CheckupThe mission of the North Dakota Medical Association is to promote the health and well-being of the citizens of North Dakota and to provide leadership to the medical community.

StaffCourtney Koebele, Director of AdvocacyLeann Tschider, Chief Operating OfficerAnnette Weigel, Administrative Assistant

Shelly Duppong, Designer & Production Manager with Clearwater Communications

Kimberly T Krohn MD, PresidentA Michael Booth MD, Vice President

Steven P Strinden MD, Secretary Treasurer Debra A Geier, MD, Speaker of the House

Gaylord J Kavlie MD, AMA DelegateRobert W Beattie MD, AMA Alternate Delegate

Councillors:Joseph E Adducci MD

Debra A Geier MDYvonne L Gomez MDCatherine E Houle MDTimothy J Luithle MDSteven R Mattson MDRupkumar Nagala MDFadel Nammour MD

Mark W Rodacker MDShelly A Seifert MDRory D Trottier MD

Harjinder K Virdee MDDerek C Wayman MD

Dennis E Wolf MD

SUBMISSIONS: The NDMA Checkup welcomes manuscript, photography and art submissions. However, the right to edit or deny publishing submissions is reserved. Submissions are returned only upon request. Letters to the Editor with name, address and phone number of the author are welcome. All letters are subject to editing.

ADVERTISING: NDMA accepts one-quarter, half page and full page ads. Contact our office for advertising rates.

Copyright 2011 North Dakota Medical Association. All rights reserved.

NDMA Checkup is printed on recycled paper.

The NDMA Checkup is published quarterly by the North Dakota Medical Association, 1622 E. Interstate Avenue, P.O. Box 1198, Bismarck, ND 58502-1198, (701) 223-9475, Fax (701) 223-9476, e-mail: staff@ndmed.com

North Dakota Medical Association

ontents Ju n e 201 1

President’s Message ........................ 3

The 62nd North Dakota Legislative Assembly ....................... 4

NDMA Briefings ...............................10

Health Information Exchange Update ...........................12

NDMA Alliance News .......................13

MMIC Risk Management ..................14

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September 9-10 ND Society of Obstetrics and Gynecology Annual Meeting Ramkota Inn, Bismarck For more information contact Dennis Lutz, MD at 701-852-1555

September 22-23 NDMA Annual Meeting Grand Forks, Alerus CenterNDMA Alliance Annual Meeting Grand Forks, Alerus Center

alendar of Upcoming eventsC

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MessagePresiDeNt’sKimberly Krohn, MD

Replacing the Irreplaceable

Without change we never go anywhere. The North Dakota Medical Association is going through a

lot of change this year! One of the great things about hav-ing a great leader, such as our departed former Executive Director Bruce Levi, is that it brings great esteem to our organization and comfort to the members of the organi-zation. The bad thing is that when he leaves to go on to well-deserved career advancement, we are left with a huge hole! Bruce represented us formally and informally on just about every health-related group and issue occurring in North Dakota for more than a decade. I often stated that Bruce Levi represents North Dakota physicians better than we could represent ourselves. And now my oft-repeated phrase is, “we are finding someone to succeed Bruce, not replace him, as we cannot replace the irreplaceable.”

The Council of the North Dakota Medical Association is our board of directors. We are charged by our bylaws with naming an executive director of the organization. Each district has representation on the Council. When Bruce resigned, I appointed an executive director selection com-mittee which included several past presidents along with the executive committee members and select other NDMA

leaders. The selection committee met almost weekly throughout December and January, culminating in inter-views of four finalists for the executive director position in early February. The selection committee made a recom-mendation to the Council which resulted in hiring a suc-cessor to Bruce. Unfortunately, after a month’s delay for notice, our new executive director resigned on his second day with NDMA March 17.

We are fortunate to have Courtney Koebele, JD, as our Director of Advocacy, Leann Benson as chief opera-tions officer and membership director and organizational memory among other duties, and Annette Weigel as our administrative assistant. They are working with the execu-tive committee regularly and carrying out the mission of our association. Courtney was at the Capitol daily and interfacing with the people and organizations that are so important to us. She overlapped with Bruce by several weeks and maintains contact. We have continued work with our affiliated organizations for which we provide administrative support, and work on our annual meeting scheduled for September 22 and 23 in Grand Forks. As always, we have many projects going and will be main-taining them throughout the transition of directors.

There has never been a better time to become involved in NDMA. I hope that each of our members reading this will think about committing to be a delegate to our House of Delegates in September, about agreeing to become an officer for a district medical society, and about becoming more active in our association. I hope that non-members will consider membership in the only organization in the state that can possibly speak for physicians as a group.

The Council continues to meet to discuss the next steps in replacing the irreplaceable. Right now we are in good hands with a stable mission and progress towards it. Thanks for your continued leadership on the front lines for our profession and the communities we serve.

Bruce and Kathy Levi at the North Central Medical Caucus Conference dinner in Minneapolis on March 19th.

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day at the capitol to roam the halls and watch the action. This program was so greatly appreciated by legislative

leaders and all legislators, really showcased the importance of primary care physician services, and gave the volunteers an inside look at the legislative process. NDMA hopes that we can continue this highly appreciated program with even more participation in the special legislative session in the fall.

On March 16 and 17 NDMA and Altru Clinic offered free health screenings to legislators and their staff. Dr. Jim Brosseau of Altru Clinic provided those medical consulta-tions. Over 100 people participated in the screenings.

MEDICAID REIMBURSEMENTNDMA priorities with respect to Medicaid reimbursement

issues were to work to maintain the proposed Department of Human Services budget maintaining the level of reim-bursement achieved last session, with proposed 3% increas-es in each year of the upcoming biennium.

Last session, NDMA was successful in rebasing physi-cian Medicaid payment through $39 million in additional state/federal funding to rebase physician payments to 89% of cost, resulting in a substantial increase. This session’s executive budget in SB 2012 maintained that level of reim-bursement with proposed 3% increases in each year of the upcoming biennium. NDMA testimony encouraged law-makers to further rebase physician payments. The Senate Appropriations Committee confirmed the 3% increases. Unfortunately, the House eliminated both the 39 million dollars in funding given last session and the 3% increase in the governor’s budget, despite protests from a number of physicians and administrators throughout the state. Questions were raised in the House of Representatives about the substantial increase from last session. Because of the reduction, the bill went to conference committee with members from both the House and the Senate.

Courtney Koebele, JD, Director of Advocacy

The 2011 North Dakota Legislative Assembly met for 78 legislative days, adjourning sine die on

April 28, 2011. The NDMA legislative agenda was adopted by

NDMA members, participating as delegates from their District Medical Society and state specialty societies to the NDMA House of Delegates, at the 2010 NDMA annual meeting in Fargo. The NDMA Commission on Legislation chaired by Fadel Nammour, MD, recom-mended policy priorities and worked with members of the NDMA Council to refine the agenda prior to the session and take positions on other bills as they were introduced.

NDMA priorities include physician recruitment and retention strategies, Medicaid payment issues, national health system reform implementation and opposing inappropriate expansions of allied professional scope of practice including the proposed elimination of collabora-tive prescriptive agreement for nurse practitioners, and the licensing of naturopaths and lay midwives. This leg-islative session was active regarding the Medicaid reim-bursement issues, and several bills attempted to address a number of issues involving national health system reform.

What was new this session was the addition of a sec-ond physician in the Legislative Assembly: Spencer Berry, MD, a family medicine physician from Fargo. Dr. Berry served on the Senate Human Services Committee and provided a good daily perspective on issues for the committee as well as the Senate floor as those issues relate to physician practice. Along with Senator Ralph Kilzer, Senator Berry was an active participant in floor discussions and committee hearings on a variety of issues impacting physicians and public health.

Physicians were able to sign up directly for the Doctor of the Day program on the NDMA website to spend a

The 62nd ND Legislative AssemblyTop Issues – Health Care Reform

We greatly appreciate the Bismarck Center for Family Medicine for covering the Doctor of the Day program each Wednesday. A special thank you to physicians who participated in the NDMA Doctor of the Day program during the 62nd Legislative Assembly: Hani Alboushi, Gary Betting, Charles Breen, James Brosseau, A. Michael Booth, Jessie Carlson, Linda Getz-Kleiman, Jeff Hostetter, Ted Kleiman, Kimberly Krohn, Prabin Lamichhane, Tom Magill, Sarah McCullough, Fadel Nammour, Jeremiah Penn, Jackie Quisno, Sarah Schatz, Robert Sticca, Tom Strinden, Guy Tangedahl, Stephanie Traxinger, Karen Willis, Dennis Wolf and Joshua Wynne.

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with the Department of Health during the interim to craft a proposal. The dilemma is that lay midwives are sought by some parents, and the need exists to protect the public which continue to seek those services regardless of whether minimum care standards are met. Several physicians testi-fied in support of doing “something” to educate parents and lay midwives. Other physicians were opposed to any legis-lation that would “legitimize” lay midwifery. The bill was defeated in the Senate.

HB 1434 proposed eliminating the pharmacy ownership law requiring that a pharmacy be owned by a licensed phar-macist in good standing. This bill was defeated 68-26 in the House.

FEDERAl HEAlTH SySTEM REFORMDuring this session, there is an environment of partisan-

ship over federal health system reform and efforts, in some cases in conjunction with other states, to undermine or nul-lify that reform, particularly the individual mandate to pur-chase health insurance.

Insurance Commissioner BillsSeveral bills move the state forward, through the office of

state insurance commissioner, to implement health system reform (HBs 1125, 1126, 1127). What some leaders are say-ing is that many of the issues relating to the state’s imple-mentation efforts, including the need for additional staff for Medicaid and the Insurance Department, will be addressed later in the fall in the special session held for redistricting.

HB 1125 requires the Insurance Commissioner to admin-ister and enforce the provisions of the Patient Protection and Affordable Care and the provisions of the Health Care and Education Reconciliation Act of 2010 to the extent that the provisions apply to insurance companies subject to the commissioner’s jurisdiction and to the extent that the provi-sions are not under the exclusive jurisdiction of any federal agency.

HB 1126 requires the Insurance Commissioner and the Department of Human Services to plan and implement an American health benefit exchange for North Dakota that facilitates the purchase of qualified health benefit plans, provides for the establishment of a small business health options program that is designed to assist qualified small employers in facilitating the enrollment of their employees in qualified health benefit plans offered in the small group market, and meets the requirements of the Patient Protection and Affordable Care Act of 2010 as amended by the federal health reform law. The Legislative Assembly is given discre-tion to establish one exchange that will provide services to both qualified individuals and qualified small employers. The bill authorizes the Commissioner and the Department to take all actions necessary to ensure that the exchange is

Through the efforts of NDMA, the North Dakota Hospital Association, the Health Policy Consortium and numerous physician contacts, we were successful in restoring the 39 million in funding from last session. Senator Ralph Kilzer was a key player on the conference committee which restored the 39 million. Other support-ive members of the conference committee were Senator Tom Fischer, Senator Larry Robinson and Representative Lee Kaldor. Senator Berry also contributed very valu-able information to the negotiations. Unfortunately, the physicians did not receive the 3% inflationary increase. However, NDMA considered the session a success for physicians in that the previous rebase was maintained and legitimized by the 2011 Legislative Assembly.

Supplemental Medicaid Payments to Critical Access Hospitals

HB 1152 requires the Department of Human Services to provide a Medicaid supplemental payment to critical access hospitals. The Department is required to seek fed-eral Medicaid funding to support the supplemental pay-ments. As amended, the bill appropriates $1,527,802 from the state general fund, and $1,926,259 in federal funds for this purpose for the 2011-13 biennium.

BIllS THAT wERE DEFEATEDThree WSI bills were defeated this session. One of the

bills, HB 1052, would have allowed WSI to publicly pro-file physician practices and another, HB 1053, would have set generic prices if cheaper as the standard payment for brand name drugs. Another WSI effort in HB 1054 related to pain management of WSI patients. The bill, opposed by NDMA, set forth extensive new requirements and protocols for physicians in the provision of pain manage-ment, relating to both general opiate therapy during the acute stage of treatment and long-term opiate therapy. Dr. Shelley Killen of Bismarck and Dr. Kimberly Krohn of Minot testified in front of the Senate Industry Business and Labor Committee to the effect the bill would have on a physician’s practice. The bill passed in the House 81 to 8. NDMA worked to defeat it in the Senate and it was defeated 11 to 36.

In a win for ophthalmologists trying to reduce eye inju-ries in children, an effort to bring back bottle rocket sales to the state in HB 1255 was also defeated.

SB 2315 would have required the North Dakota Board of Nursing to license any person providing midwifery ser-vices under specific requirements and limitations imposed by the legislation; engaging in midwifery without a license would be a class A misdemeanor. This was a difficult bill, as efforts to prohibit the practice of lay midwifery were not successful in 2007 and a number of physicians worked

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determined, not later than January 1, 2013, by the federal government to be ready to operate not later than January 1, 2014, and that the exchange is operating on or after January 1, 2014.

HB 1127 revises appeals processes with respect to non-grandfathered plans under the Patient Protection and Affordable Care Act. The law was amended to conform appeals processes to current federal laws and rules.

Other Health Reform Related BillsHB 1165 provides that a resident of North Dakota will

not be “required to obtain or maintain a policy of individ-ual health coverage except as may be required by a court or by the Department of Human Services through a court or administrative proceeding.”

HB 1252 establishes a Legislative Management Health Care Reform Review Committee during the 2011-12 interim to monitor the impact of the federal health system reform, rules adopted by federal agencies, and any amend-ments to the reform legislation. The bill provides that if a special session of the Legislative Assembly is necessary to adopt legislation in response to the federal legislation, the committee will report to the Legislative Management before a special session; otherwise it will report to the next Legislative Assembly.

SB 2309 declared that the federal laws known as the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 likely are not authorized by the United States Constitution. The law further provided that the Legislative Assembly shall consider enacting any measure necessary to prevent the enforcement of the Patient Protection and Affordable Care Act. Finally, it stated that no provision of the Patient Protection and Affordable Care Act may interfere with an individual’s choice of a medical or insurance provider except as otherwise provided by the laws of this state.

POST GRADUATE RESIDENCy TRAINING REqUIREMENTS FOR INTERNATIONAl

SCHOOl GRADUATESA bill originating with residents at the Minot Center

for Family Medicine, HB 1222, introduced at the request of NDMA and supported by the ND Board of Medical Examiners, reduces the post graduate residency training requirement for graduates of international medical schools from three years to thirty months for purposes of qualify-ing for a full and unrestricted medical license. This allows the resident to make timely application to take the ABFM certifying examination in the summer, rather than hav-ing to seek an unrestricted license in another state or wait until the fall exam. Dr. Gaylord Kavlie of Bismarck testi-fied in favor of the bill and offered important information

to the committee. The bill was unopposed and passed both in the House and Senate.

CHAllENGES TO PHySICIAN SCOPE OF PRACTICE

Nurse Practitioners NDMA and the ND Board of Medical Examiners

opposed Senate Bill 2148 which eliminated the collabora-tive prescriptive agreement required of advanced practice registered nurses. NDMA testimony focused on the need to continue the use of the collaborative agreement as a patient safety tool that does not restrict nurse practitioners from their full level of scope of practice. Despite this tes-timony, the bill passed.

Naturopaths SB 2271 creates a state “Board of Integrative Health

Care” to regulate “naturopaths” and specifies the scope of practice of naturopaths including a naturopathic for-mulary list. NDMA expressed many concerns regard-ing the bill. The bill was amended to change references from “naturopathic physician” to “naturopath;” remove references and authority for a formulary list and clearly prohibit a naturopath from prescribing, dispensing or administering any prescription drug; and require that a naturopath may only use the title “naturopath” or “doctor of naturopathic medicine” (N.D.).

Pharmacists SB 2035 expands the current authority of pharmacists

to administer immunizations and vaccinations to children. This bill changes current law regarding the administra-tion of drugs by pharmacists. It expands current law authorizing a pharmacist, upon an order by a physician, nurse practitioner or physician’s assistant authorized to prescribe such a drug or by written protocol with a physi-cian, nurse practitioner, or physician’s assistant, to admin-ister immunizations and vaccinations by injection. The expansion is to individuals “at least eleven years of age” rather than the current authorization for individuals more than 18 years of age. NDMA proposed an amendment, which was adopted, to require the immunization to be reported as a childhood immunization and other informa-tion if required to be reported to the state’s immunization information system.

PUBlIC HEAlTH INITIATIVESThese were several of the major public health initiatives

offered this session:

Trauma SystemHB 1266 puts in place a statewide trauma and EMS

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medical director and state funding for the state trauma system which NDMA assisted in developing with the state’s Trauma Committee. NDMA supported this bill and the trauma system request for full funding. Dr. Kent Hoerauf, Dr. Steven Hamar and Dr. Steven Briggs offered testimony in support of the bill.

The original bill provided for funding of $726,516, including $416,000 for contracting for an emergency medical services and trauma medical director. The House reduced the funding to $50,000 and passed the bill. The Senate put an additional $50,000 in the bill and changed the language to “shall” when directing the state health officer to appoint an EMS medical director. The confer-ence committee changed the language back to “may” appoint a director and maintained the minimal level of funding of $50,000 for the director and $50,000 for train-ing.

Youth Concussion Management SB 2281 requires that any student or youth athletic

activity that is sponsored or sanctioned by a school be subject to the terms of a concussion management program. NDMA supported the bill as introduced. Dr. Spencer Berry was one of the primary sponsors of the bill and testified in front of the House Education com-mittee. The bill was amended to remove the requirement that a physician authorize return to practice, training or competition and allows for a licensed health care pro-vider to authorize return. The final amendment involved the authorization being given to the student, who in turn could provide it to the coach, to comply with HIPAA. The bill was also amended to apply the requirements for all schools, including non-public.

The bill also contained a mandatory study for the 2011-2012 biennium, to study concussion management with respect to youth athletics, including the nature, scope, and applicability of programs designed to prevent or eliminate concussions.

Universal Vaccine Program SB 2276 established a program through which the

Department of Health purchases vaccines through the federal vaccine purchasing contract. The Department shall supply public health units with the purchased vac-cines. A public health unit that receives vaccines under this purchasing program may not bill an insurer for the cost of the vaccine but may charge an administration fee. The Department shall fund this purchasing program through participation in the vaccines for children pro-gram, the federal section 317 vaccine program, and state funds appropriated for this purpose. The legislature pro-vided for a 1.5 million appropriation for this program.

Newborn Metabolic and Genetic DiseasesSB 2067 modified existing law to conform to the proce-

dures already in place for newborn metabolic and genetic disease testing. The bill provides that the testing will con-tinue to be an opt-out administration, with the parents being provided with written information prior to the testing. The bill also eliminated the requirement that opting out be based on conflicts with religious tenets or practices, rather than just parental choice.

Further Restrictions on Young Drivers and No More Texting for All Drivers

HB 1256 incorporates graduated drivers licensing con-cepts for young drivers in North Dakota’s motor vehicle licensing law. The bill provides that an individual would be able to request an instructional permit at age 14, but for any driver under age 16, the driver would have to hold the per-mit for 12 months (rather than the current 6 month require-ment) and meet a minimum of 50 hours of instructional driving experience before he/she could apply for a restricted license. At 15, the driver would be eligible to receive a restricted driving license, which would allow the teen to drive without adult supervision, but only between the hours of 5am - 9pm, unless going directly to or from school, work, or religious activities or if there is an individual over 18 years of age in the front seat. At age 16, the time restric-tions would be removed, but electronic device restrictions would remain. The bill bans the use of all electronic devices for drivers under the age of 18, except GPS devices.

HB 1195 prohibits the operator of a motor vehicle that is part of traffic to use a wireless communications device to compose, read, or send an electronic message.

Coverage for Uninsured and Underinsured People, Including Children

SB 2264 would have changed the eligibility test for Healthy Steps from a net income eligibility limit of 160% of the poverty line to 200% of the poverty line. Two other bills would have moved the limit to 250%. These bills were defeated and the eligibility for Healthy Steps was rolled into the Department of Human Services budget approved in the Senate at 175% net of the federal poverty line. Unfortunately the House reduced it back to 160% and that was confirmed by the conference committee and the Legislative Assembly.

Department of HealthThe Department of Health’s budget, contained in HB

1004, appropriated a total of $28,913,780 in general funds appropriation. The budget fully funded the North Dakota Stroke Registry and included $600,000 to fund a statewide STEMI initiative.

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In an attempt to replace reduced federal funding avail-able through the Department of Transportation for services provided to ambulances and for the statewide trauma program, HB 1004 partially restored it as follows: trans-fer from EMS grants line ($300,000); Department of Transportation ($124,800); and General fund ($75,000) for a total of $499,800.

During the session, the House amended HB 1004 to remove the Measure 3 language requiring that 80 per-cent of the Community Health Trust Fund be spent on tobacco prevention and control. The Senate restored this language and the conference committee maintained it. Restoring this language assured that funding of the state-wide tobacco quitline and Quitnet services continued. The Community Health Trust Fund receives 10 percent of all the tobacco settlement annual payments.

UND SCHOOl OF MEDICINE & HEAlTH SCIENCES

The UND School of Medicine & Health Sciences bud-get bill, as part of the overall university system budget bill in HB 1003, was granted $46,783,021 in total general fund appropriation. The controversial HB 1353, which would have used tobacco settlement funds to fund class and position expansions at the medical school and residen-cy programs and the construction of another UNDSMHS building, was defeated. HB 1003, the Higher Education budget bill, provided the following funding:

• $100,000 to complete a formal space study over the next two years• $1,215,219 for initiation of a Master in Public Health degree program (with the funds to be equally split with NDSU for a joint effort)• $1,151,810 for a Geriatrics Training Program, to develop educational modules for practitioners across the state• $1,800,000 for expansion of the medical, health sciences, and residency classes, with the first additional trainees arriving in the summer of 2012• $530,031 in equity funding, which will be used to augment faculty development and student support functions• $512,316 in college affordability funding, which will help limit the SMHS’s tuition increases to 2.5% over this coming biennium• $2,233,200 in merit and additional health care premium funding

Advisory Council member Representative Stacy Dahl and Representative Bob Martinson were key supporters of the Medical School’s efforts during the session, as were

Advisory Council members Senator Tim Mathern, Senator Robert Erbele, and Representative Ralph Metcalf.

The physician loan repayment law was also amended in HB 1003, by eliminating the requirement that to qualify for the plan a physician may not have practiced full time medicine in the state for more than one year before the date of application.

There is also a provision for the Legislative Management chairman to appoint a separate committee to study the ability of the University of North Dakota School of Medicine and Health Sciences to meet the health care needs of the state. The study, which was chosen by the Legislative Management, must include a review of the health care needs of the state, options to address the health care needs of the state, and the feasibility and desirability of expanding the school of medicine and health sciences to meet the health care needs of the state.

ElECTRONIC PRESCRIPTIONSSB 2122, introduced by the State Board of Pharmacy,

revised the state’s prescription laws to incorporate elec-tronic prescriptions. With respect to “brand necessary” prescriptions, the crux of the bill requires the practitioner to take the following steps: “If the prescription is created electronically by the prescriber, the required legend must appear on the practitioner’s screen. The practitioner must take a specific overt action that accomplishes the inclusion of the “brand medically necessary” language for purposes of electronic prescriptions. The bill also replaced the cur-rent “brand necessary” language for other purposes with the word “brand medically necessary.” NDMA has con-cerns with the change in the required language to “brand medically necessary.”

Under HB 1422 effective August 1, 2013, a drug prior authorization request would be required to be accessible and submitted by a health care provider and be accepted by a group purchaser electronically through a secure elec-tronic transmission (except facsimiles). Effective August 1, 2013, electronic transmission devices used to commu-nicate a prescription to a pharmacist would be prohibited from using any means or permit any other person to use any means (including alerts, advertising, messaging, and popup advertisements) to influence or attempt to influence through economic incentives or otherwise the prescribing decision of a prescribing practitioner at the point of care.

Under HB 1422, during the 2011-12 interim, the Department of Health and the Health Information Technology Advisory Committee are required to work together to establish an outline on how best to standard-ize drug prior authorization request transactions between providers and group purchasers. The outline “must be designed with the goal of maximizing administrative

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simplification and efficiency in preparation for elec-tronic transmissions and alignment with standards that are or will potentially be used nationally.” By January 1, 2012, the Department of Health and the HIT Advisory Committee will be required to provide a report to the Legislative Management regarding the outline on how best to standardize drug prior authorization request transactions between providers and group purchasers.

ABORTIONThere were two bills which addressed different aspects

of abortion. HB 1297 which passed the legislative assem-bly, creates a prohibition for anyone to prescribe any abor-tion-inducing drug to a pregnant woman unless the person who gives, sells, dispenses, administers, or otherwise provides or prescribes the abortion-inducing drug is a phy-sician. Every pregnant woman to whom a physician pro-vides any abortion-inducing drug will have to be provided with a copy of the drug’s label. The bill also provides that any physician who gives an abortion-inducing drug must enter a signed contract with another physician who agrees to handle emergencies associated with the use or ingestion of the abortion-inducing drug. The bill provides that when an abortion-inducing drug or chemical is used for the pur-pose of inducing an abortion, the drug or chemical must be administered by or in the same room and in the physi-cal presence of the physician who prescribed the drug to the patient.

The other abortion bill, HB 1450, would have defined a “human being” as “an individual member of the species homo sapiens at every stage of development,” and apply that definition to the definition of “person” for purposes of the state’s homicide and assault laws.

This bill was determined by the American Society for Reproductive Medicine to threaten the reproductive rights

New to NDMA is Courtney Koebele, JD, who began work as Advocacy Director February 16, 2011. Courtney is a North Dakota native, earning law and criminal justice degrees from the University of North Dakota. As Director of Advocacy, Courtney will

coordinate Association advocacy efforts and provide legal counsel to the Association. Since admitted to practice law in 1991, Courtney worked as a law clerk in Federal District Court for Judge Pat Conmy and Magistrate Judge Dwight Kautzmann. After clerking, Courtney represented a variety of state agencies in the civil litigation division of the attorney general’s office. Courtney was in private practice from 1996 to 2005, in both Minnesota and North Dakota. Courtney practiced in a variety of areas of law, including lobbying for the North Dakota Newspaper Association, the North Dakota Broadcasters Association, the North Dakota Judges Association, and several allied health and non-profit entities.

Most recently, Courtney was assistant bar admissions administrator for the North Dakota Board of Law Examiners. In that position, Courtney administered the bar exam and reviewed all applicants for admission to the bar in North Dakota.

Courtney is looking forward to working with the North Dakota Medical Association and furthering its goals and priorities both on the state and federal levels.

of women and criminalized the actions of the reproductive doctors working to provide women with appropriate medi-cal care. Dr. Stephanie Dahl, Dr. Shari Orser, Dr. John Witt and Dr. Steffen Christensen offered key testimony in explaining the effects of the bill on physician’s practice.

The bill passed in the House, and the Senate “laid it on the table,” prohibiting further consideration without a 2/3 vote of the Senate. There was one attempt to take the bill off of the table, which failed.

lOOKING FORwARD TO THE INTERIM AND 2013

The work in preparing for the 2013 has already begun. Several studies were prioritized for interim ND Legislative Council committees to address health care issues between legislative sessions at the Legislative Management Committee hearing on May 10. The studies chosen include: 1) the future of health care delivery in the state, focusing on the delivery of health care in rural areas of the state and include input from the University of North Dakota School of Medicine and Health Sciences Center for Rural Health, hospitals, and the medical community; 2) the ability of the University of North Dakota School of Medicine and Health Sciences to meet the health care needs of the state; 3) monitor the impact of the federal Patient Protection and Affordable Care Act and rules adopted by federal agencies as a result of that legisla-tion; and 4) the impact of PPACA on the Comprehensive Health Association of North Dakota and the statutes gov-erning the Comprehensive Health Association of North Dakota.

This Legislative session contained a number of issues of interest to physicians and their practices. NDMA remains committed to be involved and focused on bills that impact the practice of medicine.

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In times of transition, it’s not just the work accom-plishments that you think about; what comes to mind

are the people, the friendships, the difficult times and the problems we worked together to solve.

In my fourteen years with NDMA I’m left with a strong appreciation for the many physicians who took leadership roles in addressing the many challenges and opportunities facing North Dakota physicians. These are volunteers who give of themselves to serve others and serve the profes-sion of medicine in our state. In addition to serving their colleagues, these NDMA leaders have always given good support and encouragement to the NDMA staff in our daily work.

Your leadership is working to achieve a smooth transi-tion in NDMA staff, hiring Courtney Koebele, JD for advocacy and legal services. Courtney is a seasoned lob-byist in the ND Legislative Assembly. Leann Benson continues as our chief operating officer, addressing finan-cial, CME, membership and compliance matters. Annette Weigel continues to provide daily administrative support for all of our NDMA efforts.

You have been well served by your president Kimberly Krohn in this transition process, who is addressing a diffi-cult challenge in the search for staff in the midst of a very active legislative session.

This transition in staff can serve as an opportunity for all ND physicians to rediscover their NDMA. Certainly most physicians take NDMA’s advocacy work for granted or assume the work will get done, regardless of their own individual participation in the Association. Change can be embraced and this change in staff can be used as an opportunity for more physicians to step up to contribute to NDMA’s future strength and sustainability.

It’s not just about dues. All physicians, members and

non-members alike, can rediscover your NDMA – a rich tradition of nearly 125 years of important professional milestones that have substantially improved the physician practice environment in our state and the health of the public.

Rediscover the importance of physician collegial-ity statewide and locally to get done what needs to get done. Rediscover the structure in place through NDMA’s Council, House of Delegates and Commissions for devel-oping NDMA policy and the importance of advocating as one voice on behalf of your patients.

A strong NDMA gives physicians an independent platform in an environment in which physicians are becoming increasingly dependent on their employ-ers and others to take care of policy and administrative issues. Complacency is dangerous and will only foster a diminishment of physicians as just another component of healthcare “manpower” rather than a profession with an independent voice.

NDMA is an effective advocate for you and your patients. The effectiveness of NDMA in advocating for you and your patients is only as good as the ability as physicians to garner the resources necessary to do what needs to get done. While the Association’s membership has always hovered around the 70 percent mark, there is no reason why every licensed physician in North Dakota should not be a member.

NDMA works with policymakers at the federal, state and local level to improve the physician practice environ-ment, strengthen medical education including the UND School of Medicine & Health Sciences and our residency programs, strengthen our ability to recruit and retain a quality physician workforce, facilitate health information technology, improve the health of the public, and improve

Rediscover Your NDMA!

By Bruce levi

10 N D M A C H E C K U P

NDMA has also served as a strong state base for imple-menting policies advocated by your national specialty societies. NDMA works with several state specialty chap-ters in moving their policies forward and ensuring an appropriate level of staff support.

We need all North Dakota physicians to do their part in supporting NDMA advocacy efforts.

In my service to NDMA, I hope I was able to contrib-ute in a way comparable to previous NDMA executive directors including Catherine Rydell and Vernon Wagner. My work at NDMA has been helping physicians help their patients. As a calling, the work has been something that gave voice to who I am and what I want to say to the world; helping North Dakota physicians take care of people with the best that medicine has to offer.

I will continue to serve physicians in my new vocation as general counsel to the American Academy of Neurology in St. Paul. This is all work truly worth doing and I look forward to new challenges.

My sincere best to all of you!

our ability to provide some of the highest quality, safest and cost-efficient medical care in the country.

Specific examples over the years include NDMA’s suc-cessful efforts to rebase Medicaid physician and hospital payments, improve the environment for appropriate pain management, improve care at the end of life, rework the state’s advance care planning laws, address geographic disparities in Medicare payment to physicians in North Dakota, protect and repeatedly refine our medical liability reform laws including the cap on non-economic dam-ages and certificate of merit laws, maintain and improve relationships with hospitals and health systems and a raft of other agencies and organizations, build good daily relationships with our Congressional Delegation, address issues related to the monopsony power of the dominant commercial insurance carrier including patient rights’ legislation and contract revision, and improve the health of the public through our work on tobacco-related issues, trauma prevention and care, prenatal care for pregnant minors, and many other public health issues.

J U N E 2 0 1 1 11

using secure electronic transmissions and electronic devices used to communicate a prescription to a pharma-cist may not use or permit the use of alerts, advertising, messaging, and popup advertisements to influence or attempt to influence decision of a prescribing practitioner at the point of care. Additionally, during the 2011-2012 interim, the state department of health and the HITAC shall work together to establish an outline on how best to standardize drug prior authorization request transactions between providers and group purchasers and to report to legislative management by January 1, 2012.

• SENATE BIll 2012 is the Department of Human Services appropriation bill. This bill includes funding for the Medicaid meaningful use incentive program. Approval of this funding will allow the Department to make incentive payments to providers that meet the Medicaid eligibility requirements and the meaningful use requirements.

• SENATE BIll 2037 relates to participation in the health information exchange and the confidentiality of records in the exchange. Additionally, it allows for the creation of health information exchange and the devel-opment of policies and procedures to run the exchange. Finally, the bill also moves the responsibility of devel-oping and maintaining an advance directive repository from the Secretary of State’s Office to the Information Technology Department allowing the advance directive repository in the health information exchange.

Update on the health information technology can be found on the HITAC website at: http://www.healthit.nd.gov/. If you would like to be included on the HITAC list serve, please send an email to me at shwolf@nd.gov.

Sheldon wolf ND Health Information Technology Director

On September 27, 2010, the Health Information Technology Advisory Committee (HITAC) sub-

mitted a strategic and operational plan for a statewide health information exchange to the Office of the National Coordinator (ONC). The ONC reviewed and approved the plan with addendum on March 30, 2011. The original plan and the addendum can be found on the HITAC website at: http://www.healthit.nd.gov/strategic-and-operational-plans/. Now that the plan is approved, we can access the implementation funds.

To keep the process moving and start the implementa-tion process upon receiving ONC’s approval of our stra-tegic and operational plan, ITD, on behalf of HITAC, released a request for proposals for the health information exchange (HIE) infrastructure. Six HIE vendors submit-ted proposals. These proposals were reviewed by a stake-holder committee and three vendors were selected for on-site demonstrations which were held on February 28 and March 1, 2011 and again on May 5 and 6, 2011. As of the writing of this article a final vendor has not yet been selected.

Finally, below is an update on four pieces of 2011 legis-lation related to health information technology (HIT).

• HOUSE BIll 1021 is the Information Technology Department’s appropriation bill. Included in HB 1021 is the appropriation to build and operate the health infor-mation exchange. Additionally, section an additional $5 million dollars for low interest rate loans for providers to implement health information technology.

• HOUSE BIll 1422 relates to electronic prescrib-

ing and electronic prior authorizations. This bill creates requirements that, effective August 1, 2013, drug prior authorization requests must be submitted and accepted

HealtH InformatIon excHange Update

12 N D M A C H E C K U P

Dinah GoldenbergPast-President, NDMA Alliance

Director, AMA Alliance

Hello Alliance Member & Friends,June is here and spring is finally in the air. Hopefully by the time you read this all threats of flooding will have passed in

your community and we really will be enjoying spring!Over the last six years I have served at the national level of the AMA Alliance in various capacities. The last four years have

been as a member of the board of directors. It has been an honor and a privilege to serve on behalf of North Dakota. It has been a rewarding experience, one which I shall treasure always. It is with a heavy heart that I have decided not to continue my national service when my term expires in June. I will be spending more time devoted to my local commitments.

The AMA Alliance Nominating Committee met at the end of March. The following is the slate of officers for the 2011-2012 year.

• President - Emma Borders, louisiana • President-elect - Pat Hyer, Texas • Past President - Susan Todd, Texas • Secretary - Jo Terry, Tennessee • Treasurer - Sarah Sanders, Illinois • Directors - • Pat Klettke, Utah • Julie Neuman, North Carolina • Mary Rice, Colorado • Debbi Ricks, California • Mary Shuman, Missouri • Beverly wright, North Carolina • Rosemary Xavier, Florida

The AMA Alliance Annual Meeting will take place in Chicago June 19-21 at the Swissotel. At the 2010 Annual Meeting an important bylaws change was passed changing the meeting from a House of Delegates format to an Annual Meeting. This means there is no longer a delegate count per state based on membership numbers. Every member is enti-tled to attend and every member is entitled to a vote. I hope many of you will consider attending as we break new ground at the national level. Information is available on the alliance website www.amaalliance.org

If you have not renewed your membership yet, it is not too late. Please consider supporting the continued health and advocacy work of our organization. Fargo dues are $75 (district, state and national). Members at Large dues are $60 (state and national). Checks may be made out to FDMA and forwarded to:

Dinah Goldenberg2173 Victoria Rose Drive • Fargo, ND 58104

Thank you for your continued support.Happy Spring!

Warm regards,

Dinah

SAVE THE DATEND Alliance Annual Meeting Events

September 22 & 23, 2011 • Grand Forks, ND

wATCH FOR DETAIlS SOON! Contact dinahgold@cableone.net with questions

Dinah GoldenbergDirector, AMA AlliancePast President, ND Medical Alliancedinahgold@cableone.net

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MMIC Malpractice Claim Review

By Cinda Velasco RN, JD, Attorney-Risk ManagementMMIC Midwest Medical Insurance Company

Specialty: Family Practice Allegation: Delay in diagnosis and treatment

Risk Management and Patient Safety Focus: Follow-up systems Automated system alert benefits of an electronic

health record (EHR)

Facts of Case:A 53-year-old diabetic male saw his family physician

for a regular checkup. The patient requested a prostate-specific antigen (PSA) test. His physician ordered the test and the result showed a value of 19.0 ng/ml. The lab report stated that a PSA of 4.0 ng/ml or below was normal. There was no documentation in the chart regarding the test result or if the clinic notified the patient of the test result. Three years later, the patient had another PSA test and this time the result was 32 ng/ml. It was during this visit that the physician found the results of the earlier abnormal PSA unsigned and filed in the patient’s chart.

The family physician immediately referred the patient to a urologist who performed biopsies and diagnosed prostate cancer. Because of his other health issues, the urologist informed the patient that he was not a surgical candidate. The patient was treated non-surgically with radiation and subsequently developed radiation procti-tis. The proctitis caused the man to have problems with urgency, serious bladder infections, pain and sexual dysfunction. Three years later, the patient had surgery to remove his bladder, colon and part of his rectum.

The patient filed a malpractice claim alleging failure to timely diagnose and treat his prostate cancer that caused him to undergo a more aggressive treatment resulting in complications and additional surgery.

Disposition of Case:The case settled for more than $500,000 against the

family physician and the clinic.

Risk Management and Patient Safety Perspective: The experts who reviewed this case all agreed that the

clinic should have notified the patient and referred for biopsy when the clinic received the first abnormal test

result. The physician and nursing staff had no recollec-tion of the patient or of the ordered test. The clinic staff filed the abnormal result in the patient’s chart without the physician’s review.

Risk Management Tips:Effective follow-up systems are necessary to protect

patients from injury and to reduce the risks of physi-cians and clinics being involved in a malpractice action. Physicians are responsible for making certain they receive the results of any diagnostic test they order, noti-fying patients of the results and providing appropriate follow-up care.

Among the patient safety benefits of an electronic health record (EHR), are automated system tracking and alerts. Most EHRs have built-in features to track results of labs, X-rays, etc. An EHR can greatly improve your practice’s tracking of patient care and can reduce the risk of missing a test result.

Filing diagnostic tests, X-rays, consultation and other reports before the physician has reviewed them is a com-mon cause of patient injuries. Follow-up systems and policies should address the review of ALL patient infor-mation, including:

• In-house lab, X-rays and reports from other departments • Reports and patient information from outside the clinic – Outside laboratory reports – Diagnostic reports from hospitals or other facilities – Information regarding hospitalized patients – Reports from hospital emergency departments – Other information as applicable

It is crucial to establish a firm policy that only patient information with the initials of the ordering provider or other authorized person who verifies it has been reviewed be filed in the paper medical record or scanned into the EHR. Initialing of patient information prior to filing is the only guarantee that the physician has reviewed the information. Patient information or reports should never be filed without a review on the assump-tion that they will be noted at the next patient visit.

14 N D M A C H E C K U P

PRESORT STANDARDUS POSTAGE

PAIDBismarck, ND 58501

Permit No. 419

North Dakota Medical Association& NDMA Alliance Annual Meeting

September 22-23, 2011 • Alerus Center • Grand Forks, ND

New Laws BegiN with NDMa ResoLutioNsMany bills before the 62nd Legislative Assembly

began as resolutions in the NDMA House of Delegates or as recommendations from NDMA Commissions. Now is the time to begin putting your ideas for a resolution on any policy matter to paper, in time for the NDMA annual meeting in September. The NDMA staff can assist you in preparing an effective resolution with a clear action or stand that you would like NDMA to take. Call (800) 732-9477 or 223-9475 for assistance.

NDMa awaRD NoMiNatioNsthe Professional & Community services award

is given each year to an outstanding NDMA member physician. To be nominated, the physician 1) must be an NDMA member; 2) must not be deceased; 3) must not have been a previous recipient of the award; and 4) must have compiled an outstanding record of community service, which, apart from his or her specific identification as a physician, reflects well on the profession of medicine.

Promoting Physician Leadership in Ethics and Advocacy

P l a n t o at t e n d

The NDMa Friend of Medicine award is also given annually to an individual who 1) must be a person either living in or operating a business enterprise in the state; 2) must not be a Doctor of Medicine or Osteopathy; and 3) must have distinguished herself or himself by serving as an effective advocate for healthcare, patient services, or the profession of medicine in the state of North Dakota.

Members are invited to submit the names of qualified individuals for each of these awards, along with a description of the individual’s relevant background and accomplishments, to the NDMA office by June 15 for consideration this summer by NDMA’s Commission on Medical Services and Public Relations. This does not require a District nomination; any NDMA member can submit a nomination.

LoDgiNgLodging: A block of rooms has been reserved at the Canad Inn, 1000 S 42nd St, Grand Forks until August 26. The rate is $69.30. For reservations call 701-772-8404. Please indicate that you are with the North Dakota Medical Association or reference group confirmation number 212878.