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Copy and Paste At Your Own Risk: The Dangers of Electronic ‘Plagiarism’
Between "Hangovers," Bradley Cooper starred in a largely forgettable melodrama called "The Words." The main character was an aspiring writer whose career first skyrockets and then implodes when he plagiarizes an entire novel from a dusty manuscript found buried in an old briefcase bought at an antique store. As art, "The Words" is destined for the on-demand scrap heap, but it may yet be redeemed as a cautionary tale for anyone who creates electronic health records.
While EHRs have many advantages that can improve health care delivery, including easy access and portability, the same technology that affords these advantages can also promote careless practices that may call into question the accuracy of the entire record and make it difficult, if not impossible, for health care providers to defend themselves in court. Among the most troublesome EHR misuses we see in litigation is the inappropriate use of copy and paste functions, whereby a health care provider "plagiarizes" his/her own or a colleague’s prior documentation.
In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error. To avoid these insinuations, clinicians must put time and effort, as well as original thought, into medical record documentation.
Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR. The excuses we have heard for this run the gamut from unfamiliarity with the electronic system to lack of time and, ironically, the need to ensure accurate documentation. Similarly, in "The Words," when Bradley Cooper’s character starts copying another author’s manuscript – word for word – onto his laptop, he tells himself that he is doing it simply for inspiration. Excuses aside, this kind of rote replication is seductively easy but fraught with danger, particularly if the EHR later comes under scrutiny.
Next page: Consequences of plagiarism >>
When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her "accompanied by spouse" at every visit.
Sometimes EHR plagiarism goes right to the heart of the negligence claim. Where the claim is inappropriate discharge of a patient who died a few days after leaving the hospital, the defense must show that the patient’s condition improved and that troubling symptoms seen on admission responded appropriately to treatment. This effort is hampered by documentation prepared many days or weeks into a hospitalization that copies symptoms and physical findings that are no longer present. Inaccurate information in the EHR can also confuse other medical providers, and the time necessary to reconcile inconsistent information may delay treatment. Likewise, if inaccurate information is relied on for treatment decisions, the results can be disastrous.
It is often argued in litigation that if something doesn’t appear in the medical record it didn’t happen. A corollary to this dubious "rule" is that once bad information is documented in a medical record, it will be redocumented over and over and over again. Predictably, the more times the erroneous data are repeated in the EHR, the more "reliable" it becomes. This problem has been around a long time, but EHR plagiarism has made it worse.
The medical record is the most important evidence in any medical negligence case. While it is true that only a small fraction of medical records will ever see the inside of a courtroom, you should always document assuming the chart in front of you could end up there. This requires time, original thought, accuracy, and completeness. Copying and pasting the electronic medical record, while superficially efficient, is the enemy of these goals, and could leave you – like Bradley Cooper in "The Words" – wondering what happened to your promising career.
Ms. Kane and Mr. Balaguer are in private practice in Wilmington, Del. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Between "Hangovers," Bradley Cooper starred in a largely forgettable melodrama called "The Words." The main character was an aspiring writer whose career first skyrockets and then implodes when he plagiarizes an entire novel from a dusty manuscript found buried in an old briefcase bought at an antique store. As art, "The Words" is destined for the on-demand scrap heap, but it may yet be redeemed as a cautionary tale for anyone who creates electronic health records.
While EHRs have many advantages that can improve health care delivery, including easy access and portability, the same technology that affords these advantages can also promote careless practices that may call into question the accuracy of the entire record and make it difficult, if not impossible, for health care providers to defend themselves in court. Among the most troublesome EHR misuses we see in litigation is the inappropriate use of copy and paste functions, whereby a health care provider "plagiarizes" his/her own or a colleague’s prior documentation.
In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error. To avoid these insinuations, clinicians must put time and effort, as well as original thought, into medical record documentation.
Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR. The excuses we have heard for this run the gamut from unfamiliarity with the electronic system to lack of time and, ironically, the need to ensure accurate documentation. Similarly, in "The Words," when Bradley Cooper’s character starts copying another author’s manuscript – word for word – onto his laptop, he tells himself that he is doing it simply for inspiration. Excuses aside, this kind of rote replication is seductively easy but fraught with danger, particularly if the EHR later comes under scrutiny.
Next page: Consequences of plagiarism >>
When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her "accompanied by spouse" at every visit.
Sometimes EHR plagiarism goes right to the heart of the negligence claim. Where the claim is inappropriate discharge of a patient who died a few days after leaving the hospital, the defense must show that the patient’s condition improved and that troubling symptoms seen on admission responded appropriately to treatment. This effort is hampered by documentation prepared many days or weeks into a hospitalization that copies symptoms and physical findings that are no longer present. Inaccurate information in the EHR can also confuse other medical providers, and the time necessary to reconcile inconsistent information may delay treatment. Likewise, if inaccurate information is relied on for treatment decisions, the results can be disastrous.
It is often argued in litigation that if something doesn’t appear in the medical record it didn’t happen. A corollary to this dubious "rule" is that once bad information is documented in a medical record, it will be redocumented over and over and over again. Predictably, the more times the erroneous data are repeated in the EHR, the more "reliable" it becomes. This problem has been around a long time, but EHR plagiarism has made it worse.
The medical record is the most important evidence in any medical negligence case. While it is true that only a small fraction of medical records will ever see the inside of a courtroom, you should always document assuming the chart in front of you could end up there. This requires time, original thought, accuracy, and completeness. Copying and pasting the electronic medical record, while superficially efficient, is the enemy of these goals, and could leave you – like Bradley Cooper in "The Words" – wondering what happened to your promising career.
Ms. Kane and Mr. Balaguer are in private practice in Wilmington, Del. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Between "Hangovers," Bradley Cooper starred in a largely forgettable melodrama called "The Words." The main character was an aspiring writer whose career first skyrockets and then implodes when he plagiarizes an entire novel from a dusty manuscript found buried in an old briefcase bought at an antique store. As art, "The Words" is destined for the on-demand scrap heap, but it may yet be redeemed as a cautionary tale for anyone who creates electronic health records.
While EHRs have many advantages that can improve health care delivery, including easy access and portability, the same technology that affords these advantages can also promote careless practices that may call into question the accuracy of the entire record and make it difficult, if not impossible, for health care providers to defend themselves in court. Among the most troublesome EHR misuses we see in litigation is the inappropriate use of copy and paste functions, whereby a health care provider "plagiarizes" his/her own or a colleague’s prior documentation.
In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error. To avoid these insinuations, clinicians must put time and effort, as well as original thought, into medical record documentation.
Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR. The excuses we have heard for this run the gamut from unfamiliarity with the electronic system to lack of time and, ironically, the need to ensure accurate documentation. Similarly, in "The Words," when Bradley Cooper’s character starts copying another author’s manuscript – word for word – onto his laptop, he tells himself that he is doing it simply for inspiration. Excuses aside, this kind of rote replication is seductively easy but fraught with danger, particularly if the EHR later comes under scrutiny.
Next page: Consequences of plagiarism >>
When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her "accompanied by spouse" at every visit.
Sometimes EHR plagiarism goes right to the heart of the negligence claim. Where the claim is inappropriate discharge of a patient who died a few days after leaving the hospital, the defense must show that the patient’s condition improved and that troubling symptoms seen on admission responded appropriately to treatment. This effort is hampered by documentation prepared many days or weeks into a hospitalization that copies symptoms and physical findings that are no longer present. Inaccurate information in the EHR can also confuse other medical providers, and the time necessary to reconcile inconsistent information may delay treatment. Likewise, if inaccurate information is relied on for treatment decisions, the results can be disastrous.
It is often argued in litigation that if something doesn’t appear in the medical record it didn’t happen. A corollary to this dubious "rule" is that once bad information is documented in a medical record, it will be redocumented over and over and over again. Predictably, the more times the erroneous data are repeated in the EHR, the more "reliable" it becomes. This problem has been around a long time, but EHR plagiarism has made it worse.
The medical record is the most important evidence in any medical negligence case. While it is true that only a small fraction of medical records will ever see the inside of a courtroom, you should always document assuming the chart in front of you could end up there. This requires time, original thought, accuracy, and completeness. Copying and pasting the electronic medical record, while superficially efficient, is the enemy of these goals, and could leave you – like Bradley Cooper in "The Words" – wondering what happened to your promising career.
Ms. Kane and Mr. Balaguer are in private practice in Wilmington, Del. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Copy and paste at your own risk: The dangers of electronic ‘plagiarism’
Between "Hangovers," Bradley Cooper starred in a largely forgettable melodrama called "The Words." The main character was an aspiring writer whose career first skyrockets and then implodes when he plagiarizes an entire novel from a dusty manuscript found buried in an old briefcase bought at an antique store. As art, "The Words" is destined for the on-demand scrap heap, but it may yet be redeemed as a cautionary tale for anyone who creates electronic health records.
While EHRs have many advantages that can improve health care delivery, including easy access and portability, the same technology that affords these advantages can also promote careless practices that may call into question the accuracy of the entire record and make it difficult, if not impossible, for health care providers to defend themselves in court. Among the most troublesome EHR misuses we see in litigation is the inappropriate use of copy and paste functions, whereby a health care provider "plagiarizes" his/her own or a colleague’s prior documentation.
In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error. To avoid these insinuations, clinicians must put time and effort, as well as original thought, into medical record documentation.
Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR. The excuses we have heard for this run the gamut from unfamiliarity with the electronic system to lack of time and, ironically, the need to ensure accurate documentation. Similarly, in "The Words," when Bradley Cooper’s character starts copying another author’s manuscript – word for word – onto his laptop, he tells himself that he is doing it simply for inspiration. Excuses aside, this kind of rote replication is seductively easy but fraught with danger, particularly if the EHR later comes under scrutiny.
When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her "accompanied by spouse" at every visit.
Sometimes EHR plagiarism goes right to the heart of the negligence claim. Where the claim is inappropriate discharge of a patient who died a few days after leaving the hospital, the defense must show that the patient’s condition improved and that troubling symptoms seen on admission responded appropriately to treatment. This effort is hampered by documentation prepared many days or weeks into a hospitalization that copies symptoms and physical findings that are no longer present. Inaccurate information in the EHR can also confuse other medical providers, and the time necessary to reconcile inconsistent information may delay treatment. Likewise, if inaccurate information is relied on for treatment decisions, the results can be disastrous.
It is often argued in litigation that if something doesn’t appear in the medical record it didn’t happen. A corollary to this dubious "rule" is that once bad information is documented in a medical record, it will be redocumented over and over and over again. Predictably, the more times the erroneous data are repeated in the EHR, the more "reliable" it becomes. This problem has been around a long time, but EHR plagiarism has made it worse.
The medical record is the most important evidence in any medical negligence case. While it is true that only a small fraction of medical records will ever see the inside of a courtroom, you should always document assuming the chart in front of you could end up there. This requires time, original thought, accuracy, and completeness. Copying and pasting the electronic medical record, while superficially efficient, is the enemy of these goals, and could leave you – like Bradley Cooper in "The Words" – wondering what happened to your promising career.
Ms. Kane and Mr. Balaguer are in private practice in Wilmington, Del. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Between "Hangovers," Bradley Cooper starred in a largely forgettable melodrama called "The Words." The main character was an aspiring writer whose career first skyrockets and then implodes when he plagiarizes an entire novel from a dusty manuscript found buried in an old briefcase bought at an antique store. As art, "The Words" is destined for the on-demand scrap heap, but it may yet be redeemed as a cautionary tale for anyone who creates electronic health records.
While EHRs have many advantages that can improve health care delivery, including easy access and portability, the same technology that affords these advantages can also promote careless practices that may call into question the accuracy of the entire record and make it difficult, if not impossible, for health care providers to defend themselves in court. Among the most troublesome EHR misuses we see in litigation is the inappropriate use of copy and paste functions, whereby a health care provider "plagiarizes" his/her own or a colleague’s prior documentation.
In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error. To avoid these insinuations, clinicians must put time and effort, as well as original thought, into medical record documentation.
Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR. The excuses we have heard for this run the gamut from unfamiliarity with the electronic system to lack of time and, ironically, the need to ensure accurate documentation. Similarly, in "The Words," when Bradley Cooper’s character starts copying another author’s manuscript – word for word – onto his laptop, he tells himself that he is doing it simply for inspiration. Excuses aside, this kind of rote replication is seductively easy but fraught with danger, particularly if the EHR later comes under scrutiny.
When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her "accompanied by spouse" at every visit.
Sometimes EHR plagiarism goes right to the heart of the negligence claim. Where the claim is inappropriate discharge of a patient who died a few days after leaving the hospital, the defense must show that the patient’s condition improved and that troubling symptoms seen on admission responded appropriately to treatment. This effort is hampered by documentation prepared many days or weeks into a hospitalization that copies symptoms and physical findings that are no longer present. Inaccurate information in the EHR can also confuse other medical providers, and the time necessary to reconcile inconsistent information may delay treatment. Likewise, if inaccurate information is relied on for treatment decisions, the results can be disastrous.
It is often argued in litigation that if something doesn’t appear in the medical record it didn’t happen. A corollary to this dubious "rule" is that once bad information is documented in a medical record, it will be redocumented over and over and over again. Predictably, the more times the erroneous data are repeated in the EHR, the more "reliable" it becomes. This problem has been around a long time, but EHR plagiarism has made it worse.
The medical record is the most important evidence in any medical negligence case. While it is true that only a small fraction of medical records will ever see the inside of a courtroom, you should always document assuming the chart in front of you could end up there. This requires time, original thought, accuracy, and completeness. Copying and pasting the electronic medical record, while superficially efficient, is the enemy of these goals, and could leave you – like Bradley Cooper in "The Words" – wondering what happened to your promising career.
Ms. Kane and Mr. Balaguer are in private practice in Wilmington, Del. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Between "Hangovers," Bradley Cooper starred in a largely forgettable melodrama called "The Words." The main character was an aspiring writer whose career first skyrockets and then implodes when he plagiarizes an entire novel from a dusty manuscript found buried in an old briefcase bought at an antique store. As art, "The Words" is destined for the on-demand scrap heap, but it may yet be redeemed as a cautionary tale for anyone who creates electronic health records.
While EHRs have many advantages that can improve health care delivery, including easy access and portability, the same technology that affords these advantages can also promote careless practices that may call into question the accuracy of the entire record and make it difficult, if not impossible, for health care providers to defend themselves in court. Among the most troublesome EHR misuses we see in litigation is the inappropriate use of copy and paste functions, whereby a health care provider "plagiarizes" his/her own or a colleague’s prior documentation.
In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error. To avoid these insinuations, clinicians must put time and effort, as well as original thought, into medical record documentation.
Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR. The excuses we have heard for this run the gamut from unfamiliarity with the electronic system to lack of time and, ironically, the need to ensure accurate documentation. Similarly, in "The Words," when Bradley Cooper’s character starts copying another author’s manuscript – word for word – onto his laptop, he tells himself that he is doing it simply for inspiration. Excuses aside, this kind of rote replication is seductively easy but fraught with danger, particularly if the EHR later comes under scrutiny.
When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her "accompanied by spouse" at every visit.
Sometimes EHR plagiarism goes right to the heart of the negligence claim. Where the claim is inappropriate discharge of a patient who died a few days after leaving the hospital, the defense must show that the patient’s condition improved and that troubling symptoms seen on admission responded appropriately to treatment. This effort is hampered by documentation prepared many days or weeks into a hospitalization that copies symptoms and physical findings that are no longer present. Inaccurate information in the EHR can also confuse other medical providers, and the time necessary to reconcile inconsistent information may delay treatment. Likewise, if inaccurate information is relied on for treatment decisions, the results can be disastrous.
It is often argued in litigation that if something doesn’t appear in the medical record it didn’t happen. A corollary to this dubious "rule" is that once bad information is documented in a medical record, it will be redocumented over and over and over again. Predictably, the more times the erroneous data are repeated in the EHR, the more "reliable" it becomes. This problem has been around a long time, but EHR plagiarism has made it worse.
The medical record is the most important evidence in any medical negligence case. While it is true that only a small fraction of medical records will ever see the inside of a courtroom, you should always document assuming the chart in front of you could end up there. This requires time, original thought, accuracy, and completeness. Copying and pasting the electronic medical record, while superficially efficient, is the enemy of these goals, and could leave you – like Bradley Cooper in "The Words" – wondering what happened to your promising career.
Ms. Kane and Mr. Balaguer are in private practice in Wilmington, Del. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Obesity: American Association of Clinical Endocrinology (AACE)
Obesity rates in the United States have skyrocketed over the last 30 years, with rates for adults having doubled and rates for children tripled from 1980 to 2010. Approximately one-third of the U.S adult population is obese; that’s 72 million people. The consequences of obesity include an increased risk for stroke, hypertension, type 2 diabetes, liver and gallbladder disease, orthopedic complications, mental health conditions, cancers, elevated lipids, obstructive sleep apnea (OSA), and reproductive complications such as infertility.
There is now solid evidence that we can intervene to help patient lose weight and decrease the complications that result from obesity. To this end, the American Association of Clinical Endocrinology (AACE) has issued recommendations giving guidance for clinicians about how to approach this issue. Intensive approaches to lifestyle modification with diet and exercise can help patients lose 7% or more of their body weight and have been show to decrease progression from prediabetes to diabetes. Two new medications, lorcaserin and phentermine/topiramate ER, have received Food and Drug Administration approval over the past 2 years as an adjunct to diet for weight loss. Bariatric surgery has emerged as a safe and effective method of weight loss as well.
The AACE guidelines focus on a "complications-centric model" as opposed to a body mass index–driven approach. The guidelines recommend treating obesity to decrease the risk of developing adverse metabolic consequences such as diabetes and metabolic syndrome, and to decrease disability from mechanical comorbidities such as osteoarthritis and obstructive sleep apnea. The AACE guidelines place obese patients into two categories: those that have obesity-related comorbidities and those that do not. The guidelines recommend a graded approach to treatment. All overweight and obese patients should receive therapeutic lifestyle counseling focusing on diet and exercise. Medical or surgical treatment is then recommended for the patients who stand to benefit the most, those with obesity-related comorbidities and those with more severe obesity who have not been able to lose weight using lifestyle modification alone.
In the initial evaluation of overweight and obese patients, the patients should be assessed for cardiometabolic and mechanical complications of obesity, as well as the severity of those complications in order to determine the level of treatment that is appropriate. Patients with obesity-related comorbidities are classified into two groups. The first group includes those with insulin resistance and/or cardiovascular consequences. For this group, evaluation should include waist circumference, fasting, and 2-hour glucose tolerance testing, and lipids, blood pressure, and liver function testing. The second group is composed of people with mechanical consequences including OSA, stress incontinence, orthopedic complications, and chronic pulmonary diseases.
It is important to determine target goals for weight loss to improve mechanical and cardiometabolic complications. Weight loss of 5% or more is enough to affect improvement in metabolic parameters such as glucose and lipids, decrease progression to diabetes, and improve mechanical complications such as knee and hip pain in osteoarthritis. The next step in the approach to treatment is to determine the type and intensity. Therapeutic lifestyle changes (TLC) are important for all patients with diabetes and prediabetes, regardless of risk factors. TLC recommendations include smoking cessation, physical activity, weight management, and healthy eating. Exercise is recommended 5 days/week for more than 30 minutes of moderate intensity activity, to achieve a more than 60% age-related heart rate. The diet recommended reduced saturated fat to less than 7% of calories, reduced cholesterol intake to 200 mg/day, increased fiber to 10-25 g/day, increased plant sterols/stanol esters to 2 g/day, caloric restriction, reduced simple carbohydrates and sugars, increased intake of unsaturated fats, elimination of trans fats, increased marine-based omega-3 ethyl esters, and restriction of alcohol to 20-30 g/day.
For patients with comorbidities and with a BMI of 27 kg/m2 or more, consideration should be given to weight-loss medication in addition to lifestyle intervention. The currently approved medications for long-term weight loss include lorcaserin and phentermine/topiramate ER. In the FDA registration studies, the lorcaserin group had an average weight loss of 5.8% after 1 year vs. 2.2% in the placebo group. Phentermine/topiramate ER had an average weight loss of 10% at 1 year vs. 1.2% in the placebo group. These medications are FDA approved as adjuncts to lifestyle modification for the treatment of overweight patients with a BMI greater than 27 kg/m2 with comorbidities and for obese patients with a BMI greater than 30 kg/m2 regardless of comorbidities. Both medications improve blood pressure, triglycerides, and insulin sensitivity and prevent the progression to diabetes in patients with diabetes. Bariatric surgery should be considered for those with a BMI of 35 kg/m2 or morewith comorbidities, especially if they have failed using other methods.
Once goals are reached, reassess the patient to evaluate for more interventions, if needed. If the targets for improvement in complications were not reached, then the weight loss therapy should become more intense.
Bottom line
The AACE recommendations recognize obesity as a disease and have formulated guidelines using a "complications-centric model." Patients should be assessed for obesity and related complications. Lifestyle counseling should be provided for all overweight and obese individuals, with the addition of weight loss medications for individuals with a BMI of 27 kg/m2 or more who have obesity-related comorbidities, and the consideration of bariatric surgery for those with a BMI of 35 kg/m2 or more with comorbidities.
Reference
American Association of Clinical Endocrinologists’ Comprehensive Diabetes Management Algorithm 2013 Consensus Statement. Published May/June 2013, Endocrine Practice, Vol. 19 (Suppl. 2).
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, Philadelphia. Dr. McDonald is a second-year resident in the Family Medicine Residency Program at Abington Memorial Hospital.
Obesity rates in the United States have skyrocketed over the last 30 years, with rates for adults having doubled and rates for children tripled from 1980 to 2010. Approximately one-third of the U.S adult population is obese; that’s 72 million people. The consequences of obesity include an increased risk for stroke, hypertension, type 2 diabetes, liver and gallbladder disease, orthopedic complications, mental health conditions, cancers, elevated lipids, obstructive sleep apnea (OSA), and reproductive complications such as infertility.
There is now solid evidence that we can intervene to help patient lose weight and decrease the complications that result from obesity. To this end, the American Association of Clinical Endocrinology (AACE) has issued recommendations giving guidance for clinicians about how to approach this issue. Intensive approaches to lifestyle modification with diet and exercise can help patients lose 7% or more of their body weight and have been show to decrease progression from prediabetes to diabetes. Two new medications, lorcaserin and phentermine/topiramate ER, have received Food and Drug Administration approval over the past 2 years as an adjunct to diet for weight loss. Bariatric surgery has emerged as a safe and effective method of weight loss as well.
The AACE guidelines focus on a "complications-centric model" as opposed to a body mass index–driven approach. The guidelines recommend treating obesity to decrease the risk of developing adverse metabolic consequences such as diabetes and metabolic syndrome, and to decrease disability from mechanical comorbidities such as osteoarthritis and obstructive sleep apnea. The AACE guidelines place obese patients into two categories: those that have obesity-related comorbidities and those that do not. The guidelines recommend a graded approach to treatment. All overweight and obese patients should receive therapeutic lifestyle counseling focusing on diet and exercise. Medical or surgical treatment is then recommended for the patients who stand to benefit the most, those with obesity-related comorbidities and those with more severe obesity who have not been able to lose weight using lifestyle modification alone.
In the initial evaluation of overweight and obese patients, the patients should be assessed for cardiometabolic and mechanical complications of obesity, as well as the severity of those complications in order to determine the level of treatment that is appropriate. Patients with obesity-related comorbidities are classified into two groups. The first group includes those with insulin resistance and/or cardiovascular consequences. For this group, evaluation should include waist circumference, fasting, and 2-hour glucose tolerance testing, and lipids, blood pressure, and liver function testing. The second group is composed of people with mechanical consequences including OSA, stress incontinence, orthopedic complications, and chronic pulmonary diseases.
It is important to determine target goals for weight loss to improve mechanical and cardiometabolic complications. Weight loss of 5% or more is enough to affect improvement in metabolic parameters such as glucose and lipids, decrease progression to diabetes, and improve mechanical complications such as knee and hip pain in osteoarthritis. The next step in the approach to treatment is to determine the type and intensity. Therapeutic lifestyle changes (TLC) are important for all patients with diabetes and prediabetes, regardless of risk factors. TLC recommendations include smoking cessation, physical activity, weight management, and healthy eating. Exercise is recommended 5 days/week for more than 30 minutes of moderate intensity activity, to achieve a more than 60% age-related heart rate. The diet recommended reduced saturated fat to less than 7% of calories, reduced cholesterol intake to 200 mg/day, increased fiber to 10-25 g/day, increased plant sterols/stanol esters to 2 g/day, caloric restriction, reduced simple carbohydrates and sugars, increased intake of unsaturated fats, elimination of trans fats, increased marine-based omega-3 ethyl esters, and restriction of alcohol to 20-30 g/day.
For patients with comorbidities and with a BMI of 27 kg/m2 or more, consideration should be given to weight-loss medication in addition to lifestyle intervention. The currently approved medications for long-term weight loss include lorcaserin and phentermine/topiramate ER. In the FDA registration studies, the lorcaserin group had an average weight loss of 5.8% after 1 year vs. 2.2% in the placebo group. Phentermine/topiramate ER had an average weight loss of 10% at 1 year vs. 1.2% in the placebo group. These medications are FDA approved as adjuncts to lifestyle modification for the treatment of overweight patients with a BMI greater than 27 kg/m2 with comorbidities and for obese patients with a BMI greater than 30 kg/m2 regardless of comorbidities. Both medications improve blood pressure, triglycerides, and insulin sensitivity and prevent the progression to diabetes in patients with diabetes. Bariatric surgery should be considered for those with a BMI of 35 kg/m2 or morewith comorbidities, especially if they have failed using other methods.
Once goals are reached, reassess the patient to evaluate for more interventions, if needed. If the targets for improvement in complications were not reached, then the weight loss therapy should become more intense.
Bottom line
The AACE recommendations recognize obesity as a disease and have formulated guidelines using a "complications-centric model." Patients should be assessed for obesity and related complications. Lifestyle counseling should be provided for all overweight and obese individuals, with the addition of weight loss medications for individuals with a BMI of 27 kg/m2 or more who have obesity-related comorbidities, and the consideration of bariatric surgery for those with a BMI of 35 kg/m2 or more with comorbidities.
Reference
American Association of Clinical Endocrinologists’ Comprehensive Diabetes Management Algorithm 2013 Consensus Statement. Published May/June 2013, Endocrine Practice, Vol. 19 (Suppl. 2).
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, Philadelphia. Dr. McDonald is a second-year resident in the Family Medicine Residency Program at Abington Memorial Hospital.
Obesity rates in the United States have skyrocketed over the last 30 years, with rates for adults having doubled and rates for children tripled from 1980 to 2010. Approximately one-third of the U.S adult population is obese; that’s 72 million people. The consequences of obesity include an increased risk for stroke, hypertension, type 2 diabetes, liver and gallbladder disease, orthopedic complications, mental health conditions, cancers, elevated lipids, obstructive sleep apnea (OSA), and reproductive complications such as infertility.
There is now solid evidence that we can intervene to help patient lose weight and decrease the complications that result from obesity. To this end, the American Association of Clinical Endocrinology (AACE) has issued recommendations giving guidance for clinicians about how to approach this issue. Intensive approaches to lifestyle modification with diet and exercise can help patients lose 7% or more of their body weight and have been show to decrease progression from prediabetes to diabetes. Two new medications, lorcaserin and phentermine/topiramate ER, have received Food and Drug Administration approval over the past 2 years as an adjunct to diet for weight loss. Bariatric surgery has emerged as a safe and effective method of weight loss as well.
The AACE guidelines focus on a "complications-centric model" as opposed to a body mass index–driven approach. The guidelines recommend treating obesity to decrease the risk of developing adverse metabolic consequences such as diabetes and metabolic syndrome, and to decrease disability from mechanical comorbidities such as osteoarthritis and obstructive sleep apnea. The AACE guidelines place obese patients into two categories: those that have obesity-related comorbidities and those that do not. The guidelines recommend a graded approach to treatment. All overweight and obese patients should receive therapeutic lifestyle counseling focusing on diet and exercise. Medical or surgical treatment is then recommended for the patients who stand to benefit the most, those with obesity-related comorbidities and those with more severe obesity who have not been able to lose weight using lifestyle modification alone.
In the initial evaluation of overweight and obese patients, the patients should be assessed for cardiometabolic and mechanical complications of obesity, as well as the severity of those complications in order to determine the level of treatment that is appropriate. Patients with obesity-related comorbidities are classified into two groups. The first group includes those with insulin resistance and/or cardiovascular consequences. For this group, evaluation should include waist circumference, fasting, and 2-hour glucose tolerance testing, and lipids, blood pressure, and liver function testing. The second group is composed of people with mechanical consequences including OSA, stress incontinence, orthopedic complications, and chronic pulmonary diseases.
It is important to determine target goals for weight loss to improve mechanical and cardiometabolic complications. Weight loss of 5% or more is enough to affect improvement in metabolic parameters such as glucose and lipids, decrease progression to diabetes, and improve mechanical complications such as knee and hip pain in osteoarthritis. The next step in the approach to treatment is to determine the type and intensity. Therapeutic lifestyle changes (TLC) are important for all patients with diabetes and prediabetes, regardless of risk factors. TLC recommendations include smoking cessation, physical activity, weight management, and healthy eating. Exercise is recommended 5 days/week for more than 30 minutes of moderate intensity activity, to achieve a more than 60% age-related heart rate. The diet recommended reduced saturated fat to less than 7% of calories, reduced cholesterol intake to 200 mg/day, increased fiber to 10-25 g/day, increased plant sterols/stanol esters to 2 g/day, caloric restriction, reduced simple carbohydrates and sugars, increased intake of unsaturated fats, elimination of trans fats, increased marine-based omega-3 ethyl esters, and restriction of alcohol to 20-30 g/day.
For patients with comorbidities and with a BMI of 27 kg/m2 or more, consideration should be given to weight-loss medication in addition to lifestyle intervention. The currently approved medications for long-term weight loss include lorcaserin and phentermine/topiramate ER. In the FDA registration studies, the lorcaserin group had an average weight loss of 5.8% after 1 year vs. 2.2% in the placebo group. Phentermine/topiramate ER had an average weight loss of 10% at 1 year vs. 1.2% in the placebo group. These medications are FDA approved as adjuncts to lifestyle modification for the treatment of overweight patients with a BMI greater than 27 kg/m2 with comorbidities and for obese patients with a BMI greater than 30 kg/m2 regardless of comorbidities. Both medications improve blood pressure, triglycerides, and insulin sensitivity and prevent the progression to diabetes in patients with diabetes. Bariatric surgery should be considered for those with a BMI of 35 kg/m2 or morewith comorbidities, especially if they have failed using other methods.
Once goals are reached, reassess the patient to evaluate for more interventions, if needed. If the targets for improvement in complications were not reached, then the weight loss therapy should become more intense.
Bottom line
The AACE recommendations recognize obesity as a disease and have formulated guidelines using a "complications-centric model." Patients should be assessed for obesity and related complications. Lifestyle counseling should be provided for all overweight and obese individuals, with the addition of weight loss medications for individuals with a BMI of 27 kg/m2 or more who have obesity-related comorbidities, and the consideration of bariatric surgery for those with a BMI of 35 kg/m2 or more with comorbidities.
Reference
American Association of Clinical Endocrinologists’ Comprehensive Diabetes Management Algorithm 2013 Consensus Statement. Published May/June 2013, Endocrine Practice, Vol. 19 (Suppl. 2).
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, Philadelphia. Dr. McDonald is a second-year resident in the Family Medicine Residency Program at Abington Memorial Hospital.
Report from the front line: A medical mission in Honduras
The poor are many
and so
impossible to forget.
Roberto Sosa, Honduran poet
In February, 20 physicians, nurses, and other health care personnel – including five members of the Family Medicine Residency Program at Abington (Pa.) Memorial Hospital – Dr. Kate Baranik, Dr. Magan Madsen, Dr. Margarita McDonald, Dr. John Russell, and Dr. Neil Skolnik – boarded a flight to Honduras for a medical mission to provide medical care to those in need there. Only 13% of people in the country have health insurance. The hospital bed ratio is 0.7 beds/1,000 people, as compared with the United States, where the ratio is 3 beds/1,000 people. These statistics make it evident that the health care system in Honduras needs restructuring. Although a group of Americans cannot restructure a whole health care system, the little steps we took in embarking on this journey to provide medical care has made a lasting impact on numerous lives, not least of which are our own.
Operation Heal Honduras was the culmination of 9 years of medical mission trips. What started as a small surgical team blossomed under the organizational leadership of an Abington Memorial Hospital general surgeon, Dr. Seth L. Newman, into a multidisciplinary group now including family medicine, general and trauma surgery, orthopedics, and ob.gyn. In addition to the five attending physicians, this year there were five residents-in-training, three certified registered nurse anesthetists, and multiple RNs and translators. While they vary in quality and cleanliness, Honduras has hospitals, operating rooms, and places to set up a clinic. More difficult is the job of obtaining the disposable items needed to perform operations and solve medical mysteries. Hospitals cannot afford to purchase these things. So the team brought gowns, gloves, sutures, gauze, mesh, casting material, ACE wraps, laparoscopic ports, drapes, and approximately $2,000 worth of medications.
While in Honduras, the team stayed at the Andrew Clinic located 15 miles north of El Progreso; the clinic is run by Dr. Florence Yoon and Dr. David Yoon. El Progreso is notable for its lush green mountains, palm trees, banana plants. On a typical day, the medical team set up a clinic in neighboring villages while the surgical team operated at the hospital in El Progreso.
One day specifically stands out in everyone’s mind. This day, like the others, started early, with a breakfast of scrambled eggs, beans, tortillas, mango, and cantaloupe, after which we left for the hospital and the mission medical clinic at 7 a.m. While driving to the hospital, it was impossible not to notice the poverty: the emaciated man walking on the side of the road with a plastic bag in hand; the muddy unpaved roads, branching off the side of the main road, each lined with wooden shacks with tin roofs; the rusted gutted cars on the side of the road; the Coca-Cola and Pepsi signs everywhere tempting people to spend money that they did not have on soda that they did not need. Everywhere we drove there were soldiers carrying machine guns to prevent crime, which is dramatically high in Honduras.
When we arrived at the hospital, the medical team consulted with the surgical team on a difficult case, and the surgeons were informed that the power to the hospital might be cut off at 8 a.m., as part of routine rotating power outages. It turned out that by 8:30, the power was still on, so the surgeons were able to operate in three operating rooms. The medical team then continued to the small village church where we were to stage a medical clinic. Pulling up to the church, we saw how the people lived in the village. They lived in small huts, with roosters, chickens, and dogs roaming freely in the muddy yards. Laundry was hanging outside each house, and smiling children played in the streets. Still, the medical team felt trepidation as we headed to care for the people in a neighborhood church built 3 years ago in a poor area of San Pedro Sula, the city known as the murder capital of the world.
Arriving, the bus turned into the narrow two-lane dirt street that was barely wider than the bus itself. When we disembarked the bus, we saw about a hundred people, young and old, waiting patiently for us in the church. The team saw about 400 people that day; we injected knees and shoulders, treated pneumonia in a young infant, gave prednisone for asthma, counseled an elderly woman with depression, gave antibiotics for wounds, saw a young child with clubfoot, and helped others who were tired, poor, and had headaches and joint pain. They waited a long time to be seen and receive the medical care we could give in the form of vitamins, antiparasite medications, antibiotics, skin creams, and others. That medical care that would not fix their lives, but it did make their lives a little better by virtue of medicines and knowing that someone cared enough to be there. Their smiles and their "gracias" connected them to us and told us a part of their story that could be told no other way.
Dr. Skolnik is professor of family and community medicine at, Temple University, Philadelphia, and associate director of the family medicine residency program there. Ms. Skolnik attends Drexel University and is a research assistant at the Children’s Hospital of Pennsylvania, both in Philadelphia. Ms. Ogen is a certified registered nurse anesthetist at Abington Memorial Hospital.
*Correction, 3/10/2014: An earlier version of this story misstated Ava Skolnik's name.
The poor are many
and so
impossible to forget.
Roberto Sosa, Honduran poet
In February, 20 physicians, nurses, and other health care personnel – including five members of the Family Medicine Residency Program at Abington (Pa.) Memorial Hospital – Dr. Kate Baranik, Dr. Magan Madsen, Dr. Margarita McDonald, Dr. John Russell, and Dr. Neil Skolnik – boarded a flight to Honduras for a medical mission to provide medical care to those in need there. Only 13% of people in the country have health insurance. The hospital bed ratio is 0.7 beds/1,000 people, as compared with the United States, where the ratio is 3 beds/1,000 people. These statistics make it evident that the health care system in Honduras needs restructuring. Although a group of Americans cannot restructure a whole health care system, the little steps we took in embarking on this journey to provide medical care has made a lasting impact on numerous lives, not least of which are our own.
Operation Heal Honduras was the culmination of 9 years of medical mission trips. What started as a small surgical team blossomed under the organizational leadership of an Abington Memorial Hospital general surgeon, Dr. Seth L. Newman, into a multidisciplinary group now including family medicine, general and trauma surgery, orthopedics, and ob.gyn. In addition to the five attending physicians, this year there were five residents-in-training, three certified registered nurse anesthetists, and multiple RNs and translators. While they vary in quality and cleanliness, Honduras has hospitals, operating rooms, and places to set up a clinic. More difficult is the job of obtaining the disposable items needed to perform operations and solve medical mysteries. Hospitals cannot afford to purchase these things. So the team brought gowns, gloves, sutures, gauze, mesh, casting material, ACE wraps, laparoscopic ports, drapes, and approximately $2,000 worth of medications.
While in Honduras, the team stayed at the Andrew Clinic located 15 miles north of El Progreso; the clinic is run by Dr. Florence Yoon and Dr. David Yoon. El Progreso is notable for its lush green mountains, palm trees, banana plants. On a typical day, the medical team set up a clinic in neighboring villages while the surgical team operated at the hospital in El Progreso.
One day specifically stands out in everyone’s mind. This day, like the others, started early, with a breakfast of scrambled eggs, beans, tortillas, mango, and cantaloupe, after which we left for the hospital and the mission medical clinic at 7 a.m. While driving to the hospital, it was impossible not to notice the poverty: the emaciated man walking on the side of the road with a plastic bag in hand; the muddy unpaved roads, branching off the side of the main road, each lined with wooden shacks with tin roofs; the rusted gutted cars on the side of the road; the Coca-Cola and Pepsi signs everywhere tempting people to spend money that they did not have on soda that they did not need. Everywhere we drove there were soldiers carrying machine guns to prevent crime, which is dramatically high in Honduras.
When we arrived at the hospital, the medical team consulted with the surgical team on a difficult case, and the surgeons were informed that the power to the hospital might be cut off at 8 a.m., as part of routine rotating power outages. It turned out that by 8:30, the power was still on, so the surgeons were able to operate in three operating rooms. The medical team then continued to the small village church where we were to stage a medical clinic. Pulling up to the church, we saw how the people lived in the village. They lived in small huts, with roosters, chickens, and dogs roaming freely in the muddy yards. Laundry was hanging outside each house, and smiling children played in the streets. Still, the medical team felt trepidation as we headed to care for the people in a neighborhood church built 3 years ago in a poor area of San Pedro Sula, the city known as the murder capital of the world.
Arriving, the bus turned into the narrow two-lane dirt street that was barely wider than the bus itself. When we disembarked the bus, we saw about a hundred people, young and old, waiting patiently for us in the church. The team saw about 400 people that day; we injected knees and shoulders, treated pneumonia in a young infant, gave prednisone for asthma, counseled an elderly woman with depression, gave antibiotics for wounds, saw a young child with clubfoot, and helped others who were tired, poor, and had headaches and joint pain. They waited a long time to be seen and receive the medical care we could give in the form of vitamins, antiparasite medications, antibiotics, skin creams, and others. That medical care that would not fix their lives, but it did make their lives a little better by virtue of medicines and knowing that someone cared enough to be there. Their smiles and their "gracias" connected them to us and told us a part of their story that could be told no other way.
Dr. Skolnik is professor of family and community medicine at, Temple University, Philadelphia, and associate director of the family medicine residency program there. Ms. Skolnik attends Drexel University and is a research assistant at the Children’s Hospital of Pennsylvania, both in Philadelphia. Ms. Ogen is a certified registered nurse anesthetist at Abington Memorial Hospital.
*Correction, 3/10/2014: An earlier version of this story misstated Ava Skolnik's name.
The poor are many
and so
impossible to forget.
Roberto Sosa, Honduran poet
In February, 20 physicians, nurses, and other health care personnel – including five members of the Family Medicine Residency Program at Abington (Pa.) Memorial Hospital – Dr. Kate Baranik, Dr. Magan Madsen, Dr. Margarita McDonald, Dr. John Russell, and Dr. Neil Skolnik – boarded a flight to Honduras for a medical mission to provide medical care to those in need there. Only 13% of people in the country have health insurance. The hospital bed ratio is 0.7 beds/1,000 people, as compared with the United States, where the ratio is 3 beds/1,000 people. These statistics make it evident that the health care system in Honduras needs restructuring. Although a group of Americans cannot restructure a whole health care system, the little steps we took in embarking on this journey to provide medical care has made a lasting impact on numerous lives, not least of which are our own.
Operation Heal Honduras was the culmination of 9 years of medical mission trips. What started as a small surgical team blossomed under the organizational leadership of an Abington Memorial Hospital general surgeon, Dr. Seth L. Newman, into a multidisciplinary group now including family medicine, general and trauma surgery, orthopedics, and ob.gyn. In addition to the five attending physicians, this year there were five residents-in-training, three certified registered nurse anesthetists, and multiple RNs and translators. While they vary in quality and cleanliness, Honduras has hospitals, operating rooms, and places to set up a clinic. More difficult is the job of obtaining the disposable items needed to perform operations and solve medical mysteries. Hospitals cannot afford to purchase these things. So the team brought gowns, gloves, sutures, gauze, mesh, casting material, ACE wraps, laparoscopic ports, drapes, and approximately $2,000 worth of medications.
While in Honduras, the team stayed at the Andrew Clinic located 15 miles north of El Progreso; the clinic is run by Dr. Florence Yoon and Dr. David Yoon. El Progreso is notable for its lush green mountains, palm trees, banana plants. On a typical day, the medical team set up a clinic in neighboring villages while the surgical team operated at the hospital in El Progreso.
One day specifically stands out in everyone’s mind. This day, like the others, started early, with a breakfast of scrambled eggs, beans, tortillas, mango, and cantaloupe, after which we left for the hospital and the mission medical clinic at 7 a.m. While driving to the hospital, it was impossible not to notice the poverty: the emaciated man walking on the side of the road with a plastic bag in hand; the muddy unpaved roads, branching off the side of the main road, each lined with wooden shacks with tin roofs; the rusted gutted cars on the side of the road; the Coca-Cola and Pepsi signs everywhere tempting people to spend money that they did not have on soda that they did not need. Everywhere we drove there were soldiers carrying machine guns to prevent crime, which is dramatically high in Honduras.
When we arrived at the hospital, the medical team consulted with the surgical team on a difficult case, and the surgeons were informed that the power to the hospital might be cut off at 8 a.m., as part of routine rotating power outages. It turned out that by 8:30, the power was still on, so the surgeons were able to operate in three operating rooms. The medical team then continued to the small village church where we were to stage a medical clinic. Pulling up to the church, we saw how the people lived in the village. They lived in small huts, with roosters, chickens, and dogs roaming freely in the muddy yards. Laundry was hanging outside each house, and smiling children played in the streets. Still, the medical team felt trepidation as we headed to care for the people in a neighborhood church built 3 years ago in a poor area of San Pedro Sula, the city known as the murder capital of the world.
Arriving, the bus turned into the narrow two-lane dirt street that was barely wider than the bus itself. When we disembarked the bus, we saw about a hundred people, young and old, waiting patiently for us in the church. The team saw about 400 people that day; we injected knees and shoulders, treated pneumonia in a young infant, gave prednisone for asthma, counseled an elderly woman with depression, gave antibiotics for wounds, saw a young child with clubfoot, and helped others who were tired, poor, and had headaches and joint pain. They waited a long time to be seen and receive the medical care we could give in the form of vitamins, antiparasite medications, antibiotics, skin creams, and others. That medical care that would not fix their lives, but it did make their lives a little better by virtue of medicines and knowing that someone cared enough to be there. Their smiles and their "gracias" connected them to us and told us a part of their story that could be told no other way.
Dr. Skolnik is professor of family and community medicine at, Temple University, Philadelphia, and associate director of the family medicine residency program there. Ms. Skolnik attends Drexel University and is a research assistant at the Children’s Hospital of Pennsylvania, both in Philadelphia. Ms. Ogen is a certified registered nurse anesthetist at Abington Memorial Hospital.
*Correction, 3/10/2014: An earlier version of this story misstated Ava Skolnik's name.
Truly connected health care
For years, we have all been promised interconnected electronic patient records – the concept that information would follow patients and be available across all care settings. Unfortunately, this reality has yet to materialize.
Regional Health Information Organizations (RHIOs) exist all over (these are hospitals, physician practices, and health networks that exchange data on a local level), but they typically present a "brick wall" at their borders where the information sharing stops. Thankfully, that is poised to change, with a new push toward meaningful interconnectedness.
Finally, health information technology (HIT) thought leaders and electronic health records (EHR) vendors are homing in on standards that will allow physicians and other healthcare providers to exchange information seamlessly regardless of EHR system or geographical location. The goal, as usual, is to improve patient care and outcomes. In this column, we felt it would be useful to highlight some of the ideas driving this effort, as there is good reason to be optimistic about the possibility of true interoperability.
A view from the top
Recently, at the annual meeting of the Health Information Management Systems Society (HIMSS) in Orlando, Dr. Karen DeSalvo, national health IT coordinator, made a strong plea for interoperability by 2017. She said "We can do national health care exchange in 3 years. ... I want this as a doctor, I want this as patient, I want this as a daughter."
Dr. DeSalvo’s words resonate because this is a concept we all expected from the earliest days of electronic records. Unfortunately, barriers – both real and artificial – have stood in the way. First and foremost are patient privacy and information security. It is essential that patient data are protected and maintained as the data pass from one system to the next, but often, even the basic function of matching patients with the right records can be challenging. Many identifiers exist, including various medical record numbers and insurance codes. If a name is misspelled or middle initial omitted, this can also create significant chaos and allow sensitive data to file into the wrong place, creating HIPAA violations and distrust among patients.
In addition to concerns over data security, the lack of standard formatting for storing and sharing records has been a huge hurdle for EHR vendors. Not surprisingly, the simultaneous development of dozens of competing EHR products has created significant fragmentation throughout the market. Instead of starting from a common set of data elements, each EHR was essentially designed "in a vacuum," and only now are their creators attempting to find a way to get them to communicate. A number of cross-platform projects currently underway highlight this effort.
VHS or Betamax?
On Feb. 25, 2014, NextGen Healthcare and Cerner announced bilateral certification of their EHR products and affirmed their commitment to interoperability. According to the press release, they are committed to "creating proactive working relationships, expanding the boundaries of current interoperability ... and supporting the efforts of [their] clients to advance the health of their communities." These may not be novel goals, but at least both vendors have demonstrated their best attempt to achieve them. Also, both companies have a huge footprint in the market, so their collaboration is certain to raise the level of attention being paid to this topic. But this isn’t the only attempt at broad-based interoperability.
EClinicalWorks (eCW), another large player in the ambulatory EHR market, has developed a product know as P2P, or Provider to Provider. Originally conceived as a way to communicate between different users of the eCW platform, it has now been expanded to all providers, regardless of their EHR, as a secure communication tool. This new product is known as P2POpen and is free to any health care professional wishing to join "the network." According to their website, P2POpen now boasts close to 22,000 users and facilitates "improved quality, safety, and efficiency of care." Like the collaboration mentioned above, P2POpen has a shot at success, but both of these efforts may also portend more debate over standardization moving forward. Will the disparity in how each company addresses the issue of interoperability lead to further fragmentation? And how can we be sure that embracing one of these ideas won’t severely limit us in the future?
Setting the standard
The only way to answer these and other looming concerns over developing a consistent interoperability protocol is to start at the top and rapidly build consensus. In other words, Dr. DeSalvo’s words need to be quickly translated into action, as she and other thought leaders agree – not only on a standard – but also on a way to properly motivate EHR vendors to adopt that standard.
One possible opportunity to enforce this as Meaningful Use stage III. The requirements for stage III EHR certification, which have yet to be finalized, should include a necessity for every vendor to adopt a consistent format for information exchange and data transmission. Making this a certification requirement will ensure that all EHR products remain cooperative if they plan to stay competitive.
Another solution being considered involves the use of centralized "Health Information Exchanges," which could collect and warehouse data from multiple sources and then retransmit those data in a universally readable format. Either way, if a consensus can be reached and issues over privacy and security addressed, it will only spell a victory for physicians and patients and truly get us on the road to improved patient care and outcomes. We tend to agree with Dr. DeSalvo, and believe that victory is well within reach.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
For years, we have all been promised interconnected electronic patient records – the concept that information would follow patients and be available across all care settings. Unfortunately, this reality has yet to materialize.
Regional Health Information Organizations (RHIOs) exist all over (these are hospitals, physician practices, and health networks that exchange data on a local level), but they typically present a "brick wall" at their borders where the information sharing stops. Thankfully, that is poised to change, with a new push toward meaningful interconnectedness.
Finally, health information technology (HIT) thought leaders and electronic health records (EHR) vendors are homing in on standards that will allow physicians and other healthcare providers to exchange information seamlessly regardless of EHR system or geographical location. The goal, as usual, is to improve patient care and outcomes. In this column, we felt it would be useful to highlight some of the ideas driving this effort, as there is good reason to be optimistic about the possibility of true interoperability.
A view from the top
Recently, at the annual meeting of the Health Information Management Systems Society (HIMSS) in Orlando, Dr. Karen DeSalvo, national health IT coordinator, made a strong plea for interoperability by 2017. She said "We can do national health care exchange in 3 years. ... I want this as a doctor, I want this as patient, I want this as a daughter."
Dr. DeSalvo’s words resonate because this is a concept we all expected from the earliest days of electronic records. Unfortunately, barriers – both real and artificial – have stood in the way. First and foremost are patient privacy and information security. It is essential that patient data are protected and maintained as the data pass from one system to the next, but often, even the basic function of matching patients with the right records can be challenging. Many identifiers exist, including various medical record numbers and insurance codes. If a name is misspelled or middle initial omitted, this can also create significant chaos and allow sensitive data to file into the wrong place, creating HIPAA violations and distrust among patients.
In addition to concerns over data security, the lack of standard formatting for storing and sharing records has been a huge hurdle for EHR vendors. Not surprisingly, the simultaneous development of dozens of competing EHR products has created significant fragmentation throughout the market. Instead of starting from a common set of data elements, each EHR was essentially designed "in a vacuum," and only now are their creators attempting to find a way to get them to communicate. A number of cross-platform projects currently underway highlight this effort.
VHS or Betamax?
On Feb. 25, 2014, NextGen Healthcare and Cerner announced bilateral certification of their EHR products and affirmed their commitment to interoperability. According to the press release, they are committed to "creating proactive working relationships, expanding the boundaries of current interoperability ... and supporting the efforts of [their] clients to advance the health of their communities." These may not be novel goals, but at least both vendors have demonstrated their best attempt to achieve them. Also, both companies have a huge footprint in the market, so their collaboration is certain to raise the level of attention being paid to this topic. But this isn’t the only attempt at broad-based interoperability.
EClinicalWorks (eCW), another large player in the ambulatory EHR market, has developed a product know as P2P, or Provider to Provider. Originally conceived as a way to communicate between different users of the eCW platform, it has now been expanded to all providers, regardless of their EHR, as a secure communication tool. This new product is known as P2POpen and is free to any health care professional wishing to join "the network." According to their website, P2POpen now boasts close to 22,000 users and facilitates "improved quality, safety, and efficiency of care." Like the collaboration mentioned above, P2POpen has a shot at success, but both of these efforts may also portend more debate over standardization moving forward. Will the disparity in how each company addresses the issue of interoperability lead to further fragmentation? And how can we be sure that embracing one of these ideas won’t severely limit us in the future?
Setting the standard
The only way to answer these and other looming concerns over developing a consistent interoperability protocol is to start at the top and rapidly build consensus. In other words, Dr. DeSalvo’s words need to be quickly translated into action, as she and other thought leaders agree – not only on a standard – but also on a way to properly motivate EHR vendors to adopt that standard.
One possible opportunity to enforce this as Meaningful Use stage III. The requirements for stage III EHR certification, which have yet to be finalized, should include a necessity for every vendor to adopt a consistent format for information exchange and data transmission. Making this a certification requirement will ensure that all EHR products remain cooperative if they plan to stay competitive.
Another solution being considered involves the use of centralized "Health Information Exchanges," which could collect and warehouse data from multiple sources and then retransmit those data in a universally readable format. Either way, if a consensus can be reached and issues over privacy and security addressed, it will only spell a victory for physicians and patients and truly get us on the road to improved patient care and outcomes. We tend to agree with Dr. DeSalvo, and believe that victory is well within reach.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
For years, we have all been promised interconnected electronic patient records – the concept that information would follow patients and be available across all care settings. Unfortunately, this reality has yet to materialize.
Regional Health Information Organizations (RHIOs) exist all over (these are hospitals, physician practices, and health networks that exchange data on a local level), but they typically present a "brick wall" at their borders where the information sharing stops. Thankfully, that is poised to change, with a new push toward meaningful interconnectedness.
Finally, health information technology (HIT) thought leaders and electronic health records (EHR) vendors are homing in on standards that will allow physicians and other healthcare providers to exchange information seamlessly regardless of EHR system or geographical location. The goal, as usual, is to improve patient care and outcomes. In this column, we felt it would be useful to highlight some of the ideas driving this effort, as there is good reason to be optimistic about the possibility of true interoperability.
A view from the top
Recently, at the annual meeting of the Health Information Management Systems Society (HIMSS) in Orlando, Dr. Karen DeSalvo, national health IT coordinator, made a strong plea for interoperability by 2017. She said "We can do national health care exchange in 3 years. ... I want this as a doctor, I want this as patient, I want this as a daughter."
Dr. DeSalvo’s words resonate because this is a concept we all expected from the earliest days of electronic records. Unfortunately, barriers – both real and artificial – have stood in the way. First and foremost are patient privacy and information security. It is essential that patient data are protected and maintained as the data pass from one system to the next, but often, even the basic function of matching patients with the right records can be challenging. Many identifiers exist, including various medical record numbers and insurance codes. If a name is misspelled or middle initial omitted, this can also create significant chaos and allow sensitive data to file into the wrong place, creating HIPAA violations and distrust among patients.
In addition to concerns over data security, the lack of standard formatting for storing and sharing records has been a huge hurdle for EHR vendors. Not surprisingly, the simultaneous development of dozens of competing EHR products has created significant fragmentation throughout the market. Instead of starting from a common set of data elements, each EHR was essentially designed "in a vacuum," and only now are their creators attempting to find a way to get them to communicate. A number of cross-platform projects currently underway highlight this effort.
VHS or Betamax?
On Feb. 25, 2014, NextGen Healthcare and Cerner announced bilateral certification of their EHR products and affirmed their commitment to interoperability. According to the press release, they are committed to "creating proactive working relationships, expanding the boundaries of current interoperability ... and supporting the efforts of [their] clients to advance the health of their communities." These may not be novel goals, but at least both vendors have demonstrated their best attempt to achieve them. Also, both companies have a huge footprint in the market, so their collaboration is certain to raise the level of attention being paid to this topic. But this isn’t the only attempt at broad-based interoperability.
EClinicalWorks (eCW), another large player in the ambulatory EHR market, has developed a product know as P2P, or Provider to Provider. Originally conceived as a way to communicate between different users of the eCW platform, it has now been expanded to all providers, regardless of their EHR, as a secure communication tool. This new product is known as P2POpen and is free to any health care professional wishing to join "the network." According to their website, P2POpen now boasts close to 22,000 users and facilitates "improved quality, safety, and efficiency of care." Like the collaboration mentioned above, P2POpen has a shot at success, but both of these efforts may also portend more debate over standardization moving forward. Will the disparity in how each company addresses the issue of interoperability lead to further fragmentation? And how can we be sure that embracing one of these ideas won’t severely limit us in the future?
Setting the standard
The only way to answer these and other looming concerns over developing a consistent interoperability protocol is to start at the top and rapidly build consensus. In other words, Dr. DeSalvo’s words need to be quickly translated into action, as she and other thought leaders agree – not only on a standard – but also on a way to properly motivate EHR vendors to adopt that standard.
One possible opportunity to enforce this as Meaningful Use stage III. The requirements for stage III EHR certification, which have yet to be finalized, should include a necessity for every vendor to adopt a consistent format for information exchange and data transmission. Making this a certification requirement will ensure that all EHR products remain cooperative if they plan to stay competitive.
Another solution being considered involves the use of centralized "Health Information Exchanges," which could collect and warehouse data from multiple sources and then retransmit those data in a universally readable format. Either way, if a consensus can be reached and issues over privacy and security addressed, it will only spell a victory for physicians and patients and truly get us on the road to improved patient care and outcomes. We tend to agree with Dr. DeSalvo, and believe that victory is well within reach.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
2013 IDSA clinical practice guideline for vaccination of the immunocompromised host
The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.
Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:
• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.
• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.
• Avoid use of the oral polio vaccine by both the patient and household members of the patient.
• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.
Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.
HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:
• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.
• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.
• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.
• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.
• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm3.
• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm3; the two doses should be at least 3 months apart.
• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.
Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:
• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.
• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.
• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.
• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.
Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:
• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.
• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.
• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.
• Other than varicella and ZOS, do not administer live vaccines.
Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:
• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.
• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.
• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.
• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.
• Live attenuated influenza vaccine (LAIV) is contraindicated.
Household members of immunosuppressed patients should receive vaccination guidance as well:
• Give yearly vaccination against influenza, preferably inactivated.
• Do not use oral polio vaccine.
• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.
• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.
• MMR, yellow fever, and typhoid vaccinations are safe to receive.
The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.
Reference
Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.
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, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.
The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.
Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:
• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.
• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.
• Avoid use of the oral polio vaccine by both the patient and household members of the patient.
• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.
Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.
HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:
• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.
• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.
• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.
• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.
• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm3.
• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm3; the two doses should be at least 3 months apart.
• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.
Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:
• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.
• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.
• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.
• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.
Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:
• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.
• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.
• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.
• Other than varicella and ZOS, do not administer live vaccines.
Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:
• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.
• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.
• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.
• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.
• Live attenuated influenza vaccine (LAIV) is contraindicated.
Household members of immunosuppressed patients should receive vaccination guidance as well:
• Give yearly vaccination against influenza, preferably inactivated.
• Do not use oral polio vaccine.
• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.
• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.
• MMR, yellow fever, and typhoid vaccinations are safe to receive.
The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.
Reference
Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.
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, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.
The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.
Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:
• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.
• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.
• Avoid use of the oral polio vaccine by both the patient and household members of the patient.
• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.
Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.
HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:
• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.
• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.
• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.
• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.
• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm3.
• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm3; the two doses should be at least 3 months apart.
• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.
Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:
• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.
• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.
• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.
• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.
Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:
• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.
• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.
• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.
• Other than varicella and ZOS, do not administer live vaccines.
Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:
• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.
• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.
• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.
• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.
• Live attenuated influenza vaccine (LAIV) is contraindicated.
Household members of immunosuppressed patients should receive vaccination guidance as well:
• Give yearly vaccination against influenza, preferably inactivated.
• Do not use oral polio vaccine.
• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.
• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.
• MMR, yellow fever, and typhoid vaccinations are safe to receive.
The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.
Reference
Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.
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, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.
Mobile health care and patient engagement
The emerging field of mHealth, which is the use of mobile applications to facilitate the delivery of medical care and to enhance patient engagement, continues to expand rapidly, largely out of sight of most primary care physicians. We suspect that it will remain out of sight until, it will seem, mobile health apps are everywhere.
The idea behind mHealth is, given that smartphones have become ubiquitous devices through which people do everything from shopping to making dinner reservations to mobile banking, they are a device that people are ready to use to improve their health. A core component of both the Patient-Centered Medical Home model and Accountable Care Organization is that the patient is at the "center" of care and is an important, if not the most important, member of the health care team.
Mobile apps fall into a number of categories, including those that allow patients to have more effective and efficient interactions with their physicians, track data for things like blood pressure and blood sugars for more effective self-management, and allow patients more direct access to their charts and medical information. We will outline a few of these types of functions below.
One new software platform seeks to improve what patients understand and remember from their physician encounter. It is a common, if not ubiquitous, experience that patients do not fully recall the details of their discussion with the physician during the office visit. It is been estimated that patients recall only about 20% of the information that is shared during an office visit; patients on average miss between 30% and 60% of the medication dosages that are prescribed. It is likely that this lack of understanding and recall interferes with adherence to both the advice and medications. One company has developed a platform with expertly developed educational modules about common diseases with full graphics. What is unique about the platform is that the conversation that the physician has with the patient, as well as annotations to the educational material and graphics, is included in a record of the patient’s visit that the patient can access through a secure portal at any time after the visit. Patients are free to review the material and share it with family members if they choose. By being able to understand their medical condition better, and the specific personalized information that their physician provides to them, patients should feel more engaged and more like they are a part of their health care team. If they are engaged in their own care, they will also be more likely to comply with the recommendation that the physician makes.
Another example of a patient engagement platform operates independently of the physician. If one assumes that information is good, then being aware of what you eat as well as receiving feedback on the number of calories consumed will naturally lead to less food eaten. This type of software has a calorie counter and a database of over 3 million foods. The user enters the type and amount of food eaten, and then the app tracks total calories, using an attractive interface. Most popular brands and restaurant choices are in the database. The mobile app makes it easy to record food that is eaten either through accessing the type of food through the mobile database, or by simply scanning the bar code from purchased foods. If one then enters the amount eaten, the app will calculate the calories consumed and add it to the personal calorie count. In addition, one can record the type and duration of exercise both to track exercise programs and to calculate the number of calories burned from the exercise. The app also has a social function and lets the user compare an exercise program and diet with that of friends or family members (with their permission, of course) to serve as mutual encouragement of each others’ goals.
Finally, electronic health record companies are developing mobile apps that integrate with the electronic health record. These apps have various functions such as allowing patients to access information in their medical record from their mobile device and providing secure two-way communication between physician and patient. Patients are able to view their lab results, request refills and referrals, access educational material, and ask questions. Some of these systems also allow providers to send reminders efficiently to patients, either individually or in bulk. Theoretically, a practice could query its database to find all patients over age 50 who have not had colorectal cancer screening in the last 10 years and then send secure HIPAA-compliant reminders to all patients in the practice who need that screening. The patients would then access the reminder through their mobile app and schedule follow-up. In addition to simply accessing information, that information is presented and collated in a thoughtful manner. For instance, instead of simply accessing a list of blood pressures, the blood pressures can be displayed in graph form over time for easier interpretation.
In summary, we stand on the precipice of a new age of medical information management where, if the dreams of mobile vendors come true, patients will be at the center of a stream of health care, disease management, and wellness information from which they, along with their doctor, with the help of real-time data, can fully participate in their health care and influence their health outcomes.
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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care.
The emerging field of mHealth, which is the use of mobile applications to facilitate the delivery of medical care and to enhance patient engagement, continues to expand rapidly, largely out of sight of most primary care physicians. We suspect that it will remain out of sight until, it will seem, mobile health apps are everywhere.
The idea behind mHealth is, given that smartphones have become ubiquitous devices through which people do everything from shopping to making dinner reservations to mobile banking, they are a device that people are ready to use to improve their health. A core component of both the Patient-Centered Medical Home model and Accountable Care Organization is that the patient is at the "center" of care and is an important, if not the most important, member of the health care team.
Mobile apps fall into a number of categories, including those that allow patients to have more effective and efficient interactions with their physicians, track data for things like blood pressure and blood sugars for more effective self-management, and allow patients more direct access to their charts and medical information. We will outline a few of these types of functions below.
One new software platform seeks to improve what patients understand and remember from their physician encounter. It is a common, if not ubiquitous, experience that patients do not fully recall the details of their discussion with the physician during the office visit. It is been estimated that patients recall only about 20% of the information that is shared during an office visit; patients on average miss between 30% and 60% of the medication dosages that are prescribed. It is likely that this lack of understanding and recall interferes with adherence to both the advice and medications. One company has developed a platform with expertly developed educational modules about common diseases with full graphics. What is unique about the platform is that the conversation that the physician has with the patient, as well as annotations to the educational material and graphics, is included in a record of the patient’s visit that the patient can access through a secure portal at any time after the visit. Patients are free to review the material and share it with family members if they choose. By being able to understand their medical condition better, and the specific personalized information that their physician provides to them, patients should feel more engaged and more like they are a part of their health care team. If they are engaged in their own care, they will also be more likely to comply with the recommendation that the physician makes.
Another example of a patient engagement platform operates independently of the physician. If one assumes that information is good, then being aware of what you eat as well as receiving feedback on the number of calories consumed will naturally lead to less food eaten. This type of software has a calorie counter and a database of over 3 million foods. The user enters the type and amount of food eaten, and then the app tracks total calories, using an attractive interface. Most popular brands and restaurant choices are in the database. The mobile app makes it easy to record food that is eaten either through accessing the type of food through the mobile database, or by simply scanning the bar code from purchased foods. If one then enters the amount eaten, the app will calculate the calories consumed and add it to the personal calorie count. In addition, one can record the type and duration of exercise both to track exercise programs and to calculate the number of calories burned from the exercise. The app also has a social function and lets the user compare an exercise program and diet with that of friends or family members (with their permission, of course) to serve as mutual encouragement of each others’ goals.
Finally, electronic health record companies are developing mobile apps that integrate with the electronic health record. These apps have various functions such as allowing patients to access information in their medical record from their mobile device and providing secure two-way communication between physician and patient. Patients are able to view their lab results, request refills and referrals, access educational material, and ask questions. Some of these systems also allow providers to send reminders efficiently to patients, either individually or in bulk. Theoretically, a practice could query its database to find all patients over age 50 who have not had colorectal cancer screening in the last 10 years and then send secure HIPAA-compliant reminders to all patients in the practice who need that screening. The patients would then access the reminder through their mobile app and schedule follow-up. In addition to simply accessing information, that information is presented and collated in a thoughtful manner. For instance, instead of simply accessing a list of blood pressures, the blood pressures can be displayed in graph form over time for easier interpretation.
In summary, we stand on the precipice of a new age of medical information management where, if the dreams of mobile vendors come true, patients will be at the center of a stream of health care, disease management, and wellness information from which they, along with their doctor, with the help of real-time data, can fully participate in their health care and influence their health outcomes.
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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care.
The emerging field of mHealth, which is the use of mobile applications to facilitate the delivery of medical care and to enhance patient engagement, continues to expand rapidly, largely out of sight of most primary care physicians. We suspect that it will remain out of sight until, it will seem, mobile health apps are everywhere.
The idea behind mHealth is, given that smartphones have become ubiquitous devices through which people do everything from shopping to making dinner reservations to mobile banking, they are a device that people are ready to use to improve their health. A core component of both the Patient-Centered Medical Home model and Accountable Care Organization is that the patient is at the "center" of care and is an important, if not the most important, member of the health care team.
Mobile apps fall into a number of categories, including those that allow patients to have more effective and efficient interactions with their physicians, track data for things like blood pressure and blood sugars for more effective self-management, and allow patients more direct access to their charts and medical information. We will outline a few of these types of functions below.
One new software platform seeks to improve what patients understand and remember from their physician encounter. It is a common, if not ubiquitous, experience that patients do not fully recall the details of their discussion with the physician during the office visit. It is been estimated that patients recall only about 20% of the information that is shared during an office visit; patients on average miss between 30% and 60% of the medication dosages that are prescribed. It is likely that this lack of understanding and recall interferes with adherence to both the advice and medications. One company has developed a platform with expertly developed educational modules about common diseases with full graphics. What is unique about the platform is that the conversation that the physician has with the patient, as well as annotations to the educational material and graphics, is included in a record of the patient’s visit that the patient can access through a secure portal at any time after the visit. Patients are free to review the material and share it with family members if they choose. By being able to understand their medical condition better, and the specific personalized information that their physician provides to them, patients should feel more engaged and more like they are a part of their health care team. If they are engaged in their own care, they will also be more likely to comply with the recommendation that the physician makes.
Another example of a patient engagement platform operates independently of the physician. If one assumes that information is good, then being aware of what you eat as well as receiving feedback on the number of calories consumed will naturally lead to less food eaten. This type of software has a calorie counter and a database of over 3 million foods. The user enters the type and amount of food eaten, and then the app tracks total calories, using an attractive interface. Most popular brands and restaurant choices are in the database. The mobile app makes it easy to record food that is eaten either through accessing the type of food through the mobile database, or by simply scanning the bar code from purchased foods. If one then enters the amount eaten, the app will calculate the calories consumed and add it to the personal calorie count. In addition, one can record the type and duration of exercise both to track exercise programs and to calculate the number of calories burned from the exercise. The app also has a social function and lets the user compare an exercise program and diet with that of friends or family members (with their permission, of course) to serve as mutual encouragement of each others’ goals.
Finally, electronic health record companies are developing mobile apps that integrate with the electronic health record. These apps have various functions such as allowing patients to access information in their medical record from their mobile device and providing secure two-way communication between physician and patient. Patients are able to view their lab results, request refills and referrals, access educational material, and ask questions. Some of these systems also allow providers to send reminders efficiently to patients, either individually or in bulk. Theoretically, a practice could query its database to find all patients over age 50 who have not had colorectal cancer screening in the last 10 years and then send secure HIPAA-compliant reminders to all patients in the practice who need that screening. The patients would then access the reminder through their mobile app and schedule follow-up. In addition to simply accessing information, that information is presented and collated in a thoughtful manner. For instance, instead of simply accessing a list of blood pressures, the blood pressures can be displayed in graph form over time for easier interpretation.
In summary, we stand on the precipice of a new age of medical information management where, if the dreams of mobile vendors come true, patients will be at the center of a stream of health care, disease management, and wellness information from which they, along with their doctor, with the help of real-time data, can fully participate in their health care and influence their health outcomes.
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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care.
The future of meaningful use
By the time you read this, you will be aware of the recent changes in the "meaningful use" timeline announced on Dec. 6, 2013. For those who may have missed it, the Centers for Medicare and Medicaid Services, in conjunction with the Office of the National Coordinator for Health Information Technology, proposed a delay in the meaningful use roll-out in response to mounting concern over the viability of the program deadlines. Essentially, this amounts to an extension of stage 2 through 2016, a hold on initiation of stage 3 criteria until 2017, and a delay in penalties for noncompliance until 2015. In response to the announcement, many physicians are breathing sighs of relief. This additional amnesty promises to ease some concerns, as well as allow for an examination of how far the MU program has come, and where it will be going in the future.
We routinely receive messages from readers outlining their concerns over the practicality of the meaningful use incentive program. We have continued to publish these comments as we feel there is tremendous benefit in giving voice to fellow doctors who are frustrated with EHR technology. We are hopeful that the thoughts expressed in this and other forums are at least partly responsible for the delay announced last week, as the concerns are real and practical. One recent message, which brings criticism (both for EHRs and for us), comes from Dr. Michael Lavery, an internist in Manchester, N.H. Dr. Lavery tells of his own experience with an EHR, which he fails to find "meaningful." He writes:
"Other than the obvious benefits of not needing scribes and paper charts, EHRs have not delivered on their promise of increased efficiency. In our large primary care practice, we are now EHR veterans, having adopted an electronic record several years ago. Since then, we have not had occasion to use the data contained therein for ‘improving population health’ or improving access to care, as those in the government would like. On the contrary, the EHR has only increased the amount of work we all have on a daily basis. I, for one, find myself continuously entering data that may or may not be easy to retrieve and can only hope for improvement in my typing skills. I am bothered when I read your column and see that you are extolling the benefits of Health IT without pointing out the shortcomings. Then, when you do speak of the challenges, you imply they are only due to a poor choice of systems or a fault of the individual physician’s unwillingness to accept the new technology. I resent this. I have always been a champion for change and completely embrace new technology when it becomes available. In the case of EHRs, however, the technology has not delivered on the promise, and our jobs are harder as a result. My experience has not been one of improved patient care, but of diminished physician lifestyle ... "
Dr. Lavery expressed a common reaction to the current state of health information technology, and EHR vendors and the government are taking notice. The change in the meaningful use implementation timeline is an indication of this acknowledgment. Industry experts have observed that the additional time is a great relief to EHR companies, which are struggling to make their products stage-2 compliant. Beyond mere compliance, we are hopeful that the extra time will also lead to improved usability of EHR systems and enhancements that are truly "meaningful" to physicians and patients. This could come in the form of improved clinical decision support, more efficient documentation, or better population management tools. We think vendors are starting to get the message and believe EHR software is maturing to adopt these ideas.
We are also optimistic as we look ahead to the stage 3 criteria. Several influential organizations – including the American Medical Association, the American Academy of Family Physicians, and others – have strongly encouraged the CMS to design the stage 3 criteria around improving patient care and physician efficiency, instead of simply demonstrating data collection capabilities. While this has been the goal of stage 3 all along, the growing pains experienced in implementing the first two stages have given reason for pause; efforts to finalize the official criteria have been put on hold until the first half of 2015. It is the intent of the CMS and the Office of the National Coordinator for Health Information Technology to carefully consider all of the feedback they receive before coming to a conclusion on the measures.
In his comments above, Dr. Lavery took issue – not only with the message – but also with the messengers. He identified columnists like us as cheerleaders for substandard technology who blame the user instead of the EHR software’s lack of usability. In response, we want to assert our fundamental belief that EHR technology only improves care delivery when it complements the "art" of medicine. We feel though that it is important to understand that these early stages of EHR adoption represent a transition point. Just as any child of the 21st century would laugh at the rudimentary nature of a 20th-century video game system, we will all likely one day reflect on this generation of EHRs with incredulity and condescension. One hopes we will also understand this era as the foundation of a new type of medicine – medicine that attends to the needs of – and values – physicians, patients, and populations through high-quality care and "meaningful" technology.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
By the time you read this, you will be aware of the recent changes in the "meaningful use" timeline announced on Dec. 6, 2013. For those who may have missed it, the Centers for Medicare and Medicaid Services, in conjunction with the Office of the National Coordinator for Health Information Technology, proposed a delay in the meaningful use roll-out in response to mounting concern over the viability of the program deadlines. Essentially, this amounts to an extension of stage 2 through 2016, a hold on initiation of stage 3 criteria until 2017, and a delay in penalties for noncompliance until 2015. In response to the announcement, many physicians are breathing sighs of relief. This additional amnesty promises to ease some concerns, as well as allow for an examination of how far the MU program has come, and where it will be going in the future.
We routinely receive messages from readers outlining their concerns over the practicality of the meaningful use incentive program. We have continued to publish these comments as we feel there is tremendous benefit in giving voice to fellow doctors who are frustrated with EHR technology. We are hopeful that the thoughts expressed in this and other forums are at least partly responsible for the delay announced last week, as the concerns are real and practical. One recent message, which brings criticism (both for EHRs and for us), comes from Dr. Michael Lavery, an internist in Manchester, N.H. Dr. Lavery tells of his own experience with an EHR, which he fails to find "meaningful." He writes:
"Other than the obvious benefits of not needing scribes and paper charts, EHRs have not delivered on their promise of increased efficiency. In our large primary care practice, we are now EHR veterans, having adopted an electronic record several years ago. Since then, we have not had occasion to use the data contained therein for ‘improving population health’ or improving access to care, as those in the government would like. On the contrary, the EHR has only increased the amount of work we all have on a daily basis. I, for one, find myself continuously entering data that may or may not be easy to retrieve and can only hope for improvement in my typing skills. I am bothered when I read your column and see that you are extolling the benefits of Health IT without pointing out the shortcomings. Then, when you do speak of the challenges, you imply they are only due to a poor choice of systems or a fault of the individual physician’s unwillingness to accept the new technology. I resent this. I have always been a champion for change and completely embrace new technology when it becomes available. In the case of EHRs, however, the technology has not delivered on the promise, and our jobs are harder as a result. My experience has not been one of improved patient care, but of diminished physician lifestyle ... "
Dr. Lavery expressed a common reaction to the current state of health information technology, and EHR vendors and the government are taking notice. The change in the meaningful use implementation timeline is an indication of this acknowledgment. Industry experts have observed that the additional time is a great relief to EHR companies, which are struggling to make their products stage-2 compliant. Beyond mere compliance, we are hopeful that the extra time will also lead to improved usability of EHR systems and enhancements that are truly "meaningful" to physicians and patients. This could come in the form of improved clinical decision support, more efficient documentation, or better population management tools. We think vendors are starting to get the message and believe EHR software is maturing to adopt these ideas.
We are also optimistic as we look ahead to the stage 3 criteria. Several influential organizations – including the American Medical Association, the American Academy of Family Physicians, and others – have strongly encouraged the CMS to design the stage 3 criteria around improving patient care and physician efficiency, instead of simply demonstrating data collection capabilities. While this has been the goal of stage 3 all along, the growing pains experienced in implementing the first two stages have given reason for pause; efforts to finalize the official criteria have been put on hold until the first half of 2015. It is the intent of the CMS and the Office of the National Coordinator for Health Information Technology to carefully consider all of the feedback they receive before coming to a conclusion on the measures.
In his comments above, Dr. Lavery took issue – not only with the message – but also with the messengers. He identified columnists like us as cheerleaders for substandard technology who blame the user instead of the EHR software’s lack of usability. In response, we want to assert our fundamental belief that EHR technology only improves care delivery when it complements the "art" of medicine. We feel though that it is important to understand that these early stages of EHR adoption represent a transition point. Just as any child of the 21st century would laugh at the rudimentary nature of a 20th-century video game system, we will all likely one day reflect on this generation of EHRs with incredulity and condescension. One hopes we will also understand this era as the foundation of a new type of medicine – medicine that attends to the needs of – and values – physicians, patients, and populations through high-quality care and "meaningful" technology.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
By the time you read this, you will be aware of the recent changes in the "meaningful use" timeline announced on Dec. 6, 2013. For those who may have missed it, the Centers for Medicare and Medicaid Services, in conjunction with the Office of the National Coordinator for Health Information Technology, proposed a delay in the meaningful use roll-out in response to mounting concern over the viability of the program deadlines. Essentially, this amounts to an extension of stage 2 through 2016, a hold on initiation of stage 3 criteria until 2017, and a delay in penalties for noncompliance until 2015. In response to the announcement, many physicians are breathing sighs of relief. This additional amnesty promises to ease some concerns, as well as allow for an examination of how far the MU program has come, and where it will be going in the future.
We routinely receive messages from readers outlining their concerns over the practicality of the meaningful use incentive program. We have continued to publish these comments as we feel there is tremendous benefit in giving voice to fellow doctors who are frustrated with EHR technology. We are hopeful that the thoughts expressed in this and other forums are at least partly responsible for the delay announced last week, as the concerns are real and practical. One recent message, which brings criticism (both for EHRs and for us), comes from Dr. Michael Lavery, an internist in Manchester, N.H. Dr. Lavery tells of his own experience with an EHR, which he fails to find "meaningful." He writes:
"Other than the obvious benefits of not needing scribes and paper charts, EHRs have not delivered on their promise of increased efficiency. In our large primary care practice, we are now EHR veterans, having adopted an electronic record several years ago. Since then, we have not had occasion to use the data contained therein for ‘improving population health’ or improving access to care, as those in the government would like. On the contrary, the EHR has only increased the amount of work we all have on a daily basis. I, for one, find myself continuously entering data that may or may not be easy to retrieve and can only hope for improvement in my typing skills. I am bothered when I read your column and see that you are extolling the benefits of Health IT without pointing out the shortcomings. Then, when you do speak of the challenges, you imply they are only due to a poor choice of systems or a fault of the individual physician’s unwillingness to accept the new technology. I resent this. I have always been a champion for change and completely embrace new technology when it becomes available. In the case of EHRs, however, the technology has not delivered on the promise, and our jobs are harder as a result. My experience has not been one of improved patient care, but of diminished physician lifestyle ... "
Dr. Lavery expressed a common reaction to the current state of health information technology, and EHR vendors and the government are taking notice. The change in the meaningful use implementation timeline is an indication of this acknowledgment. Industry experts have observed that the additional time is a great relief to EHR companies, which are struggling to make their products stage-2 compliant. Beyond mere compliance, we are hopeful that the extra time will also lead to improved usability of EHR systems and enhancements that are truly "meaningful" to physicians and patients. This could come in the form of improved clinical decision support, more efficient documentation, or better population management tools. We think vendors are starting to get the message and believe EHR software is maturing to adopt these ideas.
We are also optimistic as we look ahead to the stage 3 criteria. Several influential organizations – including the American Medical Association, the American Academy of Family Physicians, and others – have strongly encouraged the CMS to design the stage 3 criteria around improving patient care and physician efficiency, instead of simply demonstrating data collection capabilities. While this has been the goal of stage 3 all along, the growing pains experienced in implementing the first two stages have given reason for pause; efforts to finalize the official criteria have been put on hold until the first half of 2015. It is the intent of the CMS and the Office of the National Coordinator for Health Information Technology to carefully consider all of the feedback they receive before coming to a conclusion on the measures.
In his comments above, Dr. Lavery took issue – not only with the message – but also with the messengers. He identified columnists like us as cheerleaders for substandard technology who blame the user instead of the EHR software’s lack of usability. In response, we want to assert our fundamental belief that EHR technology only improves care delivery when it complements the "art" of medicine. We feel though that it is important to understand that these early stages of EHR adoption represent a transition point. Just as any child of the 21st century would laugh at the rudimentary nature of a 20th-century video game system, we will all likely one day reflect on this generation of EHRs with incredulity and condescension. One hopes we will also understand this era as the foundation of a new type of medicine – medicine that attends to the needs of – and values – physicians, patients, and populations through high-quality care and "meaningful" technology.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Hypertension
The National Institutes of Health recently announced that it is no longer going to publish guidelines and that there will never be a JNC 8. This has left much of the primary care community without clear, current, and consensus-based guidelines for the treatment of hypertension. We thought that it would be helpful to review the most recent, annually updated evidence-based guidelines from the Canadian Hypertension Education Program (CHEP).
Initial diagnosis
CHEP guidelines present a conservative approach to diagnosis, placing strong weight on the use of home blood pressure measurement and repeated BP recordings before making a diagnosis of hypertension. If a patient’s systolic blood pressure (BP) is >140 mm Hg or the diastolic blood pressure is >90 mm Hg, BP should be rechecked within 1 month. A diagnosis of hypertension can be made at the second visit if the patient has a systolic BP >180 or a diastolic BP >110, or if BP >140/90 and there is macrovascular target organ damage, diabetes mellitus or chronic kidney disease. In the absence of those criteria, one of the following must be satisfied to establish a diagnosis of hypertension:
• Office BP measurement. Average systolic BP >160 or diastolic BP >100 across three visits, or average systolic BP >140 or diastolic BP >90 across five visits.
• Ambulatory BP measurement. Average awake systolic BP >135 or diastolic BP >85, or mean 24-hour systolic BP >130 or diastolic BP >80.
• Home BP measurement. Average systolic BP >135 or diastolic BP >85 (taken twice daily over a 7-day period, first day values discarded).
If a patient has a hypertensive urgency or emergency, then the diagnosis is made at the first visit, and diagnostic tests and therapeutic plans are determined at that point. Hypertensive urgency is defined as asymptomatic diastolic BP >130, or severe elevation of BP with encephalopathy, aortic dissection, heart failure, coronary syndrome, acute kidney injury, intracranial hemorrhage, acute stroke, or eclampsia.
Laboratory evaluation
All patients should initially have blood chemistry, urinalysis, fasting glucose, fasting cholesterol, and EKG. Diabetics should have urinary albumin assessed.
Treatment goals
• Systolic BP <140 and diastolic BP <90 for most patients.
• Systolic BP <150 in the very elderly (>80 years).
• BP <140/90 in nondiabetic chronic kidney disease patients.
• BP <130/80 in diabetes mellitus patients.
Therapy
• Lifestyle. Prescribe 30-60 minutes of moderate-intensity exercise 4-7 days/wk. Resistance or weight-training exercise does not adversely influence BP in prehypertension or stage 1 hypertension. Recommend weight reduction, limiting alcohol consumption, the DASH diet, limiting sodium intake, and stress management.
• Medication. Begin antihypertensives when average systolic BP >160 or diastolic BP >100 without macrovascular organ damage or other cardiovascular risk factors, or when systolic BP >140 or diastolic BP >90 in the presence of macrovascular organ damage or other cardiovascular risk factors. For the treatment of stage 1 hypertension, it is appropriate to attempt normalization of BP with nonpharmacologic management first, particularly if the patient is low risk.
Patients without compelling indications for specific agents
Diastolic hypertension with or without systolic hypertension:
• Monotherapy with thiazide diuretic, beta-blocker (patients <60 years), angiotensin-converting enzyme (ACE) inhibitor (nonblack patients), long-acting dihydropyridine calcium channel blocker, or angiotensin receptor blocker (ARB).
• Escalate therapy if target BP goal is not achieved. Additional medication should be chosen from first-line medications not already being used. The combination of an ACE inhibitor and an ARB should not be used. If target BP is not achieved, then additional agents should be tried.
• Consider starting with two agents if initial systolic BP is 20 mm Hg, or diastolic BP is10 mm Hg, above target. Use caution in elderly.
Isolated systolic hypertension:
• Monotherapy with thiazide diuretic, calcium channel blocker, or ARB.
• Escalate therapy with another drug from the same list.
Patients with selected compelling indications for specific agents
Hypertension and coronary artery disease:
• Most patients should be on an ACE inhibitor or ARB.
• For patients with stable angina, use beta-blockers as initial therapy. Calcium channel blockers can also be used but avoid short-acting nifedipine.
Hypertension and recent myocardial infarction :
• Initial therapy with both a beta-blocker and an ACE inhibitor or ARB.
• Calcium channel blockers can be substituted for beta-blockers if necessary.
Hypertension and heart failure:
• For patients with systolic dysfunction (ejection fraction <40%), initial therapy should be an ACE inhibitor and beta-blockers.
• Add an aldosterone antagonist for recent cardiovascular hospitalization, acute MI, elevated brain natriuretic peptide, or NYHA class II-IV symptoms. Monitor for hyperkalemia.
• Use thiazide diuretics for additional BP control, or loop diuretics for volume control.
• Use a combination of hydralazine and isosorbide dinitrate if unable to use an ACE inhibitor or ARB.
Hypertension and stroke/transient ischemic attack:
• If the patient is ineligible for thrombolytic therapy, do not treat hypertension in the first 72 hours as it may exacerbate or induce ischemia. If BP is extremely elevated (systolic >220 or diastolic >120),you can reduce BP by 15%, not greater than 25%, over a 24-hour period.
• If the patient is eligible for thrombolytic therapy, then concurrent treatment for very high BP (systolic >185 or diastolic >110) should be given to avoid secondary intracranial hemorrhage.
• Post stroke: Initiate treatment with an ACE inhibitor and/or a diuretic with a target BP <140/90.
Hypertension and left ventricular hypertrophy:
• Initial therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide.
• Avoid direct arterial vasodilators.
Hypertension and nondiabetic chronic kidney disease:
• If the patient has proteinuria, initial therapy should be an ACE inhibitor, or an ARB if intolerance to ACE inhibitors.
• Escalate with thiazide diuretic for BP control, loop diuretic for volume control.
• Target BP <140/90.
• Combination of an ACE inhibitor and an ARB is not recommended.
Hypertension and diabetes mellitus:
• Initiate therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic.
• Initiate therapy with ACE inhibitor or ARB if kidney disease, cardiovascular disease, or risk factors are present.
• Be cautious in initiating with two medications in elderly patients or those with autonomic neuropathy.
• The combination of an ACE inhibitor and a dihydropyridine calcium channel blocker is preferable to an ACE inhibitor and a thiazide diuretic.
Key points
The CHEP guidelines set specific and relatively conservative criteria for both diagnosing hypertension and starting antihypertensive medications. Delaying pharmacotherapy for low-risk patients while attempting lifestyle management is acceptable, and specific recommendations are made for pharmacologic therapy.
Reference: Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program (CHEP) recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can. J. Cardiol. 2013;29:528-42 (see www.hypertension.ca).
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, Philadelphia. Dr. Sepe is a first year resident in the Family Medicine Residency Program at Abington Memorial Hospital.
The National Institutes of Health recently announced that it is no longer going to publish guidelines and that there will never be a JNC 8. This has left much of the primary care community without clear, current, and consensus-based guidelines for the treatment of hypertension. We thought that it would be helpful to review the most recent, annually updated evidence-based guidelines from the Canadian Hypertension Education Program (CHEP).
Initial diagnosis
CHEP guidelines present a conservative approach to diagnosis, placing strong weight on the use of home blood pressure measurement and repeated BP recordings before making a diagnosis of hypertension. If a patient’s systolic blood pressure (BP) is >140 mm Hg or the diastolic blood pressure is >90 mm Hg, BP should be rechecked within 1 month. A diagnosis of hypertension can be made at the second visit if the patient has a systolic BP >180 or a diastolic BP >110, or if BP >140/90 and there is macrovascular target organ damage, diabetes mellitus or chronic kidney disease. In the absence of those criteria, one of the following must be satisfied to establish a diagnosis of hypertension:
• Office BP measurement. Average systolic BP >160 or diastolic BP >100 across three visits, or average systolic BP >140 or diastolic BP >90 across five visits.
• Ambulatory BP measurement. Average awake systolic BP >135 or diastolic BP >85, or mean 24-hour systolic BP >130 or diastolic BP >80.
• Home BP measurement. Average systolic BP >135 or diastolic BP >85 (taken twice daily over a 7-day period, first day values discarded).
If a patient has a hypertensive urgency or emergency, then the diagnosis is made at the first visit, and diagnostic tests and therapeutic plans are determined at that point. Hypertensive urgency is defined as asymptomatic diastolic BP >130, or severe elevation of BP with encephalopathy, aortic dissection, heart failure, coronary syndrome, acute kidney injury, intracranial hemorrhage, acute stroke, or eclampsia.
Laboratory evaluation
All patients should initially have blood chemistry, urinalysis, fasting glucose, fasting cholesterol, and EKG. Diabetics should have urinary albumin assessed.
Treatment goals
• Systolic BP <140 and diastolic BP <90 for most patients.
• Systolic BP <150 in the very elderly (>80 years).
• BP <140/90 in nondiabetic chronic kidney disease patients.
• BP <130/80 in diabetes mellitus patients.
Therapy
• Lifestyle. Prescribe 30-60 minutes of moderate-intensity exercise 4-7 days/wk. Resistance or weight-training exercise does not adversely influence BP in prehypertension or stage 1 hypertension. Recommend weight reduction, limiting alcohol consumption, the DASH diet, limiting sodium intake, and stress management.
• Medication. Begin antihypertensives when average systolic BP >160 or diastolic BP >100 without macrovascular organ damage or other cardiovascular risk factors, or when systolic BP >140 or diastolic BP >90 in the presence of macrovascular organ damage or other cardiovascular risk factors. For the treatment of stage 1 hypertension, it is appropriate to attempt normalization of BP with nonpharmacologic management first, particularly if the patient is low risk.
Patients without compelling indications for specific agents
Diastolic hypertension with or without systolic hypertension:
• Monotherapy with thiazide diuretic, beta-blocker (patients <60 years), angiotensin-converting enzyme (ACE) inhibitor (nonblack patients), long-acting dihydropyridine calcium channel blocker, or angiotensin receptor blocker (ARB).
• Escalate therapy if target BP goal is not achieved. Additional medication should be chosen from first-line medications not already being used. The combination of an ACE inhibitor and an ARB should not be used. If target BP is not achieved, then additional agents should be tried.
• Consider starting with two agents if initial systolic BP is 20 mm Hg, or diastolic BP is10 mm Hg, above target. Use caution in elderly.
Isolated systolic hypertension:
• Monotherapy with thiazide diuretic, calcium channel blocker, or ARB.
• Escalate therapy with another drug from the same list.
Patients with selected compelling indications for specific agents
Hypertension and coronary artery disease:
• Most patients should be on an ACE inhibitor or ARB.
• For patients with stable angina, use beta-blockers as initial therapy. Calcium channel blockers can also be used but avoid short-acting nifedipine.
Hypertension and recent myocardial infarction :
• Initial therapy with both a beta-blocker and an ACE inhibitor or ARB.
• Calcium channel blockers can be substituted for beta-blockers if necessary.
Hypertension and heart failure:
• For patients with systolic dysfunction (ejection fraction <40%), initial therapy should be an ACE inhibitor and beta-blockers.
• Add an aldosterone antagonist for recent cardiovascular hospitalization, acute MI, elevated brain natriuretic peptide, or NYHA class II-IV symptoms. Monitor for hyperkalemia.
• Use thiazide diuretics for additional BP control, or loop diuretics for volume control.
• Use a combination of hydralazine and isosorbide dinitrate if unable to use an ACE inhibitor or ARB.
Hypertension and stroke/transient ischemic attack:
• If the patient is ineligible for thrombolytic therapy, do not treat hypertension in the first 72 hours as it may exacerbate or induce ischemia. If BP is extremely elevated (systolic >220 or diastolic >120),you can reduce BP by 15%, not greater than 25%, over a 24-hour period.
• If the patient is eligible for thrombolytic therapy, then concurrent treatment for very high BP (systolic >185 or diastolic >110) should be given to avoid secondary intracranial hemorrhage.
• Post stroke: Initiate treatment with an ACE inhibitor and/or a diuretic with a target BP <140/90.
Hypertension and left ventricular hypertrophy:
• Initial therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide.
• Avoid direct arterial vasodilators.
Hypertension and nondiabetic chronic kidney disease:
• If the patient has proteinuria, initial therapy should be an ACE inhibitor, or an ARB if intolerance to ACE inhibitors.
• Escalate with thiazide diuretic for BP control, loop diuretic for volume control.
• Target BP <140/90.
• Combination of an ACE inhibitor and an ARB is not recommended.
Hypertension and diabetes mellitus:
• Initiate therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic.
• Initiate therapy with ACE inhibitor or ARB if kidney disease, cardiovascular disease, or risk factors are present.
• Be cautious in initiating with two medications in elderly patients or those with autonomic neuropathy.
• The combination of an ACE inhibitor and a dihydropyridine calcium channel blocker is preferable to an ACE inhibitor and a thiazide diuretic.
Key points
The CHEP guidelines set specific and relatively conservative criteria for both diagnosing hypertension and starting antihypertensive medications. Delaying pharmacotherapy for low-risk patients while attempting lifestyle management is acceptable, and specific recommendations are made for pharmacologic therapy.
Reference: Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program (CHEP) recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can. J. Cardiol. 2013;29:528-42 (see www.hypertension.ca).
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, Philadelphia. Dr. Sepe is a first year resident in the Family Medicine Residency Program at Abington Memorial Hospital.
The National Institutes of Health recently announced that it is no longer going to publish guidelines and that there will never be a JNC 8. This has left much of the primary care community without clear, current, and consensus-based guidelines for the treatment of hypertension. We thought that it would be helpful to review the most recent, annually updated evidence-based guidelines from the Canadian Hypertension Education Program (CHEP).
Initial diagnosis
CHEP guidelines present a conservative approach to diagnosis, placing strong weight on the use of home blood pressure measurement and repeated BP recordings before making a diagnosis of hypertension. If a patient’s systolic blood pressure (BP) is >140 mm Hg or the diastolic blood pressure is >90 mm Hg, BP should be rechecked within 1 month. A diagnosis of hypertension can be made at the second visit if the patient has a systolic BP >180 or a diastolic BP >110, or if BP >140/90 and there is macrovascular target organ damage, diabetes mellitus or chronic kidney disease. In the absence of those criteria, one of the following must be satisfied to establish a diagnosis of hypertension:
• Office BP measurement. Average systolic BP >160 or diastolic BP >100 across three visits, or average systolic BP >140 or diastolic BP >90 across five visits.
• Ambulatory BP measurement. Average awake systolic BP >135 or diastolic BP >85, or mean 24-hour systolic BP >130 or diastolic BP >80.
• Home BP measurement. Average systolic BP >135 or diastolic BP >85 (taken twice daily over a 7-day period, first day values discarded).
If a patient has a hypertensive urgency or emergency, then the diagnosis is made at the first visit, and diagnostic tests and therapeutic plans are determined at that point. Hypertensive urgency is defined as asymptomatic diastolic BP >130, or severe elevation of BP with encephalopathy, aortic dissection, heart failure, coronary syndrome, acute kidney injury, intracranial hemorrhage, acute stroke, or eclampsia.
Laboratory evaluation
All patients should initially have blood chemistry, urinalysis, fasting glucose, fasting cholesterol, and EKG. Diabetics should have urinary albumin assessed.
Treatment goals
• Systolic BP <140 and diastolic BP <90 for most patients.
• Systolic BP <150 in the very elderly (>80 years).
• BP <140/90 in nondiabetic chronic kidney disease patients.
• BP <130/80 in diabetes mellitus patients.
Therapy
• Lifestyle. Prescribe 30-60 minutes of moderate-intensity exercise 4-7 days/wk. Resistance or weight-training exercise does not adversely influence BP in prehypertension or stage 1 hypertension. Recommend weight reduction, limiting alcohol consumption, the DASH diet, limiting sodium intake, and stress management.
• Medication. Begin antihypertensives when average systolic BP >160 or diastolic BP >100 without macrovascular organ damage or other cardiovascular risk factors, or when systolic BP >140 or diastolic BP >90 in the presence of macrovascular organ damage or other cardiovascular risk factors. For the treatment of stage 1 hypertension, it is appropriate to attempt normalization of BP with nonpharmacologic management first, particularly if the patient is low risk.
Patients without compelling indications for specific agents
Diastolic hypertension with or without systolic hypertension:
• Monotherapy with thiazide diuretic, beta-blocker (patients <60 years), angiotensin-converting enzyme (ACE) inhibitor (nonblack patients), long-acting dihydropyridine calcium channel blocker, or angiotensin receptor blocker (ARB).
• Escalate therapy if target BP goal is not achieved. Additional medication should be chosen from first-line medications not already being used. The combination of an ACE inhibitor and an ARB should not be used. If target BP is not achieved, then additional agents should be tried.
• Consider starting with two agents if initial systolic BP is 20 mm Hg, or diastolic BP is10 mm Hg, above target. Use caution in elderly.
Isolated systolic hypertension:
• Monotherapy with thiazide diuretic, calcium channel blocker, or ARB.
• Escalate therapy with another drug from the same list.
Patients with selected compelling indications for specific agents
Hypertension and coronary artery disease:
• Most patients should be on an ACE inhibitor or ARB.
• For patients with stable angina, use beta-blockers as initial therapy. Calcium channel blockers can also be used but avoid short-acting nifedipine.
Hypertension and recent myocardial infarction :
• Initial therapy with both a beta-blocker and an ACE inhibitor or ARB.
• Calcium channel blockers can be substituted for beta-blockers if necessary.
Hypertension and heart failure:
• For patients with systolic dysfunction (ejection fraction <40%), initial therapy should be an ACE inhibitor and beta-blockers.
• Add an aldosterone antagonist for recent cardiovascular hospitalization, acute MI, elevated brain natriuretic peptide, or NYHA class II-IV symptoms. Monitor for hyperkalemia.
• Use thiazide diuretics for additional BP control, or loop diuretics for volume control.
• Use a combination of hydralazine and isosorbide dinitrate if unable to use an ACE inhibitor or ARB.
Hypertension and stroke/transient ischemic attack:
• If the patient is ineligible for thrombolytic therapy, do not treat hypertension in the first 72 hours as it may exacerbate or induce ischemia. If BP is extremely elevated (systolic >220 or diastolic >120),you can reduce BP by 15%, not greater than 25%, over a 24-hour period.
• If the patient is eligible for thrombolytic therapy, then concurrent treatment for very high BP (systolic >185 or diastolic >110) should be given to avoid secondary intracranial hemorrhage.
• Post stroke: Initiate treatment with an ACE inhibitor and/or a diuretic with a target BP <140/90.
Hypertension and left ventricular hypertrophy:
• Initial therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide.
• Avoid direct arterial vasodilators.
Hypertension and nondiabetic chronic kidney disease:
• If the patient has proteinuria, initial therapy should be an ACE inhibitor, or an ARB if intolerance to ACE inhibitors.
• Escalate with thiazide diuretic for BP control, loop diuretic for volume control.
• Target BP <140/90.
• Combination of an ACE inhibitor and an ARB is not recommended.
Hypertension and diabetes mellitus:
• Initiate therapy with ACE inhibitor, ARB, calcium channel blocker, or thiazide diuretic.
• Initiate therapy with ACE inhibitor or ARB if kidney disease, cardiovascular disease, or risk factors are present.
• Be cautious in initiating with two medications in elderly patients or those with autonomic neuropathy.
• The combination of an ACE inhibitor and a dihydropyridine calcium channel blocker is preferable to an ACE inhibitor and a thiazide diuretic.
Key points
The CHEP guidelines set specific and relatively conservative criteria for both diagnosing hypertension and starting antihypertensive medications. Delaying pharmacotherapy for low-risk patients while attempting lifestyle management is acceptable, and specific recommendations are made for pharmacologic therapy.
Reference: Hackam DG, Quinn RR, Ravani P, et al. The 2013 Canadian Hypertension Education Program (CHEP) recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can. J. Cardiol. 2013;29:528-42 (see www.hypertension.ca).
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, Philadelphia. Dr. Sepe is a first year resident in the Family Medicine Residency Program at Abington Memorial Hospital.
EHR Report: Medical legal issues regarding electronic medical records
Electronic health records have led to recent issues appearing in the court system that can potentially convolute physician defense. Both health care attorneys and physicians are grappling with new technology that brings with it the need for close attention to new areas of detail. Certain habits, or lack of habits, can affect the medical-legal environment. Physicians who are aware of these issues can take steps to reduce their exposure.
One of the largest problems seen with EHRs is the failure of physicians to review dictated records. After a note is dictated into the electronic system, health care providers should be encouraged to read it and any accompanying documentation such as prescriptions.
Voice recognition systems are not foolproof and can lead to inaccuracies in the transcription of operative reports, office notes, and prescriptions. When a doctor is deposed and has to explain that what the record says is not really what he or she meant it to say, it decreases his or her credibility with the jury and undermines subsequent testimony. When a physician says that the record is not an accurate representation of what occurred, the jury is left with an impression of carelessness and a failure on the doctor’s part to take the time to ensure patient safety. Taking a few minutes to guarantee the accuracy of the record at the time of creation can save years of explanation after a case has been instituted.
The failure of the physician to review his or her notes can also lead to the veracity of the EHR being called into question. We are aware of at least one case in which an emergency department physician was asked to testify at trial about her interaction with a patient from many years prior. Understandably, the emergency department physician did not have a recollection of the visit and intended to rely on the record. The EHR documented the care that was provided, but the physicians had not signed it. At trial, the doctor was not allowed to testify about what she did for the patient. The rationale was that the doctor did not recall what was done, and her failure to sign the EHR contemporaneously meant that there was no evidence that the EHR was accurate.
A physician should be able to say that his or her custom and practice is to review the EHR before it is finalized and make any updates or addendums as needed. That way, even if there is no signature, the physician has given credence to the accuracy of the records.
Health care providers should be encouraged to use the "free-text" section that is available when it adds to the accuracy of the record. Often, the "drop box" does not provide an adequate selection to describe the history or physical. In anesthesia cases, for instance, the EHR drop box may allow only a description of "awake," "drowsy," or "unresponsive." These choices, while true, do not give an accurate picture of the patient. If a patient in the postanesthesia care unit is technically awake but not properly responsive, that should be documented.
Similarly, in the primary care physician’s office there are times when the general description of how a patient is looking can be informative and integral to the physician formulating an assessment. An example might be the case of a sick child. The child may be curious, playful, and smiling when pulling at the stethoscope. If we are using that information as an important part of our decision as to whether or not that child is seriously ill, then that level of detail should be included in the record. The term "NAD" (no acute distress) does not reflect the level of observation that influenced the decision not to do further testing.
If the drop box is the only source of information utilized, then the true description of the patient is not contained within the records. Sometimes, the most important bits of information cannot be explained utilizing drop boxes.
Another common issue is the failure of EHRs to document when a patient calls the physician’s office but is not actually seen for an appointment. The patient alleges that he or she called the doctor multiple times to report a problem. The HER, however, may not have any record of such a phone call. Physicians need to ensure that they are made aware of these telephone calls and that some type of note is made. The note should not just indicate that a call was made but also should document the physician response and recommendations.
Finally, a new area of concern that has emerged is failure to follow up on a recommendation once it has been made. An ideal situation would be for the EHR or physician office to send a follow-up reminder if an important test is not done. This reminder to the patient should be recorded as well as whether the patient went through with the recommendation and steps the health care provider took to encourage compliance.
This overview does not represent an exhaustive list of EHR issues but rather highlights some common issues along with steps that can be taken to minimize errors, with a goal of increasing overall safety for the patient and decreasing liability for the health care provider.
Mr. Marcoz is a health care attorney in Wilmington, Del., who is shareholder at Marshall Dennehey Warner Coleman & Goggin in the Health Care Liability Practice Group. His areas of practice include medical malpractice and dental insurance defense. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Electronic health records have led to recent issues appearing in the court system that can potentially convolute physician defense. Both health care attorneys and physicians are grappling with new technology that brings with it the need for close attention to new areas of detail. Certain habits, or lack of habits, can affect the medical-legal environment. Physicians who are aware of these issues can take steps to reduce their exposure.
One of the largest problems seen with EHRs is the failure of physicians to review dictated records. After a note is dictated into the electronic system, health care providers should be encouraged to read it and any accompanying documentation such as prescriptions.
Voice recognition systems are not foolproof and can lead to inaccuracies in the transcription of operative reports, office notes, and prescriptions. When a doctor is deposed and has to explain that what the record says is not really what he or she meant it to say, it decreases his or her credibility with the jury and undermines subsequent testimony. When a physician says that the record is not an accurate representation of what occurred, the jury is left with an impression of carelessness and a failure on the doctor’s part to take the time to ensure patient safety. Taking a few minutes to guarantee the accuracy of the record at the time of creation can save years of explanation after a case has been instituted.
The failure of the physician to review his or her notes can also lead to the veracity of the EHR being called into question. We are aware of at least one case in which an emergency department physician was asked to testify at trial about her interaction with a patient from many years prior. Understandably, the emergency department physician did not have a recollection of the visit and intended to rely on the record. The EHR documented the care that was provided, but the physicians had not signed it. At trial, the doctor was not allowed to testify about what she did for the patient. The rationale was that the doctor did not recall what was done, and her failure to sign the EHR contemporaneously meant that there was no evidence that the EHR was accurate.
A physician should be able to say that his or her custom and practice is to review the EHR before it is finalized and make any updates or addendums as needed. That way, even if there is no signature, the physician has given credence to the accuracy of the records.
Health care providers should be encouraged to use the "free-text" section that is available when it adds to the accuracy of the record. Often, the "drop box" does not provide an adequate selection to describe the history or physical. In anesthesia cases, for instance, the EHR drop box may allow only a description of "awake," "drowsy," or "unresponsive." These choices, while true, do not give an accurate picture of the patient. If a patient in the postanesthesia care unit is technically awake but not properly responsive, that should be documented.
Similarly, in the primary care physician’s office there are times when the general description of how a patient is looking can be informative and integral to the physician formulating an assessment. An example might be the case of a sick child. The child may be curious, playful, and smiling when pulling at the stethoscope. If we are using that information as an important part of our decision as to whether or not that child is seriously ill, then that level of detail should be included in the record. The term "NAD" (no acute distress) does not reflect the level of observation that influenced the decision not to do further testing.
If the drop box is the only source of information utilized, then the true description of the patient is not contained within the records. Sometimes, the most important bits of information cannot be explained utilizing drop boxes.
Another common issue is the failure of EHRs to document when a patient calls the physician’s office but is not actually seen for an appointment. The patient alleges that he or she called the doctor multiple times to report a problem. The HER, however, may not have any record of such a phone call. Physicians need to ensure that they are made aware of these telephone calls and that some type of note is made. The note should not just indicate that a call was made but also should document the physician response and recommendations.
Finally, a new area of concern that has emerged is failure to follow up on a recommendation once it has been made. An ideal situation would be for the EHR or physician office to send a follow-up reminder if an important test is not done. This reminder to the patient should be recorded as well as whether the patient went through with the recommendation and steps the health care provider took to encourage compliance.
This overview does not represent an exhaustive list of EHR issues but rather highlights some common issues along with steps that can be taken to minimize errors, with a goal of increasing overall safety for the patient and decreasing liability for the health care provider.
Mr. Marcoz is a health care attorney in Wilmington, Del., who is shareholder at Marshall Dennehey Warner Coleman & Goggin in the Health Care Liability Practice Group. His areas of practice include medical malpractice and dental insurance defense. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Electronic health records have led to recent issues appearing in the court system that can potentially convolute physician defense. Both health care attorneys and physicians are grappling with new technology that brings with it the need for close attention to new areas of detail. Certain habits, or lack of habits, can affect the medical-legal environment. Physicians who are aware of these issues can take steps to reduce their exposure.
One of the largest problems seen with EHRs is the failure of physicians to review dictated records. After a note is dictated into the electronic system, health care providers should be encouraged to read it and any accompanying documentation such as prescriptions.
Voice recognition systems are not foolproof and can lead to inaccuracies in the transcription of operative reports, office notes, and prescriptions. When a doctor is deposed and has to explain that what the record says is not really what he or she meant it to say, it decreases his or her credibility with the jury and undermines subsequent testimony. When a physician says that the record is not an accurate representation of what occurred, the jury is left with an impression of carelessness and a failure on the doctor’s part to take the time to ensure patient safety. Taking a few minutes to guarantee the accuracy of the record at the time of creation can save years of explanation after a case has been instituted.
The failure of the physician to review his or her notes can also lead to the veracity of the EHR being called into question. We are aware of at least one case in which an emergency department physician was asked to testify at trial about her interaction with a patient from many years prior. Understandably, the emergency department physician did not have a recollection of the visit and intended to rely on the record. The EHR documented the care that was provided, but the physicians had not signed it. At trial, the doctor was not allowed to testify about what she did for the patient. The rationale was that the doctor did not recall what was done, and her failure to sign the EHR contemporaneously meant that there was no evidence that the EHR was accurate.
A physician should be able to say that his or her custom and practice is to review the EHR before it is finalized and make any updates or addendums as needed. That way, even if there is no signature, the physician has given credence to the accuracy of the records.
Health care providers should be encouraged to use the "free-text" section that is available when it adds to the accuracy of the record. Often, the "drop box" does not provide an adequate selection to describe the history or physical. In anesthesia cases, for instance, the EHR drop box may allow only a description of "awake," "drowsy," or "unresponsive." These choices, while true, do not give an accurate picture of the patient. If a patient in the postanesthesia care unit is technically awake but not properly responsive, that should be documented.
Similarly, in the primary care physician’s office there are times when the general description of how a patient is looking can be informative and integral to the physician formulating an assessment. An example might be the case of a sick child. The child may be curious, playful, and smiling when pulling at the stethoscope. If we are using that information as an important part of our decision as to whether or not that child is seriously ill, then that level of detail should be included in the record. The term "NAD" (no acute distress) does not reflect the level of observation that influenced the decision not to do further testing.
If the drop box is the only source of information utilized, then the true description of the patient is not contained within the records. Sometimes, the most important bits of information cannot be explained utilizing drop boxes.
Another common issue is the failure of EHRs to document when a patient calls the physician’s office but is not actually seen for an appointment. The patient alleges that he or she called the doctor multiple times to report a problem. The HER, however, may not have any record of such a phone call. Physicians need to ensure that they are made aware of these telephone calls and that some type of note is made. The note should not just indicate that a call was made but also should document the physician response and recommendations.
Finally, a new area of concern that has emerged is failure to follow up on a recommendation once it has been made. An ideal situation would be for the EHR or physician office to send a follow-up reminder if an important test is not done. This reminder to the patient should be recorded as well as whether the patient went through with the recommendation and steps the health care provider took to encourage compliance.
This overview does not represent an exhaustive list of EHR issues but rather highlights some common issues along with steps that can be taken to minimize errors, with a goal of increasing overall safety for the patient and decreasing liability for the health care provider.
Mr. Marcoz is a health care attorney in Wilmington, Del., who is shareholder at Marshall Dennehey Warner Coleman & Goggin in the Health Care Liability Practice Group. His areas of practice include medical malpractice and dental insurance defense. 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, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
