Each Patient Counts: Massachusetts Medical Society Weblog

AMA: Proposed “Meaningful Use” EHR Timetable is Too Aggressive

The American Medical Association and 81 state and specialty medical societies told federal officials last week that proposed milestones for the physician installation of electronic health records is too aggressive because physicians “lack the necessary infrastructure, standards, and systems” to achieve the council’s proposed timetable.

The Massachusetts Medical Society was one of the state medical societies co-signing the letter.

The letter proposes a detailed alternate timetable that “is aimed at ensuring that the bar is not set too high or too low; one that is reasonable and ensures that all eligible physicians in all size practices and specialties are able to take advantage of the incentives specified” in the stimulus bill.

The letter states that the path to widespread use of EHRs should last several years. It also stated that specific check points should be met before moving from one implementation phase to the next. “This check point will help ensure not only physician readiness and the capacity of the system to meet these goals,” said the letter, “but will also help assure continued access to safe, quality care for patients.”

The federal stimulus bill signed into law earlier this year gives physicians up to $44,000 in Medicaid or Medicare incentives starting in 2012 if they can demonstrate a “meaningful use” of electronic health records. Physicians and hospitals have been awaiting the specific definition of “meaningful use” since then. The Health Information Technology Council, a new entity created by the stimulus bill, released its proposed timeline on June 16 and accepted comments through June 26.

The council will now review the comments and is expected to issue final standards by the end of the year.

AMA Federation letter

AMA Federation Proposed Timetable

MMS Flu Advisory: DPH Says Flu-Like Illness "Appears to be Ebbing"

An official of the Mass. Department of Public Health wrote today that reports of flu-like illnesses are down from their peak of three weeks ago. The US Centers for Disease Control and Prevention reported, also, that flu-like illness in the New England region is returning to normal levels.

Read more from the DPH blog post here.

MMS Flu Advisory: Novel Swine-Origin Influenza A H1N1 Infection in Pregnant Women

This advisory from the Massachusetts Department of Public Health (MDPH) is intended to provide guidance for the diagnosis and management of pregnant women with influenza like illness (ILI) during the current outbreak of novel influenza A H1N1 in Massachusetts.

Pregnant women are known to be at higher risk for complications from infection with seasonal influenza viruses, and severe disease among pregnant women was reported during past pandemics. Given the prevalence of circulating influenza A H1N1 virus, pregnant women presenting with signs and symptoms consistent with ILI (fever and respiratory symptoms, including cough or sore throat) should receive prompt empiric antiviral treatment for influenza A H1N1. Treatment should not be delayed awaiting confirmatory results of H1N1 virus testing. In particular, due to the varying sensitivity of rapid influenza A tests, pregnant women with ILI should be treated presumptively even if rapid influenza A tests are negative and should continue treatment unless more sensitive tests for influenza A H1N1 are specifically negative or until recommended treatment course is completed.

As of June 10, 37 of 1076 of confirmed cases (3.4 %) of H1N1 infection in Massachusetts were in pregnant women. For women whose hospitalization status was known, 9 of 22 or 41% were hospitalized; some requiring intubation and ventilatory support. If all those with missing data are assumed to have not been hospitalized, the hospitalization rate would be 24% (9 of 37), which is more than 3 times the overall rate of 7% among all confirmed cases. The average time between the initial clinical visit and initiation of antiviral therapy was 1.7 days.

Antiviral treatment of pregnant women*

The observed severity of illness among pregnant women in Massachusetts highlights the need for early, empiric antiviral treatment. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Pregnant women might be at higher risk for severe complications from novel influenza A (H1N1), and the benefits of treatment with zanamivir or oseltamivir likely outweigh the theoretical risks of antiviral use. Antiviral treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of influenza symptoms, with benefit greatest if started within 48 hours of onset. See Table 1 for dosing information.

Oseltamivir and zanamivir are "Pregnancy Category C " medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. Although a few adverse effects have been reported in pregnant women who took these medications, no relation between the use of these medications and those adverse events has been established.

In addition, antiviral prophylaxis is indicated for pregnant women who are close contacts of suspect, probable and confirmed cases. This includes pregnant health care workers with direct exposure to patients with ILI without appropriate respiratory protection.

For specific details about antiviral treatment of pregnant women, see the CDC guidance Pregnant women and novel influenza A H1N1: clinical considerations, available at www.cdc.gov/h1n1flu/clinician_pregnant.htm.

Table 1: Influenza A H1N1 antiviral medication dosing recommendations*

Medication	Treatment	Chemoprophylaxis
Oseltamivir	75 mg capsule twice per day for 5 days	75 mg capsule once per day
Zanamivir	Two 5 mg inhalations (10 mg total) twice per day	Two 5 mg inhalations (10 mg total) once per day

* From: Interim Guidance on Antiviral Recommendations for Patients with Novel Influenza A (H1N1) Virus Infection and Their Close Contacts; www.cdc.gov/h1n1flu/recommendations.htm.

For more information

The latest clinical guidance related to pregnant women and influenza A H1N1 can be found on the CDC website:

• Pregnant women and novel influenza A H1N1: clinical considerations: www.cdc.gov/h1n1flu/clinician_pregnant.htm
• Guidance for pregnant women in education, childcare and health care: www.cdc.gov/h1n1flu/guidance/pregnant-hcw-educators.htm
• What pregnant women should know: www.cdc.gov/h1n1flu/guidance/pregnant.htm
• Breastfeeding your baby: www.cdc.gov/h1n1flu/breastfeeding.htm
• Clinicians and laboratories must contact an MDPH epidemiologist at 617-983-6800 (available 24/7) to obtain approval for diagnostic testing at the William A Hinton State Laboratory. MDPH staff can also provide guidance about treatment and infection control measures.
• For additional information for clinicians and patients, please go to www.mass.gov/dph/swineflu.

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AMA Vote Keeps Door Open for Negotiations on "Health Reform Alternatives"

The American Medical Association House of Delegates voted this morning to "support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice, and universal access for patients."

The vote follows several days of vigorous debate at the AMA, with President Obama's proposed public health plan serving as a lightning rod for opposition. Some physicians wanted the AMA to oppose a public plan outright, for fear that it would destroy private health insurance. A report in the Dallas Morning News said that Texas physicians had proposed excluding the term "public plan" from the final resolution, in an effort find middle ground. The final policy statement did not explicitly mention the public plan proposal.

MMS President Mario E. Motta, MD, said, "We had quite a boisterous and vigorous debate. In the end, the AMA came out in favor of being more than willing to sit down at the table, and work hard with others to help craft a better health care system. We're pleased with that result."

The AMA's immediate past president, Nancy Nielsen MD, echoed those sentiments at a news conference after the vote. "People did not want to close the door on alternatives," she said. "No doors were closed."

Read the AMA's news release.

MMS Flu Advisory: Interim Guidelines for PPSV during H1N1 Outbreak

The Centers for Disease Control and Prevention (CDC) is urging health care professionals to vaccinate all individuals for whom PPSV vaccine is recommended to protect them from pneumococcal disease during this H1N1 influenza outbreak. Of special concern are persons with high-risk conditions for whom PPSV vaccine is recommended, but to whom the vaccine is rarely given. For example, in 2008, only 47% of Massachusetts adults 18 – 64 years of age with diabetes reported ever receiving pneumococcal vaccine.

CDC's Advisory Committee on Immunization Practices (ACIP) recommends a single dose of PPSV23 for all people 65 years and older and for persons 2 to 64 years of age with certain high-risk conditions. People in these groups are at increased risk of pneumococcal disease as well as serious complications from influenza.  

A single revaccination at least five years after initial  vaccination is recommended for people 65 years and older who were first vaccinated before age 65 years, as well as for people at highest risk, such as those who have no spleen, and those who have HIV infection, AIDS, or malignancy.

All people who have existing indications for PPSV23 should continue to be vaccinated according to current ACIP recommendations during the outbreak of novel influenza A (H1N1). Emphasis should be placed on vaccinating people aged younger than 65 years who have established high-risk conditions because PPSV23 coverage among this group is low and because people in this group appear to be overrepresented among severe cases of novel influenza A (H1N1) infection, based on currently available data.  

Use of PPSV23 among people without current indications for vaccination is not recommended at this time. This recommendation may be revised as the epidemiology and clinical presentation of novel influenza A (H1N1) virus infection as well as the frequency and severity of secondary pneumococcal infections are better understood.

To read the entire document, including background about pneumococcal disease and PPSV and PCV vaccines, go to: http://www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm

New Indications for PPSV

The ACIP recently released provisional recommendations recommending PPSV for all adults 19 – 64 years of age who smoke or who have asthma.   

A new Vaccine Information Statement (VIS) for PPSV in English and other languages is available at http://www.immunize.org/vis/vis_ppsv.asp.

Availability of State-Supplied PPSV in Massachusetts

In Massachusetts, state-supplied pneumococcal polysaccharide vaccine is available for all Massachusetts children younger than 19 years of age with medical condition that are indications for PPSV, regardless of where they receive care; state-supplied PPSV is available for all Massachusetts adults seen at public sites who are 65 years of age and older, or 19 – 64 years of age with a medical indication for PPSV vaccination.

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MMS Flu Advisory: First H1N1 Death in Mass. Announced

Today, the state Department of Public Health (DPH) and the Boston Public Health Commission (BPHC) announced the first death in Massachusetts linked to H1N1 influenza. The victim was a 30 year old woman from Boston. The patient was hospitalized on June 5, and test results came back positive for H1N1 on June 10, the announcement said. She died yesterday, June 14.

BPHC and DPH officials said in the announcement that those at higher risk of complications from the flu--including children under the age of 2, adults over the age of 65, pregnant women, and people with chronic conditions, such as asthma, diabetes, and heart disease--should call their doctor immediately to discuss appropriate treatment if they develop a fever with a cough, sore throat, or runny nose.

As of Sunday, June 14, there have been 441 confirmed cases of H1N1 flu in Boston and 54 hospitalizations.

As of 11:00 a.m. June 11, DPH had confirmed a total of 1,153 cases of H1N1 in the state.

Last Friday, the CDC was reporting a total of 17,855 cases of H1N1 flu infection and 45 deaths nationwide.

Last Thursday, the World Health Organization (WHO) raised the worldwide pandemic alert level to Phase 6, which means that a global pandemic is underway. The WHO’s declaration was expected, given that novel H1N1 flu (swine flu) has spread rapidly throughout the world including here in Massachusetts. It is important to note that the WHO pandemic phases are based on the geographical spread of a novel influenza virus, not the severity of illness. DPH stated that the WHO declaration did not change how the outbreak was being handled in Massachusetts.  

The state Department of Public Health (DPH) continues to work with partners at the local, state and federal levels on the H1N1 response in Massachusetts.

Read today’s health alert on the Boston Public Health Commission website.

Visit the DPH website for weekly case count and other guidance and information. CDC updates can be found at http://www.cdc.gov/h1n1flu/update.htm

International human cases of swine flu infection can be accessed through the World Health Organization at http://www.who.int/en/

Source: Massachusetts Department of Public Health (June 12, 2009) and Boston Public Health Commission (June 15, 2009).

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Obama to the AMA: "I Need Your Help"; MMS Reacts

President Obama spoke for nearly an hour this afternoon at the AMA House of Delegates, and his message was simple. "I need your help," he said. "For most Americans, you are our health care system. We listen to you. We trust you."

Obama also spoke directly about the controversial public health plan proposal, about which the AMA has expressed some reservations. "The public health plan is not your enemy. It is your friend," he said. Obama added that the public health plan option is not a "trojan horse" for the introduction of a single, government run health care system in America, though he notes it "may be working" in some countries.

Obama said many things that drew generous applause from the assembled room.

• His plan "allows you to be physicians, instead of administrators and accountants."
• "You did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers – and that's what our health care system should let you be."
• His plan would ban the denial of insurance coverage for pre-existing conditions. "The days of cherry-picking are over."
• He would generously fund a national health service corps to increase the number of primary care physicians because "so many of you are drowning in debt."

Obama also spoke of the medical liability system, which initially provoked almost a giddy response from the audience. That reaction prompted him to say, "Don't get too excited yet." Obama continued that while he doesn't support caps on malpractice awards (prompting a low murmur from the crowd), he supports "scaling back the excessive defensive medicine that increases costs." He did not provide details of this approach.

Following the speech, MMS President Mario Motta M.D., said, "The President's speech hit on all the major points that the MMS has been making about health care reform. Clearly, something must be done about health care costs. At the same time, a reform package must restore the ability of physicians to provide timely, high-quality care to their patients. This would be achieved by promoting and rewarding evidence-based medicine, reducing administrative burdens and the incentives for costly defensive medicine. A reform package must also promote the development of a robust primary care workforce, and encourage preventive care and healthy lifestyles. This is a vision that physicians and patients everywhere can unite under."

Watch the complete speech here, courtesy of msnbc.com.

Visit msnbc.com for Breaking News, World News, and News about the Economy

The complete text of his speech is available here

Obama Speaks to the AMA Today About Health Reform

After a week of crossed signals about the AMA's position on health reform, President Obama speaks to the AMA's House of Delegates today about health reform. It starts at 12:15 p.m., ET.

We'll summarize his remarks here, then follow up with comments from the AMA and the MMS leadership, who are attending the AMA conference.

MMS Comments on Public Health Plan Proposals

The MMS Committee on Legislation voted unanimously last week in favor of the concept of a public health insurance plan and outlined the following elements that would be essential for any public plan’s success:

● Physician participation in a public plan should be voluntary.

● The plan should not build on the current Medicare or Medicaid plans, particularly in their financing mechanisms.

● There should be a level playing field between public and private insurers. The public plan cannot be given any market advantage over current private insurers.

● Efficiencies must not be derived by imposing price controls, but by creating a new delivery system that promotes quality, rewards healthy lifestyles and preventive care, discourages defensive medicine, and reduces administrative burdens.

“A public health insurance plan could provide patients with choices that they don’t currently have,” said MMS President Mario Motta, M.D., “A public plan could play an important role by providing healthy competition for private health insurers.”

Monday, President Obama is scheduled to speak about health reform at the annual meeting of the AMA House of Delegates in Chicago. Last week, the AMA issued a statement clarifying its stance on health reform, following a New York Times article indicating that the AMA was flatly opposed to a public plan.

AMA President Nancy Nielsen, M.D., said, “Make no mistake: Health reform that covers the uninsured is AMA’s top priority this year. Every American deserves affordable, high-quality health care coverage.”

Nielsen continued, “The AMA opposes any public plan that forces physicians to participate, expands the fiscally-challenged Medicare program or pays Medicare rates, but the AMA is willing to consider other variations of a public plan that are currently under discussion in Congress. This includes a federally chartered co-op health plan or a level playing field option for all plans. The AMA is working to achieve meaningful health reform this year and is ready to stand behind legislation that includes coverage options that work for patients and physicians.”

Federal Health Care Bills Start to Emerge

Three major approaches to federal health care reform began to emerge this week on Capitol Hill, from both Republicans and Democrats, in both the Senate and the House.

• Sen. Edward Kennedy's Committee on Health Education Labor and Pensions released a bill with some, but not all, of the concepts that members have been discussing. It does not include, for example, language creating a public health insutrance plan, nor about an employer mandate. Sen. Kennedy said in a written statement that Democrats and republicans are still negotiating those issues.
  • Read a summary of the bill on the Boston Globe's website.
  • Download the the 615-page legislation from the HELP Committee's website.
• Republican Sen. Tom Coburn released a health care bill that differs from Kennedy's in many respects. A key feature is its reliance on tax credits to help individuals purchase health insurance.
  • Read Sen. Coburn's outline of his bill on The Huffington Post.
• A group of three House committees issued its own health bill. This "TriComm" bill is similar in many respects to the HELP bill.
  • Read the committees' summary of its legislation.

One more committee has yet to submit its own bill - the Senate Finance Committee, led by Sen. Max Baucus of Montana. That bill is expected to be released next week.

The next few weeks will be consumed with committee hearings and revisions of the bill (known on the Hill as "markups").