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PROVIDER NEWS St. Joseph Healthcare welcomes new providers:

K arin Commeret, MD, has joined OB/GYN Associates

of Southern NH, 30 Daniel Webster Highway, Suite 11

in Merrimack. Dr. Commeret received her medical degree at

Boston University School of Medicine, Boston, MA, and

completed her residency in obstetrics and gynecology at

George Washington University in Washington DC and

Lehigh Valley Health Network in Allentown, PA. Her special

interests include minimally invasive surgery and preventive

medicine. She is also proficient in Spanish. To make an appointment with Dr.

Commeret, please call (603) 883.3365………………………………………….

………………………………….

T hrough a partnership with Lahey Hospital & Medical

Center, in Burlington, MA, Valena Wright, MD,

provides gynecologic oncology care at St. Joseph Hospital.

Dr. Wright received her medical degree from Dalhousie

University, Halifax, Canada. She completed her residency in

obstetrics and gynecology and her fellowship in gynecologic

oncology at Brigham and Women’s Hospital in Boston, MA.

She is board certified in obstetrics and gynecology and

gynecologic oncology. Her clinical interests include genetic

risk of women’s cancer, robotic and minimally invasive surgery, and evaluation

and treatment of gynecologic cancers. Dr. Wright welcomes new patients for

gynecologic oncology care at St. Joseph Hospital. To make an appointment

with Dr. Wright, please call (781) 744.8593……………………………………..

A ki Shishido, CNM, APRN, has joined Full Circle

Midwifery Care, 168 Kinsley Street, Suite 19 in Nashua.

She received her Master’s in Science from New York

University College of Nursing in New York, NY. Aki’s

interests include lactation support and preventive health. To

make an appointment with Aki Shishido, CNM, APRN, please

call (603) 595.3951.

ADD/ADHD in Children: Attention-Deficit/

Hyperactivity Disorder

Tuesday, February 17, 6:00 to 8:00 pm

Presented by Dr. Susan Strahosky from Elliot Hospital

Back to the Basics: Take Better Care of Your

Back and Spine

Tuesday, March 3, 6:00 to 8:00 pm

Presented by Dr. Adrian Thomas from the New

Hampshire NeuroSpine Institute at St. Joseph Hospital

Cataract Surgery Update

Wednesday, February 4, 6:00 to 8:00 pm

Presented by Dr. Timothy Blake,

of Nashua Eye Associates

A fee of $10 includes dinner. Pre-register online at

www.stjosephhospital.com or call (603) 595.3168.

SIGN UP TODAY at LightenUpNashua.com

Session begins January 19– May 8 2015

Medical Staff Newsletter Winter 2015 Medical Staff Newsletter Winter 2015

Page 1

MEDICAL STAFF

Newsletter 172 Kinsley Street Nashua NH 03060

www.stjosephhospital.com

A Quarterly Newsletter published by the St. Joseph Healthcare Medical Staff Winter 2015

St. Joseph Healthcare Ebola Response Planning

T he widespread transmission of Ebola Virus Disease (EVD) in Guinea, Liberia, Sierra

Leone, and the limited transmission in Mali, continues to challenge healthcare

containment efforts.

The Centers for Disease Control (CDC) and federal partners have implemented a multiple

step program to prevent the further spread of Ebola in the United States. Returning

travelers from the affected areas are given a health screening at the five (5) designated

U.S. arrival airports. They are then provided with health monitoring and movement

instructions and their home states are notified to provide direct active monitoring for 21

days post return.

Recently, the CDC developed a 3 tiered hospital response framework for identifying,

isolating, and treating EVD suspect and confirmed patients. Frontline healthcare facilities

will identify and isolate suspect patients,

inform state partners, initiate low risk

testing, and train staff on the use of

appropriate personal protective equipment

(PPE). The expectation is to manage the

patient in collaboration with the NH

Department of Health and Human

Services (DHHS) for up to 36 hours.

Assessment hospitals will evaluate and

care for patients up to 96 hours. Treatment

Centers will provide care and manage the patient throughout the remaining disease course.

St. Joseph Hospital is prepared to respond to a suspect EVD patient as a frontline

healthcare facility. Our EVD screening tools are embedded in the registration and triage

process, our EVD Response Plan is robust, our isolation area is operational and our ED

staff are participating in intense primary PPE donning and doffing training. Our EVD

Incident Management Team (IMT) continues to provide oversight and direction in

response to the Ebola situation and other emerging disease outbreaks.

If you have any questions or comments, please contact Fran Dupuis, Emergency

Operations Manager at fdupuis@sjhnh.org or (603)595.5311.

Value Based Purchasing.

A New Twist

Most of us have become

somewhat acclimated to

the concept of Value Based Purchasing (VBP) over

the last few years. In its simplest form, it is

Medicare’s attempt to reward or penalize hospitals

for performance on certain key indicators

compared to peers across the nation. At the outset,

the focus had been on core measure performance

and patient satisfaction. The core measures have

mostly been process measures looking at care for

congestive heart failure, pneumonia, acute MI, and

surgical care. Hospitals have been rewarded for

high performance on such things as ensuring

patients having an acute MI received aspirin early

in their care. In many respects the performance on

core measures has improved dramatically over the

last few years, though questions remain as to how

much they have effectively influenced patient

outcomes, though most embrace that this has had a

modest beneficial impact.

Over time, the amount of payment withheld by

Medicare has increased, and will continue to do so

for the next few years. The metrics have evolved

as well, and there is a diminishing focus on core

measures as well as patient satisfaction, but a

growing emphasis on 30 day mortality and a new

metric effective October 1, 2014, characterized as

an efficiency measure. It also goes by the name

“Medicare Spend per Beneficiary”.

This measure, which will be 20% of the VBP

dollars this year, and 40% next year, looks at a

given hospital’s average performance on the cost of

care for Medicare beneficiaries.

It looks at the cost for the period starting 3 days

before the index admission, through the

admission, and inclusive of the 30 days post-

discharge.

Continued on Page 3

Published by the Planning and Marketing Department for the Medical Staff of St. Joseph

Healthcare. Please send your comments or suggestions to Dr. William Stephan at

wstephan@sjhnh.org. Forward news information and articles to Tiffany Sullivan at

tsullivan@sjhnh.org.

Rich Boehler, MD,

President/CEO of

St. Joseph Healthcare

Page 2

T he NH PDMP began operation in October. It is authorized by RSA 318-B:31 (NH Revised Statutes Annotated (RSA) forms the codified law of

the state subordinate to the NH State Constitution). What RSA 318-B:31 means is that all prescriptions for Schedules II-IV that are dispensed,

shall be reported to the program.

The intent of the program is to reduce the abuse, overuse, and diversion of controlled substances. It will also assist prescribers and dispensers

(pharmacists) in determining the legitimate pain needs of their patients and deal more systematically with the increasing challenges surrounding

diversion and abuse.

In May, Ms. Michelle Ricco Jonas was chosen to lead this project. Ms. Ricco Jonas brings a wealth of project management skills and experience in

health related state and local government initiatives. The PDMP office resides in Concord, NH at the Board of Pharmacy located at 121 South Fruit

Street. You may contact Ms. Ricco Jonas by telephone (603) 271.6980, fax (603) 271.2856 or by email at michelle.riccojonas@nh.gov.

When the program launched in October, data as far back as March 1, 2014 was preloaded into the system. New Hampshire is the 49th state to initiate

this type of program, and its operational parameters are somewhat unique to this ‘Live Free or Die’ state.

In New Hampshire, PDMP is accessible to Physicians, PAs, NPs, Pharmacists, Dentists, Optometrists, Veterinarians and other prescribers. The New

Hampshire Board of Pharmacy has contracted with Health Information Designs, LLC (HID) as a vendor to develop a database that will collect and

store prescribing and dispensing data for Schedule II, III, and IV controlled substances. HID’s prescription drug monitoring program, RxSentry, is a

web-based program that facilitates the collection, analysis, and reporting of information on the prescribing, dispensing, and use of controlled

substances. HID is a nationally recognized leader in automated healthcare solutions and serves more than 20 states including Maine and Vermont.

New Hampshire law requires that each dispenser submit information regarding each prescription dispensed for a Schedule II, III, or IV controlled

substance. Each time a controlled substance is dispensed; the dispenser shall submit the information required by New Hampshire law to the PDMP

database within seven (7) days of the date the prescription was dispensed. Even if no prescriptions for a Schedule II, III, or IV controlled substance

are dispensed over a 7 day period, a Zero Report must still be filed to the PDMP database.

Physicians are also required by law to register with the program.

Once registered they will have access to the data base through an internet portal and can review patient profiles.

Rationale for a PDMP (data from 2012):

Each day, 46 people die from an overdose of prescription painkillers in the US.

Health care providers wrote 259 million prescriptions for painkillers, enough for every American adult to have a bottle of pills.

New Hampshire was one of 21 states that had 65-82 prescription painkillers per 100 people.

Effectiveness of PDMP (success rates are being reported and are increasing):

2012 Action: Tennessee required prescribers to check the state’s prescription drug monitoring program before prescribing painkillers.

2013 Result: Saw a 36% drop in patients who were seeing multiple prescribers to obtain the same drugs, which would put them at higher risk of

overdose.

"Prescription painkillers" refers to opioid or narcotic pain relievers, including Vicodin (Hydrocodone + Acetaminophen), OxyContin (Oxycodone),

Opana (Oxymorphone), and methadone.

New Hampshire’s Prescription Drug Monitoring Program (NH PDMP) Went Live October 16, 2014

M Kosmatka, PharmD, Clinical Pharmacy Supervisor

Medical Staff Newsletter Winter 2015 Page 3

Costs are risk-adjusted (up or down) based on the severity of illness supported by physician documentation.

What’s different is that for the first time hospitals are being held accountable for not just the cost of care while an inpatient, but also the cost

of the next 30 days. We’ve not focused on this, other than avoiding penalties for re-admissions within 30 days. But whether the patient went

home without any services, or went to a long-term acute care hospital, never mattered financially up to this point. This is a big change for us

and we’ve had to look at the world a bit differently as a result.

We are approaching this as a lean project with a multidisciplinary team that includes several of our staff as well as stakeholders in the

community like Greebriar, Courville and our Acute Rehabilitation Unit. Our focus has been on optimizing the care of the patient while here,

including promoting early mobility and conditioning, as well as protocols and evidence-based practice for those patients who may require

care beyond the home. We’ve begun to see some positive impacts, which is heartening, but it will involve a continuing effort to succeed.

Ultimately, optimizing care in the right setting, and restoring patients to their home settings as soon as possible, makes tremendous sense

Regards,

Rich Boehler

MD, MBA, FACPE

If you can't feed a hundred people then feed just one--Mother Teresa

Continued from Page 1, Value Based Purchasing. A New Twist

So You Think You Can Diagnose Asthma Dyspnea, coughing, wheezing and chest tightness are well-known symptoms of asthma. Because of this, many patients are diagnosed with asthma based on symptoms alone. Sometimes patients are given a trial of medication and a diagnosis of asthma is made if the patient reports improved symptoms. Even when patients are subjected to formal diagnostic testing, many times the decision of whether the patient does or does not have asthma rests solely on the outcome of that one particular test. However, many of the tools clinicians rely upon to diagnose asth-ma aren't all that reliable. ………………………………………………………………………………………………………………… Risk Factors………………………………………………………………………………………………………………………………. There are important risk factors to consider when entertaining the possibility of asthma. Family history of asthma and allergies is a significant factor to consider. Occupational exposure to dust, smoke and chemical compounds may signal occupational asthma. Nasal polyps coupled respiratory symptoms that coincide with non-steroidal anti-inflammatory use should prompt consideration of the "asthma triad.” Signs & Symptoms……………………………………………………………………………………………………………………… As mentioned above, there are several cardinal signs and symptoms of asthma. Unfortunately, these are not specific to asthma. The most common signs and symptoms of asthma also occur in COPD, CHF, tracheomalacia, and vocal cord dysfunction syndrome (VCD). Trials of Medication………………………………………………………………………………………………………………… … Notable downsides to this approach include poor inhaler technique, placebo-effect and evidence that many patients are not truthful about their compliance with the prescribed medications. In one study, 30% of patients were found to have actuated their inhaler 100 times in the three hours prior to their follow-up appointment.………………………………………………………………………………………… Peak Flow Monitoring……………………………………………………………………………………………………………………. Peak flow monitoring is inexpensive and portable, which allows symptoms and data to be linked. When chronicled in a diary, temporal changes can be assessed in the context of therapy alterations or trigger exposure. However, there are several limitations to peak flow monitor-ing including compliance, accuracy, and low specificity.

Spirometry With Bronchodilator………………………………………………………………………………………………………… Spirometry is superior to peak flow monitoring when trying to diagnose asthma. Significant airflow obstruction, which is reversed by a bron-chodilator, significantly raises the post-test probability of asthma. The problem with spirometry/bronchodilator studies is that most asthmatics spend most of their time with normal airflow and no symptoms. Unless the patient is tested while they're symptomatic the test will likely be nor-

mal and unchanged after bronchodilator. ……………………………………….………………………………………………………………… Methacholine Challenge…………………………………………………………………………………………………………………………. Methacholine is an agent which can produce bronchoconstriction by acting directly on airway smooth muscle. Methacholine can produce bronchoconstriction in most people, even non-asthmatics, if large doses are administered. Airway hyper-responsiveness is a feature of asth-ma, so asthmatics tend to experience bronchoconstriction from small doses of methacholine. During a methacholine challenge patients are given small doses of methacholine, which are generally large enough to produce bronchoconstriction in most asthmatics but not large enough to produce bronchoconstriction in most non-asthmatics. The post-test probability of asthma increases or decreases based on this finding. Summary Making a diagnosis of asthma is like making a case to a jury. One piece of evidence, be it symptoms or a diagnostic test should not be used in isolation to diagnose asthma. Putting several pieces of evidence together to formulate the probability of asthma will result in more accurate diagnoses and better patient care.

Medical Staff Newsletter Winter 2015