Neil Skolnik, MD

On a recent rerun of the 1960s TV series, “The Addams Family,” Thing, the disembodied hand that lived without a body, came down with a cold. So Morticia Addams contacted a doctor who agreed to see Thing during a house call. While the need for convenient access to a physician has not changed in 50 years, technology is offering new solutions to fill the need for patient/physician interaction that range from e-mail to text messaging to video chat, offering both promises and pitfalls. In this article we will explore some of the emerging liability issues that these new forms of patient evaluation present.

Today, there are essentially three types of interactions between patients and physicians: in office/hospital visits, telephone conferences, and electronic communications. The first two interactions have been long practiced and physicians have a good sense of the parameters of their use. Electronic communication is new and has become popular within the past few years. Clinicians often do not have a well-honed sense of the boundaries of interaction with these new mediums and, unfortunately, electronic communications have created another avenue for physician liability.

When a physician sees a patient in person, the physician assesses the patient’s subjective complaints and objectively evaluates the patient. While it has been said that 90% of the diagnosis is arrived at through the taking of a careful history, I think we would all agree that a physical exam is an important part of a complete evaluation, and, depending upon the presenting problem and the differential diagnosis, it may be an essential part of the evaluation. When a physician interacts with a patient over the phone, that physician’s ability to evaluate the patient’s complaints through physical contact is removed, but the physician still has the ability to hear the patient’s voice and engage the patient. Voice inflections – a slight tremor in the voice of a tearful patient, the sense of heightened concern from the mother of a sick 5-year-old – can give insight into the severity of illness beyond what was conveyed by the words themselves. The conversation, in person or on the phone, allows for an iterative exchange of information, with one piece of information allowing the physician to ask the next important question, and so on. When a physician interacts with a patient through electronic communication via e-mail or text message, the tools that the physician uses to evaluate the patient objectively are removed.

Though patients are pushing for fewer in-person interactions with health care providers and have become used to electronic communications, clinicians need to be careful not to relinquish the opportunity for robust two-way conversations that allow them to obtain the information necessary to formulate a thoughtful diagnosis and plan. Recently, we have seen an important increase in lawsuits stemming from electronic interactions. In most cases, liability stems from the lack of an objective evaluation of the patient or perception of a lack of caring by the health care provider.

In a lawsuit we (G.C.) recently defended, a husband and wife had been seeing their primary care physician for 15 years. During one of the husband’s visits with the physician, the husband complained of weight loss and fatigue. The husband’s initial complaints were not concerning. However, at the next visit, the husband complained of new symptoms including chills, cramping, fatigue, and a poor appetite. A urinalysis did not point to a clear diagnosis. Thereafter, all communications between the husband and physician were conducted solely through e-mail. In those correspondences, the husband continued to make ambiguous complaints of the same symptoms. Without asking the patient to come into the office, the physician diagnosed the husband with a viral infection. Multiple e-mail exchanges ensued thereafter and, without ever setting eyes on the patient, the physician continued to assure the couple that the husband would get better over time. Meanwhile, the husband was developing endocarditis during the course of these e-mail exchanges that eventually led to his death.

What happened in this case was an unfortunate misinterpretation of the e-mails, which led to confusion, misdiagnosis, harm to the patient, and, ultimately, a lawsuit against the physician. While endocarditis is rare and difficult to diagnose under any circumstances, that physician did not ensure that he had the opportunity to evaluate the patient fully, to see with his own eyes how sick the patient might have looked, or to listen for a new murmur, or spot a Janeway lesion, all signs of more serious disease that may or may not have been apparent during a full evaluation. The uncritical use of e-mail made it easy to assume that the original diagnosis of a viral syndrome was correct, without providing the opportunity to critically reassess the patient’s concerns.

In this case, in addition to the missed diagnosis, there was an apparent violation of HIPAA. The e-mail address used by the physician was a personal e-mail account. HIPAA precludes physicians from discussing medical information through a means of communication that a non–health care provider might have access to. In an electronic age with multiple modes of communication, we have to be ever more careful to have a well thought out approach to the protection of patient privacy. It is easy to send a quick text message or e-mail to a patient, but it is important to understand that HIPAA applies even when a communication seems trivial or benign in nature.

In summary, society realizes that primary care physicians need to communicate at times other than at scheduled visits, and there is no longer an expectation that the physician will make house calls like the doctor in “The Addam’s Family” episode did 50 years ago. Society, and the courts, recognize that e-mail and text messaging are potentially useful forms of quick, convenient communication. We want to conclude with two important points. First, when using e-mails and texts to communicate with patients, use a secure HIPAA-compliant technology. Second, we need to be cautious that these convenient technologies do not creep into areas where they don’t belong, such as in making a diagnosis when doing so requires more interactive discussion and a physical exam. E-mail and text messaging are emerging as useful mediums for communication with patients, but as with any new technology, we need to be careful and thoughtful in their use.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Cannon is an attorney at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh.

On a recent rerun of the 1960s TV series, “The Addams Family,” Thing, the disembodied hand that lived without a body, came down with a cold. So Morticia Addams contacted a doctor who agreed to see Thing during a house call. While the need for convenient access to a physician has not changed in 50 years, technology is offering new solutions to fill the need for patient/physician interaction that range from e-mail to text messaging to video chat, offering both promises and pitfalls. In this article we will explore some of the emerging liability issues that these new forms of patient evaluation present.

Today, there are essentially three types of interactions between patients and physicians: in office/hospital visits, telephone conferences, and electronic communications. The first two interactions have been long practiced and physicians have a good sense of the parameters of their use. Electronic communication is new and has become popular within the past few years. Clinicians often do not have a well-honed sense of the boundaries of interaction with these new mediums and, unfortunately, electronic communications have created another avenue for physician liability.

When a physician sees a patient in person, the physician assesses the patient’s subjective complaints and objectively evaluates the patient. While it has been said that 90% of the diagnosis is arrived at through the taking of a careful history, I think we would all agree that a physical exam is an important part of a complete evaluation, and, depending upon the presenting problem and the differential diagnosis, it may be an essential part of the evaluation. When a physician interacts with a patient over the phone, that physician’s ability to evaluate the patient’s complaints through physical contact is removed, but the physician still has the ability to hear the patient’s voice and engage the patient. Voice inflections – a slight tremor in the voice of a tearful patient, the sense of heightened concern from the mother of a sick 5-year-old – can give insight into the severity of illness beyond what was conveyed by the words themselves. The conversation, in person or on the phone, allows for an iterative exchange of information, with one piece of information allowing the physician to ask the next important question, and so on. When a physician interacts with a patient through electronic communication via e-mail or text message, the tools that the physician uses to evaluate the patient objectively are removed.

Though patients are pushing for fewer in-person interactions with health care providers and have become used to electronic communications, clinicians need to be careful not to relinquish the opportunity for robust two-way conversations that allow them to obtain the information necessary to formulate a thoughtful diagnosis and plan. Recently, we have seen an important increase in lawsuits stemming from electronic interactions. In most cases, liability stems from the lack of an objective evaluation of the patient or perception of a lack of caring by the health care provider.

In a lawsuit we (G.C.) recently defended, a husband and wife had been seeing their primary care physician for 15 years. During one of the husband’s visits with the physician, the husband complained of weight loss and fatigue. The husband’s initial complaints were not concerning. However, at the next visit, the husband complained of new symptoms including chills, cramping, fatigue, and a poor appetite. A urinalysis did not point to a clear diagnosis. Thereafter, all communications between the husband and physician were conducted solely through e-mail. In those correspondences, the husband continued to make ambiguous complaints of the same symptoms. Without asking the patient to come into the office, the physician diagnosed the husband with a viral infection. Multiple e-mail exchanges ensued thereafter and, without ever setting eyes on the patient, the physician continued to assure the couple that the husband would get better over time. Meanwhile, the husband was developing endocarditis during the course of these e-mail exchanges that eventually led to his death.

What happened in this case was an unfortunate misinterpretation of the e-mails, which led to confusion, misdiagnosis, harm to the patient, and, ultimately, a lawsuit against the physician. While endocarditis is rare and difficult to diagnose under any circumstances, that physician did not ensure that he had the opportunity to evaluate the patient fully, to see with his own eyes how sick the patient might have looked, or to listen for a new murmur, or spot a Janeway lesion, all signs of more serious disease that may or may not have been apparent during a full evaluation. The uncritical use of e-mail made it easy to assume that the original diagnosis of a viral syndrome was correct, without providing the opportunity to critically reassess the patient’s concerns.

In this case, in addition to the missed diagnosis, there was an apparent violation of HIPAA. The e-mail address used by the physician was a personal e-mail account. HIPAA precludes physicians from discussing medical information through a means of communication that a non–health care provider might have access to. In an electronic age with multiple modes of communication, we have to be ever more careful to have a well thought out approach to the protection of patient privacy. It is easy to send a quick text message or e-mail to a patient, but it is important to understand that HIPAA applies even when a communication seems trivial or benign in nature.

In summary, society realizes that primary care physicians need to communicate at times other than at scheduled visits, and there is no longer an expectation that the physician will make house calls like the doctor in “The Addam’s Family” episode did 50 years ago. Society, and the courts, recognize that e-mail and text messaging are potentially useful forms of quick, convenient communication. We want to conclude with two important points. First, when using e-mails and texts to communicate with patients, use a secure HIPAA-compliant technology. Second, we need to be cautious that these convenient technologies do not creep into areas where they don’t belong, such as in making a diagnosis when doing so requires more interactive discussion and a physical exam. E-mail and text messaging are emerging as useful mediums for communication with patients, but as with any new technology, we need to be careful and thoughtful in their use.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Cannon is an attorney at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh.

On a recent rerun of the 1960s TV series, “The Addams Family,” Thing, the disembodied hand that lived without a body, came down with a cold. So Morticia Addams contacted a doctor who agreed to see Thing during a house call. While the need for convenient access to a physician has not changed in 50 years, technology is offering new solutions to fill the need for patient/physician interaction that range from e-mail to text messaging to video chat, offering both promises and pitfalls. In this article we will explore some of the emerging liability issues that these new forms of patient evaluation present.

Today, there are essentially three types of interactions between patients and physicians: in office/hospital visits, telephone conferences, and electronic communications. The first two interactions have been long practiced and physicians have a good sense of the parameters of their use. Electronic communication is new and has become popular within the past few years. Clinicians often do not have a well-honed sense of the boundaries of interaction with these new mediums and, unfortunately, electronic communications have created another avenue for physician liability.

When a physician sees a patient in person, the physician assesses the patient’s subjective complaints and objectively evaluates the patient. While it has been said that 90% of the diagnosis is arrived at through the taking of a careful history, I think we would all agree that a physical exam is an important part of a complete evaluation, and, depending upon the presenting problem and the differential diagnosis, it may be an essential part of the evaluation. When a physician interacts with a patient over the phone, that physician’s ability to evaluate the patient’s complaints through physical contact is removed, but the physician still has the ability to hear the patient’s voice and engage the patient. Voice inflections – a slight tremor in the voice of a tearful patient, the sense of heightened concern from the mother of a sick 5-year-old – can give insight into the severity of illness beyond what was conveyed by the words themselves. The conversation, in person or on the phone, allows for an iterative exchange of information, with one piece of information allowing the physician to ask the next important question, and so on. When a physician interacts with a patient through electronic communication via e-mail or text message, the tools that the physician uses to evaluate the patient objectively are removed.

Though patients are pushing for fewer in-person interactions with health care providers and have become used to electronic communications, clinicians need to be careful not to relinquish the opportunity for robust two-way conversations that allow them to obtain the information necessary to formulate a thoughtful diagnosis and plan. Recently, we have seen an important increase in lawsuits stemming from electronic interactions. In most cases, liability stems from the lack of an objective evaluation of the patient or perception of a lack of caring by the health care provider.

In a lawsuit we (G.C.) recently defended, a husband and wife had been seeing their primary care physician for 15 years. During one of the husband’s visits with the physician, the husband complained of weight loss and fatigue. The husband’s initial complaints were not concerning. However, at the next visit, the husband complained of new symptoms including chills, cramping, fatigue, and a poor appetite. A urinalysis did not point to a clear diagnosis. Thereafter, all communications between the husband and physician were conducted solely through e-mail. In those correspondences, the husband continued to make ambiguous complaints of the same symptoms. Without asking the patient to come into the office, the physician diagnosed the husband with a viral infection. Multiple e-mail exchanges ensued thereafter and, without ever setting eyes on the patient, the physician continued to assure the couple that the husband would get better over time. Meanwhile, the husband was developing endocarditis during the course of these e-mail exchanges that eventually led to his death.

What happened in this case was an unfortunate misinterpretation of the e-mails, which led to confusion, misdiagnosis, harm to the patient, and, ultimately, a lawsuit against the physician. While endocarditis is rare and difficult to diagnose under any circumstances, that physician did not ensure that he had the opportunity to evaluate the patient fully, to see with his own eyes how sick the patient might have looked, or to listen for a new murmur, or spot a Janeway lesion, all signs of more serious disease that may or may not have been apparent during a full evaluation. The uncritical use of e-mail made it easy to assume that the original diagnosis of a viral syndrome was correct, without providing the opportunity to critically reassess the patient’s concerns.

In this case, in addition to the missed diagnosis, there was an apparent violation of HIPAA. The e-mail address used by the physician was a personal e-mail account. HIPAA precludes physicians from discussing medical information through a means of communication that a non–health care provider might have access to. In an electronic age with multiple modes of communication, we have to be ever more careful to have a well thought out approach to the protection of patient privacy. It is easy to send a quick text message or e-mail to a patient, but it is important to understand that HIPAA applies even when a communication seems trivial or benign in nature.

In summary, society realizes that primary care physicians need to communicate at times other than at scheduled visits, and there is no longer an expectation that the physician will make house calls like the doctor in “The Addam’s Family” episode did 50 years ago. Society, and the courts, recognize that e-mail and text messaging are potentially useful forms of quick, convenient communication. We want to conclude with two important points. First, when using e-mails and texts to communicate with patients, use a secure HIPAA-compliant technology. Second, we need to be cautious that these convenient technologies do not creep into areas where they don’t belong, such as in making a diagnosis when doing so requires more interactive discussion and a physical exam. E-mail and text messaging are emerging as useful mediums for communication with patients, but as with any new technology, we need to be careful and thoughtful in their use.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Cannon is an attorney at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh.

According to the Institute of Medicine, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) affects 836,000 to 2.5 million Americans. ME/CFS is a disease that is characterized by profound fatigue, cognitive dysfunctions, sleep abnormalities, autonomic manifestations, pain, and other symptoms, all of which are made worse by any exertion. The Institute of Medicine (IOM) created a report developed by an expert committee to help redefine the illness and proposed new diagnostic criteria that will help medical professionals understand the illness and accurately diagnose and manage patients with this often-misunderstood disease. The IOM committee also recommended that it be renamed Systemic Exertion Intolerance Disease (SEID) to reflect the main characteristics of the disease.

Background

The true prevalence of MF/CSF is unknown because an estimated 84%-91% of affected people have not been diagnosed, and its cause is unknown; however, symptoms may be triggered by certain infections such as Epstein-Barr Virus. MF/CFS is a disease that is more common in women than men, with an average age of onset at 33 years. At some point in the course of this illness, one quarter of affected patients have been bed- or house bound. As explained by the IOM report, most patients have symptoms for years and never regain their predisease functioning level. There is no cure; however, there are interventions and therapies that are helpful in managing symptoms.

Because of the patients’ loss of functioning, high medical costs accrue that add to the overall annual economic burden of $17 billion to $24 billion.

Diagnostic criteria

The following three symptoms must be present to make the diagnosis as stated in the IOM report:

At least one of the two following manifestations also is required:

Key considerations

Diagnosing ME/CFS can be challenging. The health professional should diagnose only after a full history, physical, medical work-up, referrals to appropriate specialists to help rule out other potential disorders, and, ultimately, fulfillment of the diagnostic criteria. The severity and frequency of a patient’s symptoms over the past month and beyond should be assessed by the health professional to determine if the symptoms meet the diagnostic criteria of being chronic, moderate to severe, and frequent. An important distinguishing feature of ME/CFS is that the patient needs to have been symptomatic for 6 months, because most other causes of fatigue do not last that long. Fibromyalgia and irritable bowel syndrome are common comorbidities found in patients with ME/CFS.

Core symptoms

Fatigue and impairment. ME/CFS causes a profound fatigue that does not improve a lot by rest and is not associated with excessive exertion. This type of fatigue makes a substantial impact in decreasing a patient’s functioning and impairing the ability to return to a pre-illness state within occupational, educational, social or personal activities. The impairment secondary to fatigue must persist for at least 6 months.

Postexertional malaise. This symptom is unique to ME/CFS and was described as the primary feature. Physical or cognitive stressors that were previously tolerated now produce worsening symptoms and functioning.

Unrefreshing sleep. There was no subjective evidence of sleep disorders due to ME/CFS, but sufficient data did show that unrefreshing sleep was a complaint universally among ME/CFS patients. The IOM recommends that while polysomnography is not a requirement to diagnose ME/CFS, it is encouraged, to rule out other primary sleep disorders.

Cognitive impairment. Increased stress, effort, or time pressure all can exacerbate existing problems that a patient with ME/CFS has with thinking or executive functioning. Evidence has shown that patients with ME/CFS have slowed information processing and this may be a central aspect of these patients’ overall neurocognitive impairment.

Orthostatic intolerance. Symptoms have been shown to worsen with an upright posture according to objective measures such as orthostatic vital signs and head-up tilt testing, and symptoms improve with rest and leg elevation.

Additional symptoms

Additional common manifestations that were found present in ME/CFS are pain, immune impairment, and infection. Pain was prevalent in more severe cases and manifested as headaches, arthralgia, and myalgia, among others. The pain that these patients experience was indistinguishable from pain experienced in other disease states and healthy people. Immune impairment was evident in people with ME/CFS, in that there were data demonstrating poor NK cell cytotoxicity function. The severity of the illness correlated to the degree of immune impairment. The function of this NK cell was proposed to potentially be a biomarker for the severity of ME/CSF, although not specific to the disease. Finally, there was evidence that ME/CFS can often follow an infection with Epstein Barr Virus (EBV).

The Bottom line

ME/CFS (SEID) is a serious disease that affects many Americans and impacts their lives in cognitive, emotional, physical, and economic realms. The IOM has described a clear diagnostic algorithm for patients presenting with profound fatigue. There are tools that can be found within the report that help to assess the quality, severity, and frequency of the core symptoms. Further research is needed to determine what causes this SEID, what factors affect its course, and what therapies work for which patients.

References

IOM (Institute of Medicine). Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: The National Academies Press; 2015. http://www.iom.edu/mecfs.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Baranck Drumond is a chief resident in the family medicine residency program at Abington Memorial Hospital and is going into practice at a Federally Qualified Health Center, The Community Health Center of Cape Cod in Mashpee, Mass.

According to the Institute of Medicine, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) affects 836,000 to 2.5 million Americans. ME/CFS is a disease that is characterized by profound fatigue, cognitive dysfunctions, sleep abnormalities, autonomic manifestations, pain, and other symptoms, all of which are made worse by any exertion. The Institute of Medicine (IOM) created a report developed by an expert committee to help redefine the illness and proposed new diagnostic criteria that will help medical professionals understand the illness and accurately diagnose and manage patients with this often-misunderstood disease. The IOM committee also recommended that it be renamed Systemic Exertion Intolerance Disease (SEID) to reflect the main characteristics of the disease.

Background

The true prevalence of MF/CSF is unknown because an estimated 84%-91% of affected people have not been diagnosed, and its cause is unknown; however, symptoms may be triggered by certain infections such as Epstein-Barr Virus. MF/CFS is a disease that is more common in women than men, with an average age of onset at 33 years. At some point in the course of this illness, one quarter of affected patients have been bed- or house bound. As explained by the IOM report, most patients have symptoms for years and never regain their predisease functioning level. There is no cure; however, there are interventions and therapies that are helpful in managing symptoms.

Because of the patients’ loss of functioning, high medical costs accrue that add to the overall annual economic burden of $17 billion to $24 billion.

Diagnostic criteria

The following three symptoms must be present to make the diagnosis as stated in the IOM report:

At least one of the two following manifestations also is required:

Key considerations

Diagnosing ME/CFS can be challenging. The health professional should diagnose only after a full history, physical, medical work-up, referrals to appropriate specialists to help rule out other potential disorders, and, ultimately, fulfillment of the diagnostic criteria. The severity and frequency of a patient’s symptoms over the past month and beyond should be assessed by the health professional to determine if the symptoms meet the diagnostic criteria of being chronic, moderate to severe, and frequent. An important distinguishing feature of ME/CFS is that the patient needs to have been symptomatic for 6 months, because most other causes of fatigue do not last that long. Fibromyalgia and irritable bowel syndrome are common comorbidities found in patients with ME/CFS.

Core symptoms

Fatigue and impairment. ME/CFS causes a profound fatigue that does not improve a lot by rest and is not associated with excessive exertion. This type of fatigue makes a substantial impact in decreasing a patient’s functioning and impairing the ability to return to a pre-illness state within occupational, educational, social or personal activities. The impairment secondary to fatigue must persist for at least 6 months.

Postexertional malaise. This symptom is unique to ME/CFS and was described as the primary feature. Physical or cognitive stressors that were previously tolerated now produce worsening symptoms and functioning.

Unrefreshing sleep. There was no subjective evidence of sleep disorders due to ME/CFS, but sufficient data did show that unrefreshing sleep was a complaint universally among ME/CFS patients. The IOM recommends that while polysomnography is not a requirement to diagnose ME/CFS, it is encouraged, to rule out other primary sleep disorders.

Cognitive impairment. Increased stress, effort, or time pressure all can exacerbate existing problems that a patient with ME/CFS has with thinking or executive functioning. Evidence has shown that patients with ME/CFS have slowed information processing and this may be a central aspect of these patients’ overall neurocognitive impairment.

Orthostatic intolerance. Symptoms have been shown to worsen with an upright posture according to objective measures such as orthostatic vital signs and head-up tilt testing, and symptoms improve with rest and leg elevation.

Additional symptoms

Additional common manifestations that were found present in ME/CFS are pain, immune impairment, and infection. Pain was prevalent in more severe cases and manifested as headaches, arthralgia, and myalgia, among others. The pain that these patients experience was indistinguishable from pain experienced in other disease states and healthy people. Immune impairment was evident in people with ME/CFS, in that there were data demonstrating poor NK cell cytotoxicity function. The severity of the illness correlated to the degree of immune impairment. The function of this NK cell was proposed to potentially be a biomarker for the severity of ME/CSF, although not specific to the disease. Finally, there was evidence that ME/CFS can often follow an infection with Epstein Barr Virus (EBV).

The Bottom line

ME/CFS (SEID) is a serious disease that affects many Americans and impacts their lives in cognitive, emotional, physical, and economic realms. The IOM has described a clear diagnostic algorithm for patients presenting with profound fatigue. There are tools that can be found within the report that help to assess the quality, severity, and frequency of the core symptoms. Further research is needed to determine what causes this SEID, what factors affect its course, and what therapies work for which patients.

References

IOM (Institute of Medicine). Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: The National Academies Press; 2015. http://www.iom.edu/mecfs.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Baranck Drumond is a chief resident in the family medicine residency program at Abington Memorial Hospital and is going into practice at a Federally Qualified Health Center, The Community Health Center of Cape Cod in Mashpee, Mass.

According to the Institute of Medicine, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) affects 836,000 to 2.5 million Americans. ME/CFS is a disease that is characterized by profound fatigue, cognitive dysfunctions, sleep abnormalities, autonomic manifestations, pain, and other symptoms, all of which are made worse by any exertion. The Institute of Medicine (IOM) created a report developed by an expert committee to help redefine the illness and proposed new diagnostic criteria that will help medical professionals understand the illness and accurately diagnose and manage patients with this often-misunderstood disease. The IOM committee also recommended that it be renamed Systemic Exertion Intolerance Disease (SEID) to reflect the main characteristics of the disease.

Background

The true prevalence of MF/CSF is unknown because an estimated 84%-91% of affected people have not been diagnosed, and its cause is unknown; however, symptoms may be triggered by certain infections such as Epstein-Barr Virus. MF/CFS is a disease that is more common in women than men, with an average age of onset at 33 years. At some point in the course of this illness, one quarter of affected patients have been bed- or house bound. As explained by the IOM report, most patients have symptoms for years and never regain their predisease functioning level. There is no cure; however, there are interventions and therapies that are helpful in managing symptoms.

Because of the patients’ loss of functioning, high medical costs accrue that add to the overall annual economic burden of $17 billion to $24 billion.

Diagnostic criteria

The following three symptoms must be present to make the diagnosis as stated in the IOM report:

At least one of the two following manifestations also is required:

Key considerations

Diagnosing ME/CFS can be challenging. The health professional should diagnose only after a full history, physical, medical work-up, referrals to appropriate specialists to help rule out other potential disorders, and, ultimately, fulfillment of the diagnostic criteria. The severity and frequency of a patient’s symptoms over the past month and beyond should be assessed by the health professional to determine if the symptoms meet the diagnostic criteria of being chronic, moderate to severe, and frequent. An important distinguishing feature of ME/CFS is that the patient needs to have been symptomatic for 6 months, because most other causes of fatigue do not last that long. Fibromyalgia and irritable bowel syndrome are common comorbidities found in patients with ME/CFS.

Core symptoms

Fatigue and impairment. ME/CFS causes a profound fatigue that does not improve a lot by rest and is not associated with excessive exertion. This type of fatigue makes a substantial impact in decreasing a patient’s functioning and impairing the ability to return to a pre-illness state within occupational, educational, social or personal activities. The impairment secondary to fatigue must persist for at least 6 months.

Postexertional malaise. This symptom is unique to ME/CFS and was described as the primary feature. Physical or cognitive stressors that were previously tolerated now produce worsening symptoms and functioning.

Unrefreshing sleep. There was no subjective evidence of sleep disorders due to ME/CFS, but sufficient data did show that unrefreshing sleep was a complaint universally among ME/CFS patients. The IOM recommends that while polysomnography is not a requirement to diagnose ME/CFS, it is encouraged, to rule out other primary sleep disorders.

Cognitive impairment. Increased stress, effort, or time pressure all can exacerbate existing problems that a patient with ME/CFS has with thinking or executive functioning. Evidence has shown that patients with ME/CFS have slowed information processing and this may be a central aspect of these patients’ overall neurocognitive impairment.

Orthostatic intolerance. Symptoms have been shown to worsen with an upright posture according to objective measures such as orthostatic vital signs and head-up tilt testing, and symptoms improve with rest and leg elevation.

Additional symptoms

Additional common manifestations that were found present in ME/CFS are pain, immune impairment, and infection. Pain was prevalent in more severe cases and manifested as headaches, arthralgia, and myalgia, among others. The pain that these patients experience was indistinguishable from pain experienced in other disease states and healthy people. Immune impairment was evident in people with ME/CFS, in that there were data demonstrating poor NK cell cytotoxicity function. The severity of the illness correlated to the degree of immune impairment. The function of this NK cell was proposed to potentially be a biomarker for the severity of ME/CSF, although not specific to the disease. Finally, there was evidence that ME/CFS can often follow an infection with Epstein Barr Virus (EBV).

The Bottom line

ME/CFS (SEID) is a serious disease that affects many Americans and impacts their lives in cognitive, emotional, physical, and economic realms. The IOM has described a clear diagnostic algorithm for patients presenting with profound fatigue. There are tools that can be found within the report that help to assess the quality, severity, and frequency of the core symptoms. Further research is needed to determine what causes this SEID, what factors affect its course, and what therapies work for which patients.

References

IOM (Institute of Medicine). Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: The National Academies Press; 2015. http://www.iom.edu/mecfs.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Baranck Drumond is a chief resident in the family medicine residency program at Abington Memorial Hospital and is going into practice at a Federally Qualified Health Center, The Community Health Center of Cape Cod in Mashpee, Mass.

Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.

First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:

Prepare, but don’t panic

The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.

It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...

Audits may come before or after payment

There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …

There is no such thing as TMI (too much information)

When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.

For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...

Don’t neglect the security risk analysis

This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.

This leads us to one final important piece of advice:

Make sure you follow up

It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.

First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:

Prepare, but don’t panic

The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.

It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...

Audits may come before or after payment

There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …

There is no such thing as TMI (too much information)

When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.

For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...

Don’t neglect the security risk analysis

This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.

This leads us to one final important piece of advice:

Make sure you follow up

It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.

First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:

Prepare, but don’t panic

The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.

It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...

Audits may come before or after payment

There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …

There is no such thing as TMI (too much information)

When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.

For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...

Don’t neglect the security risk analysis

This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.

This leads us to one final important piece of advice:

Make sure you follow up

It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Older adults are at an increased risk for falls and fractures. The estimated medical cost of falls in 2010 was $28.2 billion. The lost quality of life, high rate of institutionalization, and cost to society caused by falls makes this an important topic to address. Low vitamin D can lead to balance problems, weakness, and low bone mineral density with higher fall and fracture rates. Vitamin D supplementation has been found to decrease falls sustained by elderly patients. The American Geriatrics Society has released a consensus statement, based on findings of a work group of researchers and clinicians with expertise in vitamin D and older adults, on the use of vitamin D for prevention of falls in elderly patients in either the community or institutions.

Recommendations to reduce falls and fractures in older people

The consensus statement recommends that patients 65 years and older in the community as well as in institutions should receive supplementation of at least 1,000 IU/day to help decrease the risk of falls and subsequent fractures. It was found in studies that less than 600 IU/day did not prevent falls. Calcium should be administered with the vitamin D at a dose of 1,000-1,200 mg/day. There are insufficient data to recommend vitamin D supplementation without calcium.

Optimizing vitamin D status

The goal vitamin D serum level is 30 ng/mL, and this is based on a review of trials with serum levels of > 24 ng/mL that showed lower fall rates and trials that showed higher relative risk for falls with vitamin D levels < 25 ng/mL. The vitamin D total intake found to achieve a level > 30 ng/mL (75 nmol/L) in 92% of older adults was 4,000 IU/day. This took into account dietary vitamin D, sun exposure, and supplementation. Taking 4,000 IU/day of vitamin D is well below 10,000 IU/day, the highest tolerable amount. There has not been shown to be any cases of vitamin D intoxication at levels less than 200 ng/mL or at supplement levels of less than 30,000 IU/day.

In patients without the comorbidities mentioned below, there was not found to be a role in checking vitamin D levels, before supplementation or for monitoring, if the recommended supplementation is given. For those who wish to monitor levels, you should check the vitamin 25(OH)D levels 4 months after vitamin D3 supplementation.

Special populations

Patients who take medicines such as cholestyramine, phenytoin, and phenobarbital should have their levels monitored, as these drugs can decrease vitamin D levels. Also obese patients and patients with malabsorption syndromes may need more frequent monitoring.

Vitamin D supplementation individualized

To prescribe a personalized vitamin D₃ supplementation regimen, first start with 3,000 IU and then add or subtract to determine the adequate supplementation. Subtract 150-225 IU/day for dietary intake and subtract vitamin D in multivitamins and calcium combination tablets. It is not recommended to encourage sun exposure to increase vitamin D levels, but you can subtract about 500-1,000 IU/day in the summer months for patients with regular unprotected sun exposure. About 500-800 IU/day should be added for obesity and about 300-600 IU/day should be added for darker skin pigmentation. A total of 4,000 IU/day supplementation should not be exceeded except in special populations.

Vitamin D₂ vs. D₃

Vitamin D₃ has been shown to provide higher serum levels of 25(OH)D than vitamin D₂. Vitamin D₃ is available without prescription in 400, 800, 1,000, 2,000, 5,000, and 10,000 IU formulations. Vitamin D₂ is available by prescription at a dose of 50,000 IU.

Vitamin D₂ at a dose of 50,000 IU has not been FDA approved to increase serum 25(OH)D levels. Avoid giving vitamin D with cholestyramine, high-fiber cereals, and fiber-based stool softeners. It is best to be taken with meals with oil for better absorption. Daily, weekly, and monthly vitamin D₃ supplementation has been shown to equally achieve target blood levels of vitamin D.

The bottom line

Preventing falls in our older adult population is important for many reasons including maintaining quality of life, limiting institutionalization, and helping to decrease medical cost. Maintaining adequate vitamin D serum levels has been shown to help reduce falls and fractures in older adults. A goal level of > 30 ng/mL has been shown to help with the prevention of falls and fractures. The work group came to a different conclusion from the Institute of Medicine Report, which recommended vitamin D serum levels > 20 ng/mL in older adults. In trials with serum levels of 24 ng/mL, there was a clear lower fall rate seen. In trials with levels < 25 ng/mL, there was a higher relative risk of falls. A total daily intake of vitamin D₃ of 4,000 IU has been shown to reach a serum level of 30 ng/mL in 92% on patients 65 years and older. In order to reach this goal, older adults in the community and in institutions require about 1,000 IU of vitamin D₃ supplementation daily. However, it is ideal to individualize the supplementation amount based on each person’s sun exposure, daily dietary intake, and other medications or comorbidities that they have.

Reference

American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences – American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. J. Am. Geriatr. Soc. 2014;62:147-52.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Bowry is a third year resident in the family medicine residency at Abington Memorial Hospital.

Older adults are at an increased risk for falls and fractures. The estimated medical cost of falls in 2010 was $28.2 billion. The lost quality of life, high rate of institutionalization, and cost to society caused by falls makes this an important topic to address. Low vitamin D can lead to balance problems, weakness, and low bone mineral density with higher fall and fracture rates. Vitamin D supplementation has been found to decrease falls sustained by elderly patients. The American Geriatrics Society has released a consensus statement, based on findings of a work group of researchers and clinicians with expertise in vitamin D and older adults, on the use of vitamin D for prevention of falls in elderly patients in either the community or institutions.

Recommendations to reduce falls and fractures in older people

The consensus statement recommends that patients 65 years and older in the community as well as in institutions should receive supplementation of at least 1,000 IU/day to help decrease the risk of falls and subsequent fractures. It was found in studies that less than 600 IU/day did not prevent falls. Calcium should be administered with the vitamin D at a dose of 1,000-1,200 mg/day. There are insufficient data to recommend vitamin D supplementation without calcium.

Optimizing vitamin D status

The goal vitamin D serum level is 30 ng/mL, and this is based on a review of trials with serum levels of > 24 ng/mL that showed lower fall rates and trials that showed higher relative risk for falls with vitamin D levels < 25 ng/mL. The vitamin D total intake found to achieve a level > 30 ng/mL (75 nmol/L) in 92% of older adults was 4,000 IU/day. This took into account dietary vitamin D, sun exposure, and supplementation. Taking 4,000 IU/day of vitamin D is well below 10,000 IU/day, the highest tolerable amount. There has not been shown to be any cases of vitamin D intoxication at levels less than 200 ng/mL or at supplement levels of less than 30,000 IU/day.

In patients without the comorbidities mentioned below, there was not found to be a role in checking vitamin D levels, before supplementation or for monitoring, if the recommended supplementation is given. For those who wish to monitor levels, you should check the vitamin 25(OH)D levels 4 months after vitamin D3 supplementation.

Special populations

Patients who take medicines such as cholestyramine, phenytoin, and phenobarbital should have their levels monitored, as these drugs can decrease vitamin D levels. Also obese patients and patients with malabsorption syndromes may need more frequent monitoring.

Vitamin D supplementation individualized

To prescribe a personalized vitamin D₃ supplementation regimen, first start with 3,000 IU and then add or subtract to determine the adequate supplementation. Subtract 150-225 IU/day for dietary intake and subtract vitamin D in multivitamins and calcium combination tablets. It is not recommended to encourage sun exposure to increase vitamin D levels, but you can subtract about 500-1,000 IU/day in the summer months for patients with regular unprotected sun exposure. About 500-800 IU/day should be added for obesity and about 300-600 IU/day should be added for darker skin pigmentation. A total of 4,000 IU/day supplementation should not be exceeded except in special populations.

Vitamin D₂ vs. D₃

Vitamin D₃ has been shown to provide higher serum levels of 25(OH)D than vitamin D₂. Vitamin D₃ is available without prescription in 400, 800, 1,000, 2,000, 5,000, and 10,000 IU formulations. Vitamin D₂ is available by prescription at a dose of 50,000 IU.

Vitamin D₂ at a dose of 50,000 IU has not been FDA approved to increase serum 25(OH)D levels. Avoid giving vitamin D with cholestyramine, high-fiber cereals, and fiber-based stool softeners. It is best to be taken with meals with oil for better absorption. Daily, weekly, and monthly vitamin D₃ supplementation has been shown to equally achieve target blood levels of vitamin D.

The bottom line

Preventing falls in our older adult population is important for many reasons including maintaining quality of life, limiting institutionalization, and helping to decrease medical cost. Maintaining adequate vitamin D serum levels has been shown to help reduce falls and fractures in older adults. A goal level of > 30 ng/mL has been shown to help with the prevention of falls and fractures. The work group came to a different conclusion from the Institute of Medicine Report, which recommended vitamin D serum levels > 20 ng/mL in older adults. In trials with serum levels of 24 ng/mL, there was a clear lower fall rate seen. In trials with levels < 25 ng/mL, there was a higher relative risk of falls. A total daily intake of vitamin D₃ of 4,000 IU has been shown to reach a serum level of 30 ng/mL in 92% on patients 65 years and older. In order to reach this goal, older adults in the community and in institutions require about 1,000 IU of vitamin D₃ supplementation daily. However, it is ideal to individualize the supplementation amount based on each person’s sun exposure, daily dietary intake, and other medications or comorbidities that they have.

Reference

American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences – American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. J. Am. Geriatr. Soc. 2014;62:147-52.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Bowry is a third year resident in the family medicine residency at Abington Memorial Hospital.

Older adults are at an increased risk for falls and fractures. The estimated medical cost of falls in 2010 was $28.2 billion. The lost quality of life, high rate of institutionalization, and cost to society caused by falls makes this an important topic to address. Low vitamin D can lead to balance problems, weakness, and low bone mineral density with higher fall and fracture rates. Vitamin D supplementation has been found to decrease falls sustained by elderly patients. The American Geriatrics Society has released a consensus statement, based on findings of a work group of researchers and clinicians with expertise in vitamin D and older adults, on the use of vitamin D for prevention of falls in elderly patients in either the community or institutions.

Recommendations to reduce falls and fractures in older people

The consensus statement recommends that patients 65 years and older in the community as well as in institutions should receive supplementation of at least 1,000 IU/day to help decrease the risk of falls and subsequent fractures. It was found in studies that less than 600 IU/day did not prevent falls. Calcium should be administered with the vitamin D at a dose of 1,000-1,200 mg/day. There are insufficient data to recommend vitamin D supplementation without calcium.

Optimizing vitamin D status

The goal vitamin D serum level is 30 ng/mL, and this is based on a review of trials with serum levels of > 24 ng/mL that showed lower fall rates and trials that showed higher relative risk for falls with vitamin D levels < 25 ng/mL. The vitamin D total intake found to achieve a level > 30 ng/mL (75 nmol/L) in 92% of older adults was 4,000 IU/day. This took into account dietary vitamin D, sun exposure, and supplementation. Taking 4,000 IU/day of vitamin D is well below 10,000 IU/day, the highest tolerable amount. There has not been shown to be any cases of vitamin D intoxication at levels less than 200 ng/mL or at supplement levels of less than 30,000 IU/day.

In patients without the comorbidities mentioned below, there was not found to be a role in checking vitamin D levels, before supplementation or for monitoring, if the recommended supplementation is given. For those who wish to monitor levels, you should check the vitamin 25(OH)D levels 4 months after vitamin D3 supplementation.

Special populations

Patients who take medicines such as cholestyramine, phenytoin, and phenobarbital should have their levels monitored, as these drugs can decrease vitamin D levels. Also obese patients and patients with malabsorption syndromes may need more frequent monitoring.

Vitamin D supplementation individualized

To prescribe a personalized vitamin D₃ supplementation regimen, first start with 3,000 IU and then add or subtract to determine the adequate supplementation. Subtract 150-225 IU/day for dietary intake and subtract vitamin D in multivitamins and calcium combination tablets. It is not recommended to encourage sun exposure to increase vitamin D levels, but you can subtract about 500-1,000 IU/day in the summer months for patients with regular unprotected sun exposure. About 500-800 IU/day should be added for obesity and about 300-600 IU/day should be added for darker skin pigmentation. A total of 4,000 IU/day supplementation should not be exceeded except in special populations.

Vitamin D₂ vs. D₃

Vitamin D₃ has been shown to provide higher serum levels of 25(OH)D than vitamin D₂. Vitamin D₃ is available without prescription in 400, 800, 1,000, 2,000, 5,000, and 10,000 IU formulations. Vitamin D₂ is available by prescription at a dose of 50,000 IU.

Vitamin D₂ at a dose of 50,000 IU has not been FDA approved to increase serum 25(OH)D levels. Avoid giving vitamin D with cholestyramine, high-fiber cereals, and fiber-based stool softeners. It is best to be taken with meals with oil for better absorption. Daily, weekly, and monthly vitamin D₃ supplementation has been shown to equally achieve target blood levels of vitamin D.

The bottom line

Preventing falls in our older adult population is important for many reasons including maintaining quality of life, limiting institutionalization, and helping to decrease medical cost. Maintaining adequate vitamin D serum levels has been shown to help reduce falls and fractures in older adults. A goal level of > 30 ng/mL has been shown to help with the prevention of falls and fractures. The work group came to a different conclusion from the Institute of Medicine Report, which recommended vitamin D serum levels > 20 ng/mL in older adults. In trials with serum levels of 24 ng/mL, there was a clear lower fall rate seen. In trials with levels < 25 ng/mL, there was a higher relative risk of falls. A total daily intake of vitamin D₃ of 4,000 IU has been shown to reach a serum level of 30 ng/mL in 92% on patients 65 years and older. In order to reach this goal, older adults in the community and in institutions require about 1,000 IU of vitamin D₃ supplementation daily. However, it is ideal to individualize the supplementation amount based on each person’s sun exposure, daily dietary intake, and other medications or comorbidities that they have.

Reference

American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences – American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. J. Am. Geriatr. Soc. 2014;62:147-52.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Bowry is a third year resident in the family medicine residency at Abington Memorial Hospital.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The average annual rate of stroke recurrence is at an all-time low (3%-4%) as a result of advances in stroke prevention research. The American Heart Association/American Stroke Association publishes revised guidelines every 2-3 years to arm providers with the latest recommendations on secondary stroke prevention. Below is a summary of some of the more pertinent revised 2014 recommendations on secondary stroke prevention.

Hypertension

Blood pressure (BP) therapy should be initiated in post stroke/transient ischemic attack (TIA) patients who are noted to have a persistent BP ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic. Patients already on antihypertensive therapy who have suffered a stroke/TIA should optimize therapy to drive BP to less than 140/90.

Dyslipidemia

Statins therapy with a highly potent statin is recommended in patients with a stroke/TIA history presumed to be of atherosclerotic origin regardless of baseline low-density lipoprotein cholesterol (LDL-C) and regardless of other cardiovascular comorbid conditions.

Diabetes mellitus

Patients with a TIA/stroke history should probably be screened for diabetes mellitus. The hemoglobin A_1c screening tool may be the most revealing in the immediate postevent period.

Obesity/Physical activity/Nutrition

Stroke/TIA patients should be screened for obesity and nutritional issues. The usefulness of weight loss after TIA or stroke is uncertain. Both Mediterranean and low-sodium (< 2.4 g/day) diets should be recommended.

Sleep apnea

Patients who have suffered a stroke or TIA might be screened for sleep apnea in light of the high prevalence of sleep apnea among stroke patients.

Carotid artery disease/Vertebral artery disease/Intracranial atherosclerosis

Patients who have had a stroke or TIA in the past 6 months and who have ipsilateral severe (>70%) carotid artery stenosis should be referred for carotid endarterectomy (CEA). If a patient has less severe stenosis (50%-69%), CEA may be indicated depending on a number of factors, such as age, sex, and comorbidities. When revascularization is indicated, it should be performed within 2 weeks of the index event.

Carotid angioplasty and stenting (CAS) can be considered versus CEA, with decision depending on patients age, procedural risks, and carotid anatomy.

In the poststroke setting of 50%-99% stenosis of a major intracranial artery, aspirin in a daily dose of 325 mg is recommended. In the poststroke setting of severe intracranial stenosis, the combination of aspirin 325 mg daily and clopidogrel 75 mg daily for 90 days “may be reasonable.”

Atrial fibrillation and Anticoagulation

Prolonged rhythm monitoring (30 days) for atrial fibrillation (AF) is reasonable in patients who have experienced a stroke or TIA without an apparent cause.

Dabigatran, apixaban, and vitamin K antagonists (VKA) are the preferred anticoagulation agents to prevent recurrent stroke in nonvalvular AF. Rivaroxaban is another reasonable alternative.

The use of antiplatelet agents with oral anticoagulation is not routinely indicated but is reasonable in patients with an additional history of clinically apparent coronary artery disease (CAD). Aspirin alone is recommended in patients intolerant of oral anticoagulation. The addition of clopidogrel to aspirin therapy may be considered. Oral anticoagulation can be initiated 14 days after a stroke/TIA caused by AF. Longer waiting time periods may be needed in the setting of stroke events linked with a higher risk for hemorrhagic conversion, such as larger strokes or in patients with uncontrolled hypertension.

Mechanical closure of the left atrial appendage is of uncertain benefit.

MI/Thrombus/Cardiomyopathy

Stroke/TIA events that occur in the setting of a myocardial infarction (MI) complicated by a thrombus in the left atrium or ventricle warrant > 3 months of anticoagulation. VKA therapy may be considered for 3 months in post-MI patients who have experienced a stroke/TIA and are found to have apical wall–motion abnormalities without thrombus on imaging. In patients with a stroke and a cardiomyopathy with ejection fraction < 35%, without apparent thrombus, it is unclear whether anticoagulation or antiplatelet therapy has better outcomes, and the choice of approach can be individualized.

Antiplatelet agents

The use of an antiplatelet agent is recommended to decrease the risk of recurrent stroke. Aspirin (50 mg–325 mg daily ) monotherapy or the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily is recommended. Clopidogrel 75 mg daily as monotherapy is also an option. The combination of aspirin and clopidogrel can be considered beginning within a day of a minor stroke or TIA and should be used for 90 days. The use of clopidogrel and aspirin together long term is not recommended due to increased hemorrhagic risk.

Patent foramen ovale

In patients with a patent foramen ovale (PFO), it is unclear whether anticoagulation or aspirin is more effective at preventing stroke recurrence. Available evidence does not support PFO closure when there is not evidence for concomitant DVT.

Hypercoagulation

The utility of screening for factor V Leiden, protein C deficiency, antiphospholipid antibodies, or other thrombophilic states is unclear. Anticoagulation can be considered if a coagulation abnormality is found, and if anticoagulation is not used then antiplatelet therapy is recommended.

Bottom line

Maintaining a healthy stroke-free lifestyle after a stroke/TIA requires rapid identification of stroke risk factors. The 2014 American Heart Association/American Stroke Association secondary stroke recommendations including the use of antiplatelet agents, anticoagulation for patients with atrial fibrillation, control of hypertension and hypercholesterolemia, and other risk factors are important evidence-based approaches to decrease the risk of recurrent stroke.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Mathew is a third-year resident in the family medicine residency program at Abington Memorial Hospital.

The average annual rate of stroke recurrence is at an all-time low (3%-4%) as a result of advances in stroke prevention research. The American Heart Association/American Stroke Association publishes revised guidelines every 2-3 years to arm providers with the latest recommendations on secondary stroke prevention. Below is a summary of some of the more pertinent revised 2014 recommendations on secondary stroke prevention.

Hypertension

Blood pressure (BP) therapy should be initiated in post stroke/transient ischemic attack (TIA) patients who are noted to have a persistent BP ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic. Patients already on antihypertensive therapy who have suffered a stroke/TIA should optimize therapy to drive BP to less than 140/90.

Dyslipidemia

Statins therapy with a highly potent statin is recommended in patients with a stroke/TIA history presumed to be of atherosclerotic origin regardless of baseline low-density lipoprotein cholesterol (LDL-C) and regardless of other cardiovascular comorbid conditions.

Diabetes mellitus

Patients with a TIA/stroke history should probably be screened for diabetes mellitus. The hemoglobin A_1c screening tool may be the most revealing in the immediate postevent period.

Obesity/Physical activity/Nutrition

Stroke/TIA patients should be screened for obesity and nutritional issues. The usefulness of weight loss after TIA or stroke is uncertain. Both Mediterranean and low-sodium (< 2.4 g/day) diets should be recommended.

Sleep apnea

Patients who have suffered a stroke or TIA might be screened for sleep apnea in light of the high prevalence of sleep apnea among stroke patients.

Carotid artery disease/Vertebral artery disease/Intracranial atherosclerosis

Patients who have had a stroke or TIA in the past 6 months and who have ipsilateral severe (>70%) carotid artery stenosis should be referred for carotid endarterectomy (CEA). If a patient has less severe stenosis (50%-69%), CEA may be indicated depending on a number of factors, such as age, sex, and comorbidities. When revascularization is indicated, it should be performed within 2 weeks of the index event.

Carotid angioplasty and stenting (CAS) can be considered versus CEA, with decision depending on patients age, procedural risks, and carotid anatomy.

In the poststroke setting of 50%-99% stenosis of a major intracranial artery, aspirin in a daily dose of 325 mg is recommended. In the poststroke setting of severe intracranial stenosis, the combination of aspirin 325 mg daily and clopidogrel 75 mg daily for 90 days “may be reasonable.”

Atrial fibrillation and Anticoagulation

Prolonged rhythm monitoring (30 days) for atrial fibrillation (AF) is reasonable in patients who have experienced a stroke or TIA without an apparent cause.

Dabigatran, apixaban, and vitamin K antagonists (VKA) are the preferred anticoagulation agents to prevent recurrent stroke in nonvalvular AF. Rivaroxaban is another reasonable alternative.

The use of antiplatelet agents with oral anticoagulation is not routinely indicated but is reasonable in patients with an additional history of clinically apparent coronary artery disease (CAD). Aspirin alone is recommended in patients intolerant of oral anticoagulation. The addition of clopidogrel to aspirin therapy may be considered. Oral anticoagulation can be initiated 14 days after a stroke/TIA caused by AF. Longer waiting time periods may be needed in the setting of stroke events linked with a higher risk for hemorrhagic conversion, such as larger strokes or in patients with uncontrolled hypertension.

Mechanical closure of the left atrial appendage is of uncertain benefit.

MI/Thrombus/Cardiomyopathy

Stroke/TIA events that occur in the setting of a myocardial infarction (MI) complicated by a thrombus in the left atrium or ventricle warrant > 3 months of anticoagulation. VKA therapy may be considered for 3 months in post-MI patients who have experienced a stroke/TIA and are found to have apical wall–motion abnormalities without thrombus on imaging. In patients with a stroke and a cardiomyopathy with ejection fraction < 35%, without apparent thrombus, it is unclear whether anticoagulation or antiplatelet therapy has better outcomes, and the choice of approach can be individualized.

Antiplatelet agents

The use of an antiplatelet agent is recommended to decrease the risk of recurrent stroke. Aspirin (50 mg–325 mg daily ) monotherapy or the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily is recommended. Clopidogrel 75 mg daily as monotherapy is also an option. The combination of aspirin and clopidogrel can be considered beginning within a day of a minor stroke or TIA and should be used for 90 days. The use of clopidogrel and aspirin together long term is not recommended due to increased hemorrhagic risk.

Patent foramen ovale

In patients with a patent foramen ovale (PFO), it is unclear whether anticoagulation or aspirin is more effective at preventing stroke recurrence. Available evidence does not support PFO closure when there is not evidence for concomitant DVT.

Hypercoagulation

The utility of screening for factor V Leiden, protein C deficiency, antiphospholipid antibodies, or other thrombophilic states is unclear. Anticoagulation can be considered if a coagulation abnormality is found, and if anticoagulation is not used then antiplatelet therapy is recommended.

Bottom line

Maintaining a healthy stroke-free lifestyle after a stroke/TIA requires rapid identification of stroke risk factors. The 2014 American Heart Association/American Stroke Association secondary stroke recommendations including the use of antiplatelet agents, anticoagulation for patients with atrial fibrillation, control of hypertension and hypercholesterolemia, and other risk factors are important evidence-based approaches to decrease the risk of recurrent stroke.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Mathew is a third-year resident in the family medicine residency program at Abington Memorial Hospital.

The average annual rate of stroke recurrence is at an all-time low (3%-4%) as a result of advances in stroke prevention research. The American Heart Association/American Stroke Association publishes revised guidelines every 2-3 years to arm providers with the latest recommendations on secondary stroke prevention. Below is a summary of some of the more pertinent revised 2014 recommendations on secondary stroke prevention.

Hypertension

Blood pressure (BP) therapy should be initiated in post stroke/transient ischemic attack (TIA) patients who are noted to have a persistent BP ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic. Patients already on antihypertensive therapy who have suffered a stroke/TIA should optimize therapy to drive BP to less than 140/90.

Dyslipidemia

Statins therapy with a highly potent statin is recommended in patients with a stroke/TIA history presumed to be of atherosclerotic origin regardless of baseline low-density lipoprotein cholesterol (LDL-C) and regardless of other cardiovascular comorbid conditions.

Diabetes mellitus

Patients with a TIA/stroke history should probably be screened for diabetes mellitus. The hemoglobin A_1c screening tool may be the most revealing in the immediate postevent period.

Obesity/Physical activity/Nutrition

Stroke/TIA patients should be screened for obesity and nutritional issues. The usefulness of weight loss after TIA or stroke is uncertain. Both Mediterranean and low-sodium (< 2.4 g/day) diets should be recommended.

Sleep apnea

Patients who have suffered a stroke or TIA might be screened for sleep apnea in light of the high prevalence of sleep apnea among stroke patients.

Carotid artery disease/Vertebral artery disease/Intracranial atherosclerosis

Patients who have had a stroke or TIA in the past 6 months and who have ipsilateral severe (>70%) carotid artery stenosis should be referred for carotid endarterectomy (CEA). If a patient has less severe stenosis (50%-69%), CEA may be indicated depending on a number of factors, such as age, sex, and comorbidities. When revascularization is indicated, it should be performed within 2 weeks of the index event.

Carotid angioplasty and stenting (CAS) can be considered versus CEA, with decision depending on patients age, procedural risks, and carotid anatomy.

In the poststroke setting of 50%-99% stenosis of a major intracranial artery, aspirin in a daily dose of 325 mg is recommended. In the poststroke setting of severe intracranial stenosis, the combination of aspirin 325 mg daily and clopidogrel 75 mg daily for 90 days “may be reasonable.”

Atrial fibrillation and Anticoagulation

Prolonged rhythm monitoring (30 days) for atrial fibrillation (AF) is reasonable in patients who have experienced a stroke or TIA without an apparent cause.

Dabigatran, apixaban, and vitamin K antagonists (VKA) are the preferred anticoagulation agents to prevent recurrent stroke in nonvalvular AF. Rivaroxaban is another reasonable alternative.

The use of antiplatelet agents with oral anticoagulation is not routinely indicated but is reasonable in patients with an additional history of clinically apparent coronary artery disease (CAD). Aspirin alone is recommended in patients intolerant of oral anticoagulation. The addition of clopidogrel to aspirin therapy may be considered. Oral anticoagulation can be initiated 14 days after a stroke/TIA caused by AF. Longer waiting time periods may be needed in the setting of stroke events linked with a higher risk for hemorrhagic conversion, such as larger strokes or in patients with uncontrolled hypertension.

Mechanical closure of the left atrial appendage is of uncertain benefit.

MI/Thrombus/Cardiomyopathy

Stroke/TIA events that occur in the setting of a myocardial infarction (MI) complicated by a thrombus in the left atrium or ventricle warrant > 3 months of anticoagulation. VKA therapy may be considered for 3 months in post-MI patients who have experienced a stroke/TIA and are found to have apical wall–motion abnormalities without thrombus on imaging. In patients with a stroke and a cardiomyopathy with ejection fraction < 35%, without apparent thrombus, it is unclear whether anticoagulation or antiplatelet therapy has better outcomes, and the choice of approach can be individualized.

Antiplatelet agents

The use of an antiplatelet agent is recommended to decrease the risk of recurrent stroke. Aspirin (50 mg–325 mg daily ) monotherapy or the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily is recommended. Clopidogrel 75 mg daily as monotherapy is also an option. The combination of aspirin and clopidogrel can be considered beginning within a day of a minor stroke or TIA and should be used for 90 days. The use of clopidogrel and aspirin together long term is not recommended due to increased hemorrhagic risk.

Patent foramen ovale

In patients with a patent foramen ovale (PFO), it is unclear whether anticoagulation or aspirin is more effective at preventing stroke recurrence. Available evidence does not support PFO closure when there is not evidence for concomitant DVT.

Hypercoagulation

The utility of screening for factor V Leiden, protein C deficiency, antiphospholipid antibodies, or other thrombophilic states is unclear. Anticoagulation can be considered if a coagulation abnormality is found, and if anticoagulation is not used then antiplatelet therapy is recommended.

Bottom line

Maintaining a healthy stroke-free lifestyle after a stroke/TIA requires rapid identification of stroke risk factors. The 2014 American Heart Association/American Stroke Association secondary stroke recommendations including the use of antiplatelet agents, anticoagulation for patients with atrial fibrillation, control of hypertension and hypercholesterolemia, and other risk factors are important evidence-based approaches to decrease the risk of recurrent stroke.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Mathew is a third-year resident in the family medicine residency program at Abington Memorial Hospital.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.