticians and proceduralists. Unfortunately, many clinics are now utilizing their physician extenders in exactly the wrong place, seeing the acute care problems that may be ill defined coming into the clinic. Physicians are still the best resource for quickly determining who is really sick and who is merely ill, who needs surgery and who can be treated conservatively, who requires prescription medica-tions and who can be treated with OTC meds and/or time. We can’t lose that perspective. When the phrase “physician extender” became passé for NP and PA providers, it correlated with the medical field’s perspective of where these providers provided the most benefit. I still believe that these providers are best utilized in areas where there are rigidly defined diagnostic and treatment protocols (extension of the physician) and should NOT be uti-lized in primarily evaluating ill-defined symptom complexes. In some ways, this mishandling of these providers may be part of what continues to fuel added expense in medical delivery due to increased imaging, reliance on lab testing and lack of experience and depth of knowledge to make a clinical decision.

You recently became the CMO for “Consult a Doc-tor,” providing virtual care/telemedicine services. Please describe this service and your role as CMO.

Consult A Doctor allows physicians to interact with patients, either via email, telephone and/or video for diagnostic consulta-tions, follow-up visits and other medical consults. The system includes an online and telephonic patient portal and interface for information that allows them to order a consultation. From the physician side there is a scheduling module, a telephonic and internet consult routing system that takes into account state of residence, doctors on-call, specialized areas of expertise, health plan networks, etc. that routes calls to the appropriate network of physicians. There is also a virtual care platform that contains a patient derived medical history, allows the documentation of the consultation, both in written and audio recorded format, an e-prescribing system and evidence-based guideline access. The idea behind telemedicine is to deliver some care in a virtual format. This has been done for years using specialty phy-sicians to remote physicians that allows their patients to access


specialty care (Hub and Spoke model). This new development focuses on the consumer oriented, patient-to-physician side of medical care delivery. From the physician standpoint it allows the ability to provide a more inclusive delivery of care for your own patients as well as enhance practice revenue. For additional information on this company specifically, see www.consultadr.com. As chief medical officer for Consult A Doctor, conveniently headquartered on Miami Beach, I am responsible for overseeing management of the physician network, recruiting, retaining, credentialing the physicians, meeting with health plans, health systems, and clinics all of which are interested in developing virtual care solutions to the access and cost problems. I also work with the business development team in identify-ing new areas to focus on for virtual care delivery including the integration with existing clinics, the use by private physicians, integration into retail clinics, etc.

How do you handle the logistics (provider networks, charges, claims, quality and utilization functions, etc.) involved in contracting with payers and pro-viders — or do you contract directly with consumer patients and develop your own networks and other infrastructure?

Consult A Doctor has a vast, well-established telemedicine physi-cian network comprised of reputable, U.S. board certified doctors in all 50 states. Our doctors are independent contractors that adhere to stringent quality measures. These doctors are the same doctors that are networked with payers across the nation, maintain private practices and work in hospitals and health systems as well. Our routing engine is configured to logistically match our doctors to patients appropriately. For health plans, our routing engine assigns consults to the designated network physician. Doctors can accept or decline any consult request at any time and the system will “roam” for the next doctor in the queue until the consult is accepted. We have the capability to configure real time eligibility, claims and billing and revenue cycle management. Our data can be used for clinical reporting purposes, savings and ROI analysis for the payer and utilization by group(s), conditions, consult types, time of day, state, region and hundreds of other measurements.

Has the absence of direct face-to-face/hands-on physician-patient contact been a deterrent in “sell-ing” this delivery system concept to the medical world and the public?

This solution is certainly not a panacea. In the best of all possible worlds every patient would have their own designated physician and whenever they needed to be seen, that physician would be

available. We all know that is not the case, in fact some studies suggest that fewer than 50 percent of patients have a primary care doctor and of those that do, at least 20 percent of that patient’s care is delivered in a different setting than in the physician’s office. From my perspective I have been gratified to be able to deal with my colleagues in a much more collegial atmosphere regard-ing this solution. When I developed the retail clinic model, I met great resistance from nearly all of my colleagues; in fact I still have medical friends who will not talk with me on this subject. As op-posed to that reception, nearly all of the physicians I have come in contact with, including many private practice doctors across the country understand the concept, appreciate the opportunity and are eager to integrate this into their practice. Because nearly all clinic physicians are used to taking telephone calls either from their own patients or while on call or both, they implicitly understand that they can deliver some care this way and are very comfortable doing so. As with any innovation into care delivery, there are areas where this will work well, and in some areas patients and providers who will be reluctant to use this technology. However as we meet with health plans, clinics, hospitals and employers, it is clear that this is a demand that is growing exponentially and will need to be accounted for in setting up care delivery systems.

For clinicians who use telemedicine technology is spe-cial training and/or credentialing needed or expected?

Other than a short training that takes less than 45 minutes, there is very little other training needed. Again, this is merely allowing the more complete documentation and delivery of those consul-tations most physicians are delivering in a less defined manner now. Unlike a more complicated EMR, the virtual care platform is easy to learn and use. Almost every primary care doctor I know is already an expert on delivery of telemedicine, this simply codi-fies the model into a more integrated and business like approach. There is not a specialized license for the use of telemedicine. A few states, including Minnesota have a special telemedicine license available for physicians that is less inclusive and less expensive than a full medical license.

Please comment on the privacy-confidentiality of the telemedicine environment.

The telemedicine environment is 100 percent HIPAA compliant and service connectivity and authentication is conducted over SSL to ensure complete privacy of the patient.

Do all third parties cover telemedicine delivery of Home Care services?

Telemedicine is a critical component to the delivery of Patient Centered Medical Home (PCMH) services; however there are no federal mandates to enforce the implementation of telemedicine at

Colleague Interview

(Continued from page 7)



this time. We are confident, however, that the PCMH stakeholders will quickly grasp the value and the convenience of digital health and make it a natural part of their business model. As of this writing, 14 states have passed legislation requiring third party reimbursement for telemedicine with several others having bills in various stages of passage.

Is there any class of patient or type of clinical condi-tion that is not amenable to telemedicine?

Of course. There are still patients who need hands-on and in-person evaluation and procedures. Surgical patients, medically unstable patients and patients who are unable either to understand or manipulate telephones, video monitors, etc. would not be good patients. However, as I learned with retail clinics, patients who seek this service tend to already have self-identified and are a good measure of who will use the service. Certainly as technology im-proves, the scope of what can be dealt with through telemedicine will be expanded, including video interaction, peripheral medical devices and monitoring devices.

Are hardware/software standards being developed that will allow cross utilization by major systems?

Consult A Doctor’s TeleCare 3.0 system architecture is designed for flexibility and adaptability. Our SOA architecture and plat-form infrastructure supports rich scalability options, combined with a modular appli-cation design that easily allows for con-nectivity to other systems.

How can more physicians incorporate this type of care delivery into their es-tablished clinic-based practices for their own patients?

This is a major focus of Consult A Doc-tor. We see the physicians and practices/healthsystems as the primary customer for this service. This will allow much more flexibility in scheduling visits, allow the ability to provide “follow up” care in a much more convenient setting, improv-ing compliance with these visits as well as documenting the care for the almighty clinical measures that unfortunately will continue to increase in number and im-portance from the reimbursement side. The other intangible benefit is improv-ing the physician/patient relationships. As a recent study indicated, patients with “concierge” doctors had a much lower hospitalization rate than those without a

concierge doctor. This allows the patients to have a concierge, or as I prefer to think of it more primary care based, physician and will allow the physician to have a more “concierge medicine” reimbursement model so that both sides are satisfied.

Does the availability of independent telemedicine visits lead to increased fragmentation of care, espe-cially with the push for embracing “patient centered medical homes”?

On the contrary, I believe the availability of telemedicine is es-sential for integration of off hours and out of clinic care delivery back to the primary clinic. Both for the PCMH and ACO model of care delivery, telemedicine takes a position front and center in helping accomplish the goals that these systems are supposed to have. The ultimate goal of our telemedicine company is not to set up a host of independent telemedicine delivery units, i.e. retail clinics, but rather utilize this technology to help physicians integrate virtual care as part of their care delivery.


Telemedicine: A Rising Star in Health Care Delivery


By Zoi Hills, Mary DeVany, and Stuart M. Speedy, Ph.D.

The increasing costs of health care, the Health Care Reform Act, the rise of Accountable Care Orga-

nizations (ACOs) and Certified Health Care Homes (Medical Homes) and other factors, have positioned telemedicine/tele-health as a major interest of health systems, hospitals, clinics, specialty practices and payers. While there are still many chal-lenges and issues, telemedicine has come a long way and today, many will agree, that telemedicine is an important part of the future of medicine. The role of Great Plains Telehealth Resource & Assistance Center (gpTRAC) is to help health care organizations im-plement telehealth programs. One of the most common questions asked, especial-ly by payers, is “what is the difference between telemedicine and telehealth”? The American Telemedicine Association (ATA), defines telemedicine as the use of medical information exchanged from one site to another via electronic communica-tions to improve patients’ health status. Closely associated with telemedicine is the term telehealth, which is often used to encompass a broader definition of remote health care that does not always involve clinical services. Videoconferencing, trans-mission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth. Telemedicine is not a separate medi-cal specialty. Products and services related

to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the re-imbursement fee structure, there is often no distinction made between services pro-vided on-site and those provided through telemedicine and often no separate coding is required for billing of remote services. As might be expected, reimbursement is one of the main barriers to the adoption of telemedicine. Although the rate of reim-bursement for care delivered via telemedi-cine has improved substantially in the last few years, it remains one of the areas that needs improvement. The vast difference between national, state and private payer reimbursement policies makes obtaining consistent reimbursement for telemedicine a significant challenge. Medicare reim-bursement is very structured. The patient must be located in an eligible (rural) facil-ity, seen by an eligible provider, under al-lowed CPT codes. (A copy of the Medicare information describing these details can be found at our website, gptrac.org.) At this time, 15 states have mandated that services

delivered in an in-person encounter should also be reimbursed when telemedicine is used. This has lifted some barriers and has provided greater opportunities in health care delivery using telemedicine technolo-gies. It is important to remember that the payment options for telemedicine are not reliant solely on the traditional payment model. Some of the most successful busi-ness models are based on contractual agree-ments between the distant sites (providers) and the originating sites (patient sites). Two questions that are asked fre-quently by providers or hospitals/clinics: 1) What are the benefits of telemedicine? and, 2) What are the perceived barriers to using telemedicine? Some of the rea-sons to “do it the telemedicine way” are: it improves continuity of care; it can lead to reduced hospital readmissions; it can reduce rural provider isolation; and it can improve access to care in both urban and rural settings. Some of you are probably thinking: “How can telemedicine be used by metro area physicians in addition to connecting to rural communities”? Al-though Medicare and many payers require

Mary DeVanyZoi Hills Stuart M. Speedie, Ph.D.


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the rural definition, some of the other ben-efits include: • Expandingthegeographicareaofyour

practice; • Servingyourpatientsmoreefficiently;• Connectingtoyoursatelliteclinics;• Providingopportunityforfollow-up

visits by patients who: • have to travel great distances to

see you; • are home bound (disabled);

• have chronic conditions and need to be monitored regularly.

Some of the barriers include: Inconsistent reimbursement (varies from state-to-state and payer-to-payer); available broadband in rural areas (although this is improving rapidly); the CMS reimbursement ru-ral rule that limits telemedicine to rural patients; state licensure regulations; and limited EMR remote access (prohibits the provider from seeing ALL patient data).

Telemedicine today is not the same as it was in the 1990s. This list offers a glimpse of what has improved/changed in the last 10-15 years:• Thecostofvideoconferencingequip-

ment is less than 10 percent of what it was in the 90s.

• It’snotviewedas“differentcare”butas a “tool for the care” of patients.

• It’sbeingincorporatedmoreintothestrategic goals of organizations.

• Newproviders/practitionersareex-pecting it.

• Implementationiseasier…manyofthe barriers have been removed.

• Careisbecomingmoremobileandhome-based.

• Moreservicesarebeingreimbursed.• Broadbandcommunicationsarefaster,

cheaper and better.• Moreanddifferentkindsofservices

are using it (employer programs, on-line services, medical homes).

• Patientsandpayerswantit.Health care providers and organiza-

tions who are interested in either offering medical care services via telemedicine or in using those telehealth services provided by other organizations, often don’t know how to get started, or simply don’t have the time to devote to research the details. If you have been considering how to utilize telehealth/telemedicine services in your practice, but haven’t been able to plan and organize your implementation, contact gpTRAC at [email protected] or call (888)

239-7092. All gpTRAC personnel have extensive knowledge and experience in various telemedicine applications and pro-gram implementation. We will be happy to work with you to answer your questions and provide the assistance needed.

Zoi Hills is the gpTRAC program manager. She has been involved with telemedicine since 2002; previously serving as project manager for the Minnesota Telehealth Network. She serves as a committee member at the Greater Minnesota Telehealth Broadband Initiative FCC Pilot program. She can be reached at: (612) 625-9938.

Mary DeVany is the gpTRAC director and has been involved with telemedicine activities since 1993 when she served as the statewide telemedicine activities coordinator for the state of So. Dakota. She currently serves on the board of directors for the Center for Tele-health and E-health Law and is member of the American Telemedicine Association She can be reached at: (605) 743-5902.

Stuart M. Speedie, Ph.D. is the Principal Investigator of the Great Plains Telehealth Resource and Assistance Center grant fromthe Health Resources and Services Admin-istration. He is a professor of Health Infor-matics, a fellow in Minnesota’s Institute for Health Informatics and director of Graduate Studies in Health Information at the Uni-versity of Minnesota Medical School. He can be reached at: (612) 624-4657.

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Who is gpTRAC? Great Plains Telehealth Resource & Assistance Center (gpTRAC), one of the federally designated telehealth resource centers, is a grant-funded organization whose mission it is to promote telehealth in the Great Plains region. gpTRAC serves a six-state area including Minnesota, Iowa, Nebraska, North Dakota, South Dakota and Wisconsin. Currently in its sixth year of operation, gpTRAC has already provided telehealth advice and assistance to more than 650 organiza-tions and individuals. The gpTRAC has a three-part mission: build telehealth awareness, promote education, and provide individualized consultation. The gpTRAC strives to promote health care services that take advantage of modern telecommunications technologies such as interactive videoconferencing, home health monitoring, using the secure practices of today’s internet. While gpTRAC has a special focus solving health care delivery problems for rural providers and their patients, clinics located in urban areas can also benefit. Over the years, gpTRAC has provided assistance to a number of Minnesota-based health care facilities. Examples include: conducting a Readiness Assess-ment for a rural hospital, providing generalized telehealth program and services development guidance to a large health system, presenting to a medical staff regarding the “state of telehealth,” and contracting to provide specific program development assistance to another Minnesota health system.



Telehealth Technology — Real Time Versus Store and Forward

Telehealth, Telemedicine, Telemen-talhealth….whateveryouwanttocall it. The definition according to

the American Telemedicine Association is:

“Telemedicine is the use of medical information exchanged from one site to another via electronic communica-tions to improve a patient’s clinical health status.”

That is, of course, a very broad defini-tion so let’s take a look at two categories of Telehealth technology. A few use cases for each one and things to be aware of technically.

Real Time Audio CallsReal time means the communication is in the moment, instantaneous. Telephone calls and video calls are considered real time. Telephone calls can be routed and initiated in a variety of ways. Telephone calls are typically transmitted either by the PSTN (Public Switched Telephone Net-work) or by a data network. We will leave the cellular network out of the discussion to make things simpler. A “land line” to “land line” call is an example of a 100 percent PSTN call. A Skype call computer to computer is an ex-ample of a 100 percent data network call. Most calls are actually a hybrid whether the callers know it or not. It is important to understand that very little latency can be tolerated using this technology. Mean-ing both people can talk pretty much at the same time. We have likely all been on a call that had latency and you know

how difficult and annoying it is. Like old fashion radio, each needs to wait for a significant pause by the other party before speaking. Latency issues are not too dif-ficult to accommodate in a voice-only call.

Real Time Video CallsVideo calls only work on a data connec-tion of some time. Both the video and audio are transmitted on the data connec-tion. The higher the quality of the video call, the more data is needed. How much data is needed is a subject of significant complexity so we will hit the quick high points below:1. Older video conference technology

was designed to operate with each par-ticipant using a very specific amount of bandwidth which resulted in a spe-cific quality of video. Bad things hap-pen when a participant’s bandwidth dipped below the requirement. For this reason a specific type of network was deployed that guarantied the needed amount of bandwidth. This is called Quality of Service (QoS). It is expensive and complicated to de-ploy QoS which, therefore, limited the Video Conference market and of course Telehealth applications.

2. Approximately five years ago a com-pany named Vidyo brought what iscalled Scalable Video Coding (SVC) to the video conferencing market. SVC allows the quality of the videocall to adjust automatically. Lots of bandwidth — offers a very pretty (clear) video call. Not so much band-width — a less pretty video call.

3. The market is now adopting SVC technology which means that people connecting in video conference calls no longer need expensive QoS net-work connections. Technology ad-vances will continue so that less and less bandwidth is required for effective video calls.

Non Real Time —Store and ForwardNot all use cases need real time commu-nication. In fact in some cases that would not be practical or convenient. The expert doctor may not be conveniently available exactly when the patient is available. For these cases what is generally referred to as “store and forward” technology works well. An image(s) is taken and forwarded to the doctor to be evaluated at a later point in time. Perhaps several doctors might look at this image either at the same time or at different times. Think of dermatology where an image of the area in question is sent for the doctor to evaluate when con-venient. If necessary, perhaps a follow up real time visit could occur either in person or by using more advanced technology where images of the area in question are sent in real time using video technology.

Real Time Use CasesNow let’s take a closer look at just a few use cases real time and non real time applications.

Tele-ICUThis is a very specialized real time use case. High definition cameras with Pan Tilt Zoom capabilities are placed in every ICU

By Scott Colesworthy


patient room. Then a “command center” is created where highly skilled doctors are able to interact with bedside staff imme-diately. With this model the highly skilled doctors can be in many places much more quickly. Small hospitals can get access to doctors that they would not otherwise have access to. This is likely the highest cost imple-mentation of telehealth with costs of per-haps more than a million dollars when including equipment and data facilities. For further reading on Tele-ICU refer to these sources: Simple video showing an interactionhttp://www.youtube.com/watch? v=iZb3ndrsvAQ A company specializing in Tele-ICU technology: www.reachhealth.com.

be easily wheeled into any room so the equip-ment costs can be manageable. A cart as shown here might cost $25 to $50K. The on-call stroke physician needs to have flexibility on what device and/or com-puter network they would use since the doctor could be at home or perhaps at one of several differ-ent hospitals. Some hospi-tal organizations choose to offer this service and staff with their own physicians. Other entrepreneurial doc-tor groups choose to offer this virtual telestroke service.

Tele-emergency or Tele-traumaLike telestroke, the business case/staffing issue is similar. Smaller hospitals do not have the staff expertise for some of the emergency cases that come in the door. By having on-demand access to trained emergency room doctors via video confer-ence technology, lives can be saved. Situ-ations can be immediately assessed and proper treatment can be initiated or, when necessary, the patient can be transported to a sophisticated trauma center hospital. One of the challenges of this model, especially when unpredictable demand increases, is notification. What is the pro-cess for notifying the doctor(s) on-call that an IMMEDIATE consultation is being requested? These less than perfect methods are typically used:1. A telephone call is made to a call cen-

ter or answering service. The agent an-swering has to find the on-call doctor.

2. A specific telephone number is dialed and the call rotates through the doc-tors on-call.

3. The emergency room goes to the vid-eo conference system and attempts to directly connect to doctors that may or may not be available.

4. An automated video routing system of some sort is created in a command center environment. This requires the command center to be staffed appro-priately 24 hours per day.

Newer technology that combines SVC based video conferencing technol-ogy with automated routing is now com-ing onto the market. In this example the emergency room clicks a button on the computer screen to initiate a request for an immediate consultation. An alert is sent to the on-call doctor(s) indicating a consultation is being requested. (Perhaps to their smart phone.) With one click on that smart phone the doctor connects in HD video to the emergency room. The doctor might also connect on a larger screen device.

TelestrokeAs everyone knows, timely treatment of stroke is critical. Most smaller hospitals frequently do not have stroke specialists that are immediately available. By having stroke specialists on-call who are imme-diately available to assess patients over a video connection timely treatment can happen and lives are saved. At the hospital a cart, such as shown above, is put into service. This cart can



Cost for this type of service has come down dramatically since no special net-work is required at the hospital end or by the doctor. The hospital could use high quality PTZ video cameras or lower cost devices such as common PCs or tablets, such as an iPad.

Non Real Time Use CasesA smaller segment of the market is non real time applications. Two examples are dermatology and a creative use of recorded video. It is difficult to make any general statements about whether these technolo-gies would be more or less expensive than real time. They do not use video confer-encing technology which of course lowers the cost. However, they can optionally create somewhat sophisticated software to capture the images and create a software tool surrounding these images.

If the method used is to simply transmit an image along with patient information and the doctor responds with an email or phone call, then the cost of this service would certainly be less than any real time application.

Non Real Time VideoA very creative use of non real time video is being done by Behavior Imaging Solu-tions. In this case video is being captured

Telehealth Technology



by whatever means prac-tical and that video is brought into their solu-tion for analysis and ar-chiving. Here are a few bullet points from their web site:•Capture behavioralincidents in natural environments;•Record therapy andtesting sessions for su-pervisory review;

• Recordcustomvideosforpatientsandcare givers;

• Annotateandorganizevideolibrary;• Capture behavioral incidents in

classroom;• Capturestudentprogress.

SummaryWe have only scratched the surface on the subject of telemedicine, exploring just a couple technical aspects. Another topic to become familiar with is device integration, meaning the patient is connected to some sort of device that transmits data back to the physician. Typical things measured are weight, blood pressure, glucose and many others. Some of the devices need set up and operation from a trained techni-cian. Other devices can be used with no assistance at all.

What is clear is that this technology will continue to advance and allow the expert physician to see more patients, more often than would otherwise be possible.

Scott Colesworthy is president and founder of Soltrite. A start up video conferencing service provider specializ-ing in unique ap-plications powered by Vidyo™ tech-nology. Telehealth is one of the markets Soltrite works in. He can be reached at (952) 950-5815, or [email protected].


Telestroke Offers Life-Saving Therapy

In the 21st century, acute ischemic stroke is a medical emergency. There is only one FDA approved treatment

for an acute ischemic stroke, which is in-travenous recombinant tissue plasmino-gen activator (IVrtPA). This intravenous thrombolytic treatment is time sensitive, both for efficacy and for potentially life threatening medical complications. IVrtPA has been FDA approved for more than 15 years for a patient with a “last known well time” of three hours or less. Best medical practice has recently expanded this win-dow of opportunity, in certain circum-stances, to four and a half hours. While this thrombolytic treatment of stroke mirrors the acute coronary insuf-ficiency syndrome, there is a major differ-ence in the diagnostic accuracy of the two ischemic syndromes. An acute stroke diag-nosis is strictly a clinical diagnosis. There is no diagnostic cerebral test to compare with an ECG or a cardiac enzyme assay. While a CT of the head is crucial in the workup of a stroke patient, it typically is used to rule out other causes of the patient’s syndrome or establishes that the stroke is by far too advanced for treatment. This situation has led to the prolifera-tion of Primary Stroke Centers in many large hospitals in America. These centers provide 24/7/365 access to appropriate technology, medication, and most impor-tantly, neurological specialists. To admin-ister IVrtPA to an acute ischemic stroke patient presenting to an emergency room, the entire “door to IV needle time” should be an hour or less. In this “golden hour” a patient must be examined, have a CT of the brain performed and read, have

appropriate laboratory tests performed and reported, get an accurate diagnosis, and after informed consent have the throm-bolytic treatment administered. I cannot emphasize enough that a clinical diagnosis of an acute ischemic stroke must be made quickly if the patient is to benefit from thrombolytic therapy. The risks of throm-bolysis must be acceptable, as hemorrhage, or rarely angioedema, can be potential fatal complications. The longer it takes to administer the thrombolytic treatment, the higher the risk and the less the benefit. “Treatment delayed is treatment denied.” To carry out this same protocol in a small community hospital has even more challenges. A relatively new and improv-ing technology is telemedicine, which can be used in just such a situation. This tool combines the internet, the power of the computer, an onsite robot, the electronic medical record, and the digitizing of medi-cal imaging. For the past two-plus years, I have been involved in a new Telestroke program, with Twin City “hub” hospitals and smaller “spoke” community medical centers. This

program was initiated and financed by the Allina Neuroscience Clinical Service Line, led by Dr. Steven Swanson. In the East Metro area, Allina part-nered with Neurological Associates of St. Paul and the emergency departments of United Hospital, River Falls Regional Medical Center in WI, Regina Memorial Hospital in Hastings, MN and Baldwin Community Hospital in WI. The num-ber of “spoke” hospitals continues to ex-pand each year. To date, Allina has placed leased robots (from InTouch Health out of Santa Barbara, CA) in the River Falls, Baldwin and Hastings emergency rooms. If an emergency room physician wishes for neurological consultation via telemedicine, Allina has also provided laptops to our neurologists who participate in the call schedule for this telestroke service. Our neurologist on-call can access the internet through a secure line, whether at the office, home, hospital, or car. Using an available provider, each of us can directly communicate with the potential stroke pa-tient, their family and the emergency room staff. We can see a neurological examina-tion being performed to our specifications. We can control the emergency room robot. For instance, we can zoom in on the eye exam; we can move the robot so that we can watch the patient walk; we can split the screen and simultaneously review the electronic medical record with the labs, past medical history, allergies, etc; we can simultaneously pull up the scan images to review. Performing a telemedicine consult is not the same thing as being there in person. Nuances can be missed during

By Paul Schanfield, M.D.

appropriate laboratory tests performed and



the interview. Currently, patients and their family members are typically not experi-enced with computer interviews. While the robot’s field of vision can be easily and fluidly adjusted in “real time,” it is not as broad or as accommodating as an experienced physician at the bedside. By necessity, of course, certain portions of the neurological exam must be performed by

an onsite provider. Our interpretation of this virtual examination, thru the “eyes of the robot,” provides less than 100 percent of the typical information provided by a “hands on” approach. The internet connection can be in-termittently disrupted. Sometimes the ongoing video feed is maintained with-out sound, sometimes the video is bro-ken up while the voices can still be heard, and sometimes the entire interview is

disconnected. The internet linkage can be spotty. To attempt to improve our connec-tion capabilities, we use the strongest local internet provider available, depending on where our on-call neurologist is located at the time. We also have a Verizon air card, as a backup. After informed consent, a decision to give IVrtPA has been safely made scores of times. Once thrombolytic treatment is administered locally, the small community hospital staff and the family can choose for the patient to remain in their community. In our experience, however, almost all of the patients choose to be transferred to United Hospital. The patient is then ad-mitted to the appropriate medical unit, typically the ICU or the Stroke Unit. Our neurologist sees the patient face-to-face, and the appropriate experienced hospital staff follow our established stroke pro-tocols. We also have available a team of neurovascular interventional radiologists on call 24/7/365, provided by St. Paul Radiology. This allows “the hub facility” another therapeutic modality to treat an acute ischemic stroke patient. Intra-arterial cerebrovascular clot retrieval, even after IVrtPA, has been performed safely with, at times, dramatic results. Our overall experience has been excel-lent. Patient satisfaction has been wonder-ful. The technology has provided timely and accurate information, leading to accu-rate diagnoses and appropriate treatment plans. Often, no thrombolytic treatment or transfer of the patient is necessary. In these cases, the patient, the family and the community hospital staff have felt com-fortable, after the telemedicine evaluation, to remain locally in their community for further observation, health care and evalu-ation.

Paul Schanfield, M.D. is the medical stroke director at United Hospital and practices at Neurological Associates of St. Paul. Dr. Schanfield is board certified in neurology and vascular neurology. He is an adjunct professor of neurology at the University of Minnesota and of the Family Practice and Community Medicine, University of Minne-sota. Dr. Schanfield can be reached at (651) 747-3110, or [email protected].


Telestroke



Radiology: Telemedicine has Enabled Sub-specialization and Access to Images

By John A. Eklund, M.D., Ph.D.and Steve Fischer

While the first practical instance of telemedicine occurred a century ago when a patient

telephoned his doctor requesting medical advice, radiology has been at the forefront of telemedicine advances in the past two decades. With these advances has come a broad expansion of diagnostic imaging tools, which has eliminated exploratory surgeries, added exquisite precision to brain and spine surgeries and offered much greater clarity to many conditions, such as identifying cancer “hot spots.” For over 100 years, films were taken on x-ray equipment and over the last 30 years also on more sophisticated machines such as CT and MRI. The films were de-veloped using earth unfriendly solvents and hung on light boards where radiolo-gists walked back and forth between the films, trying to interpret various images. It was not unusual, even a decade ago, to walk into a basement hospital area and see films piled high, waiting to either be interpreted or filed. Once the radiologist dictated a report, based on the films, it was transcribed, and then sent back to the radiologist for signature of the paper report. The films and the report were then transported to the treating clinician. It certainly was not unusual for the whole process to take several days. Today, the standard turnaround time for a radiology report is four hours or less. Initially, technical issues inhibited radiology telemedicine advances. The

goal of eliminating film by transmitting the diagnostic images electronically to a “reading” station computer traveled a long, frustrating road. Data transmission was exceedingly expensive and slow. With the first efforts, it would take one or two hours for the image data to be loaded and pro-cessed by a computer that was next door to the CT or MRI. Additionally, high per-formance computers of that time, which processed and displayed the images data, were extremely expensive. Additionally, each modality manufacturer had its own unique data formats and therefore required a unique, proprietary reading station. Frus-trated by this lack of interoperability, the industry created the Digital Imaging and Communications in Medicine (DICOM) standard which defined a consistent “for-mat” for the transmission of images across vendors. This, coupled with the advent of improved telecommunication capabilities and the Internet, opened the door for im-mense improvements in image transmis-sion, speed, quality and security.

Today, radiologists are arguably some of the most technically proficient health care professionals across the globe.

Advances in technology and the adjust-ments required by radiologists because of these advances have been phenomenal. Diagnostic imaging employs fast and se-cure image data transmission, downloaded to high performance computers, with the help of highly efficient data compression techniques. Many changes have been made to the data formats of the images, so that now most are primarily digital. For exam-ple, x-ray equipment produces images in a digital format so it is no longer necessary to convert the images to a transmittable form. Image storage is relatively inexpen-sive, reliable and retrievable.

These advances have allowed radiolo-gists to further subspecialize, transmitting cases to the colleague who is fellowship trained in a certain body part, such as brain or spine or chest/abdomen. This sub-specialization requires training in an ac-credited fellowship program that includes minimum supervised interpretations in each subject, and formal written and oral examinations which must be passed to demonstrate proficiency.

It is common for subspecialty radi-ologists to interpret 15,000 cases per year solely within their area of expertise us-ing pooled regional cases, offering their services over a large geographic area at virtually no added cost—impossible with-out electronic image transfer. Center for Diagnostic Imaging (CDI) provides an example of this model where subspecial-ized radiologists are not only connected


John A. Eklund, M.D., Ph.D. Steve Fischer


to over 70 imaging centers affiliated with CDI but with the ability to receive and read images from an additional 60 non-affiliated specialty groups having their own imaging equipment of various modalities. Additionally, these images and reports may be electronically transmitted to other pro-viders in the care continuum. For example, if images are needed in hospital for surgery or by the specialist for consultation, CDI can forward them, securely to any hospital or health system supporting secure con-nectivity. In addition, whether a study is read from down the hall or across the nation, the clinical history that is entered by the ordering physician or his staff ac-companies the report and is available to the radiologist at the time he/she studies and interprets the images. A telephone call is an occasional supplement.

While assigning/transmitting cases based on subspecialty is highly desirable for providing quality care for the patient, federal regulators and other entities are inadvertently thwarting some radiology best practices. The Medicare agency has added extensive paperwork requirements to the remote reading model. Additionally, state licensure requires radiologists to be licensed in the state in which the patient has had the imaging test, regardless of where the case is read, so the sub-special-ized model can only work with radiology groups who are based in one state unless the radiologists obtain multiple state medi-cal practices licenses. Further, health sys-tem institutions which are heavily invested in a vertically integrated care system may find it financially disadvantageous to allow subspecialty readers outside the care system to perform interpretations even when the expertise is not available inside the system. By directly denying privilege application or more commonly indirectly, by preventing outside physicians access to crucial elec-tronic medical records, radiology images or pathology data, external sub-specialists are sometimes “locked out” from patient care, despite their individual expertise. These challenges will remain a threat to further sub-specialization by radiology, despite the cost and quality value of this care delivery model.

Billing for radiology services varies by contract, often divided between the technical component (the imaging test) and a professional component (the radi-ologist’s interpretation of that test). Most radiologists would likely be reimbursed the professional fee less costs for overhead and any negotiated discounts, so income depends on number and types of cases. However, other radiologists are salaried or split all reading reimbursement revenue evenly among partners.

Looking to the future, radiology tech-nical improvements will continue with data transmission becoming faster and cheaper, computers becoming more powerful and devices to collect patient information more widely available. Sub-specialization

will continue as well, despite market and regulatory roadblocks. Referring clinicians prefer sub-specialist consultation. For ex-ample, orthopedic surgeons prefer remote interpretations of elbow joint magnetic resonance images by a musculoskeletal radiologist over locally-produced inter-pretations by a general radiologist. Stan-dardizing secure but unfettered access by physicians to patient electronic medical records, laboratory results, and medical images would prevent detrimental elec-tronic fences from adding cost through duplicate services while promoting quality through access to the most appropriately experienced and trained medical person-nel. This standardization may be difficult to achieve without establishing a unique health care identifier which could stream-line the information-sharing between treating professionals.

Non-invasive medical techniques such as diagnostic imaging, in a telemedicine model, can and will be part of the achieve-ment of the triple goal of lowering costs while improving quality and access.

John A. Eklund, M.D., Ph.D. is a neurora-diologist at Center for Diagnostic Imaging (CDI). He is board certified in diagnostic radiology and has certificates of added quali-fication in both neuroradiology and vascular/interventional radiology. He is a senior fellow of the American Society of Neuroradiology. He can be contacted at: [email protected].

Steve Fischer is the chief information officer at Center for Diagnostic Imaging and Insight Imaging, a 25-state enterprise of imaging-related centers and services, which partners with locally-based radiologist groups, hospi-tals and other medical professionals. He can be contacted at: [email protected].


Radiology



Telepsychiatry: Expanding Access to Care Across the State

By Joel V. Oberstar, M.D. and Todd Archbold, LSW, MBA

For some time now, psychiatrists nationally and around the world have provided psychiatric care using

televideo technology with similar clinical results and patient satisfaction as those provided in more traditional face-to-face settings. In some cases it is believed that the use of this technology has created an even safer, more private experience and, for our tech-savvy younger generation, a more familiar experience. Televideo tech-nology allows the psychiatrist to provide care to patients hundreds or even thou-sands of miles away, providing access to rural and other underserved populations. PrairieCare clinicians have had a variety of telepsychiatry experiences that provide a framework for understanding how tele-video services can expand access to care for those patients for whom distance to a nearby psychiatrist is excessive or where there simply are no clinicians available to provide care. Some examples of televideo include supporting non-medical clinicians, providing services to a rural county mental health center, residential treatment pro-grams, internal satellite locations and even internationally. Some common benefits or uses of the televideo delivery of services in mental health are:• Extendingresourcestounderserved

regions lacking adequate psychiatric resources.

• Eliminatingorreducingtheneedtotravel long distances to see a clinician.

• Providingco-locatedmentalhealthservices in a setting that patients are already familiar with (e.g., primary care offices, schools, etc.).

• Quickaccesstoconsultations,suchasNeeds Assessments or clinical triage.

• Otheradministrativepurposessuchascase consultations, staffing, or multi-site education/training opportunities.

Joel Oberstar, M.D., CEO of Prai-rieCare, experienced the capabilities of telemedicine while on the faculty at the University of Minnesota in 2010, where telepsychiatry services were provided to patients in the Mille Lacs Health System in Onamia and to Tri-County Hospital in Wadena on a rotating every-other-week basis at each site. At both sites, examina-tion rooms housed within the primary care clinic were equipped with a comput-er, monitor and camera using Polycom technology. Clinic visits by televideo were largely the same as a face-to-face encounter and lasted between 30 and 60 minutes, consisting of diagnostic evaluations, psy-chotherapy and medical evaluation and management. Laboratory orders were eas-ily transmitted verbally to the nurse, a copy of the progress note faxed to the clinic for inclusion in the patient’s medical record and prescriptions faxed to the pharmacy.

Conveniently, the medium often facilitat-ed consultation with the patient’s primary care provider, who frequently was avail-able to “pop in” after a session to discuss a shared case. While no formal data was collected, Dr. Oberstar’s impression was that both patients and their families felt the televideo aspect of the visit was mini-mally intrusive. Indeed, many children/adolescents seemed quite comfortable with the technology, undoubtedly facilitated by the explosion of Skype-related televideo services available today. The optimized value in the telepsychiatry opportunity is that these clients would likely not have been able to receive psychiatric service had it not been for the capabilities of televideo and the organizational capacity of the care providers. Fargo, ND based Prairie St. John’s has also used televideo technology when conducting Needs Assessments to its Twin Cities sites (now locally managed by Prai-rieCare) to determine care dispositions. Needs Assessment Counselors conduct

Joel V. Oberstar, M.D. Todd Archbold, LSW, MBA



Telepsychiatry



a comprehensive interview with an in-dividual or family and make recommen-dations for care that could be accessed locally. Without this technology and the available clinicians in Fargo, these indi-viduals in need would struggle to get a timely assessment without having to travel significant distances. The comprehensive assessment is shared with appropriate re-ferrals and kept in the patients’ medical record. Other services can also be per-formed in a similar manner between the Fargo and Twin Cities locations such as: psychological testing (Rorschach); spiritual care; further psychiatric consultations; and care coordination when patients are trans-ferred between sites.

While Needs Assessments are offered as a free service through PrairieCare, reim-bursement for services provided by televi-deo technology varies by payer. Billing for televideo typically involves the use of tra-ditional Current Procedural Terminology (CPT) codes published by the American Medical Association along with a televideo

“modifier.” Some arrangements provide for the psychiatrist to bill payers directly, while in other circumstances the psychiatrist is compensated based on an hourly wage and third-party payments are assigned to and collected by the host site.

Despite the triumphs that televideo technology has allowed in creating the op-portunity for increased access, it has not necessarily increased the overall capacity for providing services. While we now have the ability to provide care remotely, the supply of psychiatric clinicians able to pro-vide care continues to be far outdistanced by the profound demand for those services. When we deploy a clinician to provide care to a patient via televideo at a remote site, it is merely replacing the patient that we could be seeing face-to-face in our own office. This net zero replacement does not actually expand services, but rather expands the opportunities for providing and receiving services. The true value in offering telemedicine services may be our ability to eliminate or reduce the need for travel and bring service opportunities to areas that would otherwise not have them.

Indeed, the rapid adoption of en-hanced high quality televideo solutions has provided increased feasibility of tele-psychiatry consultation with very modest expenses. As one example, the Minne-sota Collaborative Psychiatric Consulta-tion Service uses a product called Vidyo to facilitate administrative meetings among the four participating sites (Es-sentia Health, Mayo Clinic, PrairieCare and Sanford Health). The Consultation Service aims to provide consultation to cli-nicians — many of whom are primary care providers in rural Minnesota — who are caring for children and adolescents with psychiatric illnesses. Nearly one hundred such consultations have been completed thus far, focusing on very young children on certain psychiatric medications. These consultations have been conducted using a traditional method — telephone — but in the future could expand to include televideo consultations with the clinician and/or with patients. After purchasing the equipment and service, we are able to hold televideo administrative meetings using Logitech headsets and cameras and an en-tirely web-based service facilitating high definition video. The televideo technology has advanced sufficiently such that the DSL service or cable modem used in most clinics can comfortably support televideo sessions with minimal audio-visual dis-ruption — one chief complaint articulated by early-adopters of televideo technology. Televideo is undoubtedly changing the way we are able to deliver care to our patients and creating opportunities for providers to maximize themselves as resources.

Joel V. Oberstar, M.D. serves as PrairieCare’s chief medical officer. He is an assistant pro-fessor of psychiatry, and serves as associate director of Resident Training and Education in Child and Adolescent Psychiatry for the University of Minnesota Medical School. He can be reached at: (763) 383-5800, or [email protected].

Todd Archbold, LSW, MBA is the chief de-velopment officer at PrairieCare Psychiatric Hospital and Clinics and is the practice manager of PrairieCare Medical Group. He can be reached at: (952) 826-8368, or [email protected].

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The Minnesota Department of Human Services has entered into a two-year contract with

the Mental Health Integration and Transformation coalition (Essentia, Mayo Clinic, PrairieCare and Sanford) to provide expert guidance to pediatri-cians and other primary care providers statewide who prescribe psychotropic medications for children. The new ser-vice is referred to as the “Collaborative Psychiatric Consultation Service” and is based on pilot projects that improved care and saved money.

While all Minnesota physicians will be encouraged to use the service, it will be required for Medical Assistance fee-for-service payment for certain psycho-tropic medications for children.

“This new psychiatric consultation service holds the promise of improved access and quality of care as well as great-er efficiency so resources can be focused on appropriate treatment,” said Lucinda Jesson, Human Services commissioner.

The new service will also expand the capacity and strengthen the system of oversight and monitoring of psycho-tropic medication use among children in foster care; they are up to five times more likely to be on a psychotropic medica-tion than other children on Medical As-sistance, a concern in Minnesota and nationally.

Mayo Clinic and its partners will operate a call center Monday through Friday from 7 a.m. to 7 p.m. A licensed clinical social worker will answer calls and determine the most appropriate

Minnesota Collaborative Psychiatric Consultation Service

response. For example, when possible, callers will be connected with existing services in the caller’s home community. If necessary, calls will be routed to on-call psychiatrists with qualifications specific to the request.

The goals of this new service are to:• Improvethequalityofmentalhealth

treatment by encouraging the use of evidence-based treatments in addi-tion to or in place of medication where appropriate.

• Improveaccessandqualityofcareby making more efficient use of both primary care and specialty mental health services.

• Improve collaboration betweenprimary care and behavioral health services.More information on the Minnesota

Collaborative Psychiatric Consultation Service is available at: www.mnpsychconsult.com.



Telemedicine: Emerging Technology, Emerging Risks

By Robert S. Thompson, RT, JD, MBA, LLM, CPCU, RPLU

It wasn’t long ago that clinic visits were simply that — a trip to see a health care provider at a brick and mortar

building. But increasingly, patients have more options for how they “visit” their doctor. They can choose to connect via any number of digital devices, including by email, phone, or through virtual face-to-face meetings using Skype-like technology. Technological advances in health care are expanding exponentially, and so are the risk management and patient safety concerns and professional liability risks associated with these advancements. For every improvement in speed, reach and convenience that telemedicine provides, there is potential for a corresponding de-crease in effective patient communication and the intimacy of personal interaction between patient and provider. The loss of these particular aspects of patient care increase patient safety concerns and profes-sional liability risks. The risks associated with telemedicine are vast, and many of the inherent risks are yet to be discovered. The following information brings to our attention a few known issues, and how to reduce the risks associated with them. These issues include: • healthinformationsecurity,confiden-

tiality and privacy;• professionalliabilityconcerns;• thephysician-patientrelationshipand

patient communication.

Health Information Security, Confidentiality and Privacy Security, privacy and confidentiality issues are areas of potential liability that have

increased with electronic health record implementation, and potential liability will also increase with the use of telemedi-cine. The number of sites for exposure expands from one to three with the use of telemedicine and each location/site of the patient, the transmission medium and provider location must be monitored to ensure security, privacy and confidentiality are safeguarded. • Ensurethatyourpracticeregularly

reviews and updates policies and practices regarding employee train-ing, HIPAA and the HITECH Act.

• Consultwithyourtechnologyandsoftware vendors to understand what technical capabilities are at your dis-posal from a security and privacy standpoint.

• Withanincreaseinprotectedpatientinformation flowing electronically be-tween a patient and his or her caregiv-ers via telemedicine, the potential for breach of confidentiality increases.

Impress upon your staff the need for increased scrutiny on patient confi-dentiality. Consider the use of signed staff confidentiality agreements.

Professional Liability Concerns The first line of defense in addressing medical malpractice concerns is to become familiar with the established malpractice issues most closely related to the tele-medicine activity undertaken. The basic premise of professional liability will remain intact, but will be compounded by the lack of intimacy and personal interaction inherent in telemedicine. For primary care providers, a pre-established face-to-face patient relationship can alleviate potential liability, whereas specialists must make a concerted effort to familiarize themselves with the patient’s clinical history and acute issue prior to undertaking a telemedicine visit. Professional liability concerns are heightened when telemedicine practice reaches into another state. This scenario brings into question licensure issues and questions regarding professional liability coverage. If you are providing services across state lines, ensure that your liability policy covers activities in the other state(s). Selecting an insurance carrier that has a presence in, and claim defense history for, additional state(s) is an important consideration. Set clear parameters as to what clini-cal health issues you are willing to address via telemedicine. In general, the greater the risk for potential patient harm, the less you should be willing to address the condition remotely. The risk management community has set guidelines for what


physicians and their staff can and will address telephonically, and similar poli-cies are needed for telemedicine. General telemedicine (as opposed to remote patient monitoring of patients in a health care facility) is not intended to be utilized with critically ill patients. Whenever possible, limit telemedicine practice to follow-up appointments and situations where the clinical diagnosis is clear. However, there are times when a significant amount of risk is involved that the risk/benefit ratio is outweighed in favor of treating via tele-medicine, especially when time is of the essence in the treatment proposed, and telemedicine allows for an increase in the speed of treatment. Each office and indi-vidual specialties should commit to policy and procedure what types of practice they feel are appropriate for telemedicine prac-tice. Additionally, specific instances where telemedicine is contraindicated should be spelled out and specifically prohibited in writing. Be sure that all telemedicine en-counters are properly and thoroughly

documented. Telemedicine often negates the visual interpretation you have of your patients and, even with remote camera access, nuances of patient interaction are diminished. This can translate into re-duced volume and quality of documen-tation related to your interpretation of the patient and the care rendered. Make a concerted effort to document your in-terpretation of the patient in free-flow text whenever possible in order to personalize the encounter. Telemedicine “visits” can lead to a lack of clinical recall and jeop-ardize future care when the main source of documentation is relegated to “check-the-box” documentation. Remember too, that solid documentation practices are not only imperative to the defense of a claim, but often serve to keep claims from being pursued in the first place.

The Physician-Patient Relationship and Patient Communication The importance of solid patient com-munication/relationship skills cannot be

overstated. Oftentimes lack of, or poor, communication causes patient injury and a subsequent professional liability claim. The potential for a communication break-down is exacerbated by the remote and impersonal nature of telemedicine. A few simple communication guidelines can re-duce your risk.• Wheneverpossible,establishaface-to-

face relationship with patients prior to using telemedicine. Personalizing the relationship is beneficial for both the provider and the patient and can serve to increase the quality of care being rendered and decrease the potential of a lawsuit being filed should there be an unanticipated outcome.

• Carefullyreviewthepatient’sclinicalhistory prior to telemedicine visits. Telemedicine visits focus only on the current clinical concern without tak-ing in the larger clinical picture, which may be important.

• Besuretofacilitatepatientcommu-nication with all providers involved


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Telemedicine

in the patient’s care. Telemedicine often has the negative consequence of not clearly defining who is respon-sible for what aspects of patient care. Clear communication with all parties involved builds a foundation of di-rect patient communication. Clearly define responsibilities and who will follow up with the patient after the encounter.

• Ofthelimitedcaselawinvolvingtele-medicine claims, follow-up systems errors are prevalent. Pay particular attention to follow-up systems when practicing telemedicine. Ensure that you and your staff have a clear plan to address future reports from currently ordered lab, radiology or other diag-nostic procedures. Utilize the tickler systems available to you to remind you of outstanding orders. Update your informed consent forms and processes to incorporate the use of

telemedicine. In addition to the stan-dard risks, benefits and alternatives to the proposed treatment, consider incorporating risks associated with the remote practice of medicine, such as communication interruptions or equipment failure.

• Allowyourpatientstotelltheirstory.Whether it’s verbal or written com-munication between you and your patient, solicit as much focused clini-cal information from your patients as feasible. It may be easy to proceed down a treatment path with limited information in the best of circum-stances, but with telemedicine, infor-mation received from patients is at a premium. Ask open-ended questions and encourage your patients to talk freely.

While the practice of telemedicine is yet in its infancy, predictions suggest that its use will quickly expand in the near future. With this expansion we will better understand the risks associated with tele-medicine as the establishment of case law related to professional liability emerges. Although many risk management and pa-tient safety principles apply to all aspects of the safe practice of medicine, focusing on the specific risks associated with tele-medicine and instituting best practices will help you avoid patient injuries and malpractice claims.

Author’s note: Several telemedicine risks were not addressed in this article, includ-ing licensing, credentialing, reimburse-ment concerns, teleprescribing and state and federal regulation. For additional re-sources and a deeper exploration of these and other telemedicine issues, visit the American Telemedicine Association at Americantelemed.org.

Robert S. Thompson, RT, JD, MBA, LLM(DR), AIC, ARM, ARe, RPLU, CPCU serves as director of Business Development at MMIC. He has a diversified background in law, medicine, medical professional liability insurance and health care risk management. He can be reached at: (952) 838-6810, or [email protected].

Emerging Technology, Emerging Risks


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2012 Shotwell Award Recipient Senator Linda Berglin

The 2012 Shotwell Award was pre-sented to Senator Linda Berglin at the January 8, 2013 meeting of

the Abbott Northwestern Hospital Medi-cal Staff. Chris Johnson, M.D., secretary/treasurer of the West Metro Medical Foun-dation of the Twin Cities Medical Society, presented the award. A legislator for nearly 40 years, Linda Berglin achieved a distinguished public service career. She served in the Minne-sota House of Representatives, 1973-80 (District 59A) serving as assistant majority leader from 1977-1980; and in the Senate 1981-2011 (Districts 59, 60, 61). Throughout her tenure and, especially while serving as chair of the Minnesota State Senate’s Health and Human Services Finance Committee, she was a champion

for the poor and un-derserved, using public policy to improve the lives of this population. She was an instrumental leader in the creation of MinnesotaCare, an in-novative, bipartisan effort to improve the health of Minnesotans. While not always taking the popular or easy road, she pursued her work with tremendous passion for serving the good of the people — an admirable tenacity of purpose. In addition to au-thoring legislation estab-lishing MinnesotaCare, Senator Berglin’s legislative successes include:• Expandedcoverage,access,andfund-

ing for mental health services, particu-larly for youth.

• Investmentsinpublichealthinfra-structure via the Statewide Health Improvement Program (SHIP).

• Reformingandmodernizingthestate’sadoption and foster care systems.

• StatefundingforFamilyPlanning.• State loanforgivenessprogramfor

medical professionals. • Bonding for the HCMC Hyperbaric

Chamber.• 2008health carepayment reform

legislation. Senator Berglin’s community ser-vice has included serving on the board of Minneapolis Model Cities, Peoples, Inc., PACER, Portico Health and Wellness; and

Finance Committee, she was a champion

on the capital campaigns for Touchstone, Little Earth and The American Indian Center. Senator Linda Berlin was very in-volved in the health care arena throughout her legislative career. By taking the initia-tive to immerse herself in learning about the health care system early in her career, she became the respected go-to person in the legislature for health care related issues. She retired from the legislature in 2011, and currently works as a health policy pro-gram manager for Hennepin County. The Shotwell Award is given annually to a person within the State of Minnesota for a significant contribution to the field of medicine through dedicated service to mankind, research, innovations and/or improvements in health care delivery.

Chris Johnson, M.D., West Metro Medical Foundation, presented Senator Linda Berglin with the Shotwell Award.


TCMS Annual Meeting

Edwin Bogonko, M.D. congratulates Peter J. Dehnel, M.D., outgoing president, on a successful year.

Lucinda Jesson, Commissioner, Minnesota Department of Human Services, gave the keynote address.

Edwin N. Bogonko, M.D. was installed as the 2013 president of the Twin Cities Medical Society at its annual meeting held on Tuesday, January 15. Dr. Bogonko is a native of Kenya where he received his medical degree at the University of Nai-robi, Nairobi, Kenya. He worked as an ICU physician and served as the secretary of the Kenya Medical Association for two years. He emigrated to the United States in 1999 and completed a residency in internal medicine at Hennepin County Medical Center. Dr. Bogonko currently is the clinical director of medicine and lead physician, hospitalist program, at St. Francis Regional Medical Center in Sha-kopee, MN. The following physicians join Dr. Bogonko on the 2013 TCMS Executive Committee:• LisaMattson,M.D. – President-Elect• PeterDehnel,M.D. – Immediate Past

President

• KenKephart,M.D. – Treasurer• CarolynMcClain,M.D. – Secretary • Matthew Hunt, M.D. – At Large

Member• Nicholas Meyer, M.D. – At Large

Member The keynote speaker for the evening was Minnesota Department of Human Services Commissioner Lucinda Jesson who spoke about the future of Minne-sota’s public health care programs. She said Minnesota has long been a leader and innovator in health care, including the creation two decades ago of Minne-sotaCare that made insurance affordable for low-income families. To continue the state’s record, Jesson said now is the time to re-envision programs for the poor and vulnerable that have grown too complex, costly and include coverage gaps. She of-fered four principles guiding state efforts in conjunction with federal health care reform. First, she proposed a unified public health plan that will provide better health for enrollees and better value for taxpayers in Minnesota, and said the state will pur-sue flexibility from federal rules to bring all clients into this unified plan. Other principles included a change in incentives so that providers are paid for outcomes and patients are rewarded for making healthy decisions, integration of physical health and social services, and finally, oversight and accountability to ensure the state is a strong steward of the taxpayer dollar. Dan Maddox, M.D., MMA presi-dent, brought greetings from the MMA. He stated that MMA has developed three goals, each with an accompanying work plan, based on feedback from physi-cians relating to key issues affecting their practices:• MakeMinnesotansthehealthiestin

the nation;

• MakeMinnesotathebestplacetopractice; and

• Advanceprofessionalisminmedicine. In addition, MMA will be working at the capitol, specifically focusing on: estab-lishing a Minnesota Exchange; expanding Medicaid; team approach to care; investing in medical education and the physician workforce; increasing the tobacco tax; and

New TCMS board member, Mark Destache, M.D. (center) with TCMS CEO Sue Schettle and Terry Ruane, MMA director of Commu-nications and Membership.


James J. Jordan, M.D., a retired psychiatrist and medical director of Hamm Clinic in St. Paul for 25 years, was honored with the First a Physi-cian Award presented at the annual meeting of the Twin Cities Medical Society on Tuesday, January 15, 2013.

Under Dr. Jordan’s leadership the clinic prospered and grew serving more patients, launching new initiatives, including the train-ing and research programs, a diversity initiative, and others. Each program enabled the Hamm Clinic to reach more deeply within the com-munity and to address the needs of the mentally ill. He is a clinical professor of psychiatry at the University of Minnesota and was selected as the 2002-03 Teacher of the Year. He received the Distinguished Life Fellow recognition by the American Psychiatric Association.

Dr. Jordan has held many leadership posi-tions throughout his career including serving as president of the (former) Ramsey Medical Society (now Twin Cities Medical Society). He has been an active participant in the Minnesota Psychiatric Association, the Minnesota Medical Association, and has been appointed to serve on various legislative committees including a Minnesota Care Integrated Service Network

Advisory Committee. In addition, he was ap-pointed by Governor Carlson to serve on a committee charged with developing a Universal Standard Benefit Set.

Even though Dr. Jordan is technically retired, he still remains very active. In 2012 he produced a documentary series on the treat-ment of depression that is being aired all over the state of Minnesota and mov-ing to other areas of the country.

He has always been a cham-pion for patients with mental illness—consistently advocating for quality, evidence-based psy-chotherapy and bio-psycho-social and patient-centered psychiatry care.

Described as a quiet, gentle soul with a heart of gold, Dr. Jor-dan completed his medical school training at Loyola University in Chicago and residency at the Mayo Clinic. He and his wife Mary Ellen reside in St. Paul and have five grown children.

The First a Physician Award recognizes a member of the Twin

Cities Medical Society who selflessly gives of his/her time and energy to improve the health of their patients, has made a positive impact on Organized Medicine and the medical com-munity’s ability to practice quality medicine, and/or improve the lives of others in our com-munity.

First A Physician Award

Marvin Segal, M.D. (left) receives MMA Physician Communicator Award from Daniel Maddox, M.D., MMA President and Edwin Bogonko, M.D.

ensuring the phase-out of the provider tax. Dr. Maddox encouraged TCMS mem-bers to donate to MedPac and join their colleagues at the Day at the Capitol on February 7 to meet with their legislators.

The TCMS annual meeting was also the venue for the presentation of the MMA

Physician Communicator Award awarded to Marvin S. Segal, M.D., co-editor of MetroDoctors, the journal of the Twin Cit-ies Medical Society. This award honors a physician who demonstrates exemplary skills in communicating with the public through published or broadcast work. Dr. Segal eloquently authors the tribute article, Luminary of Twin Cities Medicine.

The evening concluded with the recog-nition of Peter J. Dehnel, M.D. as the out-going TCMS president. He was presented with the President’s award in appreciation for his untiring passion for medicine and dedicated service to TCMS.

New Board member, Dr. Tierza Stephan and husband, Mark.

New Board member, Dr. Ryan Brady and wife, Danielle.

James J. Jordan, M.D. (right) receives the First a Physician Award from TCMS president, Edwin Bogonko, M.D.


Member Profile:

Meet Kacey Justensen, M.D.—

Volunteer Medical Director at Mills Health ClinicTen years out of residency and well established in her practice at Northwest Family Physicians in Crystal, why would Kacey Justesen, M.D. take a six month sabbatical to open a free medical clinic in Minnetonka? Because her heart said so. “I always knew I wanted to do something to help the underserved community,” said Dr. Justensen. “When we started talking about a free clinic affiliated with the nearby food shelf, I quickly knew that this was a region that needed a health care resource and that I was in a position to help with its conception.” Conveniently located in a renovated house in the middle of the block, the clinic is flanked by the ICA (Intercongregation Association) Food Shelf on one end and the Mills Church on the other. The Mills Health Clinic is slated to open its doors in March to serve the uninsured, pediatric to age 65 populations, in the community surrounding the Highway 494/Minnetonka Blvd site. It will serve the seven-city surrounding area, a region where currently there are minimal adult free health care services. Working as a team, Dr. Justesen, who serves as the volunteer medical director, and her MBA husband Jerad, the executive director of the clinic, recruited board members and garnered the support of other members of the community to secure financing, construction, donations, equip-ment and supplies. A strong relationship with the ICA Food shelf, which serves 2,500 people/month, provides a natural referral for both institu-tions — those needing medical care and those needing food assistance.

ICA Food Shelf also offers social services and a job coach. The relation-ship between the clinic and the food shelf is a unique, mutually beneficial one which allows the opportunity to provide wraparound, comprehensive care to people in need. “Jerad and I have been thrilled with the community response we have received as we begin this clinic. There has been an outpouring of generous support from individuals and organiza-tions to help our neighbors in need. It has been a challenging yet extremely rewarding experience — and it is only just beginning!” Mills Health Clinic is located at 13207 Minnetonka Drive, Min-netonka, MN 55305. Initially, the clinic will be open Tuesdays and Thursdays 6-9 p.m., adding days/hours as needed. Volunteer physicians are needed — both primary care and specialists. Contact: Kacey Justesen at [email protected] or (763) 258-3089.

Grand Opening Open House: Sunday, February 24, 1-4 p.m.

we play in improving health care access, enhancing affordability, promoting quality by some measure as well as reducing waste, fraud and abuse? How can our voice be heard locally even as Minnesota develops its version of a health insurance exchange? How does this affect the individual practices of our membership? Is preserving the doctor-patient relationship too much to ask? As the debate rages on, TCMS seeks to be heard at the local level and contribute positively even as the landscape for health insurance exchanges takes shape. It is clear that there is a lot of ongoing work for all of us to get involved. In 2013, we intend to engage physicians and the systems that employ them and state our case. Yes, the old adage, together we shall rise, divided we fall, is hitting home. One of my favorite quotes by Nelson Mandela says

“For to be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others.”

Coming together is more important than ever in these ex-traordinary times. Please do your part and let’s run this great relay together holding tight to the baton that has been passed on since 1855. Talk to your colleagues about participation in TCMS and

bring the issues they care about to the society so we help them find their voice. Start a conversation at your health groups about support for your membership to TCMS. Together we can share both the work and the gratitude of making a difference. For those already on the frontline, thank you for your sacrifice, service and doing your part in becoming custodians of our profession, work-ing hard to preserve the doctor-patient relationship, and standing up for what is good about this trade we all love so much. Let us stand together, at this moment in time to make it count. Thank you.

President’s Message


Dr. Bogonko with his family and friends at the TCMS Annual Meeting.


In MemoriamCHARLES D. ADKINS, M.D., age 96, passed away on December 27, 2012. Dr. Adkins attended the University of Min-nesota Medical School. After complet-ing his surgical residency he practiced at North Memorial Medical Center until his retirement. Dr. Adkins became a member in 1991.

DAVID W. ANDERSON, M.D., passed away on November 13, 2012 at the age of 76. Dr. Anderson attended the Uni-versity of Minnesota Medical School and practiced dermatology for over 40 years. Dr. Anderson became a member in 1968.

LINDA E. BOHN, M.D., passed away December 30, 2012 at the age of 63. Dr. Bohn attended the University of Minne-sota Medical School and practiced diag-nostic radiology. She served as president of the Ramsey County Medical Society in 1994, the only female to serve in this capacity for RCMS, RMS or EMMS, all predecessor organizations to the Twin Cit-ies Medical Society. Dr. Bohn became a member in 1983.

JOHN B. BRAINARD, M.D., age 87, passed away December 6, 2012. Dr. Brain-ard graduated from the University of Min-nesota Medical School and was a general surgeon for 33 years. Dr. Brainard became a member in 1961.

HERMAN H. EELKEMA, M.D., passed away on January 2, 2013. Dr. Eelkema at-tended the University of Minnesota Medi-cal School and completed his residency in radiology at the Mayo Clinic in 1958. He practiced at St. Paul Radiology until his retirement in 1993. Dr. Eelkema became a member in 1956.

GOVE HAMBIDGE, M.D., passed away on January 6, 2013. Dr. Hambidge was a psychoanalyst and alongside his private practice became a professor at the Univer-sity of Minnesota Medical School in 1953. Dr. Hambidge became a member in 1959.

ROBERT J. HAVEL, M.D., passed away at the age of 88 on December 15, 2012. He attended Creighton University Medical School, and completed his medical train-ing in the Air Force in 1947. Dr. Havel held many leadership positions and was a Clinical Associate Professor of Family Prac-tice at the University of Minnesota until retirement in 1988. Dr. Havel became a member in 1950.

NANCY R. LUND, M.D., died on Janu-ary 9, 2013 at the age of 76. Dr. Lund graduated from the University of Min-nesota Medical School and had her own pediatric practice for over 30 years. Dr. Lund became a member in 1966.

THOMAS J. MEANY, M.D., passed away on November 20, 2012 at the age of 87. He completed his medical training at Creighton University Medical School and practiced family medicine at the Columbia Heights Medical Clinic for many years. Dr. Meany became a member in 1960.

MALCOLM A. MCCANNEL, M.D., passed away at the age of 96 on Decem-ber 30, 2012. Dr. McCannel attended Temple University School of Medicine. He practiced ophthalmology and founded Ophthalmology, PA now named the Mc-Cannel Eye Clinic. He practiced there for 42 years, retiring in 1991. Dr. McCannel became a member in 1950.

GEORGE VICTOR TANGEN, M.D., age 82 of Prior Lake, passed away from myelodysplastic syndrome on January 29, 2013. Dr. Tangen earned a medical degree from the University of Minnesota in 1956, followed by a specialty degree in otolaryn-gology in 1960. He practiced medicine in the Twin Cities for 33 years, working pri-marily at Abbott Northwestern and Min-neapolis Children’s hospitals. Dr. Tangen served as chair of the Hennepin County Medical Society, member of the House of Delegates of the Minnesota Medical Association, and chairman of the board of the Midwest Medical Insurance Company. He joined the medical society in 1963.


C A R E E R O P P O R T U N I T I E S See Additional Career Opportunities on page 31.

New Members

Mohamad Y. Abbas, M.D.St. Paul Infectious Disease AssociatesInternal Medicine, Infectious Diseases

M. Vaughn Emerson, M.D.Retina Center, PAOphthalmology, Vitreoretinal Surgery

Howard R. Epstein, M.D.Institute for Clinical Systems ImprovementInternal Medicine

Jacob M. Jones, M.D., Ph.D.Retina Center, PAOphthalmology, Vitreoretinal Surgery

Ann E. Lavers, M.D.Metro Urology, PAUrology

Peter U. Lee, M.D.Consulting Radiologists, Ltd.Diagnostic Radiology

Anthony J. Polcari, M.D.Metro Urology, PAUrology

Eduardo Quinones, M.D.Consulting Radiology, Ltd.Diagnostic Radiology, Musculoskeletal Imaging

Nicholas Schneeman, M.D.North Clinic Geriatric Services of MinnesotaFamily Medicine

Andrew R. Zinkel, M.D.Regions HospitalEmergency Medicine

CALL TO ACTION

2013 MMA Annual Meeting and House of Delegates

TCMS Caucuses

Resolutions Neededby May 20, 2013

See details on page 33.

EOE/AA/LEP

A landscape of opportunities

PhysiciansGundersen Lutheran is a physician led, integrated healthcare system employing over 450 physicians. Based in La Crosse, Wis., our mission is to distinguish ourselves through excellence in patient care, education, research and improved health in the communities we serve.

Currently seeking BC/BE physicians in these areas and more:• Family Medicine • Neurology• Emergency Medicine • Dermatology• Psychiatry • Internal Medicine

Gundersen Lutheran offers generous loan forgiveness, competitive salary, excellent pension, and more. Most importantly, you will find a rewarding practice and an excellent quality of life.

Cathy Mooney (608)[email protected]

gundluth.org/MedCareers

7490- 2


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Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Shape your practice to �t your life as a part of our nationally recognized, patient-centered, evidence-based care team.

Whether your focus is work-life balance or participating in clinical quality initiatives, we have an opportunity that is right for you:

• Dermatology• Emergency Medicine• Family Medicine• General Surgery• Geriatric Medicine

Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800-842-6469 or e-mail [email protected].

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B y M a r v i n S . S e g a l , M . D .

LUMINARY

LAURENCE A. SAVETT, M.D.

of Twin Cities Medicine

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like consid-ered for this recognition to Nancy Bauer, managing editor, [email protected].

The wise physician/teacher stood before his group of pre-med students and said, “A doctor should have a good head and a good heart … and a personal commitment for ‘doing good.’”

There are many ways physicians can give of themselves beyond the recognized scope of providing clinical care to their patients. Dr. Laurence Savett chose to meaning-fully expand that medical horizon in ways that have benefitted patients, students, our community and our profession.

Having a conversation with Dr. Savett (“please, just call me Larry”) or reading his excellent book, The Human Side of Medicine, is a pleasantly comforting experience as he relays the pathway that brought him to this point in time. He was born in upstate New York, received his undergraduate degree from Hamilton Col-lege and M.D. degree from the University of Roches-ter. He headed west for his rotating internship at the Minneapolis General Hospital, completed an internal medicine residency in Cleveland, practiced both internal medicine and radiology in the U.S. Air Force during the Viet Nam War and later settled into nearly 30 years of internal medicine practice in St. Paul.

Larry has helped others in a variety of ways during his long and complex career. Perhaps the most notable of those endeavors have been to prepare young students to make a choice of and be successful in the healing arts, to relate those qualities that help to become better patients and to share concepts that aid us to become better physicians. Scores of fortunate people have availed themselves of his down-to-earth wisdom.

The fund of knowledge enabling Dr. Savett, a fellow of the American College of Physicians, to teach and dispense numerous pearls of wisdom was built via many life experiences. Those included having respected teachers and role models such as Drs. Irving Cramer and George Engel — a well known proponent of the bio-psycho-social model of illness and healing; caring for his diverse patient population; and battling a severe life-threatening illness as a patient himself.

To his pre-medical students he stresses the importance of working in the medical field as a vol-unteer or employee and the experience of spend-ing time with a practicing physician. To patients he emphasizes the need for them to collaborate with their family and their doc-tor as a team to improve the outcomes in their care. And, to his physi-cian students he states that after the diagnostic and treatment formulation takes place — step back and ask, “Is there a better way to look at this?” He believes that taking enough meaning-ful time with each patient and collaboration with other clinicians are keystone elements in the delivery of top notch care. He’s been a U of M clinical professor of Medicine and Admissions Committee member, and has lectured extensively to professional audiences from coast to coast and internationally on the Human Side of Medi-cine topic. His seminars at Macalester College and the University of St. Thomas are extremely popular and well received.

Our Luminary believes that a patient shouldn’t have to choose between a doctor with good technical skills vs. one with a pleasing bedside manner — as that physician should have both attributes. Dr. Larry Savett is a fine example of such a clinician — one with a good head, a good heart and a commitment for “doing good.”


CALL TO ACTION

2013 MMA Annual Meeting and House of Delegates

TCMS Caucuses

Resolutions Needed

This year, perhaps more than ever before, your voice and attendance is needed at the MMA House of Delegates meeting, September 20-21, 2013 at the Minneapolis Marriott Northwest, Brooklyn Park, MN.

The House of Delegates will vote on the Governance Structure proposals as presented last fall and refined throughout the year based on committee input and member listening sessions. In addition, delegates in attendance will determine the 2013 focus priorities for MMA leadership and staff.

For status updates on 2012 House of Delegates resolutions go to: http://www.mnmed.org/About-theMMA/AnnualMeeting/2012HODResolutionTracker.aspx

Call for ResolutionsDue by Monday, May 20, 2013 — email to [email protected] addition to the Governance changes, what issues and priorities would you like MMA to focus their time and energy on? Where is your passion?

Sample resolutions are available on the TCMS website: www.metrodoctors.com. Click on In Action tab, then Caucus.

Attend TCMS Caucuses:Wednesday, June 10, 2013, 6 p.m.Monday, September 16, 2013, 6 p.m. Broadway Ridge Building 3001 Broadway Street NE, Minneapolis, MN 55413

Attend MMA Annual Meeting and House of DelegatesFriday-Saturday, September 20-21, 2013 Minneapolis Marriott Northwest (formerly Northland Inn) 7025 Northland Drive North Brooklyn Park, MN 55428

For more information contact Nancy Bauer at [email protected] or (612) 623-2893.

2013 MMA Annual Meetingand House of Delegates

TCMS Caucuses

Resolutions Needed

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