Physicians’ Bi-Monthly MarchApril 2015 Population Health ......Physicians’ Bi-Monthly MarchApril...

Physicians’ Bi-Monthly March/April 2015

Goodwin Community Health Joins Million

Hearts Initiative By Cathy Smith, QI Coordinator at Goodwin Community Health

Goodwin Community Health is the latest Federally Qualified Health Center to join the Mil-lion Hearts initiative, a national campaign that brings together communities, health systems, nonprofit organizations, fed-eral agencies, and private-sector partners from across the country to fight heart disease and stroke. In New Hampshire, Goodwin has partnered with the Depart-ment of Public Health Services, the Institute for Health Policy and Practice at the University of New Hampshire, the Com-munity Health Access Network and the New Hampshire Medical Society, to help make significant change in the control rates of pa-tients with hypertension.

The project puts into practice elements from the recently re-leased “Ten Steps for Improving Blood Pressure Control in New Hampshire” manual. An elec-tronic version can be found at: http://www.dhhs.nh.gov/dphs/c d p c / d o c u m e n t s / t e n s t e p s - bpcontrol.pdf

At Goodwin, the project has al-

Million Hearts, cont. on page 9

By Wendy Gladstone, MD

Your next patient of the day is Cheryl, an 11 year old with mod-erate persistent asthma. She’s here with her father for a health main-tenance visit. Before you enter the room, your medical assistant tells you that Cheryl asked about be-ing responsible for her own medi-cations so she doesn’t have to ask her dad for her inhaler every time she wants to use it; but her father thinks she’s too young.

What do YOU think?

Learning to manage her (or his) own medication is something ev-ery child has to learn as part of a successful transition to adulthood. Adolescence is when most children acquire the necessary skills, but some studies show that fewer than 60% of health care providers talk with young adolescents about start-ing down the transition road. Are you someone who does?

When Can Children Manage Their Own Medications?

By William Kassler, MD, MPH

Many current health reform efforts call for the adoption of population health strategies. What exactly is population health and how does it relate to the practicing clinician? How does an interested clinician get started?

The New Hampshire Medical So-ciety (NHMS) and the Institute for Health Policy and Practice (IHPP) at UNH are proud to announce a new clinician learning tool, titled Popula-tion Health for the Clinician: A Podcast Series. This series aims to introduce

the listener to the principles and practices of population health and to share resources to help the clini-cian incorporate population–based strategies into their practice.

“There is so much attention be-ing paid to population health these days, yet it remains poorly under-stood,” said Dr. Bill Kassler, series host and former NHMS president. “We are fortunate to have quite a number of nationally recognized experts join us to discuss this im-portant topic.”

Population Health for the Clinician: A Podcast Series

Population Health, cont. on page 8

Medications, cont. on page 10

POPULATION HEALTH FOR THE CLINICIANA Podcast Series


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New Hamphire Medical Society7 North State Street Concord, NH 03301 603 224 1909603 226 2432 [email protected] www.nhms.org Lukas R. Kolm, MD, FACEP ..... PresidentJanet Monahan.....................Interim EVPMary West ....................................... Editor

Deadline for Planning a Truly Happy Retirement? 5 Years Before .................3

The HPV Vaccine: Providers Can Play an Important Role .......................4

EVP Corner ............................................5Is There A Doctor in the House? ...........6NHMS Welcomes New Members ............7I stand, corrected ....................................82015 NHMS Council ............................ 11Save the Date! 2015 NHMS Annual

Scientific Conference! .......................13Strategies to Prevent and Respond to

Patient Complaints ............................14Physicians can fire patients, too! ...........16Corporate Affiliate Program .................18

Mission: Our role as an organization in creating the world we envision.The mission of the New Hampshire Medical Society is to bring together physicians to advocate for the well-being of our patients, for our profession and for the betterment of the public health.

Vision: The world we hope to create through our work together. The New Hampshire Medical Society envisions a State in which personal and public health are high priorities, all people have access to quality healthcare, and physicians experience deep satisfaction in the practice of medicine.

Do you or a colleague need help?The New Hampshire Professionals’ Health Program (N.H. PHP) is here to help! The N.H. PHP is a confidential resource that assists with identification, intervention, referral and case management of N.H. physicians, physician assistants, dentists, and dental hygienists who may be at risk for or affected by substance use disorders, behavioral/mental health conditions or other issues impacting their health and well-being. N.H. PHP provides recovery documentation, education, support and advocacy – from evaluation through treatment and recovery. For a confidential consultation, please call Dr. Sally Garhart @ (603) 491-5036 or email [email protected].

*Opinions expressed by authors may not always reflect official N.H. Medical Society positions. The Society reserves the right to edit contributed articles based on length and/or appropriateness of subject matter. Please send correspondence to “Newsletter Editor,” 7 N. State St., Concord, NH 03301.

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Understanding system failures and limitations is key in being able to successfully integrate and execute multiple clinical strate-gies. The nuances and rhetoric pertaining to “transformational healthcare” that are impacting all organizations and practices have less to do with any one system de-sign as a medical home or neigh-borhood to make an accountable care organization (ACO) success-ful. The longevity of an ACO and its outcome measures are argu-ably not directly correlated or for-mulaically based on the makeup of hospital-employed physicians and independent private practi-tioners or for that matter any cre-ative combination of patient care models or modified service lines. Nor will there be predictably re-liable long-term reimbursement agreements based on attempts to govern larger groups of employed providers as a means to reduce risk attached to increased access with higher quality care at lower costs. The best of the best and the worst of all will in some direct causal re-lationship be largely due to their particular dynamic utilization of informational systems. The most

agile IT networks integrating the newest technologies with wide-spread connectivity should be considered a necessary strategic advantage to enhance and sup-port overall flexibility, necessary to integrate teams of providers of various backgrounds.

The migration away from long-standing traditional delivery of healthcare is well underway. There is lots of movement that is exciting and provocative that many seasoned providers and healthcare experts find challeng-ing. One of the greatest challeng-es is how to become positioned for the future as soon as possible without making fatal mistakes in doing so. On many accounts it is to not disproportionately pursue the R and D of new drugs or the most technically advanced surgi-cal equipment or the incessant push for the best electronic medi-cal record system to rise from the morass of competitors.

The more necessary migration pattern is away from the norm, to align multidisciplinary teams of providers from social services, leadership, management and fi-nance to be integrated with direct clinical care. This is the directive from the Centers for Medicare & Medicaid Services, academics and an appreciated perspective to cre-ate a more affordable means of healthcare delivery in the United States and ultimately in the world. In order to realistically and effec-tively slow the growth of health care costs, a shared understand-ing of how to tailor systems within systems to deliver multifaceted care outside of hospitals is essen-

President’s PerspectiveHealthcare Informatics Technology & Telemedicine “The Medical Hub”

President’s Perspective, cont. on page 12

Lukas Kolm, MD, MPH, MBA, FACEP


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By Brian O’Connell Jan 23, 2015, Horsemouth, LLC

TheStreet: Want a happy retire-ment? Here’s why you need to plan well in advance. If you’re looking to put the finishing touches on your retirement plans, a study from MassMutual1 has a suggestion on timing. “Retirees who expressed the highest levels of satisfaction in retirement are also those who took concrete steps to put both their emotional and fi-nancial lives in order at least five years or more before retirement.”

Unfortunately, only 31% of U.S. adults heading toward retirement “carefully research and plan every detail of their retirement plans,” MassMutual says. And only 11% map out “every detail” of their retirement, while 36% admit to “winging it” with their financial strategy. (MassMutual points out that U.S. adults are three times more likely to wing their retire-ment than their vacation plans.)

There is some good news for fu-ture retirees, who could use some at a time so many struggle to cobble together a decent retirement fund. A majority of retirees say they are happy in retirement and that pre-retirement anxieties about being bored or financially strapped are significantly overstated.

“Our research on retirees and pre-retirees tells us that retirement can be and should be an extraordinari-ly happy time in our lives as long as we start to strengthen our emo-tional bonds and exercise financial planning discipline well before we plan to retire,” says Elaine Sarsyn-ski, executive vice president at

MassMutual Retirement Services. “The happiest retirees provide us with a road map for success, which is especially instructive for those who are close to embarking on the journey.”

The study has more “lessons learned” from retirees on how they found happiness in retirement:

• Retirees who took steps to “build stronger connections” to their loved ones and “pur-sued new interests” were far more likely to enjoy their post-career years.

• Retirees who laid out a careful plan for the financial side of retirement (such as calculating the best time to start collecting Social Security), and who ac-celerated retirement savings as they neared retirement, ap-peared “most satisfied.”

• The biggest good retirement surprises included having no time constraints, keep-

ing busy, and having enough money; bad surprises includ-ed suffering an illness or weak health and having unexpected cash problems. �

________________________

Brian O’Connell is a Doylestown, Pa.-based freelance writer with 17 years experience covering business news and trends, particularly in the finan-cial, health and sciences, Internet and technology, political and career management sectors. A former Wall Street bond trader, Brian’s byline has appeared in many publications—CBS News, Time, MSN Money, The Wall Street Journal, CNBC, The Street.com, Yahoo Finance, CBS Market-watch, and many more.

Provided by Troy Zerveskes and Robert C. Burns, Jr., CFP, CLU, ChFC, Baystate Financial advisors to NHMS member-physicians. Baystate Financial’s subscrip-tion agreement with Horsemouth grants them permission to reprint articles.

Deadline for Planning a Truly Happy Retirement? 5 Years Before

1 https://wwwrs.massmutual.com/rsstaticfiles/retire/pdffolder/rs5853.pdf


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Human papillomavirus (HPV) in-fects approximately one in four adults in the United States and is known to be a precursor to cervical and several other types of cancer. Many of these can be prevented with HPV vaccination. Providers can play an important role in increasing pre-teen HPV vaccinations by providing infor-mation and recommending the complete three-dose series of HPV vaccine during preventative care visits when other vaccines are administered. According to the Centers for Disease Control, as many as two-thirds of 11- and 12-year old vaccine-eligible girls may not be receiving HPV vac-cines when visiting their doctor for other preteen vaccines (Tdap, meningococcal, and influenza).

Individuals and organizations need to coordinate their efforts to create a well-organized system that can deliver clear messaging to providers and parents in New Hampshire about the impor-tance of early HPV vaccination as a cancer prevention strategy. The 2015-2020 NH Cancer Plan includes an objective to increase the percentage of youth who complete the HPV vaccination se-ries. The Cancer Collaboration,

in partnership with Dartmouth-Hitchcock Norris Cotton Cancer Center, recently released a new emerging issue brief, The HPV Vaccine. The full version of the brief can be found at: http://www.nhcancerplan.org/images/downloads/issue-briefs/NHCCC_Emerging_Issues_12-2014.pdf. Below is an excerpt.

Barriers to HPV Vaccination

Researchers at Norris Cotton Cancer Center in Lebanon, NH collaborated with the State Immu-nization Program of New Hamp-shire to look at attitudes and practices related to HPV vaccina-tion when it was first introduced in 2007. They conducted a small study of 52 primary care clini-cians who cared for adolescents

and found the most common bar-riers perceived for parents were:

• lack of understanding about HPV diseases,

• safety concerns,

• implied consent for early on-set of sexual behaviors.

In December 2013, the NH state chapter of the American Academy of Pediatrics surveyed 200 prima-ry care clinicians about their per-ceptions about HPV vaccination and again found the most com-mon barrier to HPV immuniza-tion was lack of knowledge about HPV diseases, lack of parental ac-ceptance, preference to wait until older, or sexual activity concerns. Of note, 33 percent of clinicians also cited patient fear of side ef-fects as a barrier.

Similar barriers were reported by parents in a national immuniza-tion survey of 2008-2010 (Pedi-atrics 2013; 131; 645-651). Over three years, the proportion of parents refusing HPV vaccina-tion because of safety concerns or side effects increased from 4.5 to 16.4 percent, despite the absence of any newly reported adverse events. In contrast, for other ado-lescent vaccines, the rate was sta-ble at less than 1 percent. Clearly, public perceptions about HPV vaccinations have not improved over the years. We need to reas-sess current messaging, publically and in the primary care setting. �

The HPV Vaccine: Providers Can Play an Important Role

...the most common barrier to HPV

immunization was lack of knowledge about HPV diseases, lack of parental acceptance, preference to wait until older, or sexual

activity concerns.


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By Janet Monahan Interim Executive Vice President

The process of searching for a new executive vice president for the Medical Society has prompted members and potential applicants to ask, “What exactly does the So-ciety do?” “What does advocating for physicians and public health entail?”

As an employee of the Medical Society for the past 28 years, I have been directly or indirectly involved with many issues that impact the day-to-day practice of medicine, children, public health, malpractice, health insurance, end-of-life care, workers’ com-pensation, professional licensure, drug use and abuse, etc. If some-thing is even remotely related to health care, chances are, the Med-ical Society has a representative at the table.

Many issues bring state-wide headlines, such as passage of the NH Health Plan Protection Pro-gram (Medicaid expansion) and the court battle involving the NH Medical Malpractice Joint Under-writers Association’s (JUA) return of excess premiums to physicians. The majority of issues the Medical Society undertakes, unfortunately never make the six o’clock news.

To some, it appears that the Medical Society is focused mainly on legislative activities. Yes, the Medical Society is seasonally in-volved with legislative work but more time and energy goes into other policy-making activities. As a member of the Medical So-ciety, you have staff and volun-teer physician representatives serving on an assortment of very

important committees and task forces covering: impaired physi-cians, opioid use, workers’ com-pensation, exchange of electronic health information, telemedicine, physician workforce and access to care, end-of-life health care poli-cies, prescription monitoring pro-gram, health insurance network adequacy, therapeutic cannabis, public health, CME accredita-tion, the state-wide medical care advisory committee, state health claims data base, business hu-man resources, PTSD, women’s health issues, suicide prevention, oral health, immunizations, etc. Some of these activities have leg-islative roots while others have grown from public health needs, the business side of medicine, and patient care concerns. Recently, the Medical Society has been part of a broad group of stakehold-ers trying to resolve serious is-sues surrounding the safe access to compounded medications, and with another group, the Society is seeking resolution or reinterpre-

tation of a CMS regulation that is adversely impacting hospice pa-tients.

The Medical Society works with dozens of New Hampshire or-ganizations and associations, in-cluding the Hospital Association, Bi-State Primary Care, Founda-tion for Healthy Communities, Endowment for Health, Business & Industry Association, AARP, Cancer Society, Lung Association, Dental Society, Public Health As-sociation, Medical Group Manag-ers Association, Vaccine Associa-tion, and health insurers.

The Society also routinely inter-acts with New Hampshire’s Exec-utive Branch offices, departments and bureaus: Governor, Attor-ney General, Board of Medicine, Board of Pharmacy, Health & Human Services, Medicaid, Pub-lic Health, Motor Vehicles, Insur-ance, Labor, Safety, Secretary of State, etc.

EVP CornerRepresenting Your Interests

EVP Corner, cont. on page 15


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Skip Berrien, MD Rockingham District 18 – Exeter

I am a retired pediatrician who has continued to advocate for children and families during re-tirement through my association with New Hampshire CASA, the New Hampshire Children’s Trust and the New Hampshire Chil-dren’s Alliance.

My interest in seeking a position in the legislature is to continue advocacy through public policy. In particular I am interested in programs and policies that sup-port vulnerable families in order that children can grow and devel-op into productive and contribut-ing members of our society. With New Hampshire’s aging popula-tion, we need to encourage policies which encourage young people to remain engaged and participat-ing in our economy. Initiating these policies at birth establishes a foundation on which to build a satisfying and productive life for all of New Hampshire’s families. As a member of the House Chil-dren and Family Law Committee, I have found legislative colleagues who share my commitment to families and children.

John Fothergill, MD Coos District 1 - Colebrook

For the past 27 years I have had the honor and privilege to serve the Colebrook area as an inter-nist. In this time, I have grown to know my patients and neighbors quite well and have had broad opportunities in medicine includ-

ing both clinical work and roles in leadership.

My clinical practice started as a private practice and evolved into a rural health center and, as it is now, into a Federally Qualified Health Center. I have provided a leadership role at my clinical prac-tice as well as at the local hospital, nursing home and, at times, EMS.

I have a longstanding interest in politics and public policy, but the opportunity for me to engage at the statewide level was limited be-cause of my local responsibilities. Fortunately, our health center re-cently recruited two very capable providers so I now have the flex-ibility to spend half of my time in Concord while still practicing medicine in Colebrook.

Is There A Doctor in the House?

Doctor, cont. on page 7

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Thankfully, my constituents agreed with my plans and voted me into office. In Concord, I serve on the House Health & Human Services and Elderly Affairs Committee, which is a perfect fit for me. As a novice elected official, my initial goals are to develop relationships and to learn the system. The work load is substantial, but I look for-ward to communicating and col-laborating with people through-out the state to make things better. While my experience in Concord is limited, if you think I can help, I’d be happy to talk with you. Do not hesitate to contact me: [email protected]

Joseph Hagan, MD Rockingham, District 7 – Auburn, Chester and Sandown

I am a retired (27-year) USN Medical Corps Officer, serving in my fourth term in the New Hampshire House and fourth term on the Judiciary Committee. For the next two years I am part of House leadership as the Vice Chair of the Judiciary Committee. As a state representative, I look forward to advancing medical malpractice reforms and halting trial lawyer resistance to the same.

I am very concerned about Med-icaid expansion with the federal debt approaching 19 billion dol-lars. Ultimately Washington will renege on its promises and New Hampshire will need to pay for another unfunded mandate! Where will New Hampshire find the revenue necessary to meet the Medicaid expansion obliga-tion? New Hampshire may be better off finding our own solu-tion before it is too late; remem-bering that Vermont could not afford its health plan.

I want to thank the New Hamp-shire Medical Society for your kind assistance in my develop-ment as a legislator.

Thomas M. Sherman, MD Rockingham District 24 - Rye and New Castle

This is my second two-year term in the New Hampshire House and second term on the House Health Committee. I am fortunate to be able to balance my work as a gas-troenterologist with the legislative schedule. Bringing a physician’s perspective to the role of state rep-resentative is critical. Many health care related decisions are made at the State House and there are very few providers to deliver that perspective. The areas where I believe I had the greatest impact were with legislation related to the Exeter hepatitis C outbreak and drug diversion, Medicaid ex-pansion and women’s health is-sues. It is wonderful that we have more physician representatives in Concord for this biennium. It has been incredibly rewarding to pro-vide advocacy for my patients, my constituents and my profession. I strongly encourage all physicians to become engaged at some level in this process. [email protected] �

Doctor, cont. from page 6

NHMS Welcomes New Members

Ali A. Al-Awan, MDDanielle T. Albushies, MDDiana M. Alexandru, DOJosee L. BourBeau, MDMatthew V. Buck, MDCarrie L. Cocklin, MDJan L. Cook, MDAlan E. Cordts, MDPeter H. Crow, MDJames F. Dana, II, MDKevin P. Desrosiers, MDStefanie L. Diamond, PA-CMarc P. Duhaime, DOCharles R. Felton, MDAdam B. Fleit, MDEric C. Flint, MDJennifer L. Hendricks, DOCraig R. Hricz, PA-CSmita C. Kherde, MDPeter Kiprop, MDSrilatha Kodali, MDAaron Mancuso, MDHerb T. Meyer, DOJohn F. Nigriny, Jr., MDSteven T. Olive, MDAlexander Ortiz, MDJane C. Primm, MDMichele G. Rush, MDBetsy B. Sandberg, MDAngela L. Shepard, MDGurpinder Singh, MDPaul P. Wang, MDSarah P. Young-Xu, MD


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The Podcast Series will feature episodes on working with state health departments and commu-nity-based organizations, advo-cacy and leadership, a case study on putting prevention into your practice, and what can be done to address health disparities. Guests include leading academicians and medical educators, senior leader-ship from CDC and state health departments, the chief medical officers of a safety net clinic and a Pioneer ACO, and several prac-ticing physicians who have under-taken leadership roles, including a state legislator.

“Educating health care provid-ers and improving the health of our population are central to the mission of the College of Health and Human Services,” said Mike Ferrara, Dean of the College of Health and Human Services and the Kent P. Falb Professor of Ki-nesiology at the University of New Hampshire. “The College is pleased to support this effort to advance the knowledge and prac-tice of health care providers in New Hampshire.”

The Podcast Series will be re-leased in March 2015 and will be available on the NHMS website at https://www.nhms.org/pophealth Each of the eight 15-minute episodes will confer 0.25 hours of ACCGME CME credit. For more information contact Mary West at [email protected] or 603.224.1909.

Funding for the Podcast Series project has been provided by the UNH College of Health and Hu-man Services and the New Hamp-shire Medical Society.

About the Institute for Health Policy and Practice at UNH

The Institute for Health Policy and Practice (IHPP) at the Uni-versity of New Hampshire is an applied research institute, estab-lished in 1999, to conduct and disseminate high-quality, cutting-edge applied research and policy work that enables health system

partners to implement evidence-based strategies to improve public health. More information is avail-able at www.chhs.unh.edu/ihpp. �

Population Health, cont. from page 1

I stand, corrected.By Tom Lanahan

Plates, screws, scars were involved.Even HumptyDumpty could have been saved,

given the technical prowess employed.This, however, is only the mechanical, visual repair.

The deeper, hidden truth is that I was “Blitzed”.Elaboration of this term follows.

From his first words in the ER,to the gentle, firm admonitions during visits,

warning that any foolishness on my partwould break the healing spell.

A spell crafted over a lifetime and more.

Built upon the history and wisdomof timeless healers that understood “wholeness”.

His is the manner of Shaman, disguised in a white coat.(although he would deny this mantle, it is so)

I suspect his pockets filled with talismans.Small stones perhaps, nestled among sacred bones.

He seems to inhabit worlds diverse, vast, mysterious.One could say anachronistic and dissonant.

Not so.Those worlds inhabit him as well,

serving as protection, balance, grace.A cradle for nascent potions as it were, with a window.

Peeking in reveals his powerful tools.Curiosity, spirit, care, fealty to the oath.

Bound tightly by the engagement and presence of the man.It is his being that heals.

Hands, heart, hope, faith, and a spell created.Within it’s power, I now stand, corrected.

Grateful, humbled, healed.


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lowed for the development of a provider dashboard, a patient registry for existing electronic health records and the addition of a reporting function on a new hy-pertensive measure supported by the CDC-NQF18. Also, Goodwin Community Health used resourc-es from the “Ten Steps” manual to train staff on proper blood pres-sure measurement techniques, equipment and calibration, and to help engage providers, staff, patients, local hospitals and com-munity partners. Locally, Good-win has partnered with a local mental health center, Community Partners, and two local hospitals, Wentworth-Douglass Hospital and Frisbie Memorial Hospital,

to help distribute Million Hearts wallet cards. The wallet cards are a patient engagement tool and were donated by the New Hamp-shire Medical Society.

As Goodwin Community Health’s Quality Improvement Coordina-tor, it is very exciting to see the suc-cess of the Million Hearts initiative making a local impact, as it has al-lowed us to connect with other facilities in ways that the practice has not before. In fact, when I at-tended the Million Hearts Learn-ing Collaborative in Washington, DC, a few months ago, I found no other state had partnered with a local mental health center to help improve health outcomes as it re-

lates to managing cardiovascular disease.

There is an upcoming interac-tive, half-day workshop to sup-port practitioners and practice administrators in implementing the strategies in ways similar to Goodwin Community Health. The workshop is scheduled for Thursday, March 26, from 9 a.m.-12 p.m. at the New Hamp-shire Department of Transpor-tation, Granite State Conference Room, 7 Hazen Drive, Concord, New Hampshire. Space is lim-ited. You can register at: http://chhs.unh.edu/ihpp/public-health-and-health-promotion. �

Million Hearts, cont. from page 1

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What are some effective ways to help a young person become able to manage medication? Where can you find resources to help guide families with this step to-ward independence?

For some patients, medication doesn’t just keep them healthy, it keeps them alive. Taking 21 days of amoxicillin for sinusitis is im-portant, but when a child takes medication to prevent seizures, normalize blood sugar, prevent graft rejection or avoid broncho-spasm, the stakes are higher. Then it’s especially important to be sure your patient gets it right. Lots of patients don’t. This is especially a problem as young people tran-sition from pediatric providers to practitioners of adult medicine. As adolescents with kidney trans-plants assume responsibility for their own anti-rejection medica-tions, adherence declines and the risk of graft loss rises. A study of 13 to 20 year olds with rheuma-tologic conditions who managed their own medications showed that 6% of them missed doses at least three times per week. That’s a lot

of missed medication. Are we as providers good at getting a “feel” for whether a patient is skipping doses? Studies show that we don’t do so well. Of course we should ask the patients and their parents (or other caregivers) about how they’re doing with consistently getting their medications, but the best way to know is to have some-thing objective to measure, like a drug level. Sometimes the re-sults will surprise everybody, but at least you’ll know which families need additional support.

Managing medication is more than knowing to take the little white pill in the morning, a green one at lunch and a white and pink one in the evening. Having a pill “app” or a daily pill dispenser can help, but there are bigger con-cepts to think about before your patient can be in charge of things. Here are some steps necessary for Cheryl* to take before she be-comes a responsible manager of her own medication:

1. She knows her diagnosis.

2. She knows the name and dose of her medication.

3. She knows what the medica-tion does and how to tell if it’s working (or not).

4. She knows what side effects to watch out for.

5. She knows how to contact your office with any ques-tions.

6. She knows whether there are medications she shouldn’t take because of allergy or in-tolerance.

7. She knows what constitutes an “emergency” and what to do about it.

8. She knows how to plan ahead and successfully or-

der a refill so it gets to her in time.

9. She knows what to watch out for if she runs out and sud-denly stops her medication (or simply forgets to take it).

10. She knows what to do about breakthrough symptoms if that happens, even if she has just restarted the medi-cation.

(*Her father should know all this already!)

Adolescence is marked by lots of changes. It’s to be expected that from time to time teenagers will be forgetful because of things on their minds or interfering activi-ties. Lack of planning can lead to hurrying and that can lead to mis-takes. Parent-child conflict can re-sult in skipped doses as a way of rejecting what the parent wants. An adolescent has to be able to delay gratification if he thinks his medication is causing a side effect but he can’t change to another one until the next appointment with you.

An excellent resource for transi-tioning young people from pedi-atric to adult care can be found at www.gottransition.org. You’ll find tools to implement this important phase and ways to assist your pa-tients and their families through it. The site points out that by age 12 families should be aware that the transition takes planning and should occur as a gradual process with the child learning the steps it takes to manage her (or his) own care. This means starting con-versations well before that age. Start by encouraging children to learn what “asthma” or “seizures” means. It also means spending part of a visit alone with your pa-

Medications, cont. from page 1

Medications, cont. on page 11


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2015 NHMS Council President Lukas R. Kolm, MD

President-Elect John R. Butterly, MD

Immediate Past President Stuart J. Glassman, MD

Penultimate Past President P. Travis Harker, MD, MPH

Vice President Deborah A. Harrigan, MD

Secretary Seddon R. Savage, MD

Treasurer Paul F. Racicot, MD

Speaker Richard P. Lafleur, MD

Vice Speaker Tessa J. Lafortune-Greenberg, MD

AMA Delegate William J. Kassler, MD, MPH

AMA Alternate Delegate Cynthia S. Cooper, MD

Chair, Board of Trustees David C. Charlesworth, MD

Medical Student Vivienne Meljen

Physician Assistant Mark H. Rescino, PA-C

N.H. Osteopathic Assn. Rep. Robert G. Soucy, Jr., DO

Young Physician Rep. Vladimir Sinkov, MD

Young Physician Rep. Jeffrey C. Fetter, MD

Member-at-large Tina C. Foster, MD

Member-at-large Gregory Kaupp, MD

Member-at-large John L. Klunk, MD

Member-at-large Edmund Schiavoni, Jr., MD

Member-at-large Anthony V. Mollano, MD

Member-at-large Everett J. Lamm, MD

Physician Member of N.H. Board of Medicine Nicholas Perencevich, MD Sarah Blodgett, Esq.

Lay Person Martin Honigberg, Esq.

Physician Rep. of the N.H. Dept. Health Human Services Jose T. Montero, MD

Specialty Society Reps.:

· N.H. ACOG Oglesby H. Young, III, MD

· N.H. Academy of Family Physicians Gary A. Sobelson, MD

· N.H. Chapter of the American College of Physicians Richard P. Lafleur, MD

· N.H. Chapter of the American College of Cardiology Daniel Philbin, MD

· N.H. Chapter of Emergency Physicians Michelle S. Nathan, MD

· N.H. Orthopaedic Society Robert J. Heaps, MD

· N.H. Pediatric Society Tessa J. Lafortune-Greenberg, MD

· N.H. Psychiatric Society Leonard Korn, MD

· N.H. Society of Anesthesiologists Steven J. Hattamer, MD

· N.H. Society of Eye Physicians & Surgeons Sonalee M. Desai-Bartoli, MD

· N.H. Society of Pathologists Jeoffry B. Brennick, MD

Trustee David C. Charlesworth, MD

Trustee Charles M. Blitzer, MD

Trustee Cynthia S. Cooper, MD

Invited Guest: MGMA Rep. Dave Hutton

tient so you can help model pa-tient-provider interactions. Ado-lescents with chronic conditions are less likely to have problems with transitioning if their care is integrated and multidisciplinary. Some children do well when they attend a camp focused on their condition where peer support and intensive education help them to become more independent. Hav-ing a written care plan makes it easier for a teenager to have im-portant information available at all times.

Finally, if you’re a pediatric pro-vider, get to know your adult medicine colleagues and which of them are especially interested in helping young people transi-tion to “grown-up” care. Your planning ahead will make it easier for your patients to be successful as they move on in life and take responsibility for their own treat-ment. It’s one of the most impor-tant roles we play as providers for children and adolescents, and one of the most gratifying, too. �

Additional resources for these and other supports can be found at the following websites:

• American Academy of Pediatrics’ clinical report on transitioning: http://pediatrics.aappublications.org/content/128/1/182

• American Camping Association (for accredited specialty camps)

• New Hampshire’s Department of Health and Human Services’ website where information on transitioning and links to NH Family Voices and the Youth for Education, Advocacy and Healthcare groups are posted: http://www.dhhs.nh.gov/dcbcs/bds/sms/transition.htm

• Seattle Children’s Hospital (for a sample care plan)

• Teenshealth.org (especially for adolescents)

Medications, cont. from page 10


12

tial. “Over the next decade the delivery of health care will be-come much more integrated and team based.” Reinventing American Health Care, by Ezekiel Emanuel, 2014, p340. One, if not the most, important key focus is to univer-sally and collectively grow health-care informatics interconnectivity and rapid development of tele-medicine capabilities.

There is opinion that a real bite at the apple for a universal EHR was one of the gravest missed oppor-tunities. Furthermore, no real re-strictions placed on the largest in-formatics companies has allowed them to experience exponential growth without delivering EHRs that can be implemented without tremendous amounts of modifi-cations to integrate them within different organizations and, even more so, continue to have major barriers with health information exchange networks for more than a decade. “While successful net-works exist, their sustainability is complicated by the existence of multiple stakeholders with differ-ing incentives for participation.” “Health Information Exchange Networks Understanding Stake-holders View,” AMIA Annual Symposium Proceedings Archive. 2005, p1044.

The here and now is that elec-tronic medical records and the ability to deliver healthcare re-motely through other modali-ties, such as telemedicine, are al-ready advanced enough, having undergone several technological generations of development and maturation. “While the concept of telehealth has been around for more than 40 years, it did not become feasible for use until the 1980’s with the expansion of digi-tal communication. Unfortunate-

ly, the incorporation of telehealth into practice was slow to be adapt-ed by physicians and hospitals due to concerns regarding cost, privacy, reimbursement, as well as logistics of setting up a telehealth network.” Telehealth in Emergency Medicine: A Primer, by Neal Sik-ka, MD, et al. ACEP Emergency Telemedicine Section, June 2014.

Telemedicine, in conjunction with even a rudimentary but well-inte-grated EHR, could be considered the next greatest thing overarch-ing all of the shifting components in the delivery of healthcare. The combination of the two offers a cohesive, synchronous platform that can span the transforma-tion in medical education, out of hospital patient care and wellness programs, retail based healthcare models, to disease-specific tertiary care centers along with shared re-sources to help sustain many nec-essary but threatened critical ac-cess or rural hospitals throughout the country. Those who might be considered more risk aware than risk adverse may actually be true pioneers. Institutions that wait to see what will really prove to be most sticky over three to five years will find it more challenging to truly align themselves with greater access along with high quality care at lower costs. A common point of short sightedness is a lack of in-vestment in appropriately trained and experienced leaders that can actually ex-ecute processes and train oth-ers. “The big problem with putting more emphasis on digi-tal medicine in medical schools is the paucity of well-trained facul-ty. Not only will medical schools need to change their curricula; they will need to add nontradi-

tional faculty to address this gap.” Reinventing American Health Care, by Ezekiel Emanuel, 2014, p342. This is not uncommon in many arenas. A reluctance to invest in resources results in not enough expertise to properly integrate functional systems essential for increasing accessibility. Refer to “ACO’s: Results from the Front Lines,” by Lola Butcher, Leader-ship+, Fall 2014, pp 9-11.

Similarly, non-conforming atypi-cal considerations of how to ex-pand licensure for out of state physicians that provide teleradiol-ogy services, or how to invest in and oversee the prescribing prac-tices of telepsychiatry providers, need to be vetted and given the ability to move forward, as just two examples among many that will benefit by telemedicine. What some have realized is that a need to move forward with technology in a unified manner is part of be-ing culturally committed and vital in making timely changes. There simply is no way to continue on a similar course without having

President’s Perspective, cont. on page 14

President’s Perspective, cont. from page 2


13

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By Lisa Anthony, MPH, Loss Prevention Specialist

In spite of our best efforts, we will not be able to please all patients all of the time. All patients have the potential to complain. When we work collaboratively toward managing or exceeding patient expectations, a substantial num-ber of patient complaints can be averted. What do most patients want from a medical practice?

• Access

• Clear communications

• Skilled clinicians

• Respect

• Healing

• Empathy

Risk Reduction Strategies for Complaints

RESPONDRespond promptly to the patient’s concern about care.

LISTENAllow the person reasonable, un-interrupted time to vent the con-cern. Avoid being defensive by responding with a calm and per-sonable approach.

ADVISEAdvise the patient that you are pleased to be informed about the concern as it could help you to im-prove the practice.

CLARIFY THE CONCERNAsk questions. Then re-state the situation to show understanding. The patient may be angry at a sit-uation over which he has no con-trol or does not understand.

BE EMPATHETICIt is appropriate to express kind-ness and empathy.

APOLOGIZE“I am sorry that we did not meet your expectations. What can I do to make the situation better?” Explain what you can and can-not do for the patient/situation. Often times, a staff team member or the physician has the power to take some action on the patient’s behalf. Also, a meeting can be arranged in the office if the pa-tient prefers. Keep the person informed-if you make a promise, keep it.

TAKE ACTION AND DOCU-MENTA brief factual note in the pa-tient’s record is sufficient. Use quotes. Include an action plan and follow-up.

• Refer to the sample policy lo-cated on the CMIC website (www.cmic.biz) under Loss Prevention Resources. �

Links by state for posting to advise patients as to how to file a com-plaint with the DPH about care:

Connecticut www.ct.gov/dph

Massachusetts www.mass.gov/eohhs/topics

www.mass.gov/massmedboard

New Hampshire www.dhhs.nh.gov/dphs

Rhode Islandwww.health.RI.gov/complaints - about healthcare professionals and facilities.

http://www.health.ri.gov/part-ners/boards/medicallicensureand-discipline/

Strategies to Prevent and Respond to Patient Complaints

a far greater implementation of well proven technology to link providers and services together in order to deliver healthcare more efficiently and be agile enough to adapt to change. Risk cannot be entirely controlled, but it can be managed, by creating relevant means or stop gaps within sys-tems. “You can bring the whole healthcare team together in the room for the virtual visit. Being

able to get all the professionals to see the patient at one time… makes a tremendous difference.” Carol Smith, PhD, RN, as cited in “How Mobile Health is Changing Care Delivery,” by Karen Wagner, Leadership +; Fall 2014, p.25.

Understanding system failures and limitations is key in being able to successfully integrate and execute multiple clinical strate-gies. New strategies can under-

standably be more challenging to adopt in one fell swoop. How-ever, more of us are now all here together than ever before. A col-lective front with an acceptance of incremental change, rather than an unwillingness to change, while utilizing and sharing highly devel-oped technology as a medical hub or a foundation, is an identifiably efficient way to support a team-based approach to healthcare. �

President’s Perspective, cont. from page 12


15

Beyond our state borders, Medi-cal Society staff and physician members represent you in Wash-ington, at the New England state medical societies’ regional meet-ings, at the AMA House of Del-egates and at the Accreditation Council for Continuing Medi-cal Education (ACCME). These groups influence regional and na-tional health policies that impact your practice environment as well as patient care.

The Medical Society provides on-going staff support to the orga-nized medical specialty societies in New Hampshire: emergency medicine, family practice, ophthal-mology, osteopathic, psychiatry, anesthesia, pediatrics, orthopedics, internists, and medical directors.

In closing, I may have forgotten to mention a group or two in this article, but hope that members see the value and depth of Medi-cal Society support for you and many of your issues.

Please share your comments and questions with me: [email protected]. �We’re in this together.

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EVP Corner, cont. from page 5


16

By Jeremy A. Wale, JD, ProAssurance Risk Resource Advisor

The physician-patient relationship is created by mutual agreement be-tween the physician and the patient. As such, the physician may termi-nate the relationship for any non-discriminatory reason. Valid reasons may include (but are not limited to) non-compliance with medical advice, combative or threatening behavior, or outstanding medical bills.

Patient non-compliance is one of the most common reasons for terminat-ing the physician-patient relation-ship. Patients who routinely miss or cancel appointments or refuse to heed medical advice may be consid-ered non-compliant.

Non-compliant patients might be your practice’s biggest liability risk. Patients are less likely to get better when they don’t comply with medical advice, placing them at higher risk for ad-verse outcomes. By properly termi-nating non-compliant patients, you may help reduce your risk of malprac-tice claims. It also is appropriate for practices to terminate hostile, aggres-sive, or verbally abusive patients.

Proper termination is important to help avoid a claim of patient aban-donment. While the legal definition of abandonment varies from state to state, the following elements typically exist in a patient abandonment claim:

• termination of a professional re-lationship between the physician and patient without good reason or at an unreasonable time;

• termination occurred when the patient was in need of continuing medical care;

• the patient was not given reason-able notice sufficient to secure an alternate physician; and

• the patient was harmed as a result.i

The American Medical Association (AMA) summarizes your responsibil-ity this way: once a physician-patient relationship exists, physicians are

ethically obligated to place the pa-tient’s welfare above all other con-siderations, including the physician’s own self-interest.ii

Once you’ve determined it’s prudent to terminate a patient from your prac-tice, lower the risk of a patient’s claim of abandonment or malpractice by:

• Evaluating the patient’s condition and rendering stabilizing care, if needed. Avoid discharging a patient during treatment for an acute condition until the treat-ment is finished or the condition is resolved.

• When possible, discuss the ter-mination and your reason(s) for termination with the patient. You may conduct the conversation via telephone or in person. We en-courage the physician to have this conversation with the patient. Be sure to document this discussion in the patient’s medical record.

• Send a written letter to the pa-tient confirming his or her ter-mination from the practice. We suggest sending the letter by both regular mail and certified mail with return-receipt requested. If you choose to include the reason for termination in the letter, be sure you are objective and tactful in your choice of words. We sug-gest you include:

o A specified period of time dur-ing which you will continue to provide care. The AMA sug-gests at least 30 days’ notice;

however, there is at least one state that requires at least 60 days’ notice. Review your state’s laws before you terminate a physician-patient relationship.

o A statement encouraging the patient to find another physi-cian as quickly as possible.

o Referral services to aid the pa-tient in finding another physi-cian. These services may in-clude the local medical society or the state board of medicine.

o Information on how the pa-tient can get a copy of his or her medical record. You may want to consider including a re-lease-of-records form to make this process easier.

o A signature. We encourage the terminating physician to per-sonally sign the letter and re-tain a copy of the letter in the patient’s medical record.

We also encourage you to contact any third-party payer or managed care provider that may be involved in the patient’s care. Some third-party pay-ers and managed care providers have specific contractual obligations you must follow prior to terminating one of their covered patients. �

___________________i American Medical Association. Ending the patient-physician relationship. 2013. Accessed August 25, 2014.

ii American Medical Association, Code of Medical Ethics Opinion 10.015.

Copyright © 2014 ProAssurance Corpo-ration

This article is not intended to provide legal advice, and no attempt is made to suggest more or less appropriate medical conduct.

ProAssurance is a national provider of medi-cal professional liability insurance and risk resource services. For more information about the company, visit ProAssurance.com.

Physicians can fire patients, too!

Patient non-compliance is

one of the most common reasons

for terminating the physician-patient

relationship.


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On January 5, the New Hampshire Department of Health and Human Services’ Bureau of Drug and Alcohol Services announced the launch of a new website directory for locating alcohol and other drug treatment services in New Hampshire. The site, www.nhtreatment.org, was developed to help New Hampshire citizens in need of substance abuse treatment find available service providers. You can download promotional materials such as the cards below at http://nhtreatment.org/promotional-materials/

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