Northern Wisconsin

Health News from Northern Wisconsin

A shortage of rural physicians won’t affect Eagle River residents
Orthopedic surgeons at Ministry Medical Group in Rhinelander
  Kent Jason Lowry, MD
  Daniel Tvedten, MD
  James Dyreby, MD
  William Padgett, MD
Germs Don’t Work 9-5


A shortage of rural physicians won’t affect Eagle River residents

Thanks to an innovative pilot program created by Ministry Health Care the residents of Eagle River can count on care at Ministry Eagle River Memorial Hospital for years to come – even in the light of the predicted national shortage of primary care providers in rural areas.

The program, which was recently approved by the Department of Health and Human Services and State of Wisconsin Board of Nursing, allows advanced practice nurse prescribers (APNPs) to admit patients at Ministry Eagle River Memorial Hospital (MERMH).

Under the pilot program, advanced practice nurse prescribers would act as non-physician hospitalists at Ministry Eagle River Memorial to ensure that patients in Eagle River are able to receive care within their home community whenever possible. An advanced practice nurse prescriber is an advanced practice nurse who has been granted a certificate to issue prescriptions.

Special training is required

The pilot program is designed to ensure that any participating advanced practice nurse prescriber will have the requisite education, training and experience to admit and care for eligible patients.

Prior to providing hospitalist services, the APNP hospitalist will receive six to twelve months of additional education and training at Ministry Saint Mary’s Hospital in Rhinelander, under the supervision of a physician specializing in hospital medicine. During this time, the APNP hospitalist will learn how to triage patients to the appropriate level of care, manage a previously identified scope of diseases, provide care using evidence-based order sets, and learn to use telemedicine.

Only after this training would the APNP hospitalist be transferred to Ministry Eagle River Memorial Hospital to provide inpatient care that is consistent with the pilot program. As a result, the design of the program ensures that the APNP hospitalist will be well equipped to admit and manage select groups of patients in a safe and effective manner. Two APNPs began the program in March.

"From a rural hospital administrator’s perspective, I whole-heartedly believe the advanced-practice-clinician-hospitalist model could be a sustainable solution for ensuring long-term access to inpatient care for rural communities, especially in light of the forecasted shortages of primary care physicians," said Ministry Howard Young Health Care President Sheila Clough. "Without innovative models like this one, small rural hospitals will struggle to recruit and retain physicians, which will significantly limit access to care."

To begin the process of utilizing APNP hospitalists in Eagle River, Ministry leaders explored the types of acute illnesses a hospitalist would deal with on a day-to-day basis. The research determined the bulk of admissions fell into 15 disease categories. Common diseases included pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), alcohol withdrawal, urinary tract infection, atrial fibrillation, and delirium, among others. The expectation during the pilot program for APNPs is to gain knowledge of the acute illnesses from an experienced hospitalist.

A special provision was granted for the APNP hospitalist program

Until now, there wasn’t a provision to allow nurse practitioners to be the attending provider in the hospital as state law requires a physician, dentist or podiatrist to admit patients. Ministry Eagle River Memorial Hospital applied for a waiver from the State of Wisconsin to allow advanced practice nurse prescribers to admit patients, and was granted the waiver in January 2013.

"The education the APNPs receive from the hospitalists during their six to twelve month period at Ministry Saint Mary’s was a major factor in the decision to grant Ministry the waiver," said Ministry Medical Group Director of Hospitalist Service, John Almquist, MD. "Another helpful aspect is the consultation the APNPs will receive using telemedicine from Ministry Saint Mary’s."

Technology will play a major role

The hospitalist pilot program uses Marshfield Clinic TeleHealth to connect the APNP hospitalist in Eagle River with the hospitalist in Rhinelander. Despite being 23 miles apart, the high-resolution cameras and equipment allow the hospitalist at Ministry Saint Mary’s to communicate directly with the APNP and the patient at Ministry Eagle River Memorial.

"The technology allows the patient in Eagle River to interact with the physician at Ministry Saint Mary’s as if they were in the same room," said Laura Magstadt, director of nursing and operations, Ministry Eagle River Memorial Hospital. "The hospitalist in Rhinelander can listen to the patient’s heart, lung and bowel sounds; the hospitalist can also look in a patient’s ears or mouth to learn about their condition. It’s an exciting approach to connecting the patient and physician from different locations."

The hospitalist can also view the patient’s electronic medical record, X-rays and lab work from his or her office at Ministry Saint Mary’s.

The pilot program trains the APNPs to care for patients with conditions that hospitalists encounter on a regular basis. To support their practice, the APNP hospitalists will use evidence based order sets.

John Almquist, MD
"We wrote order sets for the common diseases we would see at Ministry Eagle River Memorial Hospital, as well as other supporting order sets," said Dr. Almquist. "For instance, there would be order sets for heart failure, COPD, urinary tract infection, and congestive heart failure, but then there would also be supporting order sets for things like pain management, gout, correction of low potassium or high potassium, dehydration, nausea and vomiting, and other linkable order sets.

"So if the APNP admitted someone, they’d have the admitting order, or if they admitted someone with congestive heart failure, they’d have the standard admitting order set and the heart failure order set."

According to Dr. Almquist, the program that began in March could revolutionize the way hospitalists are utilized in rural communities. "This will be the first time that an APNP hospitalist has been supported by a regular hospitalist in another location," he said. "Once we get the pilot program up and running, Ministry could provide hospitalist services to all of its Critical Access Hospitals. Think about how many places throughout rural America this could be done."

In June 2013, Ministry Health Care leaders will be presenting the APNP hospitalist pilot program to CEOs in health care organizations across the country.


When you need orthopedic care, you can count on four board certified orthopedic surgeons at Ministry Medical Group in Rhinelander

Kent Jason Lowry, MD, is double board certified in both orthopedic surgery and orthopedic sports medicine. He has special interests in orthopedic sports medicine, trauma / fracture care, total joint replacement and hand surgery. In addition, he also shares an interest in arthroscopic and minimally invasive techniques.

Kent Jason Lowry, MD
Kent received his medical degree from the University of Missouri in Columbia, where he also completed an internship in surgery and a residency in orthopedics. His undergraduate degree in mechanical engineering is from the University of Missouri in Rolla.

"I believe the best treatment plan for a patient is obtained through shared decision making," said Dr. Lowry. "My job is to educate patients about their options and come up with a plan that suits the individual."

When he’s not taking care of patients, Dr. Lowry enjoys spending time with his family, learning guitar, and pursuing outdoor activities.

Daniel Tvedten, MD, is a board-certified orthopedic surgeon. He specializes in sports medicine procedures such as arthroscopic surgery of the shoulder, knee and ankle. He also specializes in reconstructive surgery of the knee and hip for adults.

Daniel Tvedten, MD
Dr. Tvedten received his medical degree from the University of Minnesota Medical School in Minneapolis. He completed an internship in general surgery and a residency in orthopedic surgery at the Naval Medical Center in Oakland, California. His undergraduate degree is from St. Cloud State University in St. Cloud, Minnesota.

"I believe in education," said Dr. Tvedten. "When a patient has good information about their medical problem, they can make better decisions about their treatment. I value working together to create a plan to achieve the desired outcome."

When he’s not taking care of patients, Dr. Tvedten enjoys woodworking, downhill skiing, golf, motorcycling, hunting and target shooting.

James Dyreby, MD, is a board certified orthopedic surgeon who has advanced training in joint replacement surgery, hand surgery and arthroscopy. He provides surgical care for patients with trauma, arthritis and athletic injuries.

Dr. Dyreby has done volunteer work in St. Lucia and Bhutan providing care to patients and teaching the local health care providers.

James Dyreby, MD
Dr. Dyreby attended the University of Wisconsin at Madison, receiving honors in his undergraduate and medical degrees. He continued his training in Madison, completing his internship and residency there.

"With nearly three decades of experience in the Rhinelander area, I have developed a reputation for excellent outcomes. Whether I’m replacing an arthritic joint, woodworking or tending to my bees, my focus and attention to detail are the keys to success."

When he’s not taking care of his patients, Dr. Dyreby enjoys sailing, beekeeping, woodworking, forestry and spending time with his family, two dogs, three horses and 60,000 bees.

William Padgett, MD, is a board-certified orthopedic surgeon. He is able to provide a full complement of orthopedic procedures, including arthroscopy, knee reconstruction, carpal tunnel surgery, hand surgery, fracture care and total joint replacements.

William Padgett, MD
Bill received his medical degree with honors from Ohio State University in Columbus. He completed his orthopedic surgery residency at UW-Madison. His undergraduate degree in mechanical engineering is from the University of Michigan in Ann Arbor.

"In addition to medicine, I’m also trained as a mechanical engineer," said Dr. Padgett. "I frequently rely on that background when trying to restore normal functioning for my patients."

When he’s not taking care of patients, Dr. Padgett enjoys a variety of activities including hunting, fishing, golf, hockey and woodworking. Playing bass guitar in a local band has also become a favorite hobby of his.

Dr. Padgett and his family have enjoyed living in the Northwoods since 2001. His wife Mary is a dentist in Rhinelander. They have two children, Andy and Ellen.


Germs Don’t Work 9-5 (neither do we)

Illness doesn’t always arrive when it’s convenient for you. But, with our new extended hours, Ministry’s Clinics can cover the times when it is.

Call today to schedule an appointment at a Ministry Medical Group clinic near you.

400 West Glen Street*

Eagle River
930 East Wall Street*

4876 Mill Street*

2251 North Shore Drive*
1020 Kabel Avenue*

401 West Mohawk Drive**

240 Maple Street

*Outpatient department of Ministry Saint Mary’s Hospital
** Outpatient department of Ministry Sacred Heart Hospital

For more information about our primary care providers, visit


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