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Current State of Electronic Health Records - Pros and Cons. Also in this issue: TCMS Annual Meeting, Shotwell Aware, and Luminary of the Twin Cities.
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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
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.
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 3
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.
4 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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.
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 5
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
6 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 7
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)
8 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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)
Electronic Health Record
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 9
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
(Continued on page 10)
10 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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
Electronic Health Record
Colleague Interview
(Continued from page 9)
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 11
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
(Continued on page 12)
12 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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
(Continued from page 11)
Electronic Health Record
Jason Leyendecker, Au.D., Doctor of Audiology
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 13
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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MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 15
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)
16 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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.
Electronic Health Record
EMR in the Tertiary Care Setting
(Continued from page 15)
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MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 17
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.
(Continued on page 18)
18 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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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.
EHR Current State
(Continued from page 17)
Electronic Health Record
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 19
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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.
20 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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?
Electronic Health Record
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 21
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”
(Continued on page 22)
22 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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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
(Continued from page 21)
Electronic Health Record
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
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 23
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
(Continued on page 24)
24 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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.
Electronic Health Record
CHIC
(Continued from page 23)
MMA Annual Meeting
See details on page 6
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 25
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).
Search for
Twin Cities
Medical Society on
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26 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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.
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 27
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.
28 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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).
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 29
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
Diane Gayes, past president, West Metro Medical
Society Alliance (HMSA).
30 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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.
MetroDoctors The Journal of the Twin Cities Medical Society March/April 2012 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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32 March/April 2012 MetroDoctors The Journal of the Twin Cities Medical Society
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
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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)