can i have it both ways?

MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 1

V O L U M E 1 4 , N O . 2 M A R C H / A P R I L 2 0 1 2

CONTENTS

Page 28

Page 26

2 Index to Advertisers

3 IN THIS ISSUE It was the Best of Times; It was the Worst of Times By Richard R. Sturgeon, M.D.

4 PRESIDENT’S MESSAGE To Interoperability and Beyond... By Peter J. Dehnel, M.D.

5 TCMS IN ACTION By Sue Schettle, CEO

6 LETTERS Transfusion Practices

ELECTRONIC HEALTH RECORD 7 Colleague Interview: A Panel Discussion with Area Chief Medical Information Officers

13 My Experience with an EMR in the Primary Care Setting By Ellen DeVries, M.D.

15 The EMR in the Tertiary Care Setting: What’s Good, What’s Bad? By John F. O’Leary, M.D.

17 Electronic Health Records Current State By Scott W. Tongen, M.D.

19 Doctor and Patient Relationships in the Age of EMRs and PHRs By Becky Schierman

20 YOUR VOICE Electronic Health Records: Hope or Hype? By Richard J. Morris, M.D.

21 Implementing EHR: Unintended Consequences By Mike Flicker, MBA

23 Coordinating Health Information Technology Through CHIC By Cheryl M. Stephens, Ph.D.

25 Mary K. Brainerd Receives Shotwell Award

26 TCMS Celebrates 3rd Annual Board Dinner

28 First A Physician Award/National Healthcare Decisions Day

29 In Memoriam/West Metro Medical Society Alliance Archives/ Career Opportunities

30 New Members

32 LUMINARY OF TWIN CITIES MEDICINE Glen D. Nelson, M.D.

Page 7

On the cover: In transition to the digital world, hang on to the art of medicine. Articles begin on page 7.

Page 25

2 March/April 2012 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: Peter J. Dehnel, M.D.

President-elect: Edwin N. Bogonko, M.D.

Secretary: Lisa R. Mattson, M.D.

Treasurer: Kenneth N. Kephart, M.D.

Past President: Thomas D. Siefferman, M.D.

TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer(612) 362-3799

[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]

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.........................19

Audiology Concepts .........................................12

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

The Davis Group .............. Inside Front Cover

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

Hazelden ..............................................................29

Healthcare Billing Resources, Inc. ...............18

Lockridge Grindal Nauen P.L.L.P. ................. 6

Minnesota Epilepsy Group, P.A. ...................18

Minnesota Physician Services, Inc. ...................

Inside Back Cover

The MMIC Group .............Inside Back Cover

MMIC Health IT ...........Outside Back Cover

Neighborhood HealthSource .........................31

Noran Clinic Sleep Center .............................16

Saint Therese .......................................................16

Stillwater Medical Group ................................30

Toshiba Business Solutions .............................14

Uptown Dermatology & SkinSpa ................22

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

Exceptional Care for All Skin Problems

Your Patients will Look Good & Feel Great with Beautiful Skin.


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

It was the Best of Times; It was the Worst of Times

By Richard R. Sturgeon, M.D.Member, MetroDoctors Editorial Board

While not actually facing the guillotine, physicians and other cli-

nicians face daunting disruptive changes inherent in the digital

transformation of the delivery of health care. All physicians,

but especially Independent Physicians, are under significant stress during

this transition.

Studies have evaluated the impact of EHRs on documentation time for

physicians and nurses. For physicians, an average increase of 17.5 percent in

documentation time was identified. They are reluctant to embrace technol-

ogy that pulls caregivers from their primary objective — patient care.

To further complicate this problem, the incentive for physicians to

invest in EHR is out of alignment in the present environment. Benefits of

health information technology are often noted as reductions in overall health

care costs. These benefits may not be realized by providers who make the

financial investment in a system, but rather are allocated to Medicare and

to private payers.

On the other hand...Embracing e-healthcare and treating Information

Technology as a tool to improve patient safety and the quality of care enables

health care professionals to benefit from the technology formerly used for

management purposes.

Continuous systems enhancements and perhaps more important, con-

tinuous user training/learning will increase efficiency of today’s health care

IT. Workflow improvements will eventually require less and less keyboard

time. Point of care intuitive decision support will increase effectiveness of

delivered care. We have a golden opportunity to create a metro-wide system.

Several large systems already share basic EPIC software. They have already

invested significant capital in this common system. Proprietary business

information can be sequestered while effectively making clinical information

instantaneously available.

A whole new world is expected with the next generation of informa-

tion technology at the point of care. Data becomes immediately available

as information. New efficient workflows will be cost effective and free up

the physician to reclaim the interpersonal patient-doctor space.

In this issue of MetroDoctors, guest contributors present views from

the trenches using today’s technology.

The Colleague Interview has a special significance. We bring you a

virtual panel discussion on the issues provided by six metro area Chief

Medical Information Officers. You will find their collective response to the

operational and vision questions to be informative, realistic and reassuring.

This collegial and collaborative bunch has agreed to provide us future panel

discussions on more focal timely IT topics. If you have questions or issues

you would like to have them discuss, send them to Nancy Bauer, editor.

Ellen DeVries M.D., pedia-

trician, has had a positive experi-

ence both in her pediatric clinic

and hospital setting. She finds it

very easy to pull up tests and im-

ages to review with the patient/

family — a more efficient and ef-

fective process. She notes value of

thorough training before going

live and “at the shoulder help”

when first using an EMR.

John O’Leary M.D., sur-

gery specialist in a tertiary hospi-

tal, notes that his patients often

involve multiple specialists. The EHR allows input and communication

between and among these experts in real time, including off site. He has

instant data retrieval including imaging with the additional assist of decision

support and alerts.

Scott Tongen M.D., hospitalist, describes some EHR benefits to his

practice: access, legibility, treatment reminders, allergies and drug interaction

alerts. He feels we are in a “toddler stage” of learning to use this new tool.

Rebecca Schierman provides a patient’s perspective. She likes having

control of her Personal Health Record to access information and conduct

quick and convenient interactions with her clinic. She dislikes the physician

focus on the EHR instead of the patient. She sees a future use of EHR to

actively involve patients in managing their own health.

Richard Morris M.D., specialty clinic, says conversion to digital records

is “progress” in some ways: data exchange, eRX (safer), research/report gen-

eration, decreased transcription, better charge capture and systematic peer

review of “Best Practice.” Drawbacks include increased data entry burden

which reduces productivity and interferes with patient contact.

Mike Flicker, MMIC Health IT Team, says the immediate availability

of clinical data combined with embedded programs to alert physicians of

optimal care plans has the potential to significantly reduce adverse outcomes

and malpractice risks. However, the electronic health record has also shown

to bring unintended consequences that could increase the frequency of events

that increase practice risk.

Cheryl Stephens represents 170 diverse stakeholders in her role with

Community Health Information Collaborative (CHIC). They look to iden-

tify and take advantage of opportunities to coordinate health information

technology.

Progress is impossible without change. As difficult as it may be, it

is in our best interest to embrace this new technology and influence the

transformation.


President’s Message

To Interoperability and Beyond...

PETER J. DEHNEL, M.D.

Medical records are, in their broadest sense, at the core of medicine and a significant part of the “value

added” that physicians bring to the doctor-patient relationship. This edition of MetroDoctors focuses

on the seismic transformation from a paper-based system to one where all data elements are digitally

encoded and available for an incredible variety of manipulation, tracking, analysis and, ideally, bet-

ter patient care and outcomes. This title is based on the 1995 Pixar film, Toy Story, which brought

us, “To infinity and beyond!” It is the tag line of the space ranger action figure Buzz Lightyear, who

mistakenly believes the rocket pack on his back is real and that “beyond infinity” is an attainable goal.

In contrast to reaching the other side of infinity, there is a much broader world beyond basic electronic

health record interoperability. A few cautionary words are important before getting there, however.

I need to first reassure some of you that I am a firm believer in the potential that electronic health

records bring to the delivery of health care and the better practice of medicine. That said, there is a

long ways to go before they fulfill the six basic requirements of the Institute of Medicine for quality health care: safe, effective,

efficient, patient-centered, timely and equitable.

At the risk of oversimplification, but for the purposes of illustration, consider how five different EHR “systems” — A, B, C,

D and E — handle the following description: “The rain in Spain falls mainly in the plain.” Systems A, B and C process and store

this description in 35 separate data elements — 5 letter a’s, 2 e’s, 1 f , 2 h’s, 6 i’s, 4 l’s, 1 m, 6 n’s, 2 p’s, 1 r, 2 s’s (one of which is

capitalized), 2 t’s (one of which is capitalized) and 1 y. There are, in addition, 8 spaces. System A stores them in 13 categories

(each letter is a separate category) in descending order of size of the category. System B stores them as categories in alphabetical

order. System C stores them in reverse alphabetical order, and needs to separate capitalized from lower case elements. These do

not share information easily, because the rules for handling these data elements are unique and proprietary.

System D stores this description as individual word elements and therefore 8 categories (“in” is used twice). It appears

more sophisticated than the systems that store individual letters as data elements, but it cannot “reconstruct” the words from

these other systems because the software-based rules are proprietary.

System E saves this as an intact statement, but can only “share” with other systems an image of the phrase and is not readily

available for manipulation or broader analysis.

Note that in this example, the systems are all using an “alphabet compliant” format — standard English system letters.

Imagine if you allow for Chinese, Japanese or Arabic “data elements.”

Broaden your view to now include real patient data instead of just letters — height and weight, BMI and/or BMI per-

centile, blood pressure (systolic and diastolic), immunization information (which includes variable combination vaccines, the

manufacturer’s lot number, site of administration and expiration date), medication allergies, family history, physical exam and

even cancer type, stage of involvement and pertinent genetic or hormonal markers. The ongoing challenge is to safely, effectively

and reliably transmit this crucial data from one system to another.

So what is on the other side of basic EHR interoperability? It is designing, building and operating a “trusted health care

information platform.” According to Steve Tirrell, (Information Management Team at IBM), this can be summarized as an

information system (platform) that can:

I sincerely hope that you enjoy this edition of MetroDoctors. I also hope that you will see the importance of physicians

actively engaged in the development and implementation of these “information platforms” that will result in outcomes that we

all hope to see — better care for our patients.


SUE A. SCHETTLE, CEO

TCMS IN ACTION

TCMS Annual MeetingThe Twin Cities Medical Society annual

board of directors meeting was held on

Tuesday, January 24, 2012 at the Town and

Country Club in St. Paul. See page 26 for

pictures and highlights. I provided a year in

review using a TCMS Year by The Numbers

document. See below. TCMS had a very

busy and productive year thanks to many

of you. Our work with Honoring Choices

Minnesota as well as the Twin Cities Obesity

Prevention Coalition has really raised the

profile of TCMS as an organization that

takes public and community health seriously.

basis. If you have an interest in joining the

TCMS Policy Committee please let us know.

We have two openings. To learn more about

the Policy Committee visit our website at

www.metrodoctors.com.

East Metro Medical Society FoundationThe East Metro Medical Society Founda-

tion has a new member joining the Board of

Directors. Ken Britton, M.D. is a family

physician/physical medicine and rehab spe-

cialist practicing in St. Paul. Dr. Britton joins

his colleagues on the EMMS Foundation

Board of Directors serving his first term from

2011-2013.

The East Metro Medical So-

ciety Foundation is also embark-

ing on an endeavor to increase

its profile in the East Metro.

Frank Indihar, M.D. has been

chairing the EMMS Foundation

Development Committee and is

helping to spearhead the effort.

Look for more information about

the EMMS Foundation in future

issues of MetroDoctors including

information about an award that

will be given out to recognize

East Metro physicians.

West Metro Medical FoundationThe West Metro Medical Foun-

dation welcomes Lisa Bishop, MB, ChB., a pediatrician with

Allina Medical Group (Maple

Grove), Joseph Bocklage, M.D., a retired orthopedic sur-

geon, and James Struve, M.D., family

medicine, practicing at Fairview Blooming-

ton Lake Clinic.

The WMMF Board is continuing its

strategic planning discussions with a goal to

establish a new mission statement and direc-

tion for the Foundation.

Twin Cities Obesity Prevention CoalitionThe TCOPC continues to make progress in

raising the awareness of the obesity epidemic

in Minnesota (and the country) by working

with local elected officials to introduce reso-

lutions supporting obesity prevention efforts.

Over 20 physicians are directly involved in

this initiative. To learn more and get directly

involved, visit our website at www.metrodoc-

tors.com.

Honoring Choices Now in Wisconsin!The Wisconsin Medical Society is leading an

effort in Wisconsin to standardize Advance

Care Planning across the state. They are

basing their model on Honoring Choices

Minnesota and have even licensed our name.

We have also discussed the opportunity for

licensing some of the content that we have

developed as part of our relationship with

Twin Cities Public Television.

Book to be ReleasedThe Honoring Choices Minnesota model

has been getting some national attention

lately. In fact, Kent Wilson, M.D. and I

were asked to contribute a chapter in a book,

called Having Your Own Say that is being

pulled together by the Centers for Health

Care Transformation out of Washington,

DC. The book is scheduled to be published

at the end of February 2012. We hope to

elevate the profile of our project through this

book.

2011 By the Numbers

9Healthcare systems participating in Honoring Choices

Minnesota. LARGESTorganized advance care planning program

in the COUNTRY (and World?). 900 people trained to have

end-of-life discussions. 23 physicians involved in TCMS obesity

prevention efforts. 12 cities approached for the Healthy Eating

Active Living Obesity Prevention Resolution. 2 Lunch n’ Learns

with medical students. 2 awards received for MetroDoctors.

Over $1 million grant dollars raised to support operations.

15 meetings with cials. 116 New members

involved. 3,466 members subscribed to TCMS E-Newsletter.

377 members involved with the Senior Physicians Association.

33 Facebook followers. 28 Twitter followers. 7,748 unique

visitors to the TCMS website from 65 different countries.

1 Very Productive Year!

TCMS Policy CommitteeI’d like to say thanks to Ann Wendling, M.D. and Lynne Steiner, M.D. for their

time and commitment as members of the

TCMS Policy Committee since 2010. Both

Lynne and Ann spent countless hours serving

on the committee which meets on a monthly


L E T T E R S

Transfusion Practices

The thorough and informative series of ar-

ticles on transfusion practices in the January/

February issue was an important contribu-

tion to medical practice. My interest in

transfusion medicine dates back 35-45 years

of pathology practice at North Memorial,

where I had CME and blood bank respon-

sibilities. In fact, by combining the two,

I became involved in what my colleagues

described as a “crusade.” These efforts cul-

minated in an article in Minnesota Medicine

(March 1983), describing dramatic improve-

ment in transfusion practices. Herb Polesky,

formerly medical director of the Memorial

Blood Center, unofficially confirmed to

me that North administered one-fourth to

one-third as many blood transfusions for a

comparable mix of surgical cases as any other

Twin City hospital.

The current literature (NEJM Decem-

ber 29, 2011) on transfusion practices sug-

gests that we may be “reinventing the wheel.”

What we accomplished at North decades ago

is now presented as a new idea; namely that

“less” is “better” practice, both economically

and professionally. By transfusing less, in

an era when hepatitis C was not known, we

prevented hundreds of cases of serious liver

disease.

A peripheral yield to our efforts was

demonstrating that CME could modify

physician behavior in a positive direction.

This question had been raised repeatedly

in CME groups nationally, often without

solid evidence. Although long retired, my

“crusade” is history, even though we may be

“reinventing the wheel.”

Thank you for coordinating the transfu-

sion series. It is worthy of wider dissemina-

tion.

Seymour Handler, M.D.

Medicine is rapidly changing. Many powerful influences are impacting our practices. Change will

come. It is vital for you to have a say in the future direction and shape of our health care system

and our practices. Our patients depend on us to protect them from the worst of these changes

and to assure that they have ready access to the best that medicine can offer. If we say nothing,

others will decide.

This is your opportunity to have your say!

All members of the Twin Cities Medical Society are invited and encouraged to become engaged

in setting the priorities and next year’s agenda for organized medicine.

This is the time to indicate your interest to serve as a Delegate. Being a Delegate keeps you in-

formed and it assures that your voice is heard. The process works like this:

Start thinking about issues that you would like to address through the MMA. What issues

are important to you, your practice and your patients? Sample resolutions on TCMS website:

www.metrodoctors.com. Click on In Action tab, then Caucus.

Broadway Ridge Building

3001 Broadway St. NE, Minneapolis, MN 55413

Friday, September 14 and Saturday, September 15, 2012

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

Become Involved! Write a resolution, serve as a delegate, attend the MMA Annual Meeting


Where do you see the EHR “going” as the product gets better and the users more adept?

I see more advanced Clinical Decision Support (CDS) tools allowing

the EHR to warn clinicians if patients begin showing signs of sepsis,

vital sign instability and other conditions that often go undiagnosed or

unnoticed until they are in more advanced stages or the patient “codes.”

This would allow for earlier intervention and decreased morbidity and

mortality. – Brian Patty, M.D., HealthEast

There are two areas that I see evolving in the next several years. As Brian

mentioned, CDS is still in its infancy and is relatively unsophisticated.

There is tremendous duplication of work in customizing alerts across

institutions. We need to come to some relative agreement on standard

CDS that needs to be part of every EHR in areas such as drug toxici-

ties and interactions, specific disease or condition alerts, and methods

to encourage following of standard clinical guidelines. The other key

area is usability. We’ve seen the great strides taken in usability in other

consumer electronics, yet the EHR continues to be complex and not

intuitive. – Rod Tarrago, M.D., Children’s

As Brian and Rod mention, optimization of the EHR is a big part of

the road map for the next 10 years. The Twin Cities are blessed to have

such a strong EHR base. Leveraging this base for better care means fewer

clicks, better workflow, continuous training and especially, excellent clini-

cal decision support. Optimization means the time spent in the EHR is

the best it can be, and that there is more and better time to spend with

patients and their families, with our colleagues and clinical staff, and

with our own families. – Michael Shrift, M.D., Allina

I’ll take a bit of a different tack on what I think needs to evolve. First,

I think that the vendors need to back off from their proprietary nature

and embrace their tool more as a platform that encourages other vendors

to plug in or to offer additional apps that can plug in. The EHR space

is going to consolidate as there just aren’t enough opportunities for large

players. Creating an effective Software Development Kit (SDK) that other

vendors can leverage will allow a product to mature faster than under the

direct control of the principal vendor. This can enable the suggestions

made above. Additionally, I believe that we need to leverage the capa-

bilities of our EHRs to rethink documentation and workflows. There is

still WAY TOO MUCH duplication that makes us all inefficient. – Ray Gensinger, M.D., Fairview

I certainly agree with the others, but in my opinion the key change will

be that the EHR will shift its focus from the doctor and the hospital

Six hospital and health system CMIOs participated in a group

dialogue focused on the topic of Electronic Health Records.

Standing from left: Brian Patty, M.D., HealthEast Care System;

Michael Shrift, M.D., Allina Health; Rod Tarrago, M.D., Children’s

Hospitals and Clinics of Minnesota; Ray Gensinger, M.D., Fairview

Health Systems. Seated from left: Kevin Larsen, M.D., Hennepin

County Medical Center; Irfan Altaffula, M.D., North Memorial

Medical Center.

Colleague Interview: A Panel Discussion with Area Chief Medical Information Officers

Electronic Health Record

(Continued on page 8)


to the patient and the home. We are in the business of keeping people

healthy, monitoring their illness and providing patients with information.

With the explosion of technology, we can now do much more over the

web-home monitoring, e-visits, condition specific patient social media

site and giving people access to rich information. This will not only save

patients money, it will save the system money and decrease the burden of

health care that people have in their lives. – Kevin Larsen, M.D., HCMC

The EHR of today is essentially a first generation tool. There are tre-

mendous possibilities for making the systems more “intelligent.” This

would include innovative ways of data entry with sophisticated speech

recognition, touch screens, etc. that would make it easier and more ef-

ficient for users. I can see future EHRs “learning” through use, analyzing

data in real time and presenting options to users at point-of-care. The

current system of alerts is crude and not very effective and will have to

improve. I also agree with Kevin that EHRs will become the portal for

fusing data from home monitoring, smart sensors, etc. and will also serve

as a vehicle for telemedicine. – Irfan Altafullah, M.D., North Memorial

Will Independent Practices be able to financially keep up with the technology and training requirements?

I fear the expense associated with the purchase and maintenance of EHRs

will force small groups to either merge with larger groups or health care

systems or, at the very least, be “tethered” to these larger systems as a

result of “outsourcing” their EHR management and maintenance to

these systems. – Brian Patty, M.D., HealthEast

We’re currently seeing many practices in the Twin Cities and across the

country align themselves to various degrees with larger groups and hos-

pital systems in order to obtain state of the art EHR software systems. As

we see increased federal regulations, fewer smaller software vendors will

be able to meet these guidelines, thus limiting the number of available

choices to smaller practices. – Rod Tarrago, M.D., Children’s

I suspect that they will if they have a dependable vendor that will stay in

business. A very difficult future to predict. If the national CONNECT

standards continue to evolve effectively then I don’t think this will be as

big of an issue as others might think. The expectation by federal agencies

to have this be their method of communication will help those vendors

that hit the mark earliest. My preference would be to have standards

that allow sites to pick their own vendors and easily connect with me. I

offer my EHR out to others only as a convenience for them in the short

term. It is tough being a vendor and a provider both. – Ray Gensinger, M.D., Fairview

The market is primed for a robust software as a service model. Look at

what is happening in the business world, individual software applications

are being replaced by Google documents and customer management

systems by salesforce.com. Under our current model of EHRs, there

is considerable technical skill required to maintain them — servers,

upgrades, networks, etc. Currently large hospital and health systems

are essentially selling software as a service to many of these independent

providers. Someone is going to figure out this market and a software

vendor will supply a fully functional web-based EHR for a subscription

fee. – Kevin Larsen, M.D., HCMC

This has been a challenge for independent practices — not just the initial

investment, but ongoing training and optimizations. Thankfully, the

free market has responded and there are a host of companies offering

web-based “software as a service” and some of the products are quite

sophisticated and user friendly. I see a shake-up of the industry and

consolidation in a few years, once the ongoing frenzy of new installations

dies down. – Irfan Altafullah, M.D., North Memorial

How should we abet universal access to patient infor-mation at point of care? Would we allow the patient to control and “carry” his EHR (e.g. using Microsoft vault or hard copies)?

Yes, although I see “version control” becoming an issue. If we do not

allow for a central “source of truth” there is the potential for multiple

“versions” of any given patient’s EHR with the critical version at their

primary care physician’s office becoming “out-of-date.” – Brian Patty, M.D., HealthEast

This is an area where medicine as a whole is still evolving. As more

systems implement patient portals, issues of confidentiality and privacy

will come to the forefront. We have been working with our families in

this area at Children’s since we have many patients who are not legally

able to have their own personal records, but at the same time may have

issues that are discussed with their provider in privacy. We also are seeing

many discussions about a patient’s ability to interpret results that may not

have yet been verified by the provider. – Rod Tarrago, M.D., Children’s

If done well, universal access to information improves the conversation

among the patient, the family and the care-giving team. There are more

and more good practices about how to do this to reduce any risks and

concerns and maximize the benefit. – Michael Shrift, M.D., Allina

I fully support the concept of the patient owning and retaining their

record. At Fairview we say that the record does in fact belong to the

patient and that we are only the caretakers of that record for them. I

don’t know that the record will ever be physically portable. We seem

to add data to it faster than manufacturers can create a portable device

to hold it all. As the CONNECT standards and cloud-based services

mature then I think the HealthVault model may have some legs. – Ray Gensinger, M.D., Fairview

Colleague Interview

(Continued from page 7)



Patients want to own their information, but currently the tools to do that

are clumsy. More importantly, the health care systems have not built our

EHRs to have interoperable data. We first need to have full transparency

for patients — let them see everything in our EHRs. Then we need to

have a system based on interoperable data. When this is achieved there

will be many ways to aggregate a patient’s information. Maybe it is in

the cloud; maybe on a USB; maybe it is federated and compiled at each

visit. Most likely, all of these will happen. For a chronically ill person a

USB may be the ideal solution; however, for a healthy person with few

encounters in health care, a record compiled at each visit may be the

right solution. – Kevin Larsen, M.D., HCMC

This issue is complicated by privacy and data safety as well as a lack of

universal standards for EHRs. Further, society might not be ready to

accept a massive centralized database of sensitive medical information.

This is an area where societal norms will have to lead technological in-

novation. – Irfan Altafullah, M.D., North Memorial

Comment on the current status of clinical decision sup-port tools in eliminating variation and increasing the value of the care delivered. Have genuine savings been realized? Who benefits?

Great examples are showing up of “sepsis alerts” and the like being de-

veloped and drastically reducing mortality from sepsis at the hospitals

that have deployed them. At HealthEast we co-developed with our EHR

vendor a Ventilator Associated Pneumonia (VAP) monitor that displayed

in real-time all of the IHI VAP bundle elements on all ventilated patients

and we were able to markedly reduce the incidence of VAP in all of our

ICUs. These types of CDS-related morbidity and mortality reductions

are showing real savings in health care costs — not to mention the lives

saved. – Brian Patty, M.D., HealthEast

We are in the process of implementing various CDS tools to improve

safety, quality and efficiency. We’ve used a daily online safety checklist

in our pediatric ICU to help intensivists address specific issues each day.

We’ve seen significant improvements in the rate of utilization of enteral

medications instead of IV formulations, thus reducing the likelihood

of line infections. We are also beginning to look at tools to improve

our utilization of blood products as well as certain medications and IV

nutrition. Evidence-based electronic order sets have also improved the

standardized use of data driven therapies. – Rod Tarrago, M.D., Children’s

Allina is blessed to have such a wonderful, dedicated and clinically-focused

CDS team and Excellian (Epic) support team. The key is to listen to the

clinical expert groups and translate their best practice, evidence-based

care into hardwired workflows. The results, such as our heart failure,

MI and diabetes care excellence, are a testament to this teamwork and

collaboration. – Michael Shrift, M.D., Allina

CDS offers great promise for us all. And I have no better examples than

those already listed. We have some that have in fact saved hundreds of

thousands of dollars as well. Sadly, at this year’s American Medical In-

formatics Association meeting there was a presentation that suggests that

CDS is a double-edged sword ready to create a legal feeding frenzy. On

one hand, if providers expect CDS there is the risk that their independent

critical thinking abilities may be blunted and actions are taken perhaps

where not most prudent. Conversely, if a clinician chooses to ignore a

CDS recommendation does it create medical legal conflict between the

provider and organization? I suspect that while this is where the greatest

opportunity lies, we will have to be very deliberate on how we advance

in this space. – Ray Gensinger, M.D., Fairview

An ideal CDS intervention automates the parts of medicine for which

there is universal agreement, allowing the providers to focus more of

their time on complex problem solving with patients and less time in

remembering and doing routine tasks. For example flu shots. This is not

a sexy CDS topic; however, if we could get flu shots to all patients it

would have a great impact on overall health and medical care. In orga-

nizations that have done this effectively, like Virginia Mason, it has also

given the provider and patients some time back to discuss other issues

during a medical visit. CDS also holds tremendous potential for giving

visibility to complex information and interconnections. For example,

doctors are trained to risk stratify patients, but the human mind can only

calculate with a small number of variables at once — maybe 4-5. With a

sophisticated CDS algorithm, many more variables can be part of a risk

stratification decision. This will help us make better, more sophisticated

decisions, not take away our decision making autonomy. – Kevin Larsen, M.D., HCMC

We have implemented a two-pronged approach. Within the EHR, we

are using the available CDS tools to improve the quality of care with

sepsis and VAP bundles. Off-line we have implemented a third party

data warehouse and are using analytic tools to improve care in some areas

where we see variability, for example elective induction of labor, diabetes

care. The greater challenge is to change workflows and behavior patterns

of users and we have established Guidance Teams for each initiative.

We see great potential in this area, going forward. It is challenging to

quantify gains, though anecdotal data are promising. – Irfan Altafullah, M.D., North Memorial

How do you capture patient data from providers who are not on a health care systems’ platform, yet part of a net-work and part of the total cost of care performance? Do tools exist or is there a common attribution model?

We are in the early stages of blending clinic data with our inpatient data

in our data warehouse using Enterprise Master Patient Index (EMPI)

technology that uses federated matching techniques to match patient

ABC in system Y with the same patient ABC in system Z. – Brian Patty, M.D., HealthEast



This is a challenge for all systems, especially when dealing with groups

who are still on paper. The first step will be creation of health information

exchanges (HIE) between EHRs. We are also starting to look at email,

web, and text-based portal strategies that allow us to push and pull data

to and from providers who have yet to move to electronic records. – Rod Tarrago, M.D., Children’s

Much opportunity in this space. MN HIE failed in the cities as there

wasn’t enough willingness to help grow the model. It is very expensive

for automated data exchange, especially when there are few partners and

high startup costs. Many are failing across the country. A couple are doing

well but those have considerable grant funding or capital endowments to

sustain them. Connecting to those on paper has much to be desired. We

are looking at portal-like methods of gathering the key elements needed

as well as working with payers to extract those elements that they have

access to and we do not. – Ray Gensinger, M.D., Fairview

We have identified several “strategic partner” practices and are building

interfaces with their systems and the enterprise EHR. There are numer-

ous challenges in this area including legal, technical and financial. In my

opinion, this is one of the big challenges we face in the short term — how

to make the EHR truly patient-centric so that information can follow the

patient across the health care continuum. The Care Everywhere model

is a great example. – Irfan Altafullah, M.D., North Memorial

Please describe how you assess and get feedback on the impact of your EHR on the daily work of clinicians. A number of practicing physicians believe that their keyboard input is inefficient and interferes with direct doctor-patient communication and we hear complaints from patients regarding lack of interpersonal contact inherent to the EHR.

We survey our providers routinely in order to identify their pain points

with our EHR. We also have support staff routinely rounding on providers

as they work to assess work-flow issues and other sources of frustration

with the EHR. In addition we provide resources to our providers on our

intranet and via our Physician Portal that help them better interact with

patients and work the EHR and computers into their workflow. – Brian Patty, M.D., HealthEast

We have performed EHR satisfaction surveys to get key information

on usability. We also routinely round with users to see first hand the

challenges they face. As CMIO at Children’s, I have also made it a point

to continue to practice at least half time in order to use the system first

hand. Finally, we’re about to begin leveraging vendor usability tools that

give us objective data regarding user efficiency. We are able to determine

which users have taken direct routes in their tasks, and which users have

used workarounds and more clicks to accomplish the same tasks. This will

allow us to more efficiently target users in most need of education. – Rod Tarrago, M.D., Children’s

This is a very important issue and a large challenge for an 11 hospital

100 clinic health system. We are constantly trying to improve the us-

ability of our clinical technologies. A few examples of the way we listen

to end users include: hospital EHR committees, Excellian site support,

Excellian medical directors, Excellian user groups, Excellian super users

and more. The Allina Excellian Physician Users’ Group has proved a very

successful and high functioning forum for understanding end user needs

and improving the system. – Michael Shrift, M.D., Allina

I had to chuckle as I read the question as my chief assessment tool often

is how often the message waiting light is blinking on my telephone. I

typically provide my cell phone number as a way of reaching me if things

are really problematic. Not too many calls end up there and those that

do typically warrant my immediate attention. We can always do better

at getting feedback. We also try and mature a concept of super users.

Those are real users practicing real medicine on our EHR. They have extra

training as well as direct lines of communication back to the development

teams to facilitate communication. Our staff has thousands of awesome

ideas. The hard part is sifting through them and getting those done that

will add the most value overall. – Ray Gensinger, M.D., Fairview

Like the others, we have a series of feedback loops. We survey providers,

have practicing clinicians who work with our EHR teams, we watch our

users and have user groups. We are working to figure out how we can

give more ownership of the system and system decision directly to the

users. – Kevin Larsen, M.D., HCMC

Our model is similar. We have many practicing physicians who actively

participate in EHR maintenance and optimization. There are several

physician champions who are lightning rods for feedback — both good

and bad! — who are valuable conduits of information. In addition, our

organizational size enables us to have a lot of one-on-one contact with

users, in person and through email. – Irfan Altafullah, M.D., North Memorial

Do you favor segregating personal or sensitive personal information in psychiatric cases? If so, please describe how? What role does the patient or patient’s family have in developing and reviewing the information contained in a patient’s EHR?

This argument has two sides. We have segregated some types of sensi-

tive results and allowed only certain providers to see them in order to

maintain privacy. It is always a difficult decision though as many of these

segregated conditions could be important knowledge to others providing

care for the patient, and absence of the information could theoretically

compromise care in certain situations. – Rod Tarrago, M.D., Children’s


Colleague Interview



I often argue that segregated chart segments create a false sense of security

for everyone in that elements like medication lists, problem lists, and

medical history items live at the level of the patient and are not controlled

in the same way as say a clinic visit to the ED for symptoms of an STD.

While I could “hide” the ED encounter and maybe even the problem

or diagnosis, all those with chart access would still be able to see that

I administered intramuscular ceftriaxone as well as prescriptions for a

single dose of 1gm azithromycin. Every physician and nurse knows what

those mean.... Our job is to manage a record that ensures the very best

and complete care for the patient. Anything we do to restrict data access

then limits that expected result. We favor a heavy auditing procedure and

accountability for behaviors. – Ray Gensinger, M.D., Fairview

Patients need to control the flow of their own information. In order for

them to continue to trust us as an organization, me as a doctor and our

EHR, a patient must trust that their information is protected in the

ways they value. This is possible even for “sensitive” information. We

find that the vast majority of patients want this sensitive information

to move easily between providers. Therefore, we have not put many

technical segregation points in the system, but more alerts like “do you

really need to look at this information?” – Kevin Larsen, M.D., HCMC

I don’t necessarily favor segregating information, especially since some of

that information might be very relevant to patient care. We must con-

stantly strive to treat all aspects of the medical record as “sensitive” and

develop our culture accordingly. One of the big advantages of an EHR

over the traditional paper record is that now it is much easier to keep an

audit trail, implement “break the glass” alerts, etc. Once again, the major

issue here is institutional culture and behavior rather than anything to

do with the EHR necessarily. – Irfan Altafullah, M.D., North Memorial

As CMIO of a health care system, how do you encourage local engagement and innovation while simultaneously standardizing and disseminating best practices across the broad integrated family of organizations?

We hold firm on standardizing where there is clear evidence of best

practice in the literature and allow for monitored variation (in an effort

to establish localized best practices) where there is no clear evidence of

a best practice. – Brian Patty, M.D., HealthEast

This is a growing area of interest in medicine. The days of “I do it this

way because that’s the way I was taught” are becoming less common

as we see more and more evidence-based care. In areas where there is

no evidence, we encourage some degree of standardization in order to

determine best practices. Some centers have now begun to leverage the

EHR to actually create evidence where it may not exist. In areas where

the literature is lacking, the EHR can actually be used to extract case

series data to drive therapy decisions. – Rod Tarrago, M.D., Children’s

Managing this tension is the work of great health care. Our Clinical

Service Lines increasingly and continuously improve evidence-based,

best practice care. Through conversation among these clinicians and

our CDS and Excellian Support teams, these practices are standardized.

The number of our Allina order sets has decreased as a result. – Michael Shrift, M.D., Allina

My colleagues have nailed the issues. The only addition that we have is

by virtue of our affiliation with the University of Minnesota. We want

to create care pathways that can be analyzed by our scientists and then

fed back into clinical practice much more rapidly than the historic cycle

has demonstrated. We all have a role and responsibility to define the new

standards of care. – Ray Gensinger, M.D., Fairview

I aim to standardize and automate where there is good medical evidence

and agreement. This frees up time for providers to talk with patients

more and to focus more energy on difficult decisions where their isn’t

good evidence. – Kevin Larsen, M.D., HCMC

This is one of the more challenging aspects of my job. I agree with my

colleagues that where there is good evidence for best practices, there is

little push back from users. However, so much of our day-to-day medical

practice is still influenced by past experience and community standards

of care which, while effective, might not be “evidence-based.” Here,

one has to balance the physician’s autonomy with standardization of

care, and I find it most effective to focus the discussion on what’s best

for the patient, which is really everyone’s goal. – Irfan Altafullah, M.D., North Memorial

Given the diverse array of vendors already in independent practices, please give an overview on metro-wide connec-tivity, compatibility and confidentiality.

We really don’t have good cross-vendor/cross-health care system connec-

tivity in our area to any extent to date. – Brian Patty, M.D., HealthEast

At Children’s we are working on improving the interface between Cerner

and eClinical Works in associated practices. However, until we have true

interoperability, we will not be able to truly leverage the power of the

EHR across the community. – Rod Tarrago, M.D., Children’s

We continue to support the concepts of health information exchanges

and work closely with our vendor to demand interoperability and then

work with our local practices to create the same level of urgency among

their vendors as well. Like Rod mentions, we are starting with our core

vendor and those with the largest market presence and working our way

back to the rare vendors. – Ray Gensinger, M.D., Fairview

We are a very interconnected market, largely because many of us use an

application from the same vendor that is interconnected. I agree with

Ray that we need further interconnectivity, not just to other hospitals

and health systems, but also to nursing homes, pharmacies, home health

and others that provide medical care. – Kevin Larsen, M.D., HCMC



I agree that we have a good start, especially in the Twin Cities, but still

have a long way to go. I am confident we will get there in a few years

because the marketplace will demand it — patients, payers and regula-

tors. – Irfan Altafullah, M.D., North Memorial

Lastly: What should we be celebrating?

1) All of the hospitals in the greater Twin Cities metro area are up on

EHRs and CPOE! I am not aware of any other large metro area that can

make that claim. 2) Three of the Top 25 Clinical Infomaticists in the

Nov. 11, 2011 issue of Modern HealthCare came from the Twin Cities,

tied with California for the highest number from any one state. Both

of these point to the high level of engagement and success in our region

with EHRs. – Brian Patty, M.D., HealthEast

Despite the use of several different vendors, there is increasing collabora-

tion between institutions with the goal of improving patient outcomes.

We are also starting to look at areas in which we can improve the user

experience across the Twin Cities and truly make it a connected health

care system. – Rod Tarrago, M.D., Children’s

The quality and safety of health care in Minnesota is among the best in

the nation. This is due in no small part to the diligent efforts of the EHR

teams here. Very well done! – Michael Shrift, M.D., Allina

Collaboration. We regularly get together. More so those of us with the

same EHR systems, but as CMIOs we have always shared thoughts and

ideas. We give freely to each other as the work we accomplish benefits

patients and those that serve them. – Ray Gensinger, M.D., Fairview

And what must yet be accomplished?

Regional patient data connectivity. – Brian Patty, M.D., HealthEast

We still need to further leverage the EHR to truly improve patient safety,

quality and efficiency. Errors in medicine are still too common, and there

are many areas where technology could help as long as it is accompanied

by significant culture changes. – Rod Tarrago, M.D., Children’s

As discussed above, once the EHR is implemented, it must be optimized.

An optimized EHR translates ultimately into the triple aim of high qual-

ity, affordable care that improves the health of our communities. – Michael Shrift, M.D., Allina

I agree with Michael. We refer to it as transformation in that we want

to leverage our skill (clinical providers) and our tools (technologies that

include the EHR) to demonstrate magnification of the value of the care

that we provide. – Ray Gensinger, M.D., Fairview

Colleague Interview



Jason Leyendecker, Au.D., Doctor of Audiology


My Experience with an EMR in the Primary Care Setting

By Ellen Devries, M.D.

The implementation of electronic

medical records (EMR) has been an

opportunity for initiating changes in

practice, enhanced communication, increased

effectiveness of organization of patient data,

and increased efficiency. As with anything that

dramatically changes the way we work, there are

also obstacles and difficulties present with the

current use of EMRs. This article is meant to

be an objective view of both the pros and cons

of my experience as a pediatrician both at Park

Nicollet in the clinic and at Fairview Ridges

Hospital as both organizations implemented

EPIC within the past six months.

Park Nicollet was one of the first clin-

ics to implement EMR with Lastword several

years ago. Lastword had multiple short com-

ings because of its age, so I will admit I was

looking forward to using EPIC. In EPIC it is

extremely easy to pull up tests and review with

patients, go over radiology studies in the room,

and review records with the patient. Plotting

growth curves, plotting trends and presenting

data in a variety of formats for not only my

review but also to present to the patient has

been dramatically improved. It is easy to see

that greater understanding by the patient will

hopefully lead to increased compliance with

treatment and overall satisfaction. What I have

been surprised at is that currently it seems to

be limited to data review. There is no current

presentation of cost-effective drug options,

treatment options or differential diagnosis

based on combinations of signs, symptoms

and test results or analysis of results. While

it is very easy to see that these improvements

are on the horizon, I am surprised given our

technological advancement that these benefits

are not already available in EPIC.

I was also surprised at the tremendous

time input required outside of the clinic to

make the transition. This involved going to

class, reviewing and practicing online, devel-

oping smart notes (templates for the variety

of encounters), and then once implemented

reviewing patient data, updating problem lists

and family histories. This led, in the interim,

to decreased productivity until I became more

proficient at the slow and tedious data entry.

The time was also necessary and directly de-

pendent on the training level of the ancillary

staff. In those situations where the staff was

well trained and had a “super user” accessible

in the department at all times that they could

access, there was little tension and things flowed

well. Those departments that did not invest the

upfront time to have someone highly trained

suffered terribly with frustration, tension, and

poor efficiency. As a result, more time was spent

redoing information they entered, clarifying,

etc. Training is critical, not just for physicians,

but probably even more important for staff.

What has been extremely useful has been

the sharing of templates, experiences between

physicians, and the opportunity to train again.

At Park Nicollet we have had IT people skilled

in EPIC who come back multiple times to

answer questions, share tips, shortcuts, and

serve as an effective means of communication

with errors or problems we have encountered.

They have also been helpful in sharing potential

sources of errors, and increased tremendously

my skill in using EPIC. While we have tried

to be hyper vigilant to avoid errors, there are

sources of error inherently built in the program

which needed to be changed. An example was

rounding off dosages of prescriptions calcu-

lated by weight. While rounding “up” on an

8-year-old to the nearest ml would seem logical,

rounding on a neonate with a 10 or 20 percent

increase in the dose is not acceptable. There also

has been a failure to have a maximum dose for

suspension in pediatric patients. Those changes

were made quickly when the communication

was facilitated by the appropriate people. Other

specialties have discovered other potential er-

rors in the program.

In summary, the benefits of EMR are well

known and praised by the public, with ease

of access, increased communication and bet-

ter data organization. While the benefits of

prevented errors are well publicized, it is my

experience that there still exists the potential for

wrong entries, orders and dosage errors. I would

highly encourage anyone contemplating the

implementation of EPIC to do sufficient train-

ing, especially of ancillary staff, have templates

designed and in place before implementation

and invest in retraining. Only with extensive

training before and after implementation will

the true benefits of the system become evident.

Hopefully the next step of analysis of data will

develop the current unutilized potential for

enhanced tools for diagnosis, treatment, and

quality measures.

Ellen DeVries, M.D., pediatrics, Park Nicollet.

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The EMR in the Tertiary Care Setting: What’s Good, What’s Bad?

“Nowadays, the clinical history often weighs more than the patient.” Martin H. Fischer

In the old world of paper records, this was

occasionally literally true in a tertiary care

center. The challenging patient with multi-or-

gan disease and multiple recurrent admissions,

often back-to-back, always had an enormous

multi-volume chart. Inevitably, the last and

most important volume was inaccessible, usu-

ally on a shelf in the medical records depart-

ment awaiting signatures, when a complicated,

acutely ill patient arrived in the ER at mid-

night. Now, I pop open the EMR and all is

revealed instantly! Or is it? As in the old world

of scratched handwritten notes, the useful-

ness of the record still depends on the quality

of the input and output. (Remember GIGO,

i.e., garbage in garbage out?) In this article, I’d

like to review my experiences with the good,

the bad and the ugly aspects of the electronic

medical record in a large tertiary care center.

The value of an EMR system in a tertiary

care setting is manifest. None of us can imagine

how we practiced without it just five or six years

ago. Essentially every patient at our institution

requires multi-specialty input, and communica-

tion between these experts is essential. Prior to

the EMR revolution this involved a great deal of

phone calls and face-to-face interactions, which

was great for staff camaraderie, but inefficient.

Now the thoughts of everyone are easily avail-

able in real time, even at off-site locations.

As we continually expand our patient care

procedural and testing armamentarium, the

rate of data generation seems to grow expo-

nentially. The EMR offers instant data retrieval

and graphic/tabular summarization. Remote

imaging viewing lets practitioners review X-ray,

CT, US and MRI images from anywhere, often

while discussing them via telephone with the

radiologist. This can save time and lives espe-

cially when rapid on-site decision-making is

required about an unstable patient.

Complex patients require complex drug

treatment regimens. The concomitant risk of

improper ordering, administration error and

drug-drug interaction is inevitably magnified.

Built-in EMR prompts and decision support

systems aim to prevent such errors. This seems

like an obvious advantage over paper systems,

however, published data have shown variable

results in terms of actual error rate reduction.

So what’s bad and even ugly? Documenta-

tion is obviously an essential function but the

most difficult and dangerous job the EMR

must perform relates to computerized phy-

sician order entry (CPOE). There are major

unsolved problems in both areas. I will deal

with documentation issues first.

Misuse of the “copy-and-paste” is especial-

ly tempting in our complex patient/multi-spe-

cialty environment. Progress notes proliferate

forward and grow like fungus, becoming obfus-

catingly long and filled with self-contradictory

statements, e.g., stating that a “patient needs

cholecystectomy,” while noting further on in

the same note that a “cholecystectomy has been

performed.” Coding demands often drive this

process, but the implications for patient care

and legal liability are significant.

Tertiary care centers usually are teaching

institutions as well. If residents and students

rely on templates, will they still internalize

the structure of a history and physical and all

that it represents as a basis for sound patient

evaluation? Will they let “smart” computer

prompts replace critical thinking? These issues

are already subject to study by the academic

community.

The final concern I have about documen-

tation concerns the “Tower of Babel” resulting

from the lack of system-to-system compatibility

standards. In a referral hospital setting, this is

especially troubling since many of our patients

come from “out-of-system” facilities. Often

their records are electronically inaccessible to

us and ours to them, creating communication

problems both at admission and discharge.

Hopefully, a cottage industry will develop that

will build information bridges between dispa-

rate EMRs.

The ordering of actual tests, drugs and

procedures is obviously a key determinant of

patient outcomes. This is also a daunting task

for EMR designers. How do we take the vast

and endlessly intricate universe of possible med-

ical interventions and create a set of discrete pa-

rameters compatible with information system

technology? Can medical decision-making be

“cook-booked?” Much time is lost at our hos-

pital in the frustrating search for just the right

By John F. O’Leary, M.D. (Continued on page 16)


order for a test or procedure, often named in

non-conventional language. It’s a huge learning

process, which probably explains the contradic-

tory results, mentioned above, found in studies

comparing medication-related error rates before

and after EMR implementation. Hopefully, as

systems evolve and experience grows, the EMR

effect will be positive.

Finally, there’s the social cost. Video stud-

ies have shown that EMR users spend 25 to 40

percent less time looking at their patients when

a computer is in the exam room. So far, it’s also

apparent that for many providers, time spent

on documentation has gone up with EMR

introduction, taking time away from direct

patient contact as well as their home life. Col-

legial relations also suffer when all one sees in

the doctors’ lounge are the backs of troglodytes

hunched over computer screens. Ah’ well, ’tis

a brave new world!

John F. O’Leary, M.D. is a general surgeon at

Abbott Northwestern Hospital in Minneapolis,

who struggles with weighty issues as chair of the

hospital’s EMR Committee.


EMR in the Tertiary Care Setting


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Electronic Health Records

Current State

By Scott W. Tongen, M.D.

How Did We Get Here?Over the last several years more and more hos-

pitals, clinics, and health systems have been

installing some form of electronic health record

system. Until recently, these efforts were seen

as voluntary, innovative strategies to provide

what was believed to be “better care.”

Some in the physician community have

questioned the wisdom of implementing these

costly systems and profoundly changing the

practice of medicine at a very personal level.

The Electronic Health RecordBefore we look at the issue of quality improve-

ment we should ask what, exactly, do EHR

systems offer over traditional paper charts?

1. Viewing — The ability to review patient

information on previous encounters at

other facilities.

2. Documentation and Care Manage-ment — All documentation is legible and

independent of handwriting, common

problem-lists, medication lists, and allergy

lists across encounters.

3. Ordering — Allows for the system to alert

the user to allergies and drug interactions,

while eliminating transcription errors.

4. Messaging — Allows for remind-

ers, care hand-offs, and improved care

coordination.

5. Analysis and Reporting — Allows for

measurement at all levels. Previous abili-

ties were primarily financial in nature,

now systems can produce a bounty of

reports and measures without expensive,

time-consuming manual chart extraction.

6. Patient-Directed Functionality — Allows

for patients to become more involved

in their health care with access to their

medical information online. Enhances

patient education possibilities.

7. Billing — Allows for more comprehen-

sive integration between billing and the

documentation required for optimal

reimbursement.

8. Access — Allows more than one individual

to work in the chart at the same time,

while not restricting the user to be at the

bedside.

We should also look at what EHRs are not.

They don’t think. They can be programmed

with a variety of best practice advisories and

all manner of clinical decision support, but

are still prone to garbage-in-garbage-out is-

sues. Electronic health record systems offer an

abundance of documentation tools, but it is

up to the user to use them correctly and con-

scientiously. It is not the fault of the software

when a physician copies and pastes a prior

day’s note to today but neglected to edit the

text to reflect that the well-described diabetic

foot ulcer is no longer present because of an

interval amputation. Order sets can be written

to help a clinician order the appropriate anti-

biotics for a community-acquired pneumonia,

but they can’t force the physician to use them.

They don’t interfere with the doctor-patient

relationship any more than cell phones cause

accidents. Drivers who use cell phones cause

accidents, not cell phones. And physicians

who focus more on the computer than on the

patient need to learn a better approach. They

were likely the same ones who rudely focused

on the paper chart instead of listening to their

patient.

One of the greatest difficulties in under-

standing the benefits of EHRs lies in the ex-

pertise of the user. For example, the insurance

industry charges much higher premiums for

drivers with a recent history of accidents or

traffic violations. They also charge higher rates

for new drivers in spite of their pristine clean

records because the actuaries know that they

are much more likely to have an accident than

an experienced driver. It is easy to see how this

relates to the learning curve for users of a new

EHR. Indeed, those with the most training and

hands-on experience cannot only demonstrate

improved quality, but they also can deliver that

quality with greater efficiency and with measur-

able outcomes; but that is only my observation.

Why some physicians may be so vehemently

opposed to EHRs:

1. Change — The implementation of an

EHR is the most profound change to a

physician’s practice and workflow that

they will likely experience.

2. Typing — Those without, at least modest,

skills will have the greatest challenge. Even

though a small investment into improving

computer and keyboard skills would result

in an enormous return on investment,

many physicians won’t even consider this

an option and continue to struggle.

3. Exposure — There are some physicians

who may be concerned that their prac-

tices may come under increased scrutiny.



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EHRs may reveal issues that have other-

wise gone undetected. (e.g. Inappropriate

use of non-licensed individuals to “expe-

dite” work that must be done only by the

physician.)

4. Distrust of Data — EHRs allow measure-

ment of an incredible array of variables

and physicians may fear that this data

will show they are not “as good” as oth-

ers or that the data may be misused or

misinterpreted.

The EHR is long overdue, and the real

truth is that it is here to stay. As the Borg told

Captain Piquard, “Resistance is futile.” New

physicians coming out of training expect to

use these tools, and many intentionally avoid

joining hospitals or practices where an EHR

has not been implemented. Some day we will

look back and ask in bewilderment, “how did

we ever do it without an EHR?”

What’s to Come?While electronic health record systems are still

in their toddler years in terms of development

maturity, they are our only hope in managing

the volume and complexity that health care

has become. No longer do we have to reorder

studies because results from another facility are

not available. No longer do we have to wait for

a patient to return from radiology to review

what a consultant wrote in the chart. No longer

do we have to trek down to Medical Records

in the bowels of the hospital to sign charts.

The real value will be when EHRs can

truly use the data they store to tell us more

about the population of patients we serve so

we can serve them better. They will make an

even larger improvement in care when they are

programmed to provide diagnostic assistance

and alert us to long-term trends that we would

otherwise miss. These systems will continue

to make a profound impact on health care.

As scientists at heart we should embrace the

benefits they offer and learn new ways to do

our work with these tools.

Scott Tongen, M.D has worked as a hospitalist

since 1991. He currently is a medical director at

United Hospital and “physician champion” for

the Epic electronic health record and works for

Vitalize, a consulting firm that assists hospital

systems with EHR installations of many vendors.

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Doctor and Patient Relationships in the Age of EMRs and PHRs

By Becky Schierman

Do you remember the 1996 movie Jerry

McGuire? The one with the unforget-

table one-liners like “show me the

money,” or “you had me at hello.” You may

be wondering what Tom Cruise has to do with

electronic medical records, but stick with me.

One of the themes in Jerry McGuire is the im-

portance of personal relationships in business.

Jerry craves real relationships with his sports

star clients. He passionately calls on his fellow

sports agents to remember that at the core of

their profession is the relationship between the

athlete and the agent and he urges them to put

the relationship and the well-being of the athlete

at the center. Sound familiar? For several years

the health care community has issued a similar

call: focus on patient-centered care and build

meaningful physician and patient relationships.

The HITECH Act, Meaningful Use, and

incentives programs encourage the adoption of

health information technologies and may be

the show-me-the-money-moment for physi-

cians. But, at its core, health care is still about

the relationship between health care providers

and patients. In my experience, health informa-

tion technologies have changed the dynamics

of these relationships for the better — and in

some cases, for the worse.

My clinic aggressively promoted and

encouraged use of their personal health re-

cord — or PHR — at every opportunity. I am

glad they did. The PHR had me at hello. I like

being able to access my test results, track data

trends, and I appreciate the convenience and

efficiency of scheduling appointments online.

As a patient I can take a more active role in

my health care. But, what is missing for me in

this relationship is what happens in-between

my annual — or in a bad flu year, twice-year-

ly — clinic visits. Couldn’t PHRs provide an op-

portunity for an ongoing connection between

patients and health care providers? Couldn’t

my clinic use the PHR to regularly promote

adopting better health goals? Remind me to

exercise, make suggestions for healthy foods to

eat, or encourage other positive, tailored health

behaviors. If I knew my physician was keeping

an eye on me I would feel more supported and

empowered. Doctors, this is your “help me,

help you” moment. Take advantage of it.

Ironically, the same technology that helps

me be a better patient has left me feeling a little

disappointed in personal interactions. We all

know the importance of communication to

foster relationships — with spouses, friends,

and with patients. With the EMR in the room

it now seems that my physician disengages

with me and engages with the EMR. I have

also found that meaningful conversation about

me and my health — has all but disappeared.

For the record, these are not exactly “you com-

plete me” moments in my relationship with

my physician. As efforts to measure patient

experience get underway it will be important

for clinics to ensure effective and meaningful

communication are a part of each patient’s

experience. Rather than focus only on filling

out checkboxes that are embedded in the EMR,

providers can still ask open-ended questions

that get at the patient’s health agenda, assess

emotional concerns, and explore how health

problems are affecting a patient’s life. As a

patient, this is what makes our relationship

unique and trusting.

Like in Jerry McGuire, I believe that no

matter how health care transforms and tech-

nology advances — the key will always be the

relationships physicians have with their pa-

tients. But, relationships are created and cul-

tivated. So, how do you have a meaningful

relationship with someone you interact with

only a few times per year, for about 15 to 20

minutes at a time? Use the new sources of in-

formation, technology, and tools from your

EMR to educate and engage your patients,

connect with patients on a continual basis,

promote ongoing health, and engage people

in their health care.

Becky Schierman, MPH, Minnesota Medical

Association Manager, Quality Improvement.


TECHNOLOGY IS BOTH A BLESSING AND A CURSE. A mere

hundred years ago, automobiles replaced horses as our preferred mode

of transportation. Few would argue the benefits in comfort, speed,

load capacity, and commercial profit, but they came at enormous costs

for infrastructure, depletion of fossil fuels, regulation, pollution, and

lives lost in accidents.

Electronic health records are like that. Digital records are “prog-

ress,” in some but not all ways, and at great costs.

About 30 percent of clinics nationwide have an EHR; in Min-

nesota it’s about 60 percent. (In 2010, there were 46 different vendors’

products in use in Minnesota.) EHR advantages are uneven for differ-

ent users. The VA system probably couldn’t function today without an

electronic record. Small clinics won’t gain as much.

Putting our faith in an EHR requires considerably more fun-

damental analysis than just price. Consider the benefits. Data can

easily be moved among clinicians and offices. There is better report

generation, better opportunity for clinical research. Charge capture

may improve. Costs can be saved in transcription. (One administra-

tor I interviewed reduced her transcriptionists from 20 to 2.) Chronic

disease management might be facilitated. Prescribing is safer. Best

practices will be easier to achieve and peer review will be systematic.

What challenges offset the gains? There are daunting costs in

time, capital, and never-ending maintenance and upgrades; admin-

istrative distraction; temporarily reduced clinical productivity and

revenue; difficulty interfacing with systems on different platforms;

predictable rapid obsolescence; an increased burden on clinicians for

data entry; and security (Mayo Clinic has over 30,000 terminals to

secure). Independent subspecialists consulting for multiple primary

clinics which use different EHRs have a serious quandary.

Some experts opine that current EHR technology focuses on

“…data dumps…that merely result in electronic versions of clinically

cumbersome, uninformative patient records.” And, we lack national

standards for EHRs. Interoperability is still a distant dream. What if

your EHR isn’t compliant when national standards do arrive? Oops.

Will patients reap benefits from EHRs? They’ll be annoyed by

their doctor’s distraction by the computer. As one of our own, Dr.

Morrie Davidman, noted after a recent hospitalization: “The new

bond sometimes is with the keyboard as opposed to the person sitting

in the office.” If the doctor opts for more eye contact, s/he will be

entering data for hours after clinic. (Dinner with the kids? Not to-

night dear.) Notes may not be as rich and informative for colleagues.

In a major two-part review of EHRs in December 2011, Harvard’s

Dr. David Blumenthal, former national coordinator for health

information technology, said: “The difficulty of using current EHRs

constitutes a major potential barrier to their adoption and meaningful

use. Clinicians frequently comment that ‘I work for my EHR instead

of my EHR working for me.’” He has also said “Actual evidence of the

efficacy and cost-saving potential of HIT is scarce.”

Dr. Matthew Weinger of Vanderbilt University School of

Medicine wrote: “Until there is a better understanding of the safety

and usability of EHRs, their widespread promulgation is premature.

The adverse consequences of the rush to EHR adoption — spurred by

incentives — are many.”

All things considered, will patients get better quality of care?

Who’s to say? Personally, I have little faith in Minnesota Community

Measurement to tell us. The National Ambulatory Medical Care

Survey found no improvement with the change to an EHR in 15 of

17 quality measures. Another threat to quality is using paraprofes-

sionals with EHR decision support to “replace” many physicians. A

2011 review summarizes that “commercial EHR products have not

had a measurable effect on the very goals to which meaningful use

aspires…the challenge of ensuring that meaningful use actually leads

to meaningful benefits, such as improvements in safety and quality of

care, remains a serious concern.” Simply stated, EHRs will not ipso

facto improve health care.

Why did the federal government budget $19,000,000,000 to

rush the conversion? Some suspect an ulterior motive to prepare the

American health care system for eventual federal control. Interoper-

able EHRs will force consolidation of our profession and enable

manipulation of clinical decisions (“rationing”) by an outside payer,

either private or governmental. Only the naïve would think otherwise.

Progress is inexorable. Technological change is good as long as

it’s intelligently planned and for the right reasons. Like the transition

to automobiles, converting to EHRs comes with tremendous benefits

and risks, both financial and professional. There’s a need for sober

realism amidst all the testimonials and marketing hype. It’s incumbent

upon physicians and medical societies to lead the effort with eyes wide

open.

ED: References withheld due to space requirements; they are available

upon request.By Richard J. Morris, M.D.

Y O U R V O I C E

Electronic Health Records: Hope or Hype?



Implementing EHR: Unintended Consequences

By Mike Flicker, MBA

The electronic health record brings new

technology, new workflow, and a new

structure to document clinical patient

care. The immediate availability of clinical data

combined with embedded programs to alert

physicians of optimal care plans has the po-

tential to significantly reduce adverse outcomes

and malpractice risks. However, a poorly imple-

mented electronic health record has also shown

to bring unintended consequences that could

increase the frequency of events that increase

practice risk.

This article will cover six specific unin-

tended consequences of the EHR:

1) Data Overload;

2) Erratic Documentation;

3) Poor Workflow Design;

4) Alarm and Alert Mismanagement;

5) Omissions on Medication and Problem

Lists; and

6) Emotional Disengagement.

Data OverloadData Overload refers to the sheer volume of

items that require a clinician’s attention dur-

ing the course of providing patient care. Data

overload originates from insufficient time for

clinicians to process the list of EHR tasks that

require an approval or response.

The overload effect increases when each re-

quest requires multiple “clicks” to sort through

and process screens of data to find the one

piece of information critical to complete the

EHR task. All of this activity contributes to the

physician complaint, “I am less efficient with

the EHR than I was with paper.”

Data organization of user screens can

minimize user overload. EHR systems that

add irrational complexity to finding the right

clinical information prior to mak-

ing a decision increases the odds

that clinicians do not find critical

information within the EHR.

Erratic Documentation Tools to document patient care

typically include options of voice

recognition, free text entry, and

predefined templates. Erratic

Documentation becomes an un-

intended consequence of an EHR

when the documentation in the

system does not reflect what the

clinician intends to have docu-

mented in the system.

One example of erratic docu-

mentation is created by systems

that utilize automatic defaults in

portions of specific templates.

Automatic defaults have the po-

tential to have a “negative” find-

ing in the permanent record that

was not consciously selected by

the clinician.

Hybrid templates that incor-

porate free text along with checking boxes on

a template have a documentation advantage

by allowing the clinician to document unique

aspects of the encounter. However, hybrid

templates do have a downside. If clinicians

are not uniform when documenting issues as

“free text,” then the ability to query specific

patients for follow-up may be limited. Further,

clinicians may miss key information if clinical

data is in the body of a template for one patient,

and other times in the miscellaneous “free text”

addendum of another patient.

Poor Workflow DesignEHR systems change workflow in a health

care organization. Mapping the transition

of workflow in the paper world to the digi-

tal world is a critical piece of the installation

process.

Risks increase when proper time is not

allocated for planning workflow changes. One

common symptom of poor workflow design

is the presence of user “work around” paper

systems rather than utilization of the electronic

tool to complete tasks. Examples of a “work

around” include the use of paper sticky notes

to convey information on a patient phone call,

or to order a test, or to inform a clinician of

a requested prescription refill. The cause of

the paper sticky note is usually a “disconnect”



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between the electronic tools available for the

task, and a well designed workflow for users

to utilize that tool. Documentation concerns

arise when the sticky note becomes a document

that has patient information on it or reflects a

clinical decision that is not documented in the

electronic record.

Inaccurate Medication and Problem ListsRecently published studies suggest that medi-

cation and problem lists are incomplete more

often than clinicians anticipated. Efforts to

maintain an accurate medication list can be

difficult. For example, different organizations

may have different policies that define what

constitutes a “medication” within the record.

Therefore, the same patient may have an exten-

sive over-the-counter listing in one setting, and

lack those entries in another setting. Further,

the clinician is usually dependent on support

staff ’s ability to accurately update medication

Implementing EHR



lists. The “problem list” has similar pitfalls

of accuracy around data entry by staff, and

by internal definitions of what constitutes a

“problem.”

Clinicians who access different EHR

systems in multiple locations are also asked

to be proficient in Medication and Problem

List utilization under differing organizational

definitions.

Alarm and Alert MismanagementAlarm and Alert Mismanagement may be the

most frequently experienced unintended con-

sequence of electronic health records. Alert

Fatigue is a well-known term, and reaching

epidemic proportions in the departments of

some facilities.

Teams charged with creating electronic

alerts have a difficult task. The benefits of well-

designed alerts are clear. For example, systems

can prompt clinicians to avoid specific medica-

tions or to consider suggested care pathways.

However, concerns originate when alerts are

closed without documentation around the

reasons for ignoring the alert suggestion. In

many locations, entire categories of alerts are

disabled at the system level because the volume

of false alerts overwhelms the available time of

the user being asked to respond. Deactivating

alerts eliminates the potential of a system to

utilize many decision support tools.

Emotional DisengagementEmotional Disengagement of system users is an

unintended consequence of EHR implemen-

tation. Developing and implementing stan-

dardized documentation policies are a required

component of an EHR. Inevitably, standardiza-

tion causes users to lose a certain degree of free-

dom to “individualize” how clinical activities

are ordered, documented and accessed.

The process used by the organization to

prepare for that loss of “individualism” directly

affects the level of user disengagement. Disen-

gaged individuals may increase the frequency

of incomplete or inaccurate entries in the EHR

that other clinicians rely on in providing patient

care.

Anticipating unintended consequences of

electronic health records enables organizations

to avoid potential pitfalls of the EHR. With

careful planning and auditing of system utili-

zation, clinicians and patients will experience

the full benefit of the electronic health record

in delivering patient care.

Mike Flicker is a member of the MMIC Health

IT team. He has over 25 years of experience in the

health care field as administrator of rural multi-

specialty clinics. Mike has presented at regional

and national conferences on topics ranging from

EHR implementation to creating rural hospital/

physician partnerships. He has an MBA in Health

Care from St. Thomas University.

Visit TCMS at

www.metrodoctors.com


By Cheryl M. Stephens, Ph.D.

Coordinating Health Information Technology Through CHIC

The Community Health Information

Collaborative (CHIC) is a unique

partnership among hospitals, clinics,

long-term care facilities, tribal health facilities,

higher education institutions and public health

departments in Minnesota that maximizes the

health care services members are able to provide

through innovative use of technology.

By identifying and taking advantage of

opportunities to coordinate health information

technology, CHIC provides strictly controlled

access to patient health care records among care

facilities; sends Medicare claims efficiently and

quickly; recruits and trains users for MIIC,

the state’s immunization registry; administers

USAC applications for members, and coordi-

nates emergency preparedness for health care

partners under a contract with MDH Office

of Emergency Preparedness.

CHIC was developed under a Federal

Office of Rural Health Policy — Network De-

velopment grant in 1997. Taking advantage

of the opportunity the grant provided, CHIC

invested significant time and resources to de-

velop trust and productive working relation-

ships among providers that led to the creation

of a self-sustaining organization financed by

dues from its more than 170 members who

represent the entire health spectrum.

The Federal Office of the National Coor-

dinator and the state of Minnesota’s Office of

Health Information Technology have mandated

that electronic health records (EHR) systems

be installed in a variety of health care provider

organizations. You folks know who you are;

this is not going to be a discussion of Mean-

ingful Use or the process of implementing an

EHR. We are going to take a look at the other

less famous part of these requirements — the

need for interoperability and the exchange of a

standard format called the Continuity of Care

Document (CCD). This means that, no mat-

ter what type of EHR system you may install,

it must be able to exchange information with

everyone else’s EHR. Not such an easy task as

some may tell you. In fact, a new industry has

evolved to provide just this service.

Parts of this industry are very techni-

cal — for instance, the data we exchange is

encrypted before it is moved across the internet

and decrypted just after it is dropped off at the

other end. At no time is any information avail-

able for reading while traversing the internet.

Also, any person that may request information

must adhere to a Military Level 3 Authoriza-

tion/Authentication process each and every

time they enter into the HIE-Bridge™ system.

Final note, no information is ever released from

HIE-Bridge unless a signed patient release is

attested to or it is an emergency.

CHIC and its subcontractor, ApeniMED,

worked under a federal cooperative agreement

to assist in the specifications and technical ar-

chitectural design of the Nationwide Health

Information Network (NwHIN). We were

also closely involved in developing policies

and procedures for joining the NwHIN and,

in the finalization of the trust agreement, the

Data Use and Reciprocal Support Agreement

(DURSA). Through this work, we have con-

tracted with the Social Security Administration

to exchange Disability Determination patient

records electronically. This new workflow of

an old process has improved the turnaround

time for decisions regarding disability insurance

and decreased the time it takes for providers

to receive payments under this same program.

Additionally, in the Duluth area we have “gone

live” with a Veteran’s Administration program

called the Virtual Lifetime Electronic Record

(VLER) designed to build a record for all ser-

vice persons, both active and retired, containing

information from the private provider’s records

as well as the VA’s VISTA system. Thus, no

matter where a service person is stationed or

where an elderly veteran may receive care, all

of their patient information will be available

for their treatment.

We are currently working on creating an

exchange that provides a greater breadth of

services. To that end, we have joined forces with

ABILITY Network and Emdeon who have also

been certified as Health Data Intermediaries

through the state’s Health Information Ex-

change Service Provider certification process.

The HIE-Bridge service has been certified by

this same process as a Health Information Or-

ganization — the only one in the state to date.

CHIC’s existing HIE-Bridge network is



currently implemented with a provider direc-

tory, a federated record locator service, and a

consent management system that meets the

requirements of Minnesota’s current RLS legis-

lation. Expanding this platform with laboratory

directories and record locator information from

Emdeon, along with interim directories devel-

oped by ABILITY Network for the interim

solution, offers an existing solution poised to

meet the long-term requirements for Minnesota

and its health care providers.

The details of the updated offerings, ar-

chitectures, and strategies each partner brings

to the total solution, what is to be developed

and implemented under the new direction of

statewide shared HIE services and core HIE

services will continue to align with CHIC’s

core principles. These include:

members for requirements, prioritization

of projects, and governance.

privacy and security laws including patient

authorized access to their information.

services and patient information.

control of patient information to stay with

the covered entities.

To best address the near- and long-term

health information exchange needs of Min-

nesota, Community Health Information

Collaborative (CHIC), ApeniMED, ABIL-

ITY Network, and Emdeon have agreed to

collaborate to deliver best-in-class services for

statewide shared services including both short-

and long-term technical infrastructures and

Core HIE Services. This will begin with parallel

Direct and Connect strategies, recognizing the

efforts of all three existing technical infrastruc-

tures. The short-term statewide shared HIE

services will use technologies based on (1) the

Federal Direct Project specifications and (2) the

Federal NwHIN Connect specifications already

implemented in certain health care provider

organizations and being further implemented

under the 2011 eHealth Connectivity Grant.

In addition, we will augment these services

with Core HIE services to address obvious,

immediate needs around both push and pull

message exchanges, as well as for laboratory

services.

We anticipate that the need for more

robust and query-based forms of health infor-

mation exchange will result in a natural progres-

sion of certain initial use cases from a reliance

on NwHIN Direct-based message “pushes” to

NwHIN Exchange-based messages, queries,

and “pulls.” Likewise, we anticipate that for

other use cases (such as primary to specialist

care referrals), evolution may not involve so

much a change of transport mechanism (e.g.,

NwHIN Direct-based exchange) but rather

better integration with existing workflows (e.g.,

native EMR/HIS integration) or adoption of

higher-level standards (such as those underway

as part of the Federal Standards and Interoper-

ability Framework initiative). Thus, our intent

is to provide an evolving and “right-sized” tech-

nology platform at the times and places, as well

as in the manners, needed to ensure effective

and sustainable health information exchange

in Minnesota and with surrounding states.

Much has been done to help hospitals and

clinics move to the electronic age with health

information technologies. Incentive programs

such as REACH, Meaningful Use dollars, and

eHealth Connectivity grants have all focused

on these specific health care providers. These

have been important and meaningful initiatives

and have helped advance the use of electronic

health records and health information exchange

in Minnesota.

CHIC is hoping to target another im-

portant segment of the continuum of care for

patients, particularly the elderly and invalid

population residing in long-term care facili-

ties throughout Minnesota. CHIC has a goal

to integrate them into a health information

exchange to improve patient care with more

timely and complete information. We also

anticipate improvement in information flow

during transitions of care between these facili-

ties and hospitals.

We have commitments from Aging Ser-

vices of Minnesota and Care Providers of

Minnesota to work together on outreach and

implementation efforts with the plethora of fa-

cilities around the state — virtually all of whom

are members of one of these two agencies.

An interesting dimension to our strategy

is that both agencies supporting long-term care

align with respective EHR vendors (Point-Click

and MDI Achieve). Both vendors offer cloud

solutions for their customers, thereby offering

remote services. Both vendors have agreed to

work with us and our developers to integrate

HIE-Bridge services into their systems, thereby

allowing their customers to use the HIE-Bridge

health information exchange as a feature of

their offerings.

Leadership at Aging Services and Care

Providers are excited to be able to offer this ser-

vice to their members. We will work with these

agencies to promote this service, its benefits,

and ease of implementation. We also will iden-

tify the hospital and clinics that refer patients

to and receive patients from these long-term

care facilities and encourage them to partici-

pate in HIE-Bridge as well. By so doing, the

value of the exchange is enhanced, for both

the long-term care facilities and the hospitals

and clinics, since there is a greater degree of

confidence that a query for information will

be successful in bringing patient data to the

requesting provider.

CHIC’s history of providing relevant

services to its members, through close collab-

oration with members in a trust-based environ-

ment, provides the basis from which our vision

for health information exchange is founded. All

of the participating developers, ApeniMED,

ABILITY Networks, and Emdeon work with

CHIC in either existing or required relation-

ships due to the HIESP Certification program

in Minnesota which provides oversight of this

new and complex industry.

Cheryl M. Stephens, Ph.D., president and CEO,

Community Health Information Collaborative.


CHIC


MMA Annual Meeting

See details on page 6


Mary K. Brainerd Receives Shotwell Award

The 2011 Shotwell Award was pre-

sented to Mary K. Brainerd at the

January 10, 2012 meeting of the Ab-

bott Northwestern Medical Staff. Richard

D. Schmidt, M.D., chair of the West Metro

Medical Foundation of the Twin Cities Medi-

cal Society and Kent Wilson, M.D., Shotwell

Award Selection Committee member, co-

presented the award.

The Shotwell Award is bestowed annu-

ally to a person within the state of Minnesota

who has made significant innovations and/

or improvements in health care delivery.

Mary Brainerd has been an innovative

leader in health care since 1984. She currently

is president and chief executive officer for

HealthPartners, a position she has held since

2002, and served as executive vice president

and chief operating officer prior to this ap-

pointment. Before joining HealthPartners

in 1992, Mary held senior level positions

with Blue Cross and Blue Shield of Min-

nesota, including senior vice president and

chief marketing officer. She was also senior

vice president and chief executive officer of

Blue Plus.

Dedicated to serving the community in

multiple facets, Mary is recognized as one

of the founding CEOs of the Itasca Project,

a group of 40 government, civic and busi-

ness leaders addressing the issues that im-

pact long-term economic growth, including

jobs, education, transportation and economic

disparities. She also serves on the boards of

Minnesota Life/Securian, Minnesota Council

of Health Plans, The St. Paul Foundation,

Minneapolis Federal Reserve and SurModics.

In 2010 Mary accepted a leadership

role as corporate champion for Honoring

Choices Minnesota, an advance care planning

initiative of the Twin Cities Medical Society

(TCMS) and its foundation. She successfully

challenged the broader community, including

all hospitals, health plans and insurers, to em-

brace and implement a community-wide end

of life care planning initiative. Sue Schettle,

TCMS chief executive officer, said “Mary is

an incredibly passionate advocate for issues

that make communities strong and vibrant.

She’s a terrific communicator and leader.”

A St. Paul native, Mary received her

master’s degree in business administration

from the University of St. Thomas and a

bachelor of arts degree from the University

of Minnesota. She has received numerous

awards for her accomplishments as a health

care executive, a community leader and a role

model.

Mary Brainerd receives the 2011 Shotwell Award, presented by Drs. Lee Aristogui (L), Kent Wilson and Richard Schmidt (R).

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TCMS Celebrates 3rd Annual Board Dinner

PETER DEHNEL, M.D. was installed as the 3rd president of the Twin

Cities Medical Society at the annual meeting of the Board of Direc-

tors on Tuesday, January 24, 2012. His term succeeds Thomas Sieffer-

man, M.D., 2011 president, who was acknowledged with the outgoing

President’s Award. This sculpture, 98.6°, crafted by Jeff Barber, was

commissioned in recognition of the dedicated service of the outgoing

President of the Board.

98.6° stands as the norm for health. This sculpture symbolically interprets

the degrees for temperature as degrees in angles. Variations in dimen-

sion further the notion that people are not exactly 98.6° at all times.

The adult figures balance with the angles — and are directly symbolic

of those who intercede to maintain the critical balance of 98.6°; those

who have chosen medicine as their life’s interest.

Edward P. Ehlinger, M.D., commissioner, Minnesota Department

of Health, and the first president of TCMS, was the featured speaker,

emphasizing the “health of the state of Minnesota.” He noted our suc-

cesses as we are #1 for lowest rates in the country for cardiovascular

disease, occupational hazards and physical health rates. However, as we

have dropped from the first or second healthiest state in the nation to

number six, there is work to be done. Adult binge drinking has become

a huge public health issue. Minnesota has the 46th highest rate in the

state, with the majority of binge drinkers over the age of 25. Lack of

public health interventions which can be addressed with individual

responsibility in the context of community responsibility and ethnic

health disparities round out the top three health issues facing our state.

He concluded by stating that there is great opportunity for public health

and medicine to work together to return our state to the healthiest in

the nation.

Lyle Swenson, M.D., MMA president, offered greetings from the

MMA. Dr. Swenson gave a brief update on MMA Strategic Planning

activities and highlighted the four strategic goals — to make Minnesotans

the healthiest in the nation, to make Minnesota the best place to practice

medicine, to position MMA as the source for advancing professionalism

in Minnesota, and ensuring that MMA membership is an indispensable

benefit for all Minnesota physicians.

Dr. Swenson also noted the current MMA effort aimed at better

understanding the issues facing physicians in independent practice. He

welcomes any and all questions or comments and looks forward to being

of assistance to Minnesota physicians.

Peter Dehnel, M.D., president, highlighted several of the accom-

plishments of TCMS throughout the past year, calling special attention

to Honoring Choices Minnesota and the Twin Cities Obesity Prevention

Coalition.

He also noted another major project that was undertaken by the

TCMS Policy Committee — the compilation of a physician developed

model for value-added health care delivery, called the TC Network, cur-

rently in its final review. Making light of the challenging work of this

committee, Dr. Dehnel offered:

TOP TEN SIGNS THAT YOU MAY HAVE SIGNED UP FOR THE WRONG ACO

10. You are required to carefully read all 696 pages of the final rule of

Medicare’s Accountable Care Organization description.

9. In a previous job, your CFO won the Tom Petter’s Award for Creative

Accounting.

8. Your sole hospital partner just announced an agreement with CMS

to pay back $350 million in Medicare over-charges.

7. Your largest group of specialty physicians just announced they were

all moving to Texas and selling their practice to a group of recent

graduates from the American University of the Caribbean.

6. Your designated EHR station looks strangely like an early 1990s

Atari game console.

Thomas Siefferman, M.D. receives the outgoing President’s Award from Peter Dehnel, M.D.


5. You read in the paper this morning that your chief legal consultant

is under investigation by the Office of the Inspector General.

4. Your Chief Safety Officer was recently featured on the Discovery

Channel’s “Deadliest Catch” program.

3. Your CEO’s previous job was overseeing administrative improve-

ments within the Postal Service.

2. The primary reference sources for your clinical algorithms turn out

to be Google and Wikipedia; and

1. You need to disclose your bank information and other financial

holdings on the very unlikely chance that your ACO will under-

perform financially.

The work of the Board of Directors can only be as successful as its

members. On behalf of the board, Dr. Dehnel extended gratitude to the

members completing their terms: Ronnell Hansen, M.D. (also served on

the executive committee); Tony Orrechia, M.D. (also served as TCMS

Secretary); Shari Ohland, MMGMA Representative; Charles Terzian,

M.D. (MMA Trustee); and Peter Wilton, M.D. And, the following

new members were announced: Steven Darrow, M.D., AMA Alternate

Delegate; Courtney Jordan-Baechler, M.D.; Sandra Kamin, President

Elect MMGMA; William Nicholson, M.D., AMA Alternate Delegate;

and Stefan Pomrenke, M.D.

Dr. Will and Leah Nicholson, Ken Crabb, M.D., Roxanne Rosell and Robert Moravec, M.D.

Dr. Matt and Heather Hunt.

Sanjiv Kumra, M.D.

Sue Schettle, TCMS CEO, and Commissioner Ed Ehlinger, M.D.

Medical student Jessica van Lengerich and Ben Whitten, M.D.

Eric Crockett, president, MMGMA and Janet Silversmith, director of health policy, MMA

Lyle Swenson, M.D., MMA president.

TCMS staff from L: Barbara Greene, Nancy Bauer, Andrea Farina, Katie Snow, Sue Schettle, and Jennifer Anderson.


Honoring Choices Minnesota, along with other

organizations across the country, is endorsing

an effort which highlights the importance of

advance care planning — National Healthcare

Decisions Day (NHDD) on April 16. NHDD

provides an opportunity to raise awareness

about the value of future health care decision-

making and completing health care directives.

In 2011, with only 25 percent of par-

ticipating organizations reporting, 2.2 million

facility staff members received NHDD infor-

mation or training and more than one million

members of the general public participated

in NHDD events or received information on

health care directives. We hope to add to these

numbers significantly in 2012.

In addition to signing up your organiza-

tion to participate, here are some of the ways

Twin Cities Medical Society members can help

this important cause:

, lead by example…be

sure you have thoughtfully considered

and made your own health care decisions

known.

-

zation is informed about NHDD (includ-

ing all staff, board of directors, volunteers

and others) and ask for their involvement

to promote NHDD to your patients.

nation-

alhealthcaredecisionsday.org or the Min-

nesota site, mnhealthcaredecisions.info

main entrance and offer information

about advance care planning as people

come by.

and advance care planning educational

brochures in patient rooms or at upcom-

ing community events or health fairs.

For details and tools available for down-

load, including a well-done promotional video,

visit the national website at www.national-

healthcaredecisionsday.org. If you plan to hold

an event or display in honor of NHDD, contact

Katie Snow at Twin Cities Medical Society

([email protected], (612) 362-3704).

Please join us on April 16!

Get Involved in National Healthcare Decisions Day on April 16

The First a Physician Award, es-

tablished in 2007, recognizes a

member of the medical society

who has made a positive impact

on organized medicine by self-

lessly giving of his/her time and

energy to improve the public

health, enhance the medical com-

munity’s ability to practice qual-

ity medicine, and/or improve the

lives of others in our community.

The Award is given at the annual

meeting of the TCMS board of

directors.

Robert W. Geist, M.D., the

2011 First a Physician Award re-

cipient is perhaps best known to

the community of volunteer physician and legislative public policy

activists. He has expended truly incalculable personal time and re-

sources over more than 40 years as an advocate of the highest integrity

on behalf of the profession of physicians, and for the protection of

First a Physician AwardRobert W. Geist, M.D.

patients. Engaging in often complex analysis of legislative proposals,

health law, and medical economics is both challenging and demand-

ing, even for the seasoned policy expert, requiring long hours of

study, rational scrutiny, and referencing of the literature. Dr. Geist

continues to provide this service on behalf of his colleagues and our

patients daily, with energy and purpose year after year, often for

colleagues with an under appreciation of just how difficult this can

be. It is often true that it is easier to be critical of educational efforts

than for an audience to fully expend the energy to understand the

depth of the issue. With remarkable tenacity, this physician continues

to remain lighthearted and positive when in the crucible of critics,

faithfully returning again and again to present his analysis. He has

also founded and organized committees which have served as open

forums to encourage direct dialogue of physicians with diverse policy

experts to examine and critically dissect public policy direction and

affect the creation of legislation as it affects physicians and patients

within Minnesota and nationally. He is truly the thinking person’s

physician and patient advocate. In grateful recognition of his work

to enhance the medical community’s ability to practice quality

medicine, the First a Physician Award was presented to Dr. Geist.

Ronnell Hansen, M.D. presents First a Physician Award to Robert W. Geist, M.D. (left).


THOMAS W. O’KANE, M.D., passed away

on December 17, 2011 at the age of 97. Dr.

Kane graduated from the University of Illi-

nois Medical School. He became the chief of

staff at St. Joseph’s Hospital in 1964. Dr. Kane

saw over 40,000 patients, performing surger-

ies and general eye care from the 1930s until

the mid-1980s. Dr. Kane has been a member

since 1946.

EUGENE C. OTT, M.D., passed away on

January 12, 2012 at the age of 82. He gradu-

ated from the University of Minnesota Medical

School in 1954. Dr. Ott was a family physi-

cian in Edina and assistant professor in the

Department of Family Medicine for Hennepin

County Medical Center. Dr. Ott was president

of the Hennepin County Medical Society in

1994, in addition to serving on several other

professional boards throughout his career. His

time spent volunteering locally and abroad will

be remembered, including serving as medical

director of St. Mary’s Health Clinics. Dr. Ott

has been a member since 1956.

STACY ROBACK, M.D., age 70, passed away

on January 20, 2012. Dr. Roback graduated

from the Tulane University School of Medi-

cine. He completed internships and residen-

cies in pediatrics, general surgery, pediatric

surgery, and thoracic/cardiovascular surgery at

the University of Minnesota, becoming board

certified in all specialties. Dr. Roback was a

senior partner at Pediatric Surgical Associates

and the former chief of staff at Children’s Medi-

cal Center. Throughout his 45 year career Dr.

Roback shared his knowledge and experience

by mentoring and teaching students entering

the field of medicine. Dr. Roback received the

2011 Charles Bolles Bolles-Rogers award from

the Twin Cities Medical Society recognizing

his contribution and leadership in the medical

profession. Dr. Roback has been a member

since 1977.

In Memoriam

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 30.

On a cloudy, rainy and blustery day in October

of 2011, my husband Jim and I visited the

Minnesota History Center to view the recently

completed archival of the West Metro Medical

Society Alliance (WMMSA) Hennepin Medi-

cal Society Alliance/Auxillary (HMSA) 100

year history.

The history of the WMMS Alliance is

well organized and filed in the archive section

of the Minnesota History Center. The archive

includes original hand written minutes, pic-

tures, newsletters, newspaper articles and other

materials that span from 1910 – 2010. It was

reassuring to know that such a rich history

of 100 years of volunteerism by West Metro

(Hennepin County) physician spouses is so

meticulously preserved.

Minnesota History Center Houses WMMS Alliance’s 100 Year History

If you have WMMSA (HMSA) materi-

als/records such as minutes, financial records,

pictures, articles, etc. that you would like to

add to the collection or you would like to visit

the archives, please contact:

Duane P. Swanson, Curator of Manuscripts

Division of Library, Publications and

Collections

Minnesota Historical Society

345 Kellogg Boulevard West

St. Paul, MN 55102-1906

(651) 259-3318

[email protected]

Diane Gayes, past president, West Metro Medical

Society Alliance (HMSA).


Abbott Northwestern Hospital

Internal Medicine

Retina Center, P.A.

Ophthalmology

Park Nicollet C linic – Meadowbrook

Orthopedic Surgery/Sports Medicine

Progressive Eye-Care Associates, P.A.

Ophthalmology

Emergency Physicians and Consultants, P.A.

Emergency Medicine

Skin Care Doctors, P.A.

Dermatology

Children’s Respiratory & Critical Care

Specialists, P.A.

Pediatric Critical Care Medicine

Fairview Crosstown Clinic

Internal Medicine

Maxillofacial & Oral Surgery, P.A.

Oral and Maxillofacial Surgery

North Memorial Medical Center

Internal Medicine

Metropolitan Obstetrics and Gynecology, P.A.

Obstetrics and Gynecology

HealthPartners Health Center for Women

Family Medicine

Minnesota Gastroenterology, P.A.

Internal Medicine, Gastroenterology

Allina Medical Clinic – Coon Rapids

Otolaryngology

Fairview Oxboro Clinic

Internal Medicine

Dermatology Consultants, P.A.

Dermatology

Park Nicollet C linic – Chanhassen

Obstetrics and Gynecology

Yup.

Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services with locations in the St. Croix Valley, just east of the Twin Cities metro area.

Internal and Family Medicine Physician Opportunities:Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN.

Mahtomedi, MN? (Ma-toe-me-dye)So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education.

For further information please contact:Patti Lewis, Director Human Resources1500 Curve Crest Blvd, Stillwater MN(651) 275-3304, [email protected]

Internal Medicine?

Family Medicine?

Internal and Family Medicine Opportunities

NEW clinic inMahtomedi, MN?

We’ll make it all better.

New Members

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.


Contact Cathy Fangman [email protected] Winona, MN 55987 800.944.3960, ext. 4301 winonahealth.org

Join our progressive healthcare team, full-time physician opportunities available in these areas:

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

LUMINARY

GLEN D. NELSON, 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].

There are many more ways to “practice medicine”

beyond those of directly ministering to patient

needs in a clinic/office or hospital setting. Our

current Luminary, who has an impressive background in

direct patient care, has made remarkable contributions to

his chosen profession and his community in a variety of

other fashions.

Glen Nelson, M.D. was locally born and bred. He

did his undergraduate work at Harvard University and

graduated from our U of M Medical School in the early

’60s. His General Surgery Residency at Hennepin Coun-

ty Medical Center led to certification by the American

Board of Surgery in 1970 and nearly 20 years of surgical

practice at Park Nicollet Medical Center (PNMC).

The expansion of his medically related interests

began to blossom during his time at PNMC. In the midst

of a significant growth period there, Dr. Nelson served

as chairman, president and chief executive officer. There

followed a long association with Medtronic where he first

functioned as a director and thereafter was employed as

an executive vice president and a vice chairman. While at

Medtronic, he was involved in a variety of cardiac device

projects and a deep brain stimulation procedure for Par-

kinsonism. Paralleling those profound care advancements

was a marked organizational and revenue evolution in

that highly successful corporation. A pattern of organi-

zational growth emerged in those early portions of his

career. Dr. Nelson states, “I just love to play a role in the

growth of an idea or a company.”

For the last 10 years, Dr. Nelson has engaged in

supporting a wide range of medically related activities. El-

ements of that support have included electronic medical

records and technological initiatives as validated by clini-

cal research and the standardization and measurement of

care delivery interventions. He currently is involved in

assisting health care startup ventures with an emphasis on

Minnesota-based companies. He presently holds a variety

of Board positions and in the recent past was the chair-

man of MinuteClinic during its inception period. His

remarkable record of success in the growing of ideas and

organizations speaks for itself.

Through the years, Glen has

contributed to an engaging vari-

ety of medical, educational and

community bodies and activities,

including: Minnesota Public

Radio (Trustee), The United

Way (Division Chairman), St.

John’s University (Regent), Blake

Schools (Trustee), Minneapolis

Chamber of Commerce (Direc-

tor and Chairman), The Jackson

Hole Group (Member), Hen-

nepin Avenue Methodist Church

(Board Member), Harvard

University (numerous Commit-

tee and Board appointments),

Walker Art Center (Director), the Johns Hopkins Board

of Advisors…and he’s been a member of our medical

society for over 40 years.

Dr. Nelson was elected to the Bakken Society for

outstanding technical and scientific contributions, re-

ceived an Outstanding Achievement Award from the

U of M, holds a Lifetime Achievement Award by procla-

mation of the Governor of Minnesota and is an Emeritus

Clinical Professor of Surgery at the U of M.

In a recent conversation, Dr. Nelson stated, “I’ve

been lucky; most people have only had one career and I

am thankful for the balanced understanding I’ve gained

and the rewards I’ve received. The rewards in surgery are

more immediate, and though those in the commercial

world are slower, they are no less gratifying.”

Dr. Glen Nelson — a visionary with an entrepre-

neurial spirit whose career has been defined by an innova-

tive and energetic work ethic — is a welcomed addition to

our gallery of Luminaries…a medical renaissance man.

We protect your peace of mind.

It’s why we’re the right choice for

physicians. Medical liability insurance is

just the beginning. We protect what matters

most, with proven results. It’s a movement,

and we’d love to have you join us.

Contact your independent agent or broker,

or go to PeaceofMindMovement.com/MD to

see what MMIC can do for you.

To Learn More, Call (612) 362-3704

Proceeds from MPS help to support

the operations of TCMS.

Please consider our business partners listed below as you look to reduce

your operational costs.

Our Partners Include:

◆ AmeriPride Services (linens and apparel)◆ Berry Coffee (beverages and food)◆ Gallagher Benefit Services (group insurance)◆ SafeAssure Consultants (OSHA compliance)◆ AED Professionals (AED distributor)◆ IC System (debt collection)

can i have it both ways?

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