7/22/2016 Community Medicine Newsletter ­ Summer 2015

https://ui.constantcontact.com/visualeditor/visual_editor_preview.jsp?agent.uid=1121356201001&format=html&print=true 1/6

In This Issue

Network News

BUSM & GIM Updates

Education Corner

Resources

GIM Calendar

DOM Calendar

DOM Podcasts

DOM Newsletter

Featured

Feature CommunityMedicine Physician:

Dr. Theresa Lim, a physicianwho has been in practice forthe last 20 years at GreaterRoslindale Medical andDental Center, is our featurephysician this newsletter.We reached out to Dr. Lim,who was kind enough toshare her thoughts:

Q. What is the best partabout being an internist? A. In most situations, it'sexciting to be at the veryfront line of handling a widevariety of a patient'smedical issues. You literallyhave the first crack atsolving an individual'smedical issue using yourdepth of medical knowledgeand breadth of skill as an

Aug 12th, 2015

Director's Notes  The "Problem" with Problem Lists

 In the past, primary care clinicians often kept a simplelist of active and past problems in the patient's paperchart. The List ‐ a fuzzy combination of past medicalhistory, active chronic problems, and perhaps someresolved acute conditions ‐ was mostly for that provider'suse only. It facilitated the use of "SOAP" notes but rarelywas invoked in the precise manner.

Today the role and use of the Problem List is completelydifferent; the "Problems" placed on today's list serve manymasters. That shared use is now intimately tied tocompliance, billing, quality and safety reporting and evenhealth services research. No longer solely destined only forthe eyes of its creator, the Problem List enables cliniciansto efficiently share patient information by permitting it tobe read and edited among the clinicians involved in apatient's care. One of the strengths of BMC's EHR EPIC isthat it uses a strict problem oriented approach to clinicaldocumentation, ordering and billing.

The Boston HealthNet Health Centers will soon implementthe OCHIN‐EPIC EHR project. Because EPIC places theProblem List in the center of clinical documentationworkflow, clinical leaders would be wise to determinelocal rules for collaborative use of the Problem List.Current preparations for the transition will hopefully include specific training on whyand how clinicians will create andmaintain Problem Lists using astandardized approach according toclinically‐driven, network‐widedefinitions and policies. The "ProblemList" is a critical tool for clinicalcommunication and collaboration ‐nobody wants its use to be.....anotherproblem.   Warm Regards,Christopher W. Shanahan, MD MPH FACP Director, Community Medicine Unit

Network News

Boston HealthNet OCHIN Epic Implementation Update Project Implementation kick‐off sessions have beencompleted and project planning and other work is wellunderway for the first three community health centers

7/22/2016 Community Medicine Newsletter ­ Summer 2015

https://ui.constantcontact.com/visualeditor/visual_editor_preview.jsp?agent.uid=1121356201001&format=html&print=true 2/6

internist. Additionally, wehave a great support staffbacking us up at GRMDC andalso many wonderfulspecialists at BMC we couldrely upon for their opinionsand more advancedtreatments. 

Q. What drew you toworking in community‐basedPrimary Care? A. Coming from a country ofvery modest means, I haveseen many situations whenpeople couldn't receiveproper medical care due tocomplex factors such aslimited financial resources,inadequate education, poorfamily or socialsupport.....etc. America isan abundant country withexcellent medical resourcesand support from all levelsof the government. I think Iunderstand how's it's like tobe new in a country, to be aminority, to raise a familywhile being economically oreducationally challenged.On top of these, howworrisome it must be whenthese people get sick.  In myview, I can help thesepeople, albeit in a verysmall way, by working in acommunity‐based PrimaryCare.

Q. What advice would yougive medical students,pursuing a primary caretrack? A. As a primary careinternist, one must have thedepth and breadth ofmedical knowledge to dealwith patient's variousmedical issues. The profileof the medical cases oneencounters is varied,challenging but fun. Withtime, experience, andcontinued learning, onequickly becomes a verycompetent medicalprofessional. Aboveall, adhere to your medical

(CHCs) to go‐live on the OCHIN Epic Electronic HealthRecord (EHR) System this fall. The entire team is engaged,and the project is off to a great start!

Go‐live dates have been established for the first 3 CHCs:

South Boston Community Health Center:  November3, 2015Greater Roslindale Medical and Dental Center:  November 17, 2015Mattapan Community Health Center: December 8,2015  

Recently, the OCHIN team traveled to Boston andcompleted New Member Setup (NMS) Sessions for SouthBoston and Roslindale. The NMS Session for Mattapan isscheduled for July 14‐15. NMS is a working session for theteam to review the overall system, discuss build decisionsand provide information and materials necessary forOCHIN to begin the technical system build. 

Looking forward to August, analysts from Boston MedicalCenter and site specialists from the first three CHCs willtravel to OCHIN headquarters in Portland, Oregon, toattend an 8‐day system overview training session. Theseindividuals will have a key role in helping the CHCstransition to and support the new system.

Please contact Lynsey Avalone, Boston HealthNet ProgramCoordinator, with any questions.

Clinical Column by Geoffrey Modest, MD

The PADIS‐PE trial of patients with afirst unprovoked pulmonaryembolism (PE), randomized tostopping anticoagulation after 6months vs continuing additional 18months. 

Study Details

N=371 patients (mean age 58, 40% >65yo, 50%women, 45% high bleeding risk; first episode ofunprovoked, symptomatic PE, initial 6 months of avitamin‐K antagonist, then randomized in 14 Frenchcenters (2007‐2014) to continued warfarin vsplacebo for 18 months.

Target INR: 2.0‐3.0.Excluded: Patients with knownmajor thrombophilia.Outcomes:

Primary: composite of recurrentvenous thromboembolism (VTE) or majorbleeding), at 18 months

Secondary: primary outcome at 42 months,each composite components, death unrelatedto PE or bleeding at 18 and at 42 months.

7/22/2016 Community Medicine Newsletter ­ Summer 2015

https://ui.constantcontact.com/visualeditor/visual_editor_preview.jsp?agent.uid=1121356201001&format=html&print=true 3/6

ethics, and treat everypatient with courtesy,respect and dignity.

Q. What experience with apatient has stuck with youand why? A. A few years back, I had a60 yr. old patient whom for5 straight years, I hadadvised to have screeningcolonoscopy done. Eachtime she declined to do it.One day, she came in with acomplaint of bloody stools.Sadly, she was diagnosedwith metastatic coloncancer spreading to theliver. She passed away 2years later. This stuck withme since I wondered if Icould have been moreadamant with my adviceand perhaps altering thesituation. Nowadays, I usethis case as one of severalways to convince a certainsegment of patients whohesitates undergoingscreening colonoscopy tohave it done.

Q. What do you like to do,in your free time? A. I simply enjoy shopping.

 Thank you for sharing, Dr.Lim!

Community Health CenterUpdates: DotHouseHealth, Whittier Street & South End CommunityHealth Center

DotHouse Health (formerlyDorchester House) launcheda population healthmanagement program in2014 to satisfy the ever‐increasing demand foraccessible, actionable datato manage our panels. Ourquality improvement teamused arts and crafts skills tomake clinical qualitymeasures more visible andto have fun with the data

Results:

Mean % of time in the target INR range was 69.1%.

Primarycompositeoutcome (18months)Recurrent venousthromboembolism(VTE) or majorbleeding

HazardRatio(CI 95%)p‐value

Harms

GroupDuring treatmentperiod Major Bleeding

Warfarin3.3% (6/184) or2.3 events/100person‐yrs

0.22(0.09‐0.55)p=0.001

n=4

Placebo13.5% (25/187) or10.6 events/100person‐yrs

n = 1

After treatmentdiscontinuation

SymptomaticVTE recurrence

Warfarin17.7% (27/184)10.0 events/100person‐yrs

0.22(0.09‐0.55)p=0.001

25 patients, 9.3events/ 100person‐yrs, allwithoutanticoagulation,4 fatal

Placebo10.3% (17/187)5.7 events/100person‐yrs

14 patients, 4.7events/100person‐yrs, allwithoutanticoagulation

Compositeoutcome (42 months)

Warfarin  20.8%; n=33

0.22(0.09‐0.55)p=0.001

Placebo 24.0% n=420.75(0.47‐1.18)

Overall Findings:

Benefit of extended warfarin Rx was not maintainedGradual reduction in warfarin protection over thenext 24 months of observation when all were offwarfarinNo difference in rate of recurrent VTE, majorbleeding, & unrelated deathsRecurrent VTE Risk greatest in first 6 months after anticoagulation stopped, then increased linearly by4‐5% per year.  Dramatic difference during the 18 months after

7/22/2016 Community Medicine Newsletter ­ Summer 2015

https://ui.constantcontact.com/visualeditor/visual_editor_preview.jsp?agent.uid=1121356201001&format=html&print=true 4/6

while fostering meaningfulcollaboration among careteam members. Key qualitymeasures are improving, andsome have already surpassedour annual goals. Once a month, members ofthe population health teamupdate bulletin boards in theclinical hallways, bumpingsmiling climbers further upthe sides of paper mountainpeaks. Each mountainrepresents one clinicalquality measure, such asscreening for colorectalcancer. The nearer aclimber gets to a summit,the closer DotHouse is toreaching an annual qualitytarget.  DotHouse began2015 with a forty‐ninepercent colorectal cancerscreening rate, and aimed tohit sixty percent by year'send. The center eclipsed itsannual goal by May, hittingsixty‐four percent. 

 The cheerful display is afun, eye‐catching and highlyvisible approach to keepingcare teams informed ofperformance, encouragingteamwork, and sparkingfriendly competition.‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐Whittier Street Health Center is proud toannounce the opening of itsnew Wellness and FitnessClub, on Saturday, June 27.Boston Mayor Martin J.Walsh presided at the GrandOpening. The new 6,600‐square‐foot Whittier Wellness and Fitness Club, a much‐needed onsite fitness center, will be one

randomizationLow risk of major bleeding with continued warfarin,increasing <2% per year

 Thoughts & Issues: 

This study found:Like other observational studies: high risk ofrecurrent PEs in patients with initialsymptomatic unprovoked PEPatients at risk for recurrent VTE afteranticoagulation discontinued regardless ofwhether anticoagulation is 3‐6 month orlonger.Major bleeding risk with anticoagulation islow

Deciding how long to anti‐coagulate the patient:NB: those with a PE have higher likelihood ofrecurrent PE than those with DVTSome useful approaches: 

BMJ Blogs (on VTE)BMJ Blogs (Anticoag after first DVT)

When stopping anticoagulation:Low dose aspirin

~30% decreased risk of aspirin vsplacebobetter than placebo but not as good as continued anticoagulation.

An practical but untested approach (which I have been doing):

provide 6 months of anticoagulation; discuss risks/benefits to patient of continuing anticoagulation. If patient wants to stop,

check d‐dimer before and 3 weeksafter stopping anticoagulation;if d‐dimer negative, offer aspirin and discontinue anticoagulation;it would be great to have a studyseeing if underlying thrombophiliaactually matters (and, if so, would factor that into above)

If you would like to receive regular emails similar to thisone, please email Dr. Geoff Modest.

BUSM & GIM Updates

The Annual Kathleen Bennett Memorial Lecture inCommunity Medicine

We are pleased to announce that the annual Kathy BennettMemorial Lecture in Community Medicine will be presenterWeds, Oct 14th, 2015 by Dr. Daniel Simpson of South EndCommunity Health Center. He and his panel of experts willpresent and lead a discussion on Integrated BehavioralHealth and Best Practices in Our Community. Pleasemark your calendars; we look forward to seeing you there!

Date: Weds, Oct 14th, 2015Time: 8‐9am

7/22/2016 Community Medicine Newsletter ­ Summer 2015

https://ui.constantcontact.com/visualeditor/visual_editor_preview.jsp?agent.uid=1121356201001&format=html&print=true 5/6

of the most comprehensive of its type in the region,located in a culturallydiverse community. It willoffer a broad array ofservices and activities,ranging from a physicalfitness coach, exercise machines, classes inaerobics, yoga and Zumba, a life coach, and a pediatrichealthy weight coordinator. 

The Health Center is taking a revolutionary approach to addressing heathdisparities. Patients canrequest a Prescription forHealth from their PrimaryCare Physician, Psychiatristor Physical Therapist. Each prescription will be tailoredto their individual needs. A Health Coach who is afitness coach andnutritionist, will meet withthe patient to formulate their Prescription forHealth, schedule attendanceamong the activitygroups, and incorporatenutrition groups andacupuncture. Patients of theWhittier can becomemembers of the new Wellness and Fitness Club ona month‐to‐month basis for just $10 per month.‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐South End CommunityHealth Center would like toannounce that as of June 30,former CEO Bob Johnson hadstepped down from officeand Bill Walczak, previouslyCEO at Codman Square, came on‐board as new CEO,assisted by Joel Abrams. Additionally, Beth Mazyck,MD is stepping down from her role as CMO. SECHC islooking for her replacementand is seeking partiesinterested in advancing theircareer into medical leadership! In the face ofextraordinary transition,SECHC continues to grow,especially in outreach inpublic housing for residentsin the area, for which they

Location: Crosstown Building801 Mass Ave, 2nd floorRoom 2127 

NEW Community Medicine TravelScholarship Program The Community Medicine Unit (CMU)is excited to announce the new Community MedicineTravel Scholarship Program. The CMU will sponsor awardsto support travel expenses associated with travel to thenext annual national meeting of the Society of GeneralInternal Medicine for up to 3 BMC‐Affiliated CommunityPhysicians who have accepted workshops, abstracts orposters for the meeting. Click here for more informationabout next year's SGIM meeting (May 11th‐14th, 2016). 

 If you have an accepted abstract for the next NationalSGIM meeting, please consider throwing your hat in for thisbrand new scholarship! If you are interested in submittingto the scientific meeting but feel you might need somehelp getting started or figuring out the process, send anemail to Dr. Shanahan who would be happy to highlightavailable resources. 

Education Corner

Upcoming GIM & DOM Grand Rounds and AmbulatoryRounds

GIM Grand Rounds (CME)Weds, Sept 9th @ 8AM‐801 Mass Ave, 2nd flr, Rm 2127"Lung Cancer" ‐ presented by Karin Sloan, MD

Weds, Sept 30th @ 8AM‐801 Mass Ave, 2nd flr, Rm2127"Gluten and the Gut" ‐ presented by AudreyCalderwood, MD, MS, FACG, FASGE

 Weds, Oct 14th @ 8AM‐801 Mass Ave, 2nd flr, Rm2127"Kathleen Bennett Memorial Lecture in CommunityMedicine: Integrated Behavioral Health ‐ BestPractices in Our Community" ‐ presented by DanielSimpson, MD

 Weds, Oct 28th @ 8AM‐801 Mass Ave, 2nd flr, Rm2127"Imaging Dense Breasts ‐ A Special Problem in CancerScreening" ‐ presented by Tracy Battaglia, MD, MPH

Weds, Nov 4th @ 8AM‐801 Mass Ave, 2nd flr, Rm 2127"Challenging Patient Rounds" ‐ presented by  RobertSokolove, PhD

Weds, Dec 9th @ 8AM‐801 Mass Ave, 2nd flr, Rm 2127"Managing Learning Issues in Primary Care Patients" ‐presented by Robert Sokolove, PhD

Weds, Dec 23rd @ 8AM‐801 Mass Ave, 2nd flr, Rm

7/22/2016 Community Medicine Newsletter ­ Summer 2015

https://ui.constantcontact.com/visualeditor/visual_editor_preview.jsp?agent.uid=1121356201001&format=html&print=true 6/6

were awarded a HRSA grant, leading to FQHCstatus.

If your health center hasupdates that you would liketo share, please send them to us atcommunitymedicine@bu.edu

2127"The Transgendered Patient" ‐ presented by  ThomasBarber, MD

 GIM M & M Rounds (CME) 

Weds, Sept 16th @ 8AM‐801 Mass Ave, 2nd flr, Rm2127"TBD" ‐ presented by TBD

Weds, Oct 21st @ 8AM‐801 Mass Ave, 2nd flr, Rm 2127"TBD" ‐ presented by TBD

Weds, Nov 18th @ 8AM‐801 Mass Ave, 2nd flr, Rm2127"TBD" ‐ presented by TBD

Weds, Dec 16th @ 8AM‐801 Mass Ave, 2nd flr, Rm2127"TBD" ‐ presented by TBD 

DOM Grand Rounds (CME)Fri, Sept 11th @12PM‐72 E. Concord St, KeeferAuditor."TBD" ‐ presented by TBD 

DOM M & M Rounds (CME)Weds, Sept 30th @11:30AM‐72 E. Concord St, L‐110"TBD" ‐ presented by TBD

Copyright © 2014. All Rights Reserved.

Boston Medical Center, 801 Massachusetts Ave, 2nd floor, Boston, MA 02118

SafeUnsubscribe™ {recipient's email}

Update Profile | About our service provider

Sent by communitymedicine@bu.edu in collaboration with

Try it free today