January Physician Focus: Mindfulness

Posted in behavioral health, Health, mental health, Physician Focus on January 15th, 2016 by MMS Communications – Be the first to comment

The stresses of daily life – financial pressures, family demands, professional or occupational stress – can Mindfulness1produce fatigue, sleeplessness, and other physical conditions that can harm our mental and physical health.

Mindfulness is an emerging approach that can help patients deal with these concerns by helping them participate in their own health care. Proponents of mindfulness say the practice can reduce stress, improve health, help to manage chronic illnesses such as heart disease or diabetes, and even be useful in treating addiction, substance abuse, and even pain. An approach that came into practice more than 30 years ago, mindfulness is now reaching mainstream medicine, considered to be a way to complement and enhance individual health for people of any age.

The January edition of Physician Focus provides an introduction to mindfulness — how it is practiced, whom it can help, and how it can improve our mental and physical health and overall well-being. Guests are Michael Guidi, D.O. and Jefferson Prince, M.D.

Dr. Guidi (right, photo), is a family physician in Haverhill and Chair of the MMS Committee on Student Health and Sports Medicine. He is engaged in efforts to reduce youth substance abuse by introducing mindfulness to students, parents, and teachers. Dr. Prince (center, photo) is Director of Child Psychiatry and Vice Chair of the Department of Psychiatry at MassGeneral for Children at North Shore Medical Center in Salem, Mass. and is an instructor in the Medical Center’s Mindfulness-Based Stress Reduction Program. Hosting this edition is primary care physician Bruce Karlin, M.D. (photo, left).

Physician Focus, now in its 11th consecutive year of production, is available for viewing on public access television stations throughout Massachusetts. It is also available online at www.physicianfocus.org, www.massmed.org/physicianfocus, and on YouTube.

The President’s Podium: Physicians, Opioids, and Guns

Posted in gun control, opioids on January 15th, 2016 by MMS Communications – 1 Comment

by Dennis M. Dimitri, M.D., President, Massachusetts Medical Society

From Medicare to electronic medical records to telemedicine, physicians are facing a variety of issues this year. Here’s a look at three that our medical society will focus on in the months ahead.Dr. Dennis Dimitri, MMS President

A renewed spirit by physicians about our profession
In my inaugural address upon becoming president last May, I spoke about the declining satisfaction within our profession. While recognizing that physician stress and frustration have increased, and that the business of medicine has added roadblocks to our practice of medicine, I urged physicians to remember how we affect the lives of our patients, that they look to us to help them overcome their problems, and that it is our privilege to do so.

As we continue to deal with the changing aspects of our profession, let’s remind ourselves that we enjoy enormous public respect and prestige, and that we make a difference, every day, to our patients and to our communities. I believe this topic to be so important, in fact, that our Educational Program at the annual meeting in May will be built upon the theme of Sustaining Joy in the Practice of Medicine.

Reducing opioid and prescription drug abuse
The MMS has taken a leadership role in the Commonwealth in combatting opioid abuse, and our efforts in this area are a prime example of how physicians can make a difference. We have developed prescribing guidelines for physicians that address pain management and addiction and have educated patients about safe storage and disposal of opioids. We have sponsored forums and summits related to opioids, and worked with public health and elected officials in improving prescription monitoring and creating strategies to reduce prescription drug abuse.

Despite those efforts, along with those of law enforcement, state officials, legislators, and many others, the numbers of overdoses and deaths continue to rise. Further, a recent study by Boston Medical Center, showing that more than 90 percent of people who survived a prescription overdose were able to get another prescription for the drug that almost killed them, demonstrates just how hard this problem is to solve. Though many of us understand the complexities that drive continued prescribing in some of these situations, studies like this can cause physicians to close what the study authors suggest are “major gaps in communication, education, and oversight” despite our deep concern about opioid abuse.

I told MMS delegates at our Interim Meeting in December that the opioid crisis is our medical society’s top issue. It remains so, and we will continue our efforts to curb opioid misuse, while at the same time ensuring that those patients who truly need help for chronic pain will be able to get it.

A new focus on physicians and gun violence
Gun violence has continued to be one of the major issues in public health. Last March, MMS took the occasion of Doctor’s Day to raise awareness about this issue, and specifically, preservation of the right of physicians to discuss the subject with their patients. Unfortunately, the 2011 Florida law making it illegal for physicians to ask patients if they own a firearm or record information about gun ownership in their medical record was upheld in December for a third time in a decision by a three-judge panel of the U.S. Court of Appeals for the Eleventh Circuit.

According to reports, the panel’s opinion was that “the law fits well within the traditional authority of the states to define and regulate the practice of medicine.” Not to be deterred, physicians will appeal for a third time to have a full court review. This remains a critical case for physicians, as it has national implications and directly affects the physician-patient relationship.

MMS physicians have addressed violence intervention and prevention in many forms, and gun violence is as appropriate for physicians to study as youth violence, partner violence, or human trafficking. To that end, our 2016 Public Health Leadership Forum, Firearm Violence: Policy, Prevention & Public Health, will seek to provide practical information for physicians on gun violence and what we can do to protect patients from harming themselves or others.

Physician satisfaction, opioids, and gun violence certainly will not be the only subjects commanding the attention of our medical society in 2016. But each of these three is a major issue growing in importance with critical implications for both physicians and patients. Each also speaks to the mission of our medical society: to “advocate for the shared interests of patients and our profession.”

The President’s Podium appears periodically on the MMS Blog, offering Dr. Dimitri’s commentary on a range of issues in health and medicine.

CDC Opens Draft Opioid Guidelines for Public Comment

Posted in opioids, Palliative Care on December 23rd, 2015 by MMS – 1 Comment
CDC Director Tom Frieden

CDC Director Tom Frieden

The Centers for Disease Control and Prevention this month released its draft guidelines for the prescribing of opioid pain medications for chronic pain.

The recommendations are designed for primary care settings, and focus on chronic pain lasting longer than three months. They do not apply to palliative or end of life care. They were published on Dec. 14 and will be open for public comment until Jan. 13, 2016.

In its public notice the CDC stated, “The guideline is not a federal regulation; adherence to the guideline will be voluntary.” However, the American Medical Association and others noted that the guidelines would likely have significant public impact. For example, a new federal law requires the Veterans Administration to adopt the final CDC guidelines as official policy.

Here’s an outline of the CDC’s draft recommendations:

  1. Non-pharmacologic therapy and non-opioid pharmacologic therapy are “preferred” for chronic pain.
  2. Providers should establish treatment goals before starting opioid therapy for chronic pain.
  3. Providers should discuss the risks and “realistic benefits” of opioid therapy before starting opioid therapy, and periodically thereafter.
  4. Providers should prescribe immediate-release opioids for chronic pain, instead of extended-release opioids.
  5. Providers should start with the “lowest effective dosage.”
  6. For acute pain, providers should prescribe the “lowest effective dosage” for immediate-release opioids, and should prescribe “no greater quantity than needed for the expected duration of pain severe enough to require opioids. It states, “three or fewer days usually will be sufficient for most non-traumatic pain not related to major surgery.”
  7. Providers should evaluate the benefits and harms of with patients within 1 to 4 weeks of starting opioid therapy.
  8. Providers should evaluate risk factors for opioid-related harms before starting or continuing opioid therapy. These risk factors include the patient’s history of overdoses and/or history of substance abuse disorder.
  9. Providers should review the patient’s prescription history using the state prescription monitoring program when starting therapy, as well as periodically during therapy.
  10. Providers should use urine drug testing before starting opioid therapy for chronic pain, and should consider ordering such tests annually.

There have been strong reactions to the guidelines, focusing on both the content and the process under which the guidelines were developed.

The CDC did not originally plan to accept public comments before finalizing the guidelines, but the American Medical Association and other groups have criticized a “lack of transparency” in the drafting process.

An AMA letter to the CDC in October also stated the guidelines are “devoid of a patient-centered view and any real acknowledgement or empathy of the problems chronic pain patients may face.”

The House Committee on Oversight and Government Reform has also launched an investigation into the drafting process.

As of Dec. 30, the CDC’s website had collected more than 1,300 public comments. The AMA is expected to submit comments on the current draft in early January.

Background information

Everything You Need to Know About PQRS Reporting: Webinar

Posted in practice management on December 21st, 2015 by MMS – Comments Off on Everything You Need to Know About PQRS Reporting: Webinar

Our friends at the Connecticut State Medical Society are offering a webinar next month to help physician practices manage their PQRS reporting.

  • Avoid negative payment adjustments in 2017 by successfully reporting your 2015 PQRS data
  • Learn about changes in the PQRS and VM programs
  • Preview the transition from PQRS to the Merit-Based Incentive Payment System (MIPS)

The webinar will be offered at two dates and times:

  • Tuesday, January 12, 2016:  12:15 pm– 1 pm Register
  • Thursday, January 21, 2016: 4:00 pm – 4:45 pm Register

Both webinars will have opportunities for live Q&A, so bring your questions and get real-time answers.

Your EHR in 2016: Interoperability is Key Trend

Posted in Electronic health records, Electronic Medical Records, Health IT on December 18th, 2015 by Erica Noonan – Comments Off on Your EHR in 2016: Interoperability is Key Trend

Interoperability is expected be a key focus for EHR systems and the physicians who use them in 2016. We asked Micky Tripathi, founding president and CEO of the Massachusetts eHealth Collaborative, about the latest important developments on EHR interoperability and how they may impact your practice.

MMS: Tell us what the recent “KLAS” agreement means for physicians?

MT: The recent summit meeting (hosted by KLAS, the independent health information technology review organization) was a unique private sector initiative to establish objective “Consumer Reports” style measurements of interoperability performance across EHR systems. The summit brought together 10 major EHR vendors as well as 30 large provider organizations from the around the country. Over an intensive two days, the group achieved consensus on a measurement approach and process to be conducted by a credible, neutral organization. The measurement process will be the first comprehensive measurement of nationwide interoperability capturing both provider and vendor attributes. In other industries, the private sector comes together to hold itself accountable by working collaboratively on transparent measures of progress.  The KLAS agreement represents a significant step forward in the maturity of the health IT industry.

Micky Tripathi

Micky Tripathi

MMS: How will we know when interoperability is working?

MT:  When people stop complaining about it! Just joking. Interoperability isn’t a single thing – it’s a general term that describes different types of information exchange appropriate to a particular purpose. For example, email is very good for certain types of communication, but is a very poor substitute for those times when only a phone call will suffice. Similarly, sometimes a provider wants to have a complete medical summary sent to them, in which case they would want to receive a continuity-of-care document, whereas at other times they may just want to check on a medication allergy, in which case a “magic button” single-sign on viewer would be most important. Both types of exchange are important, each is appropriate to the specific clinical need.

Interoperability is already working very well in some areas — as (the science fiction author) William Gibson reportedly said, “the future is already here, it’s just not very evenly distributed.”  Take electronic prescribing, for example — a huge success across the country. Similarly, lab results delivery is very widely available in most health care delivery areas across the country.  EHR-to-EHR exchange has been harder to accomplish because it relies on coordination of many different vendors as well as many different providers. Even here we’re seeing tremendous progress though. The Massachusetts Health Information Highway has over 500 provider organizations connected and conducts over 2 million secure health information exchange transactions per month.

However, interoperability will never be “done.” As information technology gets better and medical advances continue, our expectations will grow as well.  We’ve seen with computers and smart phones that the more they do, the more we want. The same is true for interoperability as well.

MMS: What timeline do you expect in terms of seeing widespread improvements in interoperability?

MT:  We’re already seeing them. It’s important for us to have some perspective though. Just like you can’t have a good telephone network until most people have a telephone, you can’t have good interoperability until most providers have an EHR. A short 5 years ago, less than 10% of physicians had an EHR. That number is now over 75%, and for hospitals it is now over 90%.  So, why do we think that we should have universal interoperability already, when just a couple of years ago most physicians didn’t even have an EHR? No other industry has achieved it that fast, and yet, no other industry is as complex as health care.

The biggest barrier to interoperability until now has been lack of demand — physicians weren’t asking for interoperability because they didn’t have EHRs and because prevailing models of care and payment didn’t require interoperability. The world is different now, and physicians are demanding interoperability from each other and from their vendors, and we’re seeing the market respond.  Within the next few years I think we’ll see close to nationwide ability to send clinical documents to any provider in the country, and we’ll see the maturation of nationwide health information networks that also enable query and retrieve capabilities as well.

These networks are already emerging rapidly – like Epic’s Care Everywhere, Surescripts, CommonWell, the MA HIway, etc – and in the next few years we’ll see the building of “bridges” across these networks in the same way that phone networks and ATM networks are stitched together to provide universal coverage.

MMS: Do you think some regulation or a government mandate is inevitable down the road?

MT: I hope not. It would be a terrible mistake, and I guarantee that most physicians will be very unhappy with any kind of government mandate for interoperability, whether at the state or federal level.  Health care and IT are too complex to expect that the government can get it right or keep up with it. The best prescription for getting more interoperability is to expand value-based purchasing through Medicare and Medicaid that pays for better care and improved outcomes. That will create more demand for interoperability but will allow providers and their vendors to come up with the best ways to accomplish it.

— Erica Noonan

MMS Ethics Forum: Big Data Offers Big Promise, But Big Concerns As Well

Posted in Ethics Forum, Interim Meeting 2015 on December 4th, 2015 by MMS – Comments Off on MMS Ethics Forum: Big Data Offers Big Promise, But Big Concerns As Well

By Richard P. Gulla

It’s called Big Data. Its creation has spawned new companies and new professions, and it’s rapidly enveloping the health care industry.

The basic idea of Big Data is simple: amassing huge amounts of all kinds of information, analyzing it, and then applying that analysis to achieve the goal of improving health care systems and health care for patients.

Still in its infancy, Big Data’s promise looms large. Yet it arrives not without major ethical concerns.  And those concerns provided the focus for the MMS Ethics Forum, presented by the Committee on Ethics, Grievances, and Professional Standards as part of the Society’s Interim Meeting of its House of Delegates.

While Big Data offers promise, it’s also filled with what the experts call “ethical tensions:” how to use the data; the obstacles that limit the data gathering (such as HIPAA); ownership of the data; privacy laws; consent of its use; and the misuse of data, through discriminatory actions or denials of insurance coverages.

The Forum featured three prominent experts in the field.  Joe Kimura, M.D., M.P.H., Deputy Chief Medical Officer for Atrius Health; Ameet Sarpatwari, J.D., Ph.D., Instructor in Medicine at Harvard Medical School and an Associate Epidemiologist at Brigham and Women’s Hospital; and Kyu Rhee, M.D., M.P.P., Chief Health Officer for IBM.

Each of the expert’s presentations was wide ranging, but here are some highlights:

Ameet Sarpatwari: Big Data is characterized by the ‘five V’s:  Variety, used for disparate purposes; Volume, enormous amounts of information that’s gathered; Velocity, data accumulated at near real-time; and Veracity, determining the validity of the information.

The raw ingredients of Big Data in healthcare are several: insurance claims, electronic health records, wearable sensors, social media, and biological registries. Its uses include systems improvement in care, precision medicine (the new movement to personalized medicine), comparative effectiveness (which drugs, procedures, treatments work better than others), and medication adherence by patients.

Joe Kimura: Big Data at Atrius entails finding the answers to many questions.  What is appropriate or not appropriate in the search for data? How does a physician practice use information to do better? How does the data help us learn? How do we measure things that matter to use?  Above all, the goal is to use the information to make more timely decisions to help patients.

Kyu Rhee: The essence of Big Data at this time is IBM’s Watson, now being used more and more in health care applications.  It is humanly impossible to know all the data you need to know, and the goal of IBM Watson Health is to translate Big Data into Big Insights and Big Solutions.  In compiling data, Watson can read 800 million pages a second, which means the potential of cutting the time from research to practice in medicine is enormous.  But in using such data, physicians must be part of the conversation, and be “at the table” in the decision-making process – vital for the profession and the care of patients.

While the each of the experts shared his unique perspective of Big Data, they all agreed on one principle: that physicians and patients must be at the forefront of Big Data and the goals it can achieve.

Annual Oration: Doctors Need to Reshape the Value Agenda

Posted in Affordable Care Act, Health Reform, Interim Meeting 2015, MMS Oration on December 4th, 2015 by Erica Noonan – Comments Off on Annual Oration: Doctors Need to Reshape the Value Agenda

Physicians need to take a leadership role in reshaping the approach to value in health care reform for the system to see more cost-savings and quality improvements, said Ashish K. Jha, MD, MPH, in his 2015 Annual Oration address, delivered Friday at the 2015 MMS Interim Meeting.

The prevailing wisdom among policymakers that providers are being reimbursed incorrectly has driven a set of value metrics that have not yet resulted in significant improvements, he said.    jha2

Current approaches to value — such as measuring hospital readmission rates and mortality rate — have not markedly improved outcomes for patients. Furthermore, some of the measurement have penalized hospitals that care for the sickest and poorest patients, said Dr. Jha.

“There will winners and losers in a value-based world, depending on how you define value,” he said.

His address, “Getting to Value in High-Value Health Care,” was the 204th MMS Annual Oration, a Society tradition that dates back to 1804.

Accountable Care Organizations and Medicare’s Shared Savings Program are still quite new, but so far have also not showed the impact on cost and quality that many health care reformers had hoped. “If these are going to work, it’s going to take a lot more time,” Dr. Jha. “It is not going to be the panacea to fix American health care.”

To get better value measurements, physicians must be active in advocating for measures “that matter.”  They must refocus the conversation around patients and engage policymakers who are too often making decisions without enough input from practicing physicians.

“We are on a long journey towards higher value health care,” said Dr. Jha.

Watch video of the Annual Oration here.

Erica Noonan

MMS President: Be the Voice of Patients on Both Sides of the Addiction Issue

Posted in Interim Meeting 2015 on December 4th, 2015 by Erica Noonan – Comments Off on MMS President: Be the Voice of Patients on Both Sides of the Addiction Issue

With more than 1,000 overdose-related deaths last year, and the widespread suffering it has caused, the epidemic of opioid abuse in the Commonwealth has for the Massachusetts Medical Society become “issue number one this past year, and number one by a long shot,” MMS President Dennis M. Dimitri, MD, told his physician colleagues in his President’s Report to the House of Delegates at the Society’s 2015 Interim Meeting.

“What makes this public health crisis different from any other,” Dr. Dimitri said, “is that it cuts across many medical specialties and has engaged more non-medical stakeholders than any other public health issue in memory.”

Dr. Dimitri acknowledged the physician’s role in leading to the crisis.  “In our desire to control pain,” he said, “physicians unwittingly opened the door to this addiction epidemic.”

Yet he said physicians are faced with a difficult dilemma: how do we treat pain, and yet prevent addiction to the very medications that can ease pain?

“Physicians know that under-treated pain can be just as insidious as over-treated pain. We’ve embraced the concept that pain is the Fifth Vital Sign – that patients in pain are not well,” he said.

The opioid crisis presented the MMS with a challenge from state leaders to become partners in the effort to attack the crisis. The Society responded with a broad-based campaign of actions to address the crisis, including the development of prescribing guidelines, free offerings of pain management CME courses, discussions with medical school deans in coordinating pain management courses as part of the medical school curriculum and an educational campaign for the public and prescribers.

MMS leaders have also sought to improve the state’s prescription monitoring program and advocated for greater treatment and recovery programs. “Addiction is a medical issue,” he said.

The most difficult question, said Dr. Dimitri, is how success will be defined.  Changes in prescribing patterns, improved and expanded treatment services, and the reduction in overdose deaths are all intermediate goals and useful measures of success, he said, but he also issued a caution.

Physicians must never abandon patients who are in pain, said Dr. Dimitri. “We must have the wisdom to choose the right solutions, the perseverance to stay the course, and never forget those who suffer from pain, as well as those who endure the pain of addiction,” he said.  “We must be the voice of our patients on both sides of the issue.”

Read the full text of Dr. Dimitri’s Report here.

Erica Noonan

December Physician Focus: Women and Heart Disease

Posted in Health, Physician Focus on November 30th, 2015 by MMS Communications – Comments Off on December Physician Focus: Women and Heart Disease

Cardiovascular disease is the number one cause of death in American women, claiming 400,000 lives a year – more than all cancers combined.  Yet nearly half of women – 44 percent according to a recent survey by the American Heart Association – are unaware that it’s the number one threat to their health.

To raise awareness of the topic, the December edition of Physician Focus, Women and Heart Disease, examines why cardiovascular disease is such a threat to women. This program is presented in collaboration with the MMS Committee on Women in Medicine.

Guests are Malissa Wood, M.D. (center, photo) and Nandita Scott, M.D., (right) Co-Directors of the Corrigan Women’s Heart Health Center at Massachusetts General Hospital.  Hosting this edition is family physician Mavis Jaworski, M.D. (left).

Among the topics of discussion are how cardiovascular disease can affect pregnancy, the danger signs of stroke, why high blood pressure is so dangerous, what women should do to screen for heart disease, and preventive steps to take to reduce the risk.

Physician Focus, now in its 11th consecutive year of production, is available for viewing on public access television stations throughout Massachusetts. The December program is available online at www.physicianfocus.org, www.massmed.org/physicianfocus, and on YouTube.


Open Letter to the People of Massachusetts

Posted in opioids on November 16th, 2015 by MMS – Comments Off on Open Letter to the People of Massachusetts

Globe: Open Letter to the People of MassachusettsThis letter also appeared on Page A13 of the Boston Sunday Globe on Sunday, Nov. 15, 2015.

Dear Friends:

A horrible epidemic of opioid overdoses has been sweeping our Commonwealth. Thousands of people have died, and many more are addicted. It is a public health crisis that has penetrated into every community in the Commonwealth.

I have been practicing family medicine in Worcester for many years, so I know that physicians will never abandon patients who are in pain. I also know that those same physicians are committed to doing everything in their power to end the overdose crisis.

We recognize that opioid medications may lead some people to addiction. That’s why I’m calling on physicians to carefully assess addiction risk before prescribing, and then to prescribe the smallest possible dose of pain medications, for the shortest period of time possible.

I’m also encouraging patients everywhere to have open, candid conversations with their doctor about opioids. If you’re concerned, it’s OK to ask about the risks, as well as the benefits. It’s also OK to ask whether alternatives to opioids would be effective for you.

Addiction is a chronic disease that can be difficult to overcome. Patients in its grip often struggle with relapses, and can be discouraged by the challenge of maintaining their recovery. Ending this epidemic will not be easy.

However, we can beat this if we all work together. One important starting point is to prevent addiction before it starts. Your doctor stands ready to help you.


Dennis M. Dimitri, MD

President, Massachusetts Medical Society