Volume 10 Number 1
Headwaters of the Mississippi River at Lake Itasca, Itasca State Park
©Explore Minnesota Tourism
Q U A R T E R LY
Spring 2008
The mission of the Office of Rural Health & Primary Care is to promote access to
quality health care for rural and underserved urban Minnesotans. From our unique position
within state government, we work as partners with communities, providers, policymakers and
other organizations. Together, we develop innovative approaches and tailor our tools and
resources to the diverse populations we serve.
Microsoft® and Health Care Reform
Mark Schoenbaum is
director of the Office of
Rural Health and Primary
Care. He can be reached
at mark.schoenbaum@
health.state.mn.us
or (651) 201-3859.
2
DIRECTOR’S CORNER
Mark Schoenbaum
Can you say you love Microsoft and its Windows®, Office and other products? Or are
you like me? Microsoft rules how things are done, and I’ve learned to adapt to it. But I
think there has to be a better way. I put up with the bugs, the costs of expensive updates
I didn’t request but have to pay for anyway, the automatic decisions made for me about
formatting, spelling and so on. I’ve heard there are some alternatives to Microsoft, but
for now sticking with Microsoft seems the only way I can do business. And I don’t know
what the details, or the costs, would be of an alternative to the Microsoft system.
Proposals for health reform bring up similar feelings for many. In recent columns I’ve
written about the principles recommended for successful transition to a transformed
health system for rural and safety net providers. For example, the Rural Health Advisory
Committee put forward options for policymakers to consider. Among their ideas are:
• Redesign health care jobs and health care delivery for better coordination of
prevention and service delivery.
• Increase support for primary care and for educating primary care practitioners.
• Support use of proven cost-effective technology such as telehealth.
• Work toward universal coverage, making incremental changes along the way such as
improving insurance options for small employers and lower wage workers.
• Build on strengths of the rural system such as its Critical Access Hospitals, which
often serve as a hub around which to integrate and redesign community services.
Now that actual proposals are moving through the legislature, we can start to see what
health reform might look like. Under the health reform bills:
Providers would be paid for quality. For primary care, the measures contemplated—
coronary artery disease, diabetes, etc.—are already conditions commonly treated well by
rural and safety net providers. The bills propose paying for improvement, not just
meeting pre-set targets. The recommendations envision a single set of Minnesota quality
measures, and this may actually relieve some of the burden caused by the need to report
slightly different information to numerous payers.
Additional funds would be directed into primary care through new payments for
practicing in underserved areas and for coordinating care. Rural providers are already
experienced at coordinating care because needed services may not be closely or quickly
available. Under these provisions, they’d get more resources for this work. Other
provisions invest in primary care training and study health professional licensure to
ensure full utilization of the spectrum of health care professionals.
Some small and low-volume providers can face challenges to afford the infrastructure
investments needed to use and report quality information. In response, several provisions
propose new funds to assist the adoption of the technology and other infrastructure
improvements needed to report quality and establish medical homes. These would be in
addition to current state support for electronic health records, capital improvements and
community clinics.
The payment changes proposed in the bills are admittedly controversial. Many are making
their concerns known, and the proposals continue to evolve. For example, one provision
adjusts targets to account for features common to rural and safety net providers such as a
low patient base, high rates of poverty, or racial or cultural diversity.
At this writing, we don’t know what if any changes will become law. But we can start to
examine the details and compare them to the reform principles laid out by rural and
safety net leaders. And even though change is concerning, we also know that unless
things change the confluence of demographic, workforce and financial factors threatening
the rural health system will accelerate. Just like with Microsoft, there’s a price to keep the
current system or to change. I’m going to keep looking for a better way.
Microsoft, Encarta, MSN, and Windows are either registered trademarks or trademarks of Microsoft Corporation in the
United States and/or other countries.
Minnesota Rural Health Advisory Committee
Member Profile: ORHPC Talks With
Thomas L. Boe, D.D.S., M.B.A.
And your life away from work?
My life is structured by the school calendar. That allows my wife, Conni, and I to leave
our Midwest home in the summer and head to the mountains of Colorado where we fly
fish, hike and attend musical events that range from rock to opera. We head back to
Colorado during winter break, giving Conni and our 25- and 27-year-old sons a chance
to ski and snowboard those same mountains. My job is not to ski but to make the
peanut butter and jelly sandwiches that keep my family fueled on the slopes.
What do you think are the most important issues facing rural health?
The pat answer is also quite factual—the population is increasing, the number of
graduating dentists is decreasing and they lack the financial incentive to practice in a
rural area. In 1978, 150 dentists graduated with me. Now the average age of the
dentists in Minnesota is 55, and last year 94 new dentists graduated in Minnesota.
Graduating dentists are under tremendous pressure to quickly begin earning. A dentist used
to build a practice with the eventual goal of selling it as a nest egg for retirement. Now
there are few buyers so those same dentists work longer and then just close their practices.
A new dentist’s debt load almost precludes going to a rural area. When young dentists do
move to a rural area they may miss the forms of entertainment that a more urban area has
to offer and they may bring a spouse who will miss out on career opportunities.
Thomas L. Boe
PROFILE
Please explain your professional work to us . . .
After more than 25 years of practicing dentistry in rural and urban Minnesota and
Wisconsin, in 2005 I became director of Dental Assisting and Dental Hygiene Programs
at the Minnesota State Community and Technical College in Moorhead. I do some
teaching and I monitor both students and faculty. One aspect of the work that is
especially satisfying is the result of a successful grant proposal: Two years ago we opened
the Community Dental Clinic. The Clinic exists solely to provide comprehensive care to
underserved populations in our area. We wanted to fill a community need—something
that we felt compelled to do as a community school—and fill a need it does. If we had
enough staff we would be busy 24 hours a day and seven days a week. The phone rang
steadily after opening the clinic and within two weeks we couldn’t accept any more
patients. This has been a godsend to the area, with patients and even area dentists
contacting us to say “thank you.”
What we did not expect is the beneficial impact on our students. In the past our dental
assisting students’ hands-on work was delayed until the last 10 weeks of their education.
With the advent of the Community Dental Clinic these same students are observing in
the clinic during the first week of their first semester. By the end of their first semester
each student has actively assisted a practicing dentist. In their second semester they are
assigned to clinical sessions in which they perform the many functions they will be
expected to do during their dental assistant careers. This clinical experience also
enhances the classroom lectures by making the theory seem more practical and
important. Dental hygiene students start in the Community Dental Clinic during their
first semester by assisting second-year students treating patients. All of this—under the
supervision of licensed dental professionals—acts as a bridge between their education,
their internship and their practice in the workforce.
The Rural Health Advisory
Committee advises the
Commissioner of the Minnesota
Department of Health and other
state agencies on rural issues;
provides a systematic and
cohesive approach toward rural
health issues; and encourages
cooperation among rural
communities and providers.
Meeting information is online at
http://www.health.state.mn.us/
divs/orhpc/rhac/index.html or
contact Tamie Rogers at
[email protected]
or (651) 201-3856.
What do you think would make the most difference for rural health?
It is not realistic to have a dentist in every town. Instead, regional treatment centers
would serve the population and also benefit dentists who are required by the Minnesota
See “Profile”
(back page)
3
COMMUNITY FOCUS
Improving Access and Reducing Health Disparities:
Minnesota Community Health Workers
are Making a Difference
By Anne Willaert, Director of Project Design and Development for Healthcare Education Industry
Partnership, a project with Minnesota State Colleges and Universities System
Socioeconomic status, culture and language issues,
immigration or refugee status, the lack of health
insurance and transportation are all barriers to
accessing quality health care in Minnesota. Many
health care systems and organizations are discovering
the benefits of Community Health Workers, who
spread health information within their own
communities and act as links to the formal health
care system. Community Health Workers (CHW) are
becoming increasingly recognized and valued by
employers for their ability to bridge communities and
health care services where traditional approaches
have failed. CHWs work with diverse groups, such as
the deaf community, the aging population, refugees,
immigrants and other underserved populations. They
help individuals and families navigate the health and
social service system, they promote preventative
health care, and they link the uninsured to coverage.
The scope of their service is wide, ranging from oral
health to helping a client manage chronic disease to
working with pregnant and parenting women and
their infant children.
Odette Breton, public health social worker/
community health worker for Blue Earth
County, with Josefina and Salvador Alba.
Because CHWs come from the communities they
serve, they are working at the grassroots level to build
trust and vital relationships, making them effective
cultural brokers between their own communities and
systems of care.
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Community Health Workers:
• Increase health care access by helping their
clients navigate through the health care system
• Lower health disparities by providing their clients
with health care education
• Improve health outcomes by bridging the gap
between cultures.
CHWs are extremely effective and highly successful
in reaching underserved communities. As a result
they are increasing health care access and lowering
health disparities. A coalition of CHW employers,
health care systems, policymakers, community based
organizations and government agencies saw the value
in recognizing CHWs as health professionals. In
2005, a group of these stakeholders started the
Minnesota Community Health Worker (CHW) Project
with Blue Cross and Blue Shield of Minnesota
Foundation funding. This is a statewide initiative to
reduce cultural and linguistic barriers to health care,
improve the quality and cost effectiveness of care,
and increase the number of health care workers
who come from diverse backgrounds or
underserved communities.
The Project created a sustainable employment market
in Minnesota by incorporating CHWs into the health
care workforce. The Project developed and published
an 11 credit Community Health Worker Curriculum,
which is available to any accredited college. Between
2005 and 2007, 211 students enrolled in the CHW
training program, 145 graduated and of those 62
received scholarships. Seventy CHW jobs were newly
created. The Project is developing and offering
specialty training tracks for CHWs that include: oral
health, mental health, cancer, maternal child care,
heart and stroke. These new positions are called
“Community Paramedics and Community Dental
Health Coordinators.”
The Project published workforce analysis, outcome
analysis and other state and national studies to build a
foundation of support for the Community Health
Worker position. After identifying and gathering
information and documentation on the cost benefit
that CHWs bring to the health care system, and the
overall savings as it relates to meeting the needs of all
Minnesotans, the Project successfully advocated
passage of Minnesota Legislation mandating Medicaid
reimbursement for Community Health Workers.
Effective this year, CHW services—including patient
education, chronic disease management and other
services—will be reimbursable under Medicaid.
Alaska and Minnesota are the only states to have
Medicaid reimbursement for CHW services.
Pa Xiong, community health worker, and
Roxanne Tisdale, community connection
program coordinator, both with Open Cities
Health Center.
The Institute of Medicine (IOM) report, Unequal
Treatment: Confronting Racial and Ethnic Disparities,
identified CHWs as “a community-based resource to
increase racial and ethnic minorities’ access to health
care and to serve as a liaison between health care
providers and the communities they serve.” To
reduce and eliminate health disparities, the report
specifically recommends supporting CHWs as part of
a comprehensive, multidisciplinary team and as a
strategy for improving care delivery, implementing
secondary prevention strategies, and enhancing risk
reduction.
To eliminate health disparities and pursue Healthy
People 2010 goals, many Minnesota health programs
are turning to CHWs for their unique ability to serve
as bridges between health care services and the racial
and ethnic populations they serve. A developing body
of research indicates that CHWs have contributed to
reduced health care costs while significantly
improving community members’ access to care and
adherence to treatment. CHWs assume multiple roles,
including patient and community education, patient
counseling, monitoring patient health status, linking
people with health social services, and enhancing
patient-provider communication. Adding CHWs to
the patient-provider team has a beneficial effect on
the quality of care for populations most in need.
The statewide support has been absolutely
phenomenal. The momentum was illustrated during
the first ever Great Connections: Community Health
Workers as Agents of Change Conference in
November, when nearly 200 individuals came
together to discuss the Project, including how they
can work together to expand the use of CHWs
throughout Minnesota. Failure to fully integrate
Community Health Workers into public health
programs will result in increased health care costs
because of the unmet health care needs of the
underserved and untreated chronic diseases. Health
may be enhanced for all Minnesotans by continuing
to build on this momentum to expand CHW services
across the state.
Adar Kahin came from Somalia 12 years ago. She is
a community health worker, primarily in the CedarRiverside neighborhood of Minneapolis, where she
conducts home visits to teach Somali women about
breast cancer and mammograms. These are a few of
her thoughts about her work with the Somali
Women’s Breast Cancer Project, Minnesota
International Health Volunteers.
My favorite part of my job is doing home visits
because I meet a lot of different people. Sometimes
people don’t want to talk to me at first. Sometimes,
people assume I am also a doctor because I am
talking to them about health. Women make me tea,
we talk about Somalia, how people are doing back
at home. Most people are very welcoming.
Some women see me on the street and ask me
when I am coming to their house to talk about
breast cancer.
I remember one lady, maybe 70 years old. She did
not want a mammogram. I talked to her for a long
time. After I explained breast cancer many times,
she accepted. I told her that maybe right now she
might have cancer, and if she gets a mammogram
the doctors can find it and treat it. If she doesn’t
go, she will never know until it is too late.
Another lady said she didn’t want to go because
maybe they will find cancer, and she just didn’t
want to know. I said, maybe you don’t have it,
don’t think the worst all the time. Just know that
when you go you could find out you are healthy.
Just go to make sure you are healthy. It’s good
for you.
5
PROGRAM FOCUS
Electronic Health Records: Getting There
by Anne Schloegel, Technology Projects Planner for the Office of Rural Health and Primary Care
National and state policymakers around the
country are focusing on how to achieve better
health outcomes for the population while controlling
the unsustainable growth in health care costs. An
important tool for achieving a comprehensive solution
to these complex problems is the use of health
information technology. The adoption and effective
use of health information technology can play a
significant role in transforming the health care system
and in supporting healthier communities. (Legislative
Report on the Minnesota e-Health Initiative*)
A major piece of health information technology is the
electronic health record (EHR). Electronic Health
Record systems are rapidly evolving and becoming
more standardized to meet the needs of clinicians and
consumers. These EHR systems are viewed as the
foundation for the future health care system.
Minnesota law states that by 2015, all Minnesota
health care providers are required to have an
interoperable EHR in place. Recognizing the cost
associated with achieving that goal, the 2007
Legislature appropriated $7 million for an
Interconnected Electronic Health Record Grant
Program and $6.3 million for an Electronic Health
Record Loan Program for 2007-2009, and directed
the Minnesota Department of Health to target the
funding toward providers serving rural and
underserved populations. This follows an initial $1.5
million appropriation for e-Health grants in 2006.
2006 e-Health Grants: The results are in
The Minnesota Department of Health awarded the
first 11grants in 2006.
• Cuyuna Regional Medical Center, Longville
Lakes Clinic, and Central Lakes Medical Clinic
made significant progress on the implementation
of a fully interoperable EHR. Two areas targeted
for initial information sharing between the clinics
and the hospital are the emergency and preoperative surgery departments.
• Willmar started development on a Personal
Health Record (PHR) with Stratis Health.
The project completed significant formative
work to create a PHR to meet the needs of the
Willmar community.
6
• A Health Information Exchange Toolkit was
developed with the following organizations:
Minnesota Health Care Connection, Itasca
County Health Network, Community Health
Information Collaborative and Stratis Health.
• Pine Medical Center (Sandstone) implemented
the same EHR used by neighboring Mercy
Hospital and Healthcare Center (Moose Lake).
Gateway Family Health Clinic purchased software
that enabled their Moose Lake, Cromwell,
Sandstone and Hinckley locations to share
information with the hospitals.
• Lakeview Medical Clinic, part of the Sauk Centre
community collaborative, validated a partnership
with the clinic, two pharmacies and the local
hospital. All partners participated in an e-Health
needs assessment and vendor selection process,
and in the initial implementation of an
e-Prescribing system.
• Neighborhood Health Care Network, St. Paul
(Community Care Network Project) identified
key clinical information and data elements for
exchange and determined the most effective
mechanisms for transmitting that information
across care systems for patients with diabetes.
• Roseau Area Hospital (now LifeCare Medical
Center) is transmitting electronic prescriptions
between the hospital and the local pharmacy.
• The Community Health Information Collaborative
(CHIC), Duluth successfully implemented secure
e-mail, which is encrypted e-mail communications
that allow for safe and confidential transmission
of patient information, at three facilities.
• Ortonville Area Health Services used an
assessment and planning process that made this
health care organization and its collaborating
partners more aware of their current electronic
technology capabilities. As a result, Ortonville
Area Health Services and Northside Medical
Center set a goal to build a shared EMR system
that will allow more complete information to be
available to the care providers, no matter which
entity is delivering that care.
• Tri-County Hospital and Wadena Medical Center
implemented an EHR within their clinics,
providing valuable tools for the hospital EHR
implementation. Developing a fully integrated
electronic health record with the clinics, hospital,
a rural radiologist practice, a skilled nursing
facility and public health remains the goal.
Thorough and systematic planning for EHR
implementation is critical to achieving success but it
takes time—almost always longer than anticipated!
Setting modest, doable objectives and involving
key stakeholders in the entire process is essential to
ensure that everyone thoroughly understands the
project goals.
• Lac qui Parle Health Network (LqPHN)
developed a Strategic IT Plan for each of their
independent members: Johnson Memorial Health
Services of Dawson; Madison Lutheran Home,
Madison; and Appleton Area Health Services
of Appleton. A consulting firm developed a
Strategic Plan unique to each organization,
which included cost of ownership projections;
technical assessments and recommendations
along with estimated benefits for the collaborative
ownership of an EMR system through the
LqPHN. As a result of these activities, LqPHN is
participating in the HRSA CAH HIT
demonstration project grant program
Resources are vital, such as using a dedicated project
management staff and training staff from all of your
sites at a single event. Engaging internal staff and
adequately preparing those impacted directly is a
critical success factor because gaining everyone’s
commitment to the EHR process is essential.
Lessons Learned
Our grantees learned some valuable lessons.
Among them:
More information about the EHR grant and loan
programs is online at
http://www.health.state.mn.us/divs/orhpc/funding/
index.html or contact Anne Schloegel at
(651) 201-3850 or
[email protected].
*Legislative Report on the Minnesota e-Health
Initiative, February 2008 online at
http://www.health.state.mn.us/ehealth/legrpt2008.pdf
• In rural areas, funding EHRs along with other
capital expenditures, is a major financial strain.
• Budgeting time and staff for EHR implementation
is challenging as staff usually have both
management and direct patient care
responsibilities.
• Some EHR products are not a good fit in a rural
health care setting where the hospital, physicians
and long term care are often a single entity.
• A comprehensive needs assessment is crucial for
selecting the right product and consultants can
play a valuable role.
• Determining your organization’s readiness to
participate with action plans to overcome barriers
as they arise is an asset.
• Agreeing on the model helps manage competing
priorities and differing motivations.
• Selecting the right EHR product for each type of
health care provider can be challenging as the
required features can be substantially different.
7
Profile (from page 3)
Mark Schoenbaum, director
Mary Ann Radigan, editor
Cirrie Byrnes, editorial assistant
To learn more about the
Office of Rural Health & Primary
Care programs, visit our Web site:
www.health.state.mn.us/divs/orhpc
This information will be made
available in alternative format –
large print, Braille, or audio
tape – upon request.
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or request other arrangements by
contacting Cirrie Byrnes at
[email protected]
or (651) 201-3844.
85 E. 7th Place, Suite 220
P.O. Box 64882
Saint Paul, Minnesota 55164-0882
Board of Dentistry to be on call. We also need to find ways to encourage older dentists
to continue practicing longer than they may have originally planned. This would only
be a stop gap measure and not a long term solution. For the long term we must find
mechanisms that will encourage younger providers to go rural and stay rural and
many of the changes we need are legislative.
A relatively high percentage of Medical Assistance patients live in rural areas and Medical
Assistance reimbursement is quite low. Without the Minnesota State Community and
Technical College facilities and grants we could not operate our community dental clinic.
We also have staff working through Medicaid’s rules on a daily basis but in a private
practice—to compensate for the mountain of paperwork—the reimbursement rate would
need to be 150 percent of what is considered “normal and customary fees” to make up
for the additional time spent wading through the bureaucracy.
Loan repayment incentives exist but they must reflect the true cost of education.
Emphasizing the high cost of dental education, the University of Minnesota guarantees
over $200,000 in loans for every incoming student—the average debt of a University
of Minnesota Dental School graduate is $180,000. The University of Minnesota
should also receive incentives for increasing their enrollment—especially for rural
residents who are more likely to practice in a rural area.
The tax code should be changed to eliminate the tax on every provider’s gross receipts
or at a very minimum use these funds to increase access to care instead of allowing
these funds to fall into the general fund.
We have a crisis now and the crisis that is looming is even larger. With legislative
action we may begin to see a future in which all Minnesotans will receive the dental
care they need.