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Clinic & EMR Updates


EPIC "HOW TO"

posted May 8, 2015, 12:52 PM by PC/SM Chief Resident

Click here to access the EPIC evolving "how to" Google Doc.  To access the document as a contributor, let Erin Goss know your gmail account.

Retina Scans now weekly at CHCC!

posted Jun 6, 2014, 5:53 AM by PC/SM Chief Resident

From Joe:

In part due to all the hard work that the CHCC staff did in December during the 1 week retina scan pilot for our DM patients, the institution, led by the CMO, has signed a 1 year contract with the retina scan vendor.   The number of sites are expanding, but CHCC will be the first site in the rollout of pilot #2.

Some administrative hurdles -- some insurance companies charge patients co--payments for services such as retina scans.  Apparently it is not legal for institutions to waive copayments on their own.   The CMO is actively working with the insurers to ask them to waive this charge in a effort to get more DM patients screened for retinopathy.   Thus far they have been successful with Health First and Affinity, meaning that patients with this insurance have NO CO-PAYMENTS.

Retina Scans will resume at CHCC next Wednesday, June 11th -- all day.   This will continue every Wednesday.  For the first few weeks we CANNOT add patients to the list/We cannot get our pts who are seeing us that day a retina scan.   Obviously this is not want we/I want.   This WILL change over the next month.    Larry and I, but especially Larry, have been very vocal about not wanting to have 2 standards of care for our patients based on type of insurance.  We have been heard on this issue and others agree....but at same time we do not want a co-payment to limit access.   More to come on this......

For now, we will ONLY be able to scan patients from our healthfirst and affinity lists -- We rec'd this list earlier in the week -- it contains 573 names of our DM patients who have NOT had ophtho visit within the last 1 year.   
We are outreaching to ONLY those patients this week for them to  start coming in for their retina scans next week -- 573 patients will keep us busy for 1-2 months.

NOTE -- for the next 1-2 weeks I will be entering the order for retina scan and the ophtho referral -- in the future this will revert to the PCP to enter the order....more specifics about this to come as well

CICERO Update: Quantiferon at CHCC!

posted Apr 28, 2014, 6:45 PM by PC/SM Chief Resident

From Erin Goss: 

I wanted to inform you that we now have quantiferon testing available at CHCC after successful lobbying of Rob Beil and the Cicero Program! The lab staff has been trained and the tubes are now available.  


Yearly tuberculosis screening is recommended for all HIV+ patients, however only about 1/3rd of such patients at CHCC have undergone screening in the last 12 months. Help us to improve our screening rates for our HIV+ population by using this tool. 


Please note that the sensitivity of quantiferon and tuberculin skin testing (TST) are similar. False negatives are expected in patients who are anergic to TST, however the specificity of quantiferon is superior. Generally, it is not recommended to test a person with both a TST and quantiferon.

Given the increased cost of quantiferon compared to traditional tuberculin skin testing, our administrative staff have requested that we primarily use quantiferon testing for persons with an increased risk  for LTBI (e.g., recent immigrants, injection-drug users, and residents and employees of prisons and jails).  Testing of persons who are not considered to have an increased probability of infection (those who require tuberculosis screening for forms) should continue to receive traditional testing via PPD. ​


Health Care Proxies

posted Mar 5, 2014, 6:31 AM by PC/SM Chief Resident   [ updated Mar 5, 2014, 6:32 AM ]

We have a new flow for getting HCP paperwork done in clinic.  Your nurse will give your patient the HCP paperwork and introduce it, encouraging them to fill it out while waiting for you.  When you get into the room, you discuss it with your patient, if they are ready to finish it, put out your WHITE flag.  Your nurse will come in, witness the paperwork if needed (you do need two witnesses), make two photocopies, give the original and a copy to the patient, and keep a copy for EPF.  You nurse will then go ahead and document the HCP in EMR.  Although in some ways this is "just paperwork," it will hopefully prompt you and your patient (and their family!) to start a discussion about advance directives!   See attached flow for details regarding how to input HCP, etc.  For advance directives paperwork, you can find links to Montefiore papers and the NYS MOLST under Forms.   

A few additional things: Note that we are focusing on patients >65 for HCP forms.  Also note that although this is a "standardized flow" you should huddle with your nurse about it, and change it if needed to fit you and your nurse's styles better.  There are also going to be days when you are too busy to do HCP paperwork - just tell your nurse that you cannot do them that day.

Mumps outbreak in NY

posted Mar 5, 2014, 6:28 AM by PC/SM Chief Resident

ALERT # 5: Mumps in New York City1) Twenty-seven cases of mumps have occurred in students at Fordham University.
2) Keep suspect mumps cases isolated for 5 days following onset of parotitis. 
3) Immediately institute droplet precautions for patients with parotitis. 
4) If you suspect mumps, even if you do not have laboratory confirmation, report the case to the Health Department. 
5) If you suspect mumps, collect specimens and send to the Health Department for testing. 
6) Ensure that all patients and health care workers are up to date with measles-mumps-rubella (MMR) vaccination. 

Distribute to All Primary Care, Infectious Disease, Emergency Medicine, Internal Medicine, Pediatrics, Family Medicine, Laboratory Medicine, and Infection Control Staff

Dear Colleagues,

Twenty-seven cases of mumps in students attending Fordham University have occurred since January 12, 2014. Cases have ranged in age from 18 to 22 years and have occurred in students attending both the Bronx and Manhattan campuses. All cases had parotitis. One student was unvaccinated; the remaining students have at least one documented dose of mumps-containing vaccine. None of the cases have had complications of the disease.

Clinical Presentation
Mumps is an illness characterized by acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting  2 or more days, without other apparent cause. The infectious period is from 2 days before onset of symptoms to 5 days after symptoms appear. The incubation period, from exposure to illness onset, ranges from 12 through 25 days. Less common manifestations of mumps include viral meningitis, viral encephalitis, orchitis, oophoritis, pancreatitis, and sensorineural hearing loss. 

Transmission and Infection Control
In healthcare settings, providers should institute standard and droplet precautions. Exposed healthcare workers who do not have evidence of immunity at the time of exposure should be furloughed from day 12 through and including day 25 after exposure. Mumps cases at Fordham are being sent home or being isolated in their dormitory rooms. 

Reporting
Suspected cases of mumps should be reported to the Department of Health and Mental Hygiene (DOHMH) at 866-692-3641. Reports should be made at time of initial clinical suspicion. If you are considering the diagnosis of mumps and are ordering diagnostic testing, then report the case at that time. Do not wait for laboratory confirmation to report as this delays institution of measures to prevent transmission.

Laboratory Testing
Collect a buccal swab for mumps PCR as soon as mumps is suspected and blood for mumps IgM and IgG. Directions for obtaining an optimal specimen are available at http://www.nyc.gov/html/doh/html/diseases/immmum-provider.shtml. Serology may be misleading in previously vaccinated persons, as confirmed cases may be IgG positive and IgM negative. Mumps PCR is critical for confirming the diagnosis and more likely to yield positive results in previously vaccinated persons compared to serology. When you call DOHMH to report the suspected case, we will arrange pick-up and transport of the specimens to the DOHMH laboratory. Reporting suspected cases of mumps enables access to rapid testing through the DOHMH laboratory. Use synthetic (non-cotton) swabs and place the swab in liquid, viral transport media. Refrigerate specimens after collection and transport on cold packs (4oC). 

Vaccination
Mumps vaccine should be given to children at 12 months of age with a second dose at 4-6 years of age. Individuals who are not fully vaccinated against mumps are at highest risk of infection. Only physician-documented doses of MMR vaccine are considered valid. If you are unsure of the vaccination status of a patient, DOHMH recommends administration of another dose to ensure they are fully immunized. There are no risks to receiving more than 2 doses of MMR, and the benefits of ensuring that the person is immune outweigh any theoretical risk. Vaccination histories of children can be obtained through the Citywide Immunization Registry at www.nyc.gov/health/cir or by calling 347-396-2400. 

Estimates of effectiveness of mumps vaccine have ranged from 70% to 90% at preventing mumps disease. Because mumps vaccine is not fully effective at preventing illness, persons who are fully vaccinated may still develop mumps illness. As an example, at 90% effectiveness, 10 of every 100 people vaccinated would still be susceptible to infection. It is likely that without the high vaccination coverage at Fordham, the number of mumps cases would be much larger. 

Contacts of mumps cases 
Mumps is spread via large respiratory droplets. Non-immune, close contacts are at risk for developing mumps and should be isolated at home for the incubation period from day 12 through and including day 25 after exposure and should not attend school or work. Although vaccination is not considered effective post-exposure prophylaxis against mumps, MMR vaccine should be administered to eligible close contacts (including parents and other household members) who do not have documentation of one or two live mumps-containing vaccinations, as age appropriate, to protect against subsequent exposures. Spring break at Fordham is scheduled for March 15th to 24th so students may be seen more widely throughout the country. 

Thank you for your ongoing cooperation. 

Sincerely,

Jennifer Rosen, MD
Director, Epidemiology and Surveillance
Bureau of Immunization

Jane R. Zucker, MD, MSc
Assistant Commissioner
Bureau of Immunization

Summary of Bupe Meeting 2/27

posted Mar 5, 2014, 6:27 AM by PC/SM Chief Resident   [ updated Mar 5, 2014, 6:28 AM ]

From Chinazo:


1. FREE upcoming Bupe training - I am working with the NYC DOHMH and the AAAP (American Academy of Addiction Psychiatry) to coordinate a bupe training at Montefiore that will allow residents and attendings' to be trained to receive a "waiver" that will allow for a DEA "X" number that is necessary to prescribe buprenorphine. The training will be at Montefiore, FREE, and CME credit will be available. We are finalizing the details, but right now will likely occur on Saturday June 7 or 14. The training is a "half-and-half" training in which 3.5 hours of training will occur via CD-ROM and workbook that will be sent to participants prior to the training. This workbook must be completed before participating in the 4.5-hour in-person training. More information will be forthcoming.

2. Bupe Prior Authorization Process - no complaints, the process seems to be working well, except for a few cases that are the exception.

3. Bupe Groups - Aaron Fox, along with Mariya Masyukova (4th year Einstein student), is leading the bupe group initiative. Aaron was on vacation and not present at the meeting, so although it was discussed, there are still outstanding questions/issues. Aaron is likely to present the bupe group treatment initiative at a CHCC provider meeting on Monday afternoon. In general, there were questions about the goals of the groups, and the expectations that providers and patients could have regarding the groups. For example, can providers expect that pts will give urine and be given bupe scripts at the groups? Are groups going to occur every 2 weeks consistently? What are the dates of the bupe groups? etc. Providers were all very positive about the potential for groups, but several processes remained unclear. This is a work in progress, and the providers' input into these groups is likely to be helpful in shaping their format and goals.


Our next bupe provider meeting will be on Wed, March 19 from 1-2:00.

Alert from SAMHSA: Fentanyl laced heroin

posted Feb 9, 2014, 8:01 AM by PC/SM Chief Resident

The Substance Abuse and Mental Health Services Administration (SAMHSA) is alerting the treatment community and the general public that since the beginning of the year a marked increase in deaths reportedly linked to the use of heroin contaminated with the drug fentanyl has been noted. Fentanyl is a form of opioid and when used in combination with heroin can rapidly cause severe injury and even death.

There have been more than 17 deaths linked to the possible use of fentanyl-contaminated heroin in the Pittsburgh, Pa. area alone since January 24, 2014. In the first two weeks of January there were 22 such deaths reported in Rhode Island. It has been observed that these trends can expand quickly to include large and more distant geographic areas of the country. As yet the origin of the fentanyl is unknown but additional deaths have been reported from New Jersey and Vermont.

Heroin is always an extremely dangerous drug of abuse because it subjects its users to a wide array of risks such as overdose and increased exposure to Hepatitis C and HIV/AIDS and other infectious diseases. It often contains other ingredients which render it even more potentially harmful or in some deadly.

SAMHSA requests treatment providers to alert their patients and greater community stakeholders to be alert to the increased risk of fatal overdose. SAMHSA released an Opioid Overdose Toolkit late last year. It contains information on recognizing and responding appropriately to overdose. The Toolkit presents information on recognizing and responding to overdose in a manner suitable to a variety of stakeholders. It can be read or downloaded to print and share at: http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA13-4742

I recognize that as treatment providers you are daily engaged in providing the most effective form of overdose prevention: medication assisted treatment. Achieving recovery remains the best method for preventing fatal overdoses and other risks.

Those seeking treatment for opioid dependence a can find help through SAMHSA?s Treatment Locator at: 800-662-HELP (4357) or on line at:http://www.samhsa.gov/treatment/index.aspx.

Please contact Melinda Campopiano, MD at 240-276-2701 or melinda.campopiano@samhsa.hhs.gov with questions or for further information.

Sincerely,
Westley Clark Signature
H.Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director

Pharyngeal & Rectal GC/CT

posted Feb 9, 2014, 8:00 AM by PC/SM Chief Resident

From Rob Beil: 

So it seems there's a way to order DNA probe testing for gonorrhea and chlamydia of the throat and rectum.  As you know the CDC recommends GC/Ct screening in three sites (urethra/throat/anus) for sexually active MSM every six months.  Until recently the only ways I knew about at Monte to do this were to send GC culture or to label the throat or rectal swabs as urethral because the Monte lab isn't CLIA waived to run this test for those sites.

 

It turns out we can just ask them to do a send out test for these.  And we should as much as possible, partly because it's good for public health reasons and partly because the more send out tests we order the more it will light a fire under them to start doing them in house.

 

To order the tests:

 

Use the Aptima Unisex Collection kit we currently have for urethra sreening to swab either the client's throat or rectum. Label the sample as either rectal or pharyngeal swab, order the test "Chlamydia/GC (DNA probe) (swab)" - which is in the fourth column over in Frequently ordered labs of the grouping "MMC Labs" in EMR. Double click the order before you sign it and in the 'Instruction" box write that it's either a pharyngeal or rectal sample and is an "RLT" (which means Reference Lab Test or send-out).

 

One hears they're going to update the EMR order sets soon to streamline this- I'll let you know when it happens.

 

please forward this widely

 

Good luck and get swabbin'

 

PGY3s - no more MNEWs, saying good-bye to patients

posted Jan 25, 2014, 11:09 AM by PC/SM Chief Resident   [ updated Jan 25, 2014, 11:09 AM ]

From Joe:

July 1st, 2011 -- seems like just yesterday when you were brand spanking new PGY Is.... how far we come!

It's that time in your training to start winding down your continuity practice at CHCC.   

A few things:
(1)  MNEWs -- as of Feb 1st you will no longer be on the MNEW list.  Your February schedules will reflect this as they will have more MFOLs and SDAs and no slots for MNEWs
In the very rare event that we have some urgent clinical need, you MAY get asked to see an MNEW -- please be gracious, treat the patient accordingly, and drop me a note so that I can troubleshoot the obvious error.   I know all of you, and I'm SURE that you would not, but please don't say things like, "I'm not supposed to get MNEWs"   or tell the patient, "Well I'm leaving in a few months so this visit doesn't make sense"    
For those of you who are continuing at CHCC (Lucy, Mary, and Daniel -- you will continue to get MNEWS)

(2)  Starting Telling Your Patients -- over the next few months begin to let your patients know that you will be leaving in June.   This is difficult for everybody.   Let the patient know what they should call for a new patient appt (not everybody can be seen in July-Aug, so please use some clinical judgment here).   
Under NO circumstances -- do not "reassign" the patient to one of your colleagues -- do not tell the patient or send them out to the front desk with a note saying, "follow-up with Dr Abare in 2 months" -- this creates chaos and many unhappy residents -- Dr Abare with a template full of MNEWs.
Start keeping a list of patients who you think should have a "Warm handoff"  -- patients whom you are concerned about and want to make sure we set them up with an appt -- you will then send me this list of patients, MR#s and 1-2 lines about their clinical needs -- In June, we will call these patients and make sure that they have f/us
IF there is a patient whom your box buddy knows well and you both think that care should be transferred to the attending -- please include this on your "warm handoff patient list"-- AGAIN do not send patient to the front desk with a note saying, "reassign pt to Dr Swiderski" --- not OK

(3)  June Debrief Meeting -- I would like to schedule an evening/dinner with all of you as sort of a debrief about CHCC -- I know that we meet monthly and talk about systems and ideas for change, but if you could be generous with your time (one more time!) and meet with me, I would love to discuss and hear your thoughts on how to improve the resident experience.

(4)  For those of you who may be working in another Monte location come July -- we can discuss preparing a letter for your patients as some may want to follow you.

This is the first of many activities as we get ready to graduate you from residency.    You will hear it again and again over the next 5 months, but let me be the first to say that it has been a COMPLETE PLEASURE working with all of you --- You have given so much of yourselves to our patients and it has been greatly appreciated.   You will always have a home here in PCSM and at CHCC.

Thanks to all
Joe

CHCC Level 3 PCMH!

posted Jan 25, 2014, 11:08 AM by PC/SM Chief Resident

We were approved as a Level 3 Patient-Centered Medical Home at the end of December.  Thank you all for your hard work as we prepared our application, and congratulations to all!

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