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ROGER WILBUR describes his life as “controlled chaos.” With three young boys at home, Roger produces up to 38,000 bales of hay each year, drives a school bus and makes maple syrup. His life slowed down considerably following a routine day cutting trees on his property.

“I was carrying a 12-foot length of an ash tree on my shoulder,” says Wilbur. “As I was coming out from the woods through the snow, I slipped and it started to roll. I bounced it on my shoulder and that caused a herniated disc in my neck.” When he went to see his local chiropractor, his arms jumped during a procedure. It felt like cold water was running down his arm, he recalls.

Roger later had an MRI and immediately went to the Dartmouth-Hitchcock Spine Center to see an orthopaedic spine specialist. After trying cortisone injections, which were only effective short-term, Roger’s spine surgeon, Dr. William Abdu, suggested

that surgery would likely be effective in his case.

“I was a little nervous. I’ve had multiple surgeries before but this was a whole lot more involved,” he said. Roger felt Dr. Abdu prepared him well for the surgery. “I knew going in what the process leading up to surgery was going to be like.” The outcome was even better.

“For the first time in almost a year I could feel the hair on my leg with the back of my hand as I lay in the hospital bed. I didn’t have any pain.” The recovery process was tough. “Complete inactivity! I’ve never been in a position to not do anything before, but I followed exactly what Dr. Abdu told me to do. After I got the clearance to start using my 10-pound chainsaw, I was able to start moving around more.” Roger couldn’t be happier with the outcome. “In hindsight, the surgery was the best thing. It was the best choice I could have made.”

ONE LIFE: A PATIENT EXPERIENCE

Roger Wilbur, spine surgery patient and

active father, farmer and bus driver

contents

2 Forging Partnerships

8 Creating a Healthier Community

10 Just Like Showing Up in the ER

14 Creating Better, Safer Surgical Care for Patients—Everywhere

18 Patients as Teachers

21 Snapshots in Giving

22 D-H Briefs

24 Giving Futures

credits

Editors Victoria McCandless Kate Villars Managing Editor

Anne Clemens Design Erin Higgins David Jenne Writers Steve BjerklieDana Cook GrossmanTim DeanJennifer DurginVictoria McCandlessKate Villars

Photography Mark WashburnUnless otherwise noted

Published by Dartmouth-Hitchcock Communications and MarketingOne Medical Center DriveLebanon, NH 03765

dartmouth-hitchcock.org All contents © 2014.

Forging partnerships is not new for Dartmouth-Hitchcock. In fact, it is part of the organizational DNA.

2

FORGING PARTNERSHIPS: THE REAL MEANING BEHIND “IMPROVING POPULATION HEALTH”

DEANNA HOWARD’S business card reads: “Vice President of Regional Development for Dart-mouth-Hitchcock.” But it would be just as accurate to call the former music teacher a band leader: some-one whose goal it is to keep the beat for a varied ensemble, help its members stay in synch, but allow them to contribute individual trills and flourishes.

Today, a whole suite of health-care organizations—from Upper Con-necticut Valley Hospital (UCVH) near the Canadian border to institutions in southern New Hampshire and Vermont—make up Howard’s “band.” She builds relationships with hos-pitals, physician groups and home health agencies across the region, forging affiliations with other orga-nizations committed to what she and her colleagues call “population health.” That is, not just caring for patients who walk through the door, but embracing responsibility for the health of a region’s entire population.

Forging partnerships is not new for Dartmouth-Hitchcock (D-H). In fact, it is part of the organizational DNA. The institution has supplied spe-cialists to the region’s rural reaches since the 1960s, and in the 1980s it established a consortium of a dozen health-care organizations called the Dartmouth-Hitchcock Alliance, which now has transitioned to the New England Alliance for Health (NEAH) with 17 member organizations.

New London joins the D-H FamilyToday, the number of such partner-ships is increasing, and their scope is broadening. For example, New London Hospital recently entered into an affiliation after a long-standing relationship with D-H. “It’s a sub-sidiary model, not an asset merger,” says Bruce King, CEO and president of New London Hospital Association (NLHA). “Our employees are not becoming Dartmouth-Hitchcock employees. But major decisions we make—like approvals of budgets or incurring of debt—will be ratified by Dartmouth-Hitchcock.” In addition, a third of the members of NLHA’s board are now appointed by D-H.

New London Hospital is a small but complex institution that is very much a part of its community. It comprises a 25-bed hospital, a 58-bed nursing home and outpatient clinics in New London and Newport, with a staff of nearly 50 physicians and associate providers and an ambulance service. All the beds are “swing beds”—meaning, explains King, that the nursing home beds can be occupied by patients who need “either a skilled level of care or long-term care,” while the hospital beds are certified for “acute status, or we can move them down to skilled status.”

And therein lies one of the big benefits of the affiliation. Previously, King says, “I’d go up to Dartmouth-Hitchcock, and I’d hear people there talking about

Cheryl Abbott, RN, left, and Kate McDermott, RN, conduct a balance

test with patient.

Deanna Howard, right, leads one of many meetings with D-H leaders and community partners.

3

being at capacity, meaning every bed was filled,” and needing to send critically ill patients to Boston because no beds were available at D-H. “Then I’d come back down to my facility,” continues King, “and I’d see that we had empty beds—a fallow asset.” But for various arcane reasons, including federal regulations, two unaffiliated hospitals can’t share an “asset” like an empty bed.

But that’s no longer the case. If D-H has a patient who needs the tertiary- care (or specialized, consultative care) services that only a major academic center can provide, but has no free beds, it’s likely that in one of those full beds is a patient who no longer needs tertiary care but isn’t quite ready to go home. Now, that second patient can be transferred to New London Hospital—freeing up a D-H bed for the more acute patient.

In turn, New London Hospital patients gain D-H subspecialist expertise. “We serve about 33,000 people,” says King. “That population doesn’t support a fulltime ‘–ologist’—oncologist, cardiologist, whatever. And you don’t want a specialist sitting here who’s not busy. So a cardiologist comes down from D-H two days a week, a level that doesn’t exceed the demand. It makes a lot more sense to have a specialist visit a community, than to have 33,000 people driving up to D-H to see a specialist.”

In short, he concludes, both parties to the affiliation are saying, “Let’s do the right thing for this population. Let’s provide the right care within our total resources and not worry about who gets credit for the dollars or who provides the service.”

For various arcane reasons, including federal regulations, two unaffiliated hospitals can’t share an “asset” like an empty bed.

Bruce King, CEO and president of New London Hospital Association, says that the affiliation with D-H will allow New London Hospital to enhance and expand its offerings to the New London community.4

Relationships on the Horizon

Mount Ascutney Hospital in Windsor, Vermont, and Valley Regional Medical Center in Claremont, New Hampshire have similar affiliations with D-H. The CEOs of the three small hospitals meet monthly with Howard, along with Stephen LeBlanc, executive vice president for Strategy and Network Relations, and other D-H officials to confer and share ideas. Recently, D-H has entered into affiliate discus-sions with Alice Peck Day Hospital in Lebanon, NH and Cheshire Medical Center in Keene, NH.

While the affiliation between D-H and New London Hospital is still in the early stages, there are mutual benefits that could soon be realized. A big one is compatibility among the institutions’ electronic patient record systems. “There’s an expectation that soon we will be freely exchanging clinical information,” says King, “that if care is rendered at Dartmouth-Hitchcock, information about it comes back to us.”

Both D-H and its partners would like to see integration in another area, too. “I have full accounts-payable and payroll and human resources systems,” says King, “while 30 miles

With the demand for inpatient care growing, making sure that the right patients are admitted in the right areas to receive the right care can be a challenge.

To help address the bed-management problem, two new D-H inpatient units opened in the last year. A 15-bed, Medical Specialties Unit opened last July, and a 14-bed Critical Care Unit, opened in January 2014. All of these beds are available for occupancy on a 24/7 basis. “These units will allow us to continue to take care of the broad array of medical, surgical, trauma, neurosurgical and other patients requiring critical care,” explains Ed Merrens, MD, chief medical officer.

“The major reason for creating these

units is to address our longstanding issue with capacity,” says Linda von Reyn, RN, PhD, chief nursing officer. “On weekends our patients tend to discharge to home; we don’t have scheduled surgery currently on weekends, so we tend to decrease our volume a bit. But by the time we get to Monday afternoon, every single bed in our hospital is filled. And as we go through the week, we have patients who need our care either because they have a serious emergency, or they’re in outlying hospitals and need a higher level of care than can be provided there. We need to make sure we have enough room for those patients to come here.”

“To deliver the best care, partnering with critical access hosptials to better manage patients is crucial,” says

Merrens. “As we begin to expand our telehealth footprint, we’re exploring more ways to enable patients to get the care they need in regional locations, closer to home but still with access to our expertise. With this approach to care, we can ensure we take the patients who absolutely need to be at our facility. For those patients who can instead get excellent care in New Hampshire communities, such as at Crotched Mountain specialty care in Greenfield, Cheshire Medical Center in Keene or New London Hospital, our patient-centered partnerships are designed to support that. If we stay focused on quality, safety, and value, and, at the same time, reduce costs, we’ll be doing the right thing for our patients and the communities we serve.”

New Units Unjam Bed TrafficAs northern New England’s tertiary referral center, DHMC 0perates at nearly 100 percent capacity Tuesday–Saturday.

5(continued on page 6)

away Dartmouth-Hitchcock is doing the same exact things. Aren’t we duplicating functions and isn’t there a more cost-effective way to do this?”

There is, agrees D-H’s LeBlanc. “Every one of those affiliates and Dartmouth- Hitchcock don’t need to do their own patient billing, their own accounts pay-able—those back-office functions can be consolidated and that’s our vision.”

Howard notes that D-H takes a symbi-otic approach to forging relationships. “In some systems, the institutions are

completely merged,” she says. “In a merged system, you have more of a cookie-cutter approach. Here, we try to collaborate in a way that’s bringing value, but isn’t cookie-cutter. I think that differentiates us.”

In fact, there are many other kinds of relationships in D-H’s portfolio beyond the NEAH, the management services at the three hospitals and the latest affiliation discussions. Through an arrangement with Mayo Clinic, D-H and Mayo neurologists offer a “telestroke” service at Catholic Medical

Center in Manchester. (See story, page 10.) A collaboration with Boston Children’s Hospital is strengthening pediatric services for the region. And D-H was approached a few years ago by Southwestern Vermont Medical Center in Bennington, notes Howard. “They said, ‘Can you help us build a multispecialty group practice? You’re well known for that model, and we think it’s an essential need in our community.’” Today, Dartmouth-Hitchcock Putnam Physicians provide medical services in the Bennington community.

D-H is also a partner in two ac-countable care organizations, a new care-delivery model that bases pay-ments on the quality of care provided to a defined population, rather than on the volume of services. Both are for Medicare patients—one focused on New Hampshire, called D-H’s allwell™ ACO, and one created with Fletcher Allen Health Care in Burlington, VT, called OneCare Vermont. D-H, Fletch-er Allen, MaineHealth, Dartmouth College and Eastern Maine Medical Center have collaborated to assist with data support for these new models.

“In a merged system, you have more of

a cookie-cutter approach. Here, we try to collaborate in

a way that’s bringing value, but isn’t

cookie-cutter. I think that differentiates us.”

Daniel Morrison, MD, and Gatia McChesney, RN, at New London Hospital, do a follow-up

consultation with a D-H patient. 6

Beyond Building Relationships

Establishing relationships with other organizations is not a move to make D-H larger, but rather to fulfill the institution’s mission to help create a sustainable health system and improve the health of the region.

LeBlanc explains three key principles that drive D-H’s mission. “One is around population health,” he says. “There are still some places that are content with creating relationships based primarily on sustaining the academic medical center as the referral hub, to feed business into the medical center. Their thinking is ‘I’ve got a big infrastructure to support, so I’ll create relationships that ensure continued growth of my market share.’ But we take a more distributed, population- based approach. We want the right care to be delivered, in the right place, at the right time. We also need to en-gage more actively with our communi-ties and employers to improve health.”

“Number two is focusing on the value of the care we provide. How can we be as efficient as possible? How can we re-duce costs while improving outcomes? And the third principle is the need to change medicine’s payment model—to move away from payments based on quantity to payments based on episodes of care, on populations, where providers are held accountable for the outcomes and the costs.”

“Our strategy,” LeBlanc concludes, “is trying to move those three things forward. But D-H can’t do that alone. We need to partner with others across our region.”

IN DECEMBER, Dartmouth-Hitchcock (D-H) joined with CVS Caremark to open six MinuteClin-ics around New Hampshire, with a goal of enhanc-ing access to high-quality, affordable health care in the region. Under the agreement, D-H family physicians serve as medical directors for the Minu-teClinics and collaborate on patient education and disease management initiatives. Clinics are located in West Lebanon, Concord, Salem, Hampton, Man-chester and Nashua. Now, a non-D-H patient can get affordable, quality care on a Saturday afternoon or any day of the week without the need of a costly emergency department or hospital visit.

The MinuteClinics are staffed by licensed nurse practitioners who provide treatment for acute illnesses and administer wellness and prevention services, including health condition monitoring. The medical directors provide support and review care

quality. They also serve as liaisons between commu-nity physicians and the MinuteClinic sites in order to enhance collaboration and coordination between providers, patients and families.

Importantly, these clinics will provide a resource for the underserved and uninsured, and bring more patients into managed primary care. “By providing a convenient, low-cost option for care, we be-lieve we can improve the health of the population while reducing use of emergency rooms and other expensive care sites for routine illnesses and minor injuries,” says Ethan Berke, MD, MPH, director of Population Health Innovation and leader of the D-H Lebanon Community Group Practice (pictured above). “Access to the clinic care teams should also help with early diagnosis and management, particu-larly of chronic disease, giving people the timely and appropriate care they need.”

Convenient low-cost care through MinuteClinics

7

D3202MC13

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is a clinical affiliate of

Creating aHealthierCommunity

An Interview with Don Caruso, MDMedical Director of Dartmouth-Hitchcock

Keene/Cheshire Medical Center

Imagine: What role does D-H Keene/Cheshire Medical Center play in D-H’s vision of improving population health across the region?

Dr. Caruso: Population health is about improving health outcomes and not just health care delivered to a population. D-H Keene/Cheshire Medical Center improves these outcomes by integrating how health care is provided in our medical practices with the community-based interventions that make the most sense for our population. When the resources don’t exist, we help develop them or advocate and utilize what is there.

Childhood obesity is a good example of a problem we’re working to improve. When one of our primary care physicians identifies a child at risk for obesity, the physician connects the child and his or her family to our nurse care coordinator—an advantage of being in a patient-centered medical home. The nurse coordinator connects the family to community-based programs that teach the family how to shop and select appropriate foods, how to exercise and improve the child’s health options. These approaches and community advocacy have gone a very long way in making our community healthier.8

“Our efforts have reduced admissions due to respiratory ailments by 48 percent.”

Imagine: D-H Keene/Cheshire Medical Center has long been central to improving the health of the communities in your service area. What are your current goals for the community?

Dr. Caruso: Our “Healthy Monadnock 2020” initiative has a goal to make the Monadnock region the healthiest community in the nation by 2020. We’re engaging community organizations (businesses, non-profits, churches and schools) to become health champions and help us improve the environments in which we all live, learn, work and play to make the healthy choice the easy choice for all. On our own campus this translates into increasing access to healthy food through our cafeteria’s low-cost salad bar, offering a seasonal farmer’s market and increasing opportunities for physical activity with our 1.5 mile walking path and “Take the Stairs” campaign.

Recently, our Healthy Monadnock work was recognized by the American Hospital Association (AHA) with the Carolyn Boone Lewis Living the Vision Award. The award is given only when an institution fits the AHA’s vision of a “society of healthy communities where all individuals reach their highest potential for health.” This award is a tremendous honor for our staff, physicians and community.

Imagine: How is D-H Keene/Cheshire Medical Center increasing the value of health care by focusing on high-quality care at lower costs?

Dr. Caruso: As primary care providers, we can reduce costly hospital admissions and readmissions by focusing on disease prevention and chronic disease management. Our efforts have reduced admissions due to respiratory ailments by 48 percent. And, by checking in with patients within 24 hours of their discharge, our care coordinators have lowered the overall readmission rate to eight percent.

Well beyond saving money, prevention saves lives. Here in Cheshire County, for example, coronary artery disease is the leading cause of disability and death. We implemented a new blood pressure initiative and care delivery model and have improved blood pressure control (readings of less than 140/90) from 69 percent of patients in 2010 to over 84 percent of patients in 2013. This included all providers at D-H Keene/Cheshire Medical Center—including satellite offices and specialty departments—and community partners such as the Keene Family YMCA, Home Healthcare, Hospice and Community Services, area workplaces, etc. Now, when a person has their blood pressure checked in select places around our community, they’re being referred to D-H Keene services that will help them avoid a health crisis. 9

10The power of telehealth connects health care facilities in the region with the expertise of Dartmouth-Hitchcock.

IN THE ER

JUST LIKE SHOWING UP

The multi-platform Telehealth program, launched last year, brings Dartmouth-Hitchcock and partner expertise to rural hospitals to treat patients close to home.

THE PATIENT who arrived at the emergency room at Catholic Medical Center (CMC) in Manchester, New Hampshire, one Thursday night in October showed acute signs of stroke. But a CT scan didn’t show any stroke evidence, at least not yet. With precious minutes ticking away, the CMC team quickly plugged in a computerized wireless medical cart and called in, via internet videoconferencing, the expertise of vascular neurologists at Dartmouth-Hitchcock Medical Center in Lebanon and Dartmouth-Hitchcock’s (D-H) telestroke partner, Mayo Clinic in Arizona. These specialists immediately reviewed the patient’s condition and test results with the CMC physicians and concluded that, indeed, she was likely suffering an ischemic stroke—a stroke that’s characterized by a clot in the brain. She was given a clot-busting drug and returned home the next day after receiving a clean bill of health.

Making Connections with Rural Hospitals“That patient’s story exemplifies the power of telehealth to connect health care facilities and hospitals across our sometimes very rural region with the expertise of D-H and our partners, including the Mayo Clinic,” explains Sarah Pletcher, MD, director of the Center for Telehealth and the Center for Rural Emergency Services and Trauma at D-H. The program, launched in 2012, serves a vast region in northern New England, including all of Vermont, New Hampshire and Maine. “It’s a lot of patients, two million, over 49,000 square miles,” she says. “Not every patient can come to us when they need care. Rural patients pay a penalty in terms of access, especially when it comes to trauma, stroke and psychiatric needs.”

Evaluating and treating stroke, in particular, is a challenge in rural regions. There’s one vascular

neurologist in New Hampshire (at DHMC), just one in Vermont and none in Maine. Yet the speed and accuracy of a diagnosis is critical. While thrombolytic drugs can effectively treat the more common ischemic stroke, they must be administered within three hours of the onset of symptoms. And administering these drugs to a patient with a hemorrhagic stroke (caused by a ruptured blood vessel) can be fatal. Often in rural north-ern New England, much of those critical three hours is taken up just getting the patient to an emergen-cy room, so the time pressure on local clinicians to quickly make an accurate diagnosis can be extreme. This is where the D-H Center for Telehealth’s telestroke program can be life-saving: by instantly calling a videoconference consult with a D-H or Mayo neurologist, the local providers can confirm or change their initial diagnosis in time to make a dramatic difference for the patient. Patients benefit from world-class expertise while being treated close to home.

11

“With telestroke, we’re getting the stroke neurologist to the patient’s bedside,” Pletcher comments. “We can make a full exam—consulting lab reports, charts, the whole thing. It’s just like our neurologist has shown up in the local hospital’s emergency room.”

While using tele-technology is now the gold standard of stroke care as defined by the American Stroke Association, Pletcher explains that for most hospitals, especially rural hospitals, access to the technology “remains elusive, particularly in our region.” The technology required for telehealth can be expensive, and staff must be trained on the equipment—it’s not quite as simple as video-phon-ing a friend on a smartphone. But the advantages are huge. Telestroke “greatly leverages the capabilities of our neurovascular team here at D-H and at Mayo,” she says. D-H’s part-nership with the neurology team at

Mayo Clinic’s facility in Arizona means that access to D-H/Mayo expertise is available on a 24/7 basis for hospitals in the telestroke network.

Learning What WorksOne of the telehealth pilot programs, up and running now at Weeks Medical Center in Lancaster, NH, brings D-H specialty rheumatology and dermatology consults to Weeks’ patients. Respiratory therapy and psychiatry consults will follow soon. “The strategy is to reach out to practice managers from many different departments and get the dialogue moving forward,” says Tom Winchell, D-H’s telehealth technology manager. “We’re still trying to learn what types of conditions lend themselves to remote examinations. What’s the capacity in terms of appointment slots? We hope to have 20 of these kinds of services up and running by late next year.”

Pletcher notes that Dermatology is particularly suited to telehealth be-cause, in many cases, a high-resolution digital photograph of a skin condition, transmitted electronically to D-H dermatologists can be more accurately diagnosed than by an in-office visual inspection. “A high-resolution photo-graph will show things that might not be immediately visible to the human eye and might be missed in an exam room,” she comments. “We can make the diagnosis here and immediately transmit the results back to the local hospital or provider for treatment.”

Partnerships Made Possible by TechnologyDue to what Pletcher describes as “a huge, huge need” in northern New England, telestroke is the first of several telehealth programs to launch, and CMC is the first partner in the program. Other programs, some of which are still in the pilot phase, include outpatient specialty clinics, virtual visits (which allow doctors to connect with patients directly using audiovisual, real-time technology), acute care, store and forward (e.g.,

“This is the Internet at its best. This is connecting not just to people or websites but to the clinical expertise that can literally make

a life-or-death difference in a diagnosis.”

Eric Martin, MD, a surgeon for D-H’s Trauma Program, regularly uses a

tablet to view images remotely. 12

A patient in Detroit has injured his back on the job. He is out of work on disability and in chronic pain. His physician has recommended surgery. He—and his employer—would like a second opinion. Where does he turn?

Thanks to a new initiative called IvyMD, spine patients across the country can now consult physicians at Dart-mouth-Hitchcock’s (D-H) internationally recognized Spine Center, using secure web-based tools.

While Dartmouth-Hitchcock’s Center for Telehealth is bringing the expertise of D-H physicians to patients and provid-ers across the region, IvyMD seeks to bring D-H’s unique brand of high-value care to patients beyond northern New England. Patients can submit relevant health records and have an online video consultation with a D-H spine surgeon via IvyMD’s web portal.

Although only a year old, IvyMD al-ready has a contract with a large global employer to provide second opinions in spine care to its employees, and is talking with other companies interested in these services.

“Spine care is a big driver of healthcare costs,” explains Mary Oseid, director

of IvyMD. “We know that overutilization is a significant reason for that. The Spine Patient Outcomes Research Trial, led by D-H, suggests that more than 90 percent of patients with back problems have the best success with non-surgical treatments. That research has also shown which patients are most likely to benefit from surgery. Our surgeons bring that knowledge to their conversations with patients, as well as a commitment to informed choice: helping patients understand their options, weigh the risks and benefits and make the decision that’s right for them.”

Second opinions for spine patients are just the start of IvyMD’s expanded offerings. IvyMD plans to offer second opinions and consultations in other specialties, as well as urgent care and wellness services, says Oseid. “We’re focusing on those areas in which care can be delivered effectively—or even better—over the web,” she explains. “Instead of investing in bricks and mortar, we’re making investments in innovations that we believe will reduce the cost of care and help the nation with its healthcare challenges. Value, effectiveness, and access—those are our three goals.”

Learn more at ivymd.com.

BRINGING D-H CARE TO PATIENTS NATIONWIDE

remote reading in radiology and dermatology), e-consults (provider-to-provider second opinions), mobile health, home monitoring, and patient education and outreach. Overall, the telehealth network has grown to include up to 30 regional hospitals and clinics, though participation is limited by technology or cost for some members of the network.

Sometimes, Pletcher admits, she’s awestruck by the opportunities that telehealth and its individual programs, such as telestroke, offer to patients. “This is the Internet at its best. This is connecting not just to people or websites but to the clinical expertise that can literally make a life-or-death difference in a diagnosis,” she enthus-es. “We’ve already seen that happen. It means bringing a higher measure of health care to people in rural loca-tions, especially, without taking away a patient’s relationship with a local provider or hospital. It’s a true part-nership made possible by technology.”

At the same time, she adds, “this isn’t really a new idea.” On her computer, she pulls up an old magazine page from the 1920s. A headline stating “The Radio Doctor” is positioned above an illustration of a gentleman doctor talking into a large radio mi-crophone. “Medicine has been trying to do this for a long time,” she says.

What’s especially exciting about the fledgling D-H telehealth program, Tom Winchell adds, is that it’s “an opportunity to build something from the ground up, to be part of constructing the solution here at D-H for northern New England.” 13

Dartmouth-Hitchcock creates one of the most advanced surgical research and clinical care facilities in the world.

14

CREATING BETTER, SAFER SURGICAL CARE FOR PATIENTS—EVERYWHERE

WHY BUILD a new surgery center in the current health care environment? How does the new Center for Surgical Innovation align with Dartmouth-Hitchcock’s (D-H) philosophy to provide the right care, in the right place, at the right time? These questions will be answered when D-H opens the new center this winter, fulfilling a dream of a team of dedicated clinicians and scientists to create one of the most advanced surgical research and clinical care facilities in the world. Built as a partnership between Dartmouth-Hitchcock, the Geisel School of Med-icine, and the Thayer School of Engineering at Dartmouth, with the backing of the National Institutes of Health (NIH), the Center for Surgical Innovation will be dedicated to improving surgical procedures and developing new surgi-cal tools and technologies to advance patient care locally, regionally and nationally.

What makes the Center for Surgical Innovation different from other advanced surgery centers is that it harnesses the power of state-of-the-art equipment and D-H’s innovative research capabilities. A key feature is the ability to move an

MRI machine and a CT scanner in and out of the spacious operating rooms on tracks mounted to the ceiling, allowing precise imaging to be done during surgery without mov-ing the patient back and forth from an operating room to an imaging room. “There are two operating rooms in the center,” explains Keith Paulsen, PhD, the center’s scientific director and the Robert A. Pritzker Professor of Biomedical Engineering at Thayer. “This is one of only a few operating rooms in the world at this time that has both MRI and CT scanning.”

Conducting research in standard operating rooms is extreme-ly difficult because research can be disruptive to timely pa-tient care, Paulsen explains. “Since the center is prioritized for research, our biomedical engineers and physician-scientists will have the time and space they need to advance their work much more quickly than could be done in the traditional set-ting. And we’ll have an environment that provides a fantastic opportunity for learning and education. We can all come to-gether in a space, giving access to students and trainees that would be very difficult for them to attain otherwise.” 15

“Our goal is to make the facility

easily accessible and inexpensive for anyone

with a good idea. We want the center to

be a resource not just for Dartmouth and our region, but for

students, trainees, and researchers throughout

the country.”

Sohail Mirza, MD, MPH, chair of Orthopaedics at Dartmouth-Hitchcock, left, and Keith Paulsen, PhD, the Robert A. Pritzker Professor of Biomedical Engineering at the Thayer School of Engineering at Dartmouth, are the key collaborators leading the new Center for Surgical Innovation.

16

Helping PatientsIn addition to being a research facility, the Center for Surgical Innovation will be a resource for patients with diffi-cult-to-treat conditions. “We’ll be able to offer services for very complex, high-risk cases like pediatric spine surgery, certain types of brain tumor surgery and spine cancer surgery that we wouldn’t be able to offer without the technology in the center,” says Sohail Mirza, MD, MPH, CSI medical director and chair of D-H Orthopaedics. “This will benefit local patients and the population we serve in northern New England.”

Surgeons are too often limited by what they cannot see, including anatomy that is difficult to reach or medical conditions that are not visible to the naked eye. “Advances in imaging such as real-time X-rays during surgery and MRI and CT scans prior to surgery have helped to improve many surgical procedures, but further innovation is needed,” explains Mirza, who also is a spine surgeon. “An example would be the fractures of the second vertebrae in older adults, where inserting a screw to stabilize the fracture requires extreme precision. Being off target by as little as a millimeter can mean catastrophe if a blood vessel is injured. But with 3-D im-aging during procedures and technolo-gies like robotic surgery, we’ll be able to be much more precise and overcome a lot of human limitations.”

While other institutions have ad-vanced surgical facilities, those spaces are usually reserved for a particular subspecialty area such as neurosurgery or cardiology. The Center for Surgical

Innovation will be open to all disciplines for patient procedures as well as re-search. Dozens of research projects, led by Geisel and Thayer faculty, are being planned and will include the fields of orthopaedics, neurosurgery, oncology, psychiatry, solid organ transplantation and biomedical imaging. For instance, one project will test a new method for viewing brain tumors during surgery us-ing fluorescence, to help neurosurgeons more accurately distinguish between cancerous and normal brain tissue.

Investing in Surgery’s FutureCreating a facility as high-tech and far-reaching as the Center for Surgical Innovation has required a substantial shared investment of $20 million be-tween the NIH, D-H, Geisel and Thay-er. Continued philanthropic support will play a critical role in building and supporting the cutting-edge capabili-ties of the center.

“A wide variety of gifts can support the center and help accelerate the trans-lation of better, safer care from the research phase into clinical practice,” says Paulsen. “For example, we have some significant equipment needs be-yond the CT and MRI scanners, such as a robotic fluoroscopy machine, which allows cardiovascular procedures to be performed in the facility. That’s very important in helping us broaden our research base. Obtaining pilot research funds is also crucial, as pilot data is required by the NIH and other federal funding sources in order to apply for sizeable research grants. Endowments for training can also make the center a

great resource for surgical training and research fellowships.”

Paulsen and Mirza believe that these investments can help lower the cost of surgical care in the future, by reducing the number of repeat surgeries that are needed and by proving that sim-pler procedures work. “For example, we are developing an inexpensive ul-trasound probe to help back surgeons better ‘see’ behind delicate spinal nerves so they don’t have to move them during surgery and risk injury to the patient,” says Paulsen. “Once approved by the FDA, the low-cost technology could be disseminated to community hospitals and be available for any orthopaedic surgeon to use.”

“The Center for Surgical Innovation re-ally started with an idea, a dream about a facility that could make surgery better and safer for patients everywhere,” says Mirza. “We’ve mostly built the facility

with funding from the NIH and our own institutions. But we will need philan-thropic endowments and scholarships to maximize its use and potential to create breakthroughs for surgery.”

“Our goal is to make the facility easily accessible and inexpensive for anyone with a good idea. We want the center to be a resource not just for Dartmouth and our region, but for students, trainees and researchers throughout the coun-try,” Mirza adds. “We have a very unique facility. We believe that we can dramat-ically accelerate surgical improvements to benefit society as well as patients individually. We’re ready to partner with people who share that vision—whether they be donors who want to advance science or who have a personal goal to improve surgery, or corporations who want to accelerate the development of new technology.”

Learn more at dartmouth-hitchcock.org/csi.

This rendering illustrates the center track that allows the MRI and CT scanner to move between the operating rooms.

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PATIENTS AS TEACHERS

Asha Clarke, right, takes notes as a Patient Support Corps volunteer, while plastic surgeon Gary Freed, MD, consults with a patient.

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RECEIVING A SERIOUS DIAGNOSIS for yourself or a loved one can feel like getting punched in the gut. Strong emotions take over, clouding even the clearest-thinking minds. That’s how Christine Giddings describes how she felt when she learned she had breast cancer.

“The doctor would say one thing and after that I would hear blah, blah, blah because my mind couldn’t go any further,” she explains. But with lots of support from family and friends, she made it through her treatment successfully. Several months later, when she was ready to consider breast reconstruction surgery, she was surprised to be offered a new, free service called the Patient Support Corps (PSC).

Now funded by a generous grant from the Arthur Vining Davis Foundations, the PSC began as a pilot program

in 2011. The PSC selects and trains medical students from the Geisel School of Medicine at Dartmouth and undergraduates from Dartmouth College to support patients at Dartmouth-Hitchcock (D-H) in two primary ways. First, PSC student volunteers use a structured coaching process to help patients develop their own question lists before an appointment. The volunteer types up the questions, reviews them with the patient, and then sends them to the patient’s doctor so the doctor can be sure to address all of the patient’s concerns. The second way that PSC volunteers support patients is by taking notes and capturing an audio recording during the appointment, which they then give to the patient.

Asha Clarke, a member of the Geisel Class of ’16, is a PSC volunteer who worked with Giddings when she was weighing options for breast reconstruction. For many women, this is a complex decision involving

not just medical considerations but personal values and lifestyle concerns as well.

“It was great having Asha there be-cause it meant somebody was taking notes, somebody was recording, and I could totally focus on the doctor,” says Giddings. “Just that one piece alone took a tremendous load off me. I wish this program had been available to me the day I was diagnosed.”

For Clarke, the experience was just as meaningful.

“What’s so different about this pro-gram is that it really forces you as the student volunteer to absolutely focus on the patient’s concerns… to not insert what you think is best into the conversation,” says Clarke, who has assisted eight patients so far. “It’s such a different skill, and it’s so valuable to me as I train to become a physician.”

A joint program between Dartmouth-Hitchcock and the Geisel School of Medicine is a win-win for patients and students.

“It was great having Asha there because it meant somebody was taking notes, somebody was recording, and I could totally focus on the doctor,” says Christine Giddings, a patient.

Christine Giddings and more than 50 other patients have been paired with medical students, who help patients develop question lists and take notes during appointments.

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Giving Patients a VoicePSC volunteers receive training at Dartmouth-Hitchcock’s Center for Shared Decision Making, a service that provides patients with tools and resources to help them make informed choices that are right for them when faced with more than one option for treatment.

Dr. Dale Vidal, who was one of Giddings’ surgeons, directs the PSC, as well as the Center for Shared Decision Making. Vidal is also a faculty member of the Geisel School of Medicine and is working with the school to incorporate the PSC into its new curriculum.

Vidal was inspired to start a PSC at D-H after learning about the PSC program at the University of California San Francisco Breast Care Center. The leader of that program, Jeff Belkora, PhD, and Vidal worked closely to launch the program at D-H.

“For some patients who are less likely to speak up and express their thoughts to a doctor, the question lists that they create with the Patient Support Corps volunteer give them their voice immediately in the consultation,” says Vidal. “I love having this information about my patients during our visit.”

So far the PSC at D-H has served more than 50 patients, mostly from the breast reconstruction service. With the support of the recent grant from the Arthur Vining Davis Foundations, the program will now have the resources to hire a program coordinator, train more student

volunteers, expand into other clinical areas and help launch similar programs at other medical centers. That’s great news for patients like Christine Giddings.

“When I first decided to consider reconstruction, I tried to write out specific questions that I wanted to ask

Dr. Vidal,” recalls Giddings. “I found that my mind was very scattered. Then I received the phone call from Clarke. She helped me get clarity about what I needed to know from Dr. Vidal in order to make a decision. Neither Clarke nor Dr. Vidal led me down one path or the other, but we got right down to what I wanted.”

With support from the Arthur Vining Davis Foundations, the program will have the resources it needs to expand.

Snapshots in Giving

Susan Berg (right), program director of the Center for Shared Decision Making, manages the Patient Support Corps and helps train students like Asha Clarke (center), with the assistance of Inger Imset (left), a health coach at the Center.

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Young heroes: Up for the challenge

Mix young people, athletics and philan-thropy and you get “awesome results,” according to Positive Tracks, a national nonprofit. Indeed! For the fourth year in a row, Positive Tracks contributed a match-ing challenge grant for the October 2013 CHaD HERO, a fundraising event for the Children’s Hospital at Dartmouth-Hitch-cock. Five local organizations joined in, too, doubling Positive Tracks’ $100,000 match. Young people participating in the CHaD HERO 5k, half marathon and fun run met and surpassed that goal, result-ing in a grand total of $431,000. 

Positive Tracks—which was first inspired by the CHaD HERO—is a national, non-profit that motivates young people to get active and give back by matching youth dollars raised through charitable athletic efforts. “It’s crucial to get young people involved with giving back in a hands-on, active way,” says Nini Meyer, founder of Positive Tracks and a member of the Friends of CHaD board. “Through events like the CHaD HERO, they learn how to connect daily actions to the greater social good.” 

Enduring legacy, lasting impact

The late Murray B. Bornstein, MD, was a renowned clinician and researcher in the field of multiple sclerosis. So it’s fitting that his legacy will live on in an endowed professorship, made possible by the gen-erosity of his wife, Selma, and their five children—Joshua, Mimi, David, Judith and Daniel. The Murray B. Bornstein Pro-fessorship in Neurology will be awarded to a clinician in Geisel’s Department of Neurology who conducts research in pro-gressive, disabling neurological diseases, preferably multiple sclerosis.

Murray Bornstein was a 1939 graduate of Dartmouth College and former adjunct professor at the medical school. “En-dowing this professorship is a profound experience for me,” says Mrs. Bornstein, “because it establishes an enduring legacy for Murray and makes it easier for future researchers to make important dis-coveries about a disease to which Murray dedicated his life and work in search of the cause and a cure.”

Keeping her on the trail

Jocelyn Gutchess of Sandwich, New Hampshire, was in her early seventies and an avid mountain climber when she began to have trouble with her arteries. But thanks to multiple surgeries and the expert care of D-H vascular surgeon Dr. Robert Zwolak, she was able to keep climbing mountains, “having adventures all over the world,” says Gutchess. Now age 92, she is still active and enjoys hiking but chooses shorter, forest trails for her excursions.

“Dr. Zwolak has been keeping me going for all these years and the hospital has been wonderful to me.” In appreciation for the care she received, Gutchess recently made a generous gift to the Vascular Surgery Fund in honor of Dr. Zwolak. The fund supports research that directly benefits patients.

Supporting a regional resource

A generous gift from the estate of Willmott “Bin” Lewis will support the programs of the Centers for Health and Aging at Dartmouth-Hitchcock—including its Aging Resource Center, which provides free classes, support groups and a lending library for seniors and their caregivers. Lewis, who spent his career in the newspaper business, served as publisher of the Valley News from 1980 to 1993. He cared deeply for the Upper Valley region, serving as president of United Way and as a member of the founding committee for ILEAD (Institute for Lifelong Education at Dartmouth). He—and his companion of 28 years, Barbara Jones—also served on a task force to study the needs of seniors in the region. Lewis and Jones enjoyed the Aging Resource Center’s fitness classes and library, and this gift will help ensure that seniors can continue to benefit from the Center—which depends on charitable gifts to sustain its programming.

Snapshots in Giving

The generosity of donors is vital to Dartmouth-Hitchcock’s mission of advancing health through research, education, patient care and community partnerships. Thanks to all who help us sustain our mission.

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Bringing New Precision to Radiation TherapyHaving access to the latest technology in radiation treatments not only allows for more targeted and effective treatments, it can make those treatments more comfortable for patients. Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC) recently installed a new linear accelerator—called the Varian TrueBeam 6 Degrees of Freedom (6DOF) couch—which is an advanced patient table that enhances the accuracy and efficiency of radiation treatments, especially in delicate areas of the body where millimeter accuracy is essential. This installation is the second in the United States and the fourth worldwide, clearly distinguishing NCCC as a leader in new technology implementation.

Dartmouth-Hitchcock Named One of the Greenest HospitalsBecker’s Hospital Review recently named Dartmouth-Hitchcock (D-H) one of America’s 50 greenest hospitals, noting D-H “has been an environmen-tal leader, earning awards from the EPA, Practice Greenhealth and other environmental agencies.” In 2009, the hospital began calculating its ecolog-ical footprint—by-products, energy, food, waste, transportation, water and built land—to pinpoint the best ways to identify and reduce waste.

Individual and institutional efforts really add up. Last year, for example,

D-H saved an estimated $689,000 by actively recycling, avoiding disposal fees and avoiding unnecessary purchases. D-H still generates tons of waste, sending 1,564 tons to the landfill every year; however, that’s many fewer tons (2,790 fewer tons per year—or 7.6 tons per day) than would be headed to the landfill otherwise. D-H’s commitment to recycling pays dividends every year—not only in dollars saved but in reducing the institution’s environmental footprint. That’s good for the environment and good for the people D-H serves.

The Power of Listening in Patient CareBeing admitted to the hospital can be a frightening, difficult and stressful experience. In addition to not feeling well because of an illness or injury, patients may not always find it easy to provide honest feedback about the care they receive.

That’s why Dartmouth-Hitchcock (D-H) includes the Patient Family Voices Volunteers in patient care. “We’re the ones who interview patients on the inpatient units to see what their perceptions of their stay have been,” explains Nancy Bassett, one of 10 Patient Family Voices Volunteers at D-H. “Mainly, we do a lot of listening, and patients seem to really appreciate knowing that there’s one more person there who cares about them and is paying attention to how they feel.”

Pat Stockwell, RN, helped boost recycling in surgical areas by more than 400 percent.

D - H B R I E F S

$18 Million CTSA Grant Spurs Translational Research An $18 million research grant awarded to Dartmouth College by the National Institutes of Health will spur advances in medical research and patient care at Dartmouth-Hitchcock (D-H) and the Geisel School of Medicine. The highly competitive Clinical and Translational Science Award (CTSA) puts D-H and its partner insti-tutions among an elite group of U.S. academic medical centers.

Translational research brings laboratory discoveries to clinical practice, transforming scientific and therapeutic breakthroughs into new treatments, cures, and other improved health outcomes for patients. In this way, the CTSA will improve health and health care for patients and communities served by D-H. It will be matched by an additional $20 million investment from D-H and the Geisel School. Announced in October, the award comes as construction of the new Williamson Translational Research Building is underway on the DHMC campus.

Overcoming Colonoscopy FearsAccording to a recent study, 40 percent of all cases of colon cancer could be prevented with regular screenings. While the medical community recommends that people begin getting colonoscopies soon after turning 50, many skip them, citing anxieties. The results of a recent study at Dartmouth-Hitchcock show that patient education and engagement can actually lower anxiety before a colonoscopy.

“We found that patients who viewed patient-education videos had significantly decreased anxiety and actually increased their knowledge, as we would expect,” says Corey Siegel, MD, lead investigator for the study and director of the Dartmouth-Hitchcock Inflammatory Bowel Disease Center. “But, more so, they actually had lower doses of sedation medications during the procedure and shorter procedure times. If we can educate patients better, engage them in the process, and, therefore, lower their anxiety and worry, then it makes their experience better.”

Beyond the Fine Print: Facts about DrugsIf you’ve picked up a prescription from your pharmacy recently, you’ve probably noticed the label inserts are loaded with so much information (most of it in fine print) that they’re completely overwhelm-ing. In the “laundry list” of possible side effects, it’s hard to know which side effects matter and how often they occur.

That’s just one example of how essential information about prescription drugs is poorly communicated, say Geisel School of Medicine physician-research-ers Steven Woloshin, MD, and Lisa Schwartz, MD, founders of Informulary.

Working with the Food and Drug Administration (FDA), Woloshin and Schwartz have developed a tool called the Drug Facts Box. Inspired by the nutrition labels that appear on the side of cereal boxes, the tool provides key information about a drug’s benefits and harms, in an easy-to-read format.

The box is organized in a simple one-page summary of drug benefit and side effect information, using the same data the FDA uses in its drug approval pro-cess, but it’s presented in a way that is unbiased and accessible to consumers.

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D - H B R I E F S

Bill and Jan Wesson

Giving Futures

Bill and Jan Wesson of New London, New Hampshire, have provided for Dartmouth-Hitchcock’s Norris Cotton Cancer Center in their estate plans. “We’ve lost our parents and several close friends to the ravages of cancer,” says Jan. “That’s why we’re committed to supporting the researchers and doctors at the Cancer Center who work tirelessly to find a cure. By including the Cancer Center in our estate planning, we know that our giving will continue even after we’re gone. We feel privileged to be able to help.”

Planned gifts sustain the excellence in patient care, research and teaching at Dartmouth-Hitchcock and the Geisel School of Medicine. Whether in the form of a bequest, a charitable gift annuity, or some other giving method, you can join people like Jan and Bill Wesson in making a lasting difference.

To learn more, please call Rick Peck or Mark Dantos at 603.653.0734 or toll free at 866.272.1955, or visit us on the web at giving.dartmouth-hitchcock.org.

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