Through our exceptional health
care services, we reveal
the healing presence of God.

December 2012 

In This Issue

Reminder: SSM and Dean Policy More Strict Than HIPAA
Black Tie & Blue Jean Blitz
Problem List is No Longer a Problem!
6 West Now for Observation
Hybrid Surgical Suite in Full Operation
Major Drug Supplier's Uncertain Affect Pharmacy
New Bike Lockers are Brainchild of Colleagues
Physician Resource Center Library Hours
Physician Spotlight: Leila Midelfort, MD
Honors and Recognitions

Physician Breakfast: December 20
7-9 a.m. St. Mary’s PRC

Annual Medical Staff Meeting: January 15
7-8:30 a.m. St. Mary’s Bay 1

CME Grand Rounds: February 7
7-8 a.m., St. Mary's, Bay 1
“Alcohol Withdrawal Management ”

Cardiology Conference: March 1
8 a.m. - 5 p.m. St. Mary’s Bay 1

2012 Goals
  1. Achieve 100% on all 5 core measures
  2. Restructure our peer review system
  3. Engage medical staff in improving the quality and safety outcomes of our patients
  4. Improve the patient experience
  5. Improve physician satisfaction and engagement
  6. Increase physician input and participation in hospital decision-making

    From the Medical Staff Directors—
    Reminder: SSM and Dean Policy More Strict Than HIPAA

    Several instances of inappropriate physician use of the medical record have come up recently. This is in part due to SSM Health Care policy being slightly different from state regulations. As we look to start a brand new year, it seems like a good time to clarify SSM’s privacy compliance policy and provide helpful information.

    HIPAA regulations state that no one may access, use or disclose a patient’s health information without having either a business reason for doing so or a legal right to have the information. This means, among other things, that HIPAA strictly limits us in accessing the medical records of spouses and adult children.

    Furthermore, while HIPAA does not prevent us from accessing our own records or those of our minor children, SSM corporate policy does. SSM (and Dean Clinic) policy states that no employee or physician may enter any medical record without a business reason for doing so. This includes our own medical records, those of our children, both minor and adult, our spouses and partners, and any other person whom we are not treating. We realize that some systems and clinics DO allow physicians to access their own medical records, so please note the SSM policy for when you are accessing St. Mary’s Hospital/Dean Epic.

    One alternative to accessing your own record or the records of your family members would be to use MyChart. For Dean Clinic patients, MyChart can be found at mychart.deancare.com. You can find specific instructions on signing up by clicking on “Sign Up Now” in the yellow box designated for first-time users. (Other health care networks also have My Chart, usually found on the provider’s website home page.) In addition to using MyChart, any person may request a printed copy of his or her medical record from St. Mary’s Health Information Management; that office can be reached at 608.258.6689.

    Charts are regularly monitored for violations of these policies. Those found to have stepped over the line will be discussing their actions with the Medical Directors and one of our compliance officers. Those same actions will be reported to the Medical Executive Committee, who will decide what disciplinary action, if any, should be taken.

    We emphasize that this is SSM corporate policy, and we as medical directors do not have control over this policy. Nevertheless, we welcome the opportunity to discuss any of your questions or concerns. Please feel free to contact any of us about this or other matters.

    Happy Holidays!
    St. Mary’s Hospital Medical Staff Directors

    Kay Barrett, Lee Carter, Timothy Crummy, James Goodsett, Anne-Marie Lozeau, Kyle Martin, Jeff Welch

    Black Tie & Blue Jean Blitz
    Annual Medical Staff Appreciation

    Friday, February 8
    Monona Terrace

    Mix it up and live it up in honor of the different professional styles that make up our amazing health care partnership. It’s a night to celebrate in style, whether you’re wearing a tuxedo or jeans, evening gown or denim skirt, wingtips or boots, heels or sneakers. You won’t want to miss this evening. Fantastic food and fun are guaranteed! Mark your calendar and watch for more details to come.


    Problem List is No Longer a Problem!
    An accurate, up-to-date problem list is the best place for a quick overview. Thanks to many of you, Problem List use has markedly increased. Reports show that, since Epic improvements last May, at least one Hospital Problem is now identified in 93% of patients, which is up from 44%. And the Principal Problem is now identified 34% of the time, up from 22%. Congratulations!

    Why is this important?
    • An accurate, up-to-date Problem List allows all providers to consider all of the patients’ medical conditions. The result is better treatment decisions.
    • Decision-making is predominantly based on information in the Problem List. Accuracy is critical.
    Why the improvement?
    Providers own the Problem List. Any improvements are due to their conscientious use of this tool. Three changes have occurred that have helped make use of the Problem List less onerous.
    • The Problem List is now conveniently located as an action button in each inpatient Navigator.
    • The Admission Order Sets require an admission diagnosis. That admission diagnosis is automatically added to the Problem List.
    • Using of the Smart Link .HProbList automatically adds the Hospital Problem List to your progress note. This helps focus the note impression and plan while encouraging updating the List to be more specific and accurate as the patient’s condition changes during the hospital stay.
    —Jim Porter, MD

    6 West Now for Observation

    The sixth floor of the West Wing opening January 6 will become a dedicated unit for observation patients.

    The unit monitors patients who sought emergency help for an acute clinical condition and whose need for acute care hospitalization is unclear after their initial evaluation. 6W will open first as a six-bed monitored unit for patients with an unclear chest pain diagnosis. It will expand to 21 beds with an additional set of predefined diagnoses. The new unit will free up the current chest pain observation unit in the ER and will consolidate all observation cases to one area. The new unit will be overseen by hospitalists as well as nurses from the cardiovascular care unit. Mary Kay Leonard (director, 4E) and Denise Mitton (emergency cardiac coordinator) will provide the initial interim leadership for this unit.

    Hybrid Surgical Suite in Full Operation
    A new hybrid surgical suite opened this fall on 2 East, providing advanced medical imaging during an array of heart and vascular procedures. The suite has been activated as an approved site for performing Transcatheter Aortic Valve Replacement (TAVR). The core TAVR Heart Team (a requirement of both the FDA and CMS) is headed up by Dr. Russ Reiss and is expected to begin offering that procedure in January. The Heart Team brings together surgery and medicine in a unique way. Doctors Reiss, Phelan, Kantamneni, Jung, Bachhuber, Kleiber, Itani and Snider, along with valve coordinators Michelle Anderson and Erika Warren, represent the core. Other procedures include Endovascular Aortic Aneurysm Repair (EVAR), Mini Sternotomy AVRs, Hybrid Coronary Revascularization and Hybrid Peripheral Vascular interventions. The hybrid team is composed of staff from the cath lab and the cardiovascular operating room.

    Major Drug Supplier’s Uncertain Status Affects Pharmacy
    The closure of Ameridose has significantly impacted the Pharmacy Department, and perhaps your patient’s care. Read more.

    New Bike Lockers are Brainchild
    of Colleagues

    Thanks to avid cyclists Dr. Tracy Cotter, Dr. Dave Decock and nurse-anesthetist Rodney Galstad, five weather-tight lockers will arrive soon for use on a first-come, first-served basis. The lockers, likely to be placed in the Park Street Ramp, will accommodate 10 bicycles. Users must provide their own locks. Dr. Cotter worked with St. Mary’s Foundation on the project and provided the funding for the lockers. Thank you, Tracy!


    Physician Resource Center Library Hours
    Currently we staff a satellite library in the Physician Resource Center from 7 to 9 a.m. Monday through Friday. In October and November, we piloted lunchtime hours in the PRC. Now we’d like your feedback on our staffed hours in the PRC. When you have a minute, please complete this short survey. We appreciate your feedback! 


    Physician Spotlight: Leila Midelfort, MD
    Leila Midelfort has roamed the halls of St. Mary’s since she was a kid, enjoying a community feeling that has seeped into her own health care practice today at Wildwood Family Clinic and St. Mary’s Hospital.

    Professional Information: Dr. Midelfort joined Wildwood Family Clinic in 2009, serving the Cottage Grove office, after finishing her UW Family Medicine Residency at St. Mary’s. Her medical interests include women’s health, maternity care, Spanish and Latino health and access to health care issues.

    Previous Positions: From 1999-2001, she worked in the Peace Corps in Honduras, where she was introduced to the field of medicine because she did medical translating for brigades that came to that rural area.

    Further back into her past, she and her brother would often substitute for a neighbor whose newspaper route included patient rooms at St. Mary's. In addition to getting good tips, she loved the route because of the chance to interact with people and not just drop off the paper on people’s doorsteps.

    Special Interests: Dr. Midelfort has rowed for many years with crew and loves the meditative process along with the camaraderie of this sport. However, these days her attention is taken up more by her 3-year-old twins and enjoying time with them. She is proud of her association with St. Mary's because of the great community feel of this hospital where people know one another by first name.

    One thing she would change about health care in general for the good of our community is to provide good, sustainable health insurance to everyone.

    New Faces on the Medical Staff Click here.

    Honors and Recognitions
    Congratulations are in order for institutional successes and for our colleagues who go above and beyond the duty of their day (or night) jobs. 

    Dr. Frank Byrne, president of St. Mary’s Hospital, was made an honorary alumnus of St. Mary’s School of Nursing. Even though the school closed in 1974, the alumni organization still has nearly 1,000 members.


    Dr. Cynthia Haq was inducted into the Wisconsin Academy Fellows, sponsored by the Wisconsin Academy of Sciences, Arts & Letters. A Wisconsin resident since 1983, Dr. Haq has worked to improve health care and medical education to address the health needs of communities near and far. At the University of Wisconsin–Madison, she is a professor of family medicine and has enjoyed caring for patients in rural Belleville, Madison, and Milwaukee. She loves teaching, has led educational programs for the Department of Family Medicine, and has designed and implemented patient-centered communication curricula. In Milwaukee, she established the Training in Urban Medicine and Public Health (TRIUMPH) program to prepare medical students to become physician leaders to care for medically underserved urban populations.

    Dr. Haq has promoted global health in Wisconsin and abroad. She served as a visiting professor to strengthen health professional education and to establish family medicine training programs at Aga Khan University in Karachi, Pakistan; at Makerere University in Kampala, Uganda; and at Addis Ababa University in Ethiopia. She worked with the World Health Organization and World Organization of Family Doctors to co-author the book Improving Health Systems: the Contribution of Family Medicine (2002), which encourages development of health systems built on a strong foundation of community-based primary health care. She collaborated with UW colleagues to establish the Center for Global Health to catalyze global health education, field programs, research, and partnerships in low-resource settings.

    Guardian Angels:
    Nine physicians have been honored as Guardian Angels during the second and third quarters of 2012 for their exceptional care. Patients and families have made a gift to St. Mary’s Foundation to honor the following physicians:

    Dr. Richard J. Baker

    Dr. Jensena Carlson
    (Family Medicine)

    Dr. Joseph Fok

    Dr. Patrick Huffer
    (Family Medicine)

    Dr. Gregory H. Motl
    (Internal Medicine)

    Dr. John Phelan

    Dr. John Snider
    (cardiovascular surgery)

    Dr. Matthew Swedlund
    (Family Medicine)

    Dr. Gary E. Waters




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