Neil Skolnik, MD

Our past several columns have focused on the challenges presented by EHR technology, as viewed through the experience of our readers. The response to our request for feedback has been truly astounding, and in spite of an attempt to present a balanced perspective, there has certainly been a bias toward frustration with the current state of health IT.

But even with the challenges of today, we’ve always believed there are better days ahead. We constantly find ourselves asking: What will the future of EHRs look like, and how will the questions of today be answered by the innovations of tomorrow? Will the questions even still apply? As health care continues to evolve, will it lead the change in technology, or will advancements in technology shape the future of health care?

Recently, we had the opportunity to catch a glimpse of that future and find some answers to our questions, while attending a users’ conference presented by a major EHR vendor. As the company laid out its vision for tomorrow, several core themes were woven throughout it. We’ll attempt to highlight some of those here but will also offer this disclaimer: We left feeling encouraged overall by what we saw but certainly recognize that many might find their ideas challenging or even threatening to the way they practice. If the ideas below become reality – and it appears many already are – the landscape of medicine will be changed dramatically and hardly resemble the way it appears today. In other words, regardless of whether or not we are ready for it, change is coming and will redraw the map for the next generation of health care delivery. Here are some of the ways that will happen.

Patient engagement: Giving your patients the wheel

One of the most significant themes that ran through the conference was the idea of patient engagement. This has long been a "holy grail" in medicine, and one that seemed – at times – impossible to achieve. Any success was completely dependent on the talents of the physician and willingness of the patient, and no tools existed to help make it happen. That has completely changed. Enhancements to existing EHR software are finally putting patients at the very center of their care.

We have spoken before of web-based patient portals that allow patients to view labs and medication lists, but this is just the beginning. Now, vendors have created "apps" for iOS and Android devices, that completely integrate with the EHR. With these, patients are able to both view information and interact with their physicians in new ways. From a mobile device, a patient can now schedule an appointment, check in upon arriving at the office without interacting with the front desk, and even receive a text message when the doctor is ready to see them. They can also upload readings from connected devices, such as BP cuffs or glucometers, and see those data filter directly into the electronic medical record automatically.

Now we realize that some might see the EHR revolution as detrimental to the physician-patient relationship and accuse it of dehumanizing care. Throughout the last few months, we have received and repeatedly published those concerns. But there is no question that patients who are more engaged in their care have better overall outcomes and improved satisfaction. Also, the current generation of patients uses their smartphones for everything, eschewing paper and even their PCs for organization and communication. EHR vendors have decided to leverage this in an attempt to enhance care. For example, the new applications can remind patients about important health interventions (e.g., "You’re due for a mammogram."), and automate the process of communicating appointment reminders and health campaigns (e.g., "Get your flu shot now!").

Data: The new engine of progress

In almost every industry, information has become the currency of success. Headlines declaring that we are living in the era of "Big Data" assault us on all fronts, and health care is no exception. So many of our colleagues resent this idea, believing that the EHR has forced them to become glorified "data entry technicians." Adding to the frustration has been a limited ability to mine the data for salient information and manipulate it to improve outcomes and care outreach. But this is changing rapidly, and health IT vendors are finally placing a high priority on data collation tools to address these concerns. In response to changing trends in health policy, such as accountable care organizations and value-based care delivery, companies have developed tools that allow users to not only sort through their own data but also harness the power of a connected health network, and finally deliver on the promise of true population management and community health.

Quality: Passing the driver’s exam

Much of the confusion in health policy today stems from the seemingly countless quality incentive programs that exist at both the federal and state levels. From Meaningful Use and PCMH, to PQRS and HEDIS, it is easy to become overwhelmed by the myriad ways our care is being evaluated and monitored. Enhancements in EHR software are focusing in on quality, with the goal of streamlining and automating the process of reporting. Bringing all of those measures together, highlighting overlap, and simplifying data collection are just the first steps. Many new tools also offer suggestions for improvement and cost-benefit analyses to help providers determine which programs make financial sense, and which will end up being more trouble than they are worth.

Follow the map or take the road less traveled?

We want to again acknowledge the controversy in all of these concepts. Issues like patient empowerment and quality assessment seem in many ways to fly in the face of medicine’s tradition of physician autonomy and respect. Certainly there are those who will continue to resist complying with the above trends, and for many – especially those close to retirement – that might make good sense. But for the rest of us who are fearful that health care is becoming a commodity, we have to at least acknowledge that patients are consumers and are increasingly able to make informed decisions about how and where they purchase care. If for no other reason, that should force us to consider getting rid of our "maps" and investing in a new "GPS"; with how fast things are moving, soon there may not be time to stop and ask for directions when we get lost!

Dr. Notte practices family medicine and health care informatics at Abington (Pa.) Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a company that creates mobile apps. They are partners in EHR Practice Consultants. Contact them at [email protected].

Our past several columns have focused on the challenges presented by EHR technology, as viewed through the experience of our readers. The response to our request for feedback has been truly astounding, and in spite of an attempt to present a balanced perspective, there has certainly been a bias toward frustration with the current state of health IT.

But even with the challenges of today, we’ve always believed there are better days ahead. We constantly find ourselves asking: What will the future of EHRs look like, and how will the questions of today be answered by the innovations of tomorrow? Will the questions even still apply? As health care continues to evolve, will it lead the change in technology, or will advancements in technology shape the future of health care?

Recently, we had the opportunity to catch a glimpse of that future and find some answers to our questions, while attending a users’ conference presented by a major EHR vendor. As the company laid out its vision for tomorrow, several core themes were woven throughout it. We’ll attempt to highlight some of those here but will also offer this disclaimer: We left feeling encouraged overall by what we saw but certainly recognize that many might find their ideas challenging or even threatening to the way they practice. If the ideas below become reality – and it appears many already are – the landscape of medicine will be changed dramatically and hardly resemble the way it appears today. In other words, regardless of whether or not we are ready for it, change is coming and will redraw the map for the next generation of health care delivery. Here are some of the ways that will happen.

Patient engagement: Giving your patients the wheel

One of the most significant themes that ran through the conference was the idea of patient engagement. This has long been a "holy grail" in medicine, and one that seemed – at times – impossible to achieve. Any success was completely dependent on the talents of the physician and willingness of the patient, and no tools existed to help make it happen. That has completely changed. Enhancements to existing EHR software are finally putting patients at the very center of their care.

We have spoken before of web-based patient portals that allow patients to view labs and medication lists, but this is just the beginning. Now, vendors have created "apps" for iOS and Android devices, that completely integrate with the EHR. With these, patients are able to both view information and interact with their physicians in new ways. From a mobile device, a patient can now schedule an appointment, check in upon arriving at the office without interacting with the front desk, and even receive a text message when the doctor is ready to see them. They can also upload readings from connected devices, such as BP cuffs or glucometers, and see those data filter directly into the electronic medical record automatically.

Now we realize that some might see the EHR revolution as detrimental to the physician-patient relationship and accuse it of dehumanizing care. Throughout the last few months, we have received and repeatedly published those concerns. But there is no question that patients who are more engaged in their care have better overall outcomes and improved satisfaction. Also, the current generation of patients uses their smartphones for everything, eschewing paper and even their PCs for organization and communication. EHR vendors have decided to leverage this in an attempt to enhance care. For example, the new applications can remind patients about important health interventions (e.g., "You’re due for a mammogram."), and automate the process of communicating appointment reminders and health campaigns (e.g., "Get your flu shot now!").

Data: The new engine of progress

In almost every industry, information has become the currency of success. Headlines declaring that we are living in the era of "Big Data" assault us on all fronts, and health care is no exception. So many of our colleagues resent this idea, believing that the EHR has forced them to become glorified "data entry technicians." Adding to the frustration has been a limited ability to mine the data for salient information and manipulate it to improve outcomes and care outreach. But this is changing rapidly, and health IT vendors are finally placing a high priority on data collation tools to address these concerns. In response to changing trends in health policy, such as accountable care organizations and value-based care delivery, companies have developed tools that allow users to not only sort through their own data but also harness the power of a connected health network, and finally deliver on the promise of true population management and community health.

Quality: Passing the driver’s exam

Much of the confusion in health policy today stems from the seemingly countless quality incentive programs that exist at both the federal and state levels. From Meaningful Use and PCMH, to PQRS and HEDIS, it is easy to become overwhelmed by the myriad ways our care is being evaluated and monitored. Enhancements in EHR software are focusing in on quality, with the goal of streamlining and automating the process of reporting. Bringing all of those measures together, highlighting overlap, and simplifying data collection are just the first steps. Many new tools also offer suggestions for improvement and cost-benefit analyses to help providers determine which programs make financial sense, and which will end up being more trouble than they are worth.

Follow the map or take the road less traveled?

We want to again acknowledge the controversy in all of these concepts. Issues like patient empowerment and quality assessment seem in many ways to fly in the face of medicine’s tradition of physician autonomy and respect. Certainly there are those who will continue to resist complying with the above trends, and for many – especially those close to retirement – that might make good sense. But for the rest of us who are fearful that health care is becoming a commodity, we have to at least acknowledge that patients are consumers and are increasingly able to make informed decisions about how and where they purchase care. If for no other reason, that should force us to consider getting rid of our "maps" and investing in a new "GPS"; with how fast things are moving, soon there may not be time to stop and ask for directions when we get lost!

Dr. Notte practices family medicine and health care informatics at Abington (Pa.) Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a company that creates mobile apps. They are partners in EHR Practice Consultants. Contact them at [email protected].

Our past several columns have focused on the challenges presented by EHR technology, as viewed through the experience of our readers. The response to our request for feedback has been truly astounding, and in spite of an attempt to present a balanced perspective, there has certainly been a bias toward frustration with the current state of health IT.

But even with the challenges of today, we’ve always believed there are better days ahead. We constantly find ourselves asking: What will the future of EHRs look like, and how will the questions of today be answered by the innovations of tomorrow? Will the questions even still apply? As health care continues to evolve, will it lead the change in technology, or will advancements in technology shape the future of health care?

Recently, we had the opportunity to catch a glimpse of that future and find some answers to our questions, while attending a users’ conference presented by a major EHR vendor. As the company laid out its vision for tomorrow, several core themes were woven throughout it. We’ll attempt to highlight some of those here but will also offer this disclaimer: We left feeling encouraged overall by what we saw but certainly recognize that many might find their ideas challenging or even threatening to the way they practice. If the ideas below become reality – and it appears many already are – the landscape of medicine will be changed dramatically and hardly resemble the way it appears today. In other words, regardless of whether or not we are ready for it, change is coming and will redraw the map for the next generation of health care delivery. Here are some of the ways that will happen.

Patient engagement: Giving your patients the wheel

One of the most significant themes that ran through the conference was the idea of patient engagement. This has long been a "holy grail" in medicine, and one that seemed – at times – impossible to achieve. Any success was completely dependent on the talents of the physician and willingness of the patient, and no tools existed to help make it happen. That has completely changed. Enhancements to existing EHR software are finally putting patients at the very center of their care.

We have spoken before of web-based patient portals that allow patients to view labs and medication lists, but this is just the beginning. Now, vendors have created "apps" for iOS and Android devices, that completely integrate with the EHR. With these, patients are able to both view information and interact with their physicians in new ways. From a mobile device, a patient can now schedule an appointment, check in upon arriving at the office without interacting with the front desk, and even receive a text message when the doctor is ready to see them. They can also upload readings from connected devices, such as BP cuffs or glucometers, and see those data filter directly into the electronic medical record automatically.

Now we realize that some might see the EHR revolution as detrimental to the physician-patient relationship and accuse it of dehumanizing care. Throughout the last few months, we have received and repeatedly published those concerns. But there is no question that patients who are more engaged in their care have better overall outcomes and improved satisfaction. Also, the current generation of patients uses their smartphones for everything, eschewing paper and even their PCs for organization and communication. EHR vendors have decided to leverage this in an attempt to enhance care. For example, the new applications can remind patients about important health interventions (e.g., "You’re due for a mammogram."), and automate the process of communicating appointment reminders and health campaigns (e.g., "Get your flu shot now!").

Data: The new engine of progress

In almost every industry, information has become the currency of success. Headlines declaring that we are living in the era of "Big Data" assault us on all fronts, and health care is no exception. So many of our colleagues resent this idea, believing that the EHR has forced them to become glorified "data entry technicians." Adding to the frustration has been a limited ability to mine the data for salient information and manipulate it to improve outcomes and care outreach. But this is changing rapidly, and health IT vendors are finally placing a high priority on data collation tools to address these concerns. In response to changing trends in health policy, such as accountable care organizations and value-based care delivery, companies have developed tools that allow users to not only sort through their own data but also harness the power of a connected health network, and finally deliver on the promise of true population management and community health.

Quality: Passing the driver’s exam

Much of the confusion in health policy today stems from the seemingly countless quality incentive programs that exist at both the federal and state levels. From Meaningful Use and PCMH, to PQRS and HEDIS, it is easy to become overwhelmed by the myriad ways our care is being evaluated and monitored. Enhancements in EHR software are focusing in on quality, with the goal of streamlining and automating the process of reporting. Bringing all of those measures together, highlighting overlap, and simplifying data collection are just the first steps. Many new tools also offer suggestions for improvement and cost-benefit analyses to help providers determine which programs make financial sense, and which will end up being more trouble than they are worth.

Follow the map or take the road less traveled?

We want to again acknowledge the controversy in all of these concepts. Issues like patient empowerment and quality assessment seem in many ways to fly in the face of medicine’s tradition of physician autonomy and respect. Certainly there are those who will continue to resist complying with the above trends, and for many – especially those close to retirement – that might make good sense. But for the rest of us who are fearful that health care is becoming a commodity, we have to at least acknowledge that patients are consumers and are increasingly able to make informed decisions about how and where they purchase care. If for no other reason, that should force us to consider getting rid of our "maps" and investing in a new "GPS"; with how fast things are moving, soon there may not be time to stop and ask for directions when we get lost!

Dr. Notte practices family medicine and health care informatics at Abington (Pa.) Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a company that creates mobile apps. They are partners in EHR Practice Consultants. Contact them at [email protected].

Celiac disease affects roughly 1% of the general population. While most physicians recognize the gluten-free diet as the treatment of choice, identification and appropriate diagnostic testing are often a challenge.

In February 2013, the American College of Gastroenterology released guidelines on the work-up of celiac disease and recommendations on management.

Celiac disease results from inflammation of the mucosa of the small intestine, causing blunting of villi, which leads to a loss of absorptive area and subsequent decreased absorption of vitamins and minerals. Symptoms typically include abdominal pain and bloating, diarrhea, and weight loss with less-common symptoms of dyspepsia, constipation, and neuropathy. Presentation can often be subtle, and the decision to embark on diagnostic testing requires an understanding that patient may present with nonspecific symptoms and signs including iron deficiency, weight loss, abnormal transaminases, irritable bowel symptoms, infertility, amenorrhea, and chronic fatigue. Celiac disease has been associated with various conditions, including diseases of the thyroid, unexplained iron-deficiency anemia, elevated transaminases, and even seizures. When celiac disease is treated the associated symptoms resolve. If left untreated, the disease can progress and cause decreased bone mineralization, increasing fatigue, gastrointestinal symptoms, anemia, weight loss, peripheral neuropathy, menstrual abnormalities, and cancer, particularly lymphoma of the small bowel and esophagus.

Celiac disease is associated with other medical conditions, particularly type 1 diabetes mellitus, and Down syndrome. Between 3% and 10% of patients with type 1 diabetes will test positive for celiac disease and approximately 10% of those with Down syndrome test positive.

In addition to its relationship to certain medical conditions, celiac disease shows a genetic predominance. There is approximately a 20% elevated risk of celiac disease in siblings and 10% in other first-degree relatives and up to 5% in second-degree relatives of patients who have been diagnosed with celiac disease. Celiac disease has a strong relation to testing positive for the HLA-DQ gene, perhaps explaining not only its genetic predominance but also its connection to certain other diseases, such as type 1 diabetes, which also has an increased prevalence in individuals with positive HLA-DQ typing.

The diagnosis of celiac disease relies on two factors: the genetic risk of a patient to develop the condition, and the symptomatology of that patient. In the past, antigliadin antibodies and antiendomysial antibodies served as diagnostic markers, although each suffered from a relatively low sensitivity and specificity for the condition. Testing for antitissue transglutaminase (anti-TTG) antibodies is now the diagnostic test of choice as it is more sensitive and specific for celiac disease than its two predecessors. Anti-TTG should be ordered in the following individuals:

• Those with a first-degree relative diagnosed with celiac disease, regardless of whether currently expressing symptoms.

• Those with symptoms suggestive of celiac disease.

• Those expressing symptoms and concurrently suffering from a predisposing condition, such as type 1 diabetes.

The correct diagnostic algorithm for ruling-in celiac disease in most situations is to first test with anti-TTG antibodies and then to confirm the positive antibody finding with a small bowel biopsy looking for villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes. A trial of a gluten-free diet is not recommended to help establish the diagnosis of celiac disease because both celiac disease and nonceliac gluten sensitivity will respond to the gluten-free diet; only the former has known associated morbidity. In addition, strict adherence of the diet will cause levels of anti-TTG antibodies to drop to within normal limits, with the time for this to occur varying from patient to patient.

If a patient is already on a gluten-free diet, HLA-DQ typing can be helpful in ruling out celiac disease as it is found in the vast majority of those suffering from that disease, with a negative predictive value of 99%. A positive finding on HLA-DQ typing is not specific though, so is not useful for ruling in the diagnosis of celiac disease, as it is found in numerous other conditions including type 1 diabetes as well as in individuals without other illness. Anti-TTG antibodies can have false-negative results in the setting of a patient with IgA deficiency. IgA deficiency is rare in the general population, with a prevalence of about 0.2%, but has about a 10-fold higher prevalence in patients with celiac disease, affecting about 2%-3% of patients. Therefore, when the suspicion of celiac disease is high, it is reasonable to check total IgA levels in addition to anti-TTG antibodies and to consider further diagnostic testing beyond anti-TTG if total IgA levels are low.

Treatment for celiac disease is a gluten-free diet, with avoidance of foods or drinks made with or containing wheat, rye, or barley. For dietary advice, monitoring, and follow-up, referral to a nutritionist is important. In addition, the patient should advise first-degree relatives on the need to get tested for the condition. Follow-up should confirm the resolution of elevated anti-TTG antibodies on a gluten-free diet. Ongoing follow-up should be done on an annual basis, providing support for compliance with a gluten-free diet and checking antibodies to confirm control of the disease.

The Bottom Line

Celiac disease affects roughly 1% of patients and often goes undiagnosed. Elevated anti-TTG with confirmatory duodenal biopsy establishes the diagnosis. Treatment consists of lifelong adherence to a gluten-free diet.

Reference

Rubio-Tapia, A., Hill, I., Ciaran, K., Calderwood, A., & Murray, J. ACG clinical guidelines: Diagnosis and management of celiac disease (Am. J. Gastroenterol. 2013;108:656-76).

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 medicine residency program at Abington.

Celiac disease affects roughly 1% of the general population. While most physicians recognize the gluten-free diet as the treatment of choice, identification and appropriate diagnostic testing are often a challenge.

In February 2013, the American College of Gastroenterology released guidelines on the work-up of celiac disease and recommendations on management.

Celiac disease results from inflammation of the mucosa of the small intestine, causing blunting of villi, which leads to a loss of absorptive area and subsequent decreased absorption of vitamins and minerals. Symptoms typically include abdominal pain and bloating, diarrhea, and weight loss with less-common symptoms of dyspepsia, constipation, and neuropathy. Presentation can often be subtle, and the decision to embark on diagnostic testing requires an understanding that patient may present with nonspecific symptoms and signs including iron deficiency, weight loss, abnormal transaminases, irritable bowel symptoms, infertility, amenorrhea, and chronic fatigue. Celiac disease has been associated with various conditions, including diseases of the thyroid, unexplained iron-deficiency anemia, elevated transaminases, and even seizures. When celiac disease is treated the associated symptoms resolve. If left untreated, the disease can progress and cause decreased bone mineralization, increasing fatigue, gastrointestinal symptoms, anemia, weight loss, peripheral neuropathy, menstrual abnormalities, and cancer, particularly lymphoma of the small bowel and esophagus.

Celiac disease is associated with other medical conditions, particularly type 1 diabetes mellitus, and Down syndrome. Between 3% and 10% of patients with type 1 diabetes will test positive for celiac disease and approximately 10% of those with Down syndrome test positive.

In addition to its relationship to certain medical conditions, celiac disease shows a genetic predominance. There is approximately a 20% elevated risk of celiac disease in siblings and 10% in other first-degree relatives and up to 5% in second-degree relatives of patients who have been diagnosed with celiac disease. Celiac disease has a strong relation to testing positive for the HLA-DQ gene, perhaps explaining not only its genetic predominance but also its connection to certain other diseases, such as type 1 diabetes, which also has an increased prevalence in individuals with positive HLA-DQ typing.

The diagnosis of celiac disease relies on two factors: the genetic risk of a patient to develop the condition, and the symptomatology of that patient. In the past, antigliadin antibodies and antiendomysial antibodies served as diagnostic markers, although each suffered from a relatively low sensitivity and specificity for the condition. Testing for antitissue transglutaminase (anti-TTG) antibodies is now the diagnostic test of choice as it is more sensitive and specific for celiac disease than its two predecessors. Anti-TTG should be ordered in the following individuals:

• Those with a first-degree relative diagnosed with celiac disease, regardless of whether currently expressing symptoms.

• Those with symptoms suggestive of celiac disease.

• Those expressing symptoms and concurrently suffering from a predisposing condition, such as type 1 diabetes.

The correct diagnostic algorithm for ruling-in celiac disease in most situations is to first test with anti-TTG antibodies and then to confirm the positive antibody finding with a small bowel biopsy looking for villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes. A trial of a gluten-free diet is not recommended to help establish the diagnosis of celiac disease because both celiac disease and nonceliac gluten sensitivity will respond to the gluten-free diet; only the former has known associated morbidity. In addition, strict adherence of the diet will cause levels of anti-TTG antibodies to drop to within normal limits, with the time for this to occur varying from patient to patient.

If a patient is already on a gluten-free diet, HLA-DQ typing can be helpful in ruling out celiac disease as it is found in the vast majority of those suffering from that disease, with a negative predictive value of 99%. A positive finding on HLA-DQ typing is not specific though, so is not useful for ruling in the diagnosis of celiac disease, as it is found in numerous other conditions including type 1 diabetes as well as in individuals without other illness. Anti-TTG antibodies can have false-negative results in the setting of a patient with IgA deficiency. IgA deficiency is rare in the general population, with a prevalence of about 0.2%, but has about a 10-fold higher prevalence in patients with celiac disease, affecting about 2%-3% of patients. Therefore, when the suspicion of celiac disease is high, it is reasonable to check total IgA levels in addition to anti-TTG antibodies and to consider further diagnostic testing beyond anti-TTG if total IgA levels are low.

Treatment for celiac disease is a gluten-free diet, with avoidance of foods or drinks made with or containing wheat, rye, or barley. For dietary advice, monitoring, and follow-up, referral to a nutritionist is important. In addition, the patient should advise first-degree relatives on the need to get tested for the condition. Follow-up should confirm the resolution of elevated anti-TTG antibodies on a gluten-free diet. Ongoing follow-up should be done on an annual basis, providing support for compliance with a gluten-free diet and checking antibodies to confirm control of the disease.

The Bottom Line

Celiac disease affects roughly 1% of patients and often goes undiagnosed. Elevated anti-TTG with confirmatory duodenal biopsy establishes the diagnosis. Treatment consists of lifelong adherence to a gluten-free diet.

Reference

Rubio-Tapia, A., Hill, I., Ciaran, K., Calderwood, A., & Murray, J. ACG clinical guidelines: Diagnosis and management of celiac disease (Am. J. Gastroenterol. 2013;108:656-76).

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 medicine residency program at Abington.

Celiac disease affects roughly 1% of the general population. While most physicians recognize the gluten-free diet as the treatment of choice, identification and appropriate diagnostic testing are often a challenge.

In February 2013, the American College of Gastroenterology released guidelines on the work-up of celiac disease and recommendations on management.

Celiac disease results from inflammation of the mucosa of the small intestine, causing blunting of villi, which leads to a loss of absorptive area and subsequent decreased absorption of vitamins and minerals. Symptoms typically include abdominal pain and bloating, diarrhea, and weight loss with less-common symptoms of dyspepsia, constipation, and neuropathy. Presentation can often be subtle, and the decision to embark on diagnostic testing requires an understanding that patient may present with nonspecific symptoms and signs including iron deficiency, weight loss, abnormal transaminases, irritable bowel symptoms, infertility, amenorrhea, and chronic fatigue. Celiac disease has been associated with various conditions, including diseases of the thyroid, unexplained iron-deficiency anemia, elevated transaminases, and even seizures. When celiac disease is treated the associated symptoms resolve. If left untreated, the disease can progress and cause decreased bone mineralization, increasing fatigue, gastrointestinal symptoms, anemia, weight loss, peripheral neuropathy, menstrual abnormalities, and cancer, particularly lymphoma of the small bowel and esophagus.

Celiac disease is associated with other medical conditions, particularly type 1 diabetes mellitus, and Down syndrome. Between 3% and 10% of patients with type 1 diabetes will test positive for celiac disease and approximately 10% of those with Down syndrome test positive.

In addition to its relationship to certain medical conditions, celiac disease shows a genetic predominance. There is approximately a 20% elevated risk of celiac disease in siblings and 10% in other first-degree relatives and up to 5% in second-degree relatives of patients who have been diagnosed with celiac disease. Celiac disease has a strong relation to testing positive for the HLA-DQ gene, perhaps explaining not only its genetic predominance but also its connection to certain other diseases, such as type 1 diabetes, which also has an increased prevalence in individuals with positive HLA-DQ typing.

The diagnosis of celiac disease relies on two factors: the genetic risk of a patient to develop the condition, and the symptomatology of that patient. In the past, antigliadin antibodies and antiendomysial antibodies served as diagnostic markers, although each suffered from a relatively low sensitivity and specificity for the condition. Testing for antitissue transglutaminase (anti-TTG) antibodies is now the diagnostic test of choice as it is more sensitive and specific for celiac disease than its two predecessors. Anti-TTG should be ordered in the following individuals:

• Those with a first-degree relative diagnosed with celiac disease, regardless of whether currently expressing symptoms.

• Those with symptoms suggestive of celiac disease.

• Those expressing symptoms and concurrently suffering from a predisposing condition, such as type 1 diabetes.

The correct diagnostic algorithm for ruling-in celiac disease in most situations is to first test with anti-TTG antibodies and then to confirm the positive antibody finding with a small bowel biopsy looking for villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes. A trial of a gluten-free diet is not recommended to help establish the diagnosis of celiac disease because both celiac disease and nonceliac gluten sensitivity will respond to the gluten-free diet; only the former has known associated morbidity. In addition, strict adherence of the diet will cause levels of anti-TTG antibodies to drop to within normal limits, with the time for this to occur varying from patient to patient.

If a patient is already on a gluten-free diet, HLA-DQ typing can be helpful in ruling out celiac disease as it is found in the vast majority of those suffering from that disease, with a negative predictive value of 99%. A positive finding on HLA-DQ typing is not specific though, so is not useful for ruling in the diagnosis of celiac disease, as it is found in numerous other conditions including type 1 diabetes as well as in individuals without other illness. Anti-TTG antibodies can have false-negative results in the setting of a patient with IgA deficiency. IgA deficiency is rare in the general population, with a prevalence of about 0.2%, but has about a 10-fold higher prevalence in patients with celiac disease, affecting about 2%-3% of patients. Therefore, when the suspicion of celiac disease is high, it is reasonable to check total IgA levels in addition to anti-TTG antibodies and to consider further diagnostic testing beyond anti-TTG if total IgA levels are low.

Treatment for celiac disease is a gluten-free diet, with avoidance of foods or drinks made with or containing wheat, rye, or barley. For dietary advice, monitoring, and follow-up, referral to a nutritionist is important. In addition, the patient should advise first-degree relatives on the need to get tested for the condition. Follow-up should confirm the resolution of elevated anti-TTG antibodies on a gluten-free diet. Ongoing follow-up should be done on an annual basis, providing support for compliance with a gluten-free diet and checking antibodies to confirm control of the disease.

The Bottom Line

Celiac disease affects roughly 1% of patients and often goes undiagnosed. Elevated anti-TTG with confirmatory duodenal biopsy establishes the diagnosis. Treatment consists of lifelong adherence to a gluten-free diet.

Reference

Rubio-Tapia, A., Hill, I., Ciaran, K., Calderwood, A., & Murray, J. ACG clinical guidelines: Diagnosis and management of celiac disease (Am. J. Gastroenterol. 2013;108:656-76).

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 medicine residency program at Abington.

Exercise-induced bronchoconstriction is defined as acute, reversible airway narrowing that occurs during or after strenuous exercise. It is a very common problem, especially in physically active people, and can occur with or without underlying asthma. It is estimated that 10%-20% of the general population and up to 90% of people previously diagnosed with asthma have exercise-induced bronchoconstriction. Some studies suggest that exercise-induced bronchoconstriction can occur in as many as 30-70% of Olympic or elite-level athletes.

The following evidence-based guidelines were developed by the American Thoracic Society (ATS) to provide clinicians with practical guidance for the diagnosis and treatment of exercise-induced bronchoconstriction (EIB).

Diagnosis

Diagnosing EIB can be difficult as symptoms tend to be nonspecific and variable. Further, the presence or absence of common respiratory symptoms (such as chest tightness, cough, wheezing, and dyspnea) has very poor predictive value for the confirmation of EIB. Symptom severity ranges from mild to moderate – defined as causing impairment of athletic performance but rarely significant respiratory distress – and can be provoked by exercise or specific environments such as snowy mountains, ice rinks, or indoor swimming pools. An official EIB diagnosis should be established by monitoring changes in lung function provoked by exercise, not simply on the basis of symptoms.

Testing

To determine if EIB is present and to quantify the severity of the disorder, providers should conduct serial lung function measurements after a specific exercise or hyperpnea challenge. An example of an exercise challenge protocol is 5-8 minutes of exercise at 85% of maximum heart rate or 80% of maximal oxygen uptake (80% VO₂ max). The type, duration, and intensity of exercise and the temperature and water content of the air are variables that should be considered. According to ATS and the European Respiratory Society guidelines, at least two reproducible FEV₁ (forced expiratory volume in 1 second) values should be measured after the exercise challenge, with the highest value recorded at each interval – usually 5, 10, 15, and 30 minutes after exercise. Experts prefer measuring FEV₁ because it is more discriminating and has better repeatability than peak expiratory flow rate.

There are a number of alternatives for testing, described in detail in ATS’s online supplement, which may be easier to implement than exercise challenges. These alternatives include eucapnic voluntary hyperpnea of dry air and inhalation of hyperosmolar aerosols of 4.5% saline or dry powder mannitol.

Interpreting results

Airway response is first calculated by finding the difference between the pre-exercise FEV₁ value and the lowest FEV₁ value recorded within 30 minutes after exercise. The percent fall in FEV₁ from the baseline value is used to diagnose EIB, requiring a percentage fall of greater than 10% for official diagnosis. The severity of EIB can be graded as mild (more than 10% but less than 25% fall in FEV₁), moderate (more than 25% but less than 50%), or severe (more than 50%).

Treatment

To prevent EIB, ATS recommends that patients use an inhaled short-acting beta₂-agonist (SABA) 15 minutes prior to exercise and perform "interval or combination warm-up exercises" when possible. Use of a SABA prior to exercise provides 2-4 hours of attenuation of exercise-induced bronchospasm. Because of the potential for environmental triggers, ATS also recommends routine use of an air-warming and humidifying mask during exercise in cold weather. Daily use of a SABA may result in the development of tolerance, with reduction in the amount and duration of protection from EIB. This is thought to be due to desensitization of the beta₂-receptors on mast cells.

For patients who have an inadequate response to an inhaled SABA before exercise and/or patients who require an inhaled SABA daily or more frequently, a controller agent such as an inhaled corticosteroid or a leukotriene receptor antagonist is recommended. Patients should be informed that maximal therapeutic benefit may take 2-4 treatment weeks.

In addition to the daily regime, ATS suggests the addition of a mast cell stabilizing agent or an inhaled anticholinergic agent before exercise if needed (both are relatively weaker recommendations). And finally, they recommend against daily use of an inhaled long-acting beta₂-agonist (LABA) as a single therapy because of the strong concern for adverse side effects.

Special provisions

ATS recommends antihistamine use for patients with EIB and allergies who continue to be symptomatic despite daily or more frequent inhaled SABA use. They recommend against using antihistamines for patients who have EIB but who do not have allergies.

ATS also provides some weaker recommendations for those who want to control EIB symptoms with dietary modification. A low-salt diet supplemented with fish oils and ascorbic acid may increase symptom control.

Bottom line

EIB is an acute, reversible airway narrowing that occurs during or after strenuous exercise. A high percentage of physically active patients have EIB, regardless of whether they have underlying asthma conditions. Administration of an inhaled SABA 15 minutes prior to exercise and a variety of warm-up exercises act as a first-line treatment, with an inhaled corticosteroid or a leukotriene receptor antagonist effective for those who do not respond to the SABA alone.

Reference

J. P. Parsons et al. "An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction," Am. J. Respir. Crit. Care Med. 2013;187:1016-27.

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. Beddis is an attending physician in the Abington Health Network at Wyncote Family Medicine.

Exercise-induced bronchoconstriction is defined as acute, reversible airway narrowing that occurs during or after strenuous exercise. It is a very common problem, especially in physically active people, and can occur with or without underlying asthma. It is estimated that 10%-20% of the general population and up to 90% of people previously diagnosed with asthma have exercise-induced bronchoconstriction. Some studies suggest that exercise-induced bronchoconstriction can occur in as many as 30-70% of Olympic or elite-level athletes.

The following evidence-based guidelines were developed by the American Thoracic Society (ATS) to provide clinicians with practical guidance for the diagnosis and treatment of exercise-induced bronchoconstriction (EIB).

Diagnosis

Diagnosing EIB can be difficult as symptoms tend to be nonspecific and variable. Further, the presence or absence of common respiratory symptoms (such as chest tightness, cough, wheezing, and dyspnea) has very poor predictive value for the confirmation of EIB. Symptom severity ranges from mild to moderate – defined as causing impairment of athletic performance but rarely significant respiratory distress – and can be provoked by exercise or specific environments such as snowy mountains, ice rinks, or indoor swimming pools. An official EIB diagnosis should be established by monitoring changes in lung function provoked by exercise, not simply on the basis of symptoms.

Testing

To determine if EIB is present and to quantify the severity of the disorder, providers should conduct serial lung function measurements after a specific exercise or hyperpnea challenge. An example of an exercise challenge protocol is 5-8 minutes of exercise at 85% of maximum heart rate or 80% of maximal oxygen uptake (80% VO₂ max). The type, duration, and intensity of exercise and the temperature and water content of the air are variables that should be considered. According to ATS and the European Respiratory Society guidelines, at least two reproducible FEV₁ (forced expiratory volume in 1 second) values should be measured after the exercise challenge, with the highest value recorded at each interval – usually 5, 10, 15, and 30 minutes after exercise. Experts prefer measuring FEV₁ because it is more discriminating and has better repeatability than peak expiratory flow rate.

There are a number of alternatives for testing, described in detail in ATS’s online supplement, which may be easier to implement than exercise challenges. These alternatives include eucapnic voluntary hyperpnea of dry air and inhalation of hyperosmolar aerosols of 4.5% saline or dry powder mannitol.

Interpreting results

Airway response is first calculated by finding the difference between the pre-exercise FEV₁ value and the lowest FEV₁ value recorded within 30 minutes after exercise. The percent fall in FEV₁ from the baseline value is used to diagnose EIB, requiring a percentage fall of greater than 10% for official diagnosis. The severity of EIB can be graded as mild (more than 10% but less than 25% fall in FEV₁), moderate (more than 25% but less than 50%), or severe (more than 50%).

Treatment

To prevent EIB, ATS recommends that patients use an inhaled short-acting beta₂-agonist (SABA) 15 minutes prior to exercise and perform "interval or combination warm-up exercises" when possible. Use of a SABA prior to exercise provides 2-4 hours of attenuation of exercise-induced bronchospasm. Because of the potential for environmental triggers, ATS also recommends routine use of an air-warming and humidifying mask during exercise in cold weather. Daily use of a SABA may result in the development of tolerance, with reduction in the amount and duration of protection from EIB. This is thought to be due to desensitization of the beta₂-receptors on mast cells.

For patients who have an inadequate response to an inhaled SABA before exercise and/or patients who require an inhaled SABA daily or more frequently, a controller agent such as an inhaled corticosteroid or a leukotriene receptor antagonist is recommended. Patients should be informed that maximal therapeutic benefit may take 2-4 treatment weeks.

In addition to the daily regime, ATS suggests the addition of a mast cell stabilizing agent or an inhaled anticholinergic agent before exercise if needed (both are relatively weaker recommendations). And finally, they recommend against daily use of an inhaled long-acting beta₂-agonist (LABA) as a single therapy because of the strong concern for adverse side effects.

Special provisions

ATS recommends antihistamine use for patients with EIB and allergies who continue to be symptomatic despite daily or more frequent inhaled SABA use. They recommend against using antihistamines for patients who have EIB but who do not have allergies.

ATS also provides some weaker recommendations for those who want to control EIB symptoms with dietary modification. A low-salt diet supplemented with fish oils and ascorbic acid may increase symptom control.

Bottom line

EIB is an acute, reversible airway narrowing that occurs during or after strenuous exercise. A high percentage of physically active patients have EIB, regardless of whether they have underlying asthma conditions. Administration of an inhaled SABA 15 minutes prior to exercise and a variety of warm-up exercises act as a first-line treatment, with an inhaled corticosteroid or a leukotriene receptor antagonist effective for those who do not respond to the SABA alone.

Reference

J. P. Parsons et al. "An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction," Am. J. Respir. Crit. Care Med. 2013;187:1016-27.

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. Beddis is an attending physician in the Abington Health Network at Wyncote Family Medicine.

Exercise-induced bronchoconstriction is defined as acute, reversible airway narrowing that occurs during or after strenuous exercise. It is a very common problem, especially in physically active people, and can occur with or without underlying asthma. It is estimated that 10%-20% of the general population and up to 90% of people previously diagnosed with asthma have exercise-induced bronchoconstriction. Some studies suggest that exercise-induced bronchoconstriction can occur in as many as 30-70% of Olympic or elite-level athletes.

The following evidence-based guidelines were developed by the American Thoracic Society (ATS) to provide clinicians with practical guidance for the diagnosis and treatment of exercise-induced bronchoconstriction (EIB).

Diagnosis

Diagnosing EIB can be difficult as symptoms tend to be nonspecific and variable. Further, the presence or absence of common respiratory symptoms (such as chest tightness, cough, wheezing, and dyspnea) has very poor predictive value for the confirmation of EIB. Symptom severity ranges from mild to moderate – defined as causing impairment of athletic performance but rarely significant respiratory distress – and can be provoked by exercise or specific environments such as snowy mountains, ice rinks, or indoor swimming pools. An official EIB diagnosis should be established by monitoring changes in lung function provoked by exercise, not simply on the basis of symptoms.

Testing

To determine if EIB is present and to quantify the severity of the disorder, providers should conduct serial lung function measurements after a specific exercise or hyperpnea challenge. An example of an exercise challenge protocol is 5-8 minutes of exercise at 85% of maximum heart rate or 80% of maximal oxygen uptake (80% VO₂ max). The type, duration, and intensity of exercise and the temperature and water content of the air are variables that should be considered. According to ATS and the European Respiratory Society guidelines, at least two reproducible FEV₁ (forced expiratory volume in 1 second) values should be measured after the exercise challenge, with the highest value recorded at each interval – usually 5, 10, 15, and 30 minutes after exercise. Experts prefer measuring FEV₁ because it is more discriminating and has better repeatability than peak expiratory flow rate.

There are a number of alternatives for testing, described in detail in ATS’s online supplement, which may be easier to implement than exercise challenges. These alternatives include eucapnic voluntary hyperpnea of dry air and inhalation of hyperosmolar aerosols of 4.5% saline or dry powder mannitol.

Interpreting results

Airway response is first calculated by finding the difference between the pre-exercise FEV₁ value and the lowest FEV₁ value recorded within 30 minutes after exercise. The percent fall in FEV₁ from the baseline value is used to diagnose EIB, requiring a percentage fall of greater than 10% for official diagnosis. The severity of EIB can be graded as mild (more than 10% but less than 25% fall in FEV₁), moderate (more than 25% but less than 50%), or severe (more than 50%).

Treatment

To prevent EIB, ATS recommends that patients use an inhaled short-acting beta₂-agonist (SABA) 15 minutes prior to exercise and perform "interval or combination warm-up exercises" when possible. Use of a SABA prior to exercise provides 2-4 hours of attenuation of exercise-induced bronchospasm. Because of the potential for environmental triggers, ATS also recommends routine use of an air-warming and humidifying mask during exercise in cold weather. Daily use of a SABA may result in the development of tolerance, with reduction in the amount and duration of protection from EIB. This is thought to be due to desensitization of the beta₂-receptors on mast cells.

For patients who have an inadequate response to an inhaled SABA before exercise and/or patients who require an inhaled SABA daily or more frequently, a controller agent such as an inhaled corticosteroid or a leukotriene receptor antagonist is recommended. Patients should be informed that maximal therapeutic benefit may take 2-4 treatment weeks.

In addition to the daily regime, ATS suggests the addition of a mast cell stabilizing agent or an inhaled anticholinergic agent before exercise if needed (both are relatively weaker recommendations). And finally, they recommend against daily use of an inhaled long-acting beta₂-agonist (LABA) as a single therapy because of the strong concern for adverse side effects.

Special provisions

ATS recommends antihistamine use for patients with EIB and allergies who continue to be symptomatic despite daily or more frequent inhaled SABA use. They recommend against using antihistamines for patients who have EIB but who do not have allergies.

ATS also provides some weaker recommendations for those who want to control EIB symptoms with dietary modification. A low-salt diet supplemented with fish oils and ascorbic acid may increase symptom control.

Bottom line

EIB is an acute, reversible airway narrowing that occurs during or after strenuous exercise. A high percentage of physically active patients have EIB, regardless of whether they have underlying asthma conditions. Administration of an inhaled SABA 15 minutes prior to exercise and a variety of warm-up exercises act as a first-line treatment, with an inhaled corticosteroid or a leukotriene receptor antagonist effective for those who do not respond to the SABA alone.

Reference

J. P. Parsons et al. "An Official American Thoracic Society Clinical Practice Guideline: Exercise-induced Bronchoconstriction," Am. J. Respir. Crit. Care Med. 2013;187:1016-27.

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. Beddis is an attending physician in the Abington Health Network at Wyncote Family Medicine.

The response to our request for readers to share their experiences with electronic health records continues to be intense, with comments that generally recognize the advantages of EHRs but emphasize the challenges they have presented for workflow and patient interactions. Some responses are downright negative, and reflect a level of frustration and disappointment in a system that they feel is no longer working for them or their patients.

Mark Goldberg is a family doctor in Alpharetta, Ga. He has practiced in a variety of settings over the last 29 years, and recently moved to urgent care from traditional primary care medicine in large part because of EHR implementation in his office practice.

His practice, part of a large health system, was located in a rural, underserved county. He had been a part of that practice for 16 years, and worked in an office with four other physicians. He describes their practice as serving the community in all capacities, including walk-in, same-day appointments. As he says it, "If our patients needed us, we saw them." Their average appointment load per doctor was about 25-30 patients per day. Their practice used paper charts, which where often dictated. Dr. Goldberg, on making the transition to an EHR:

At large cost, the owners of the clinic implemented an EHR, and initial users were dissatisfied with both the difficulty of using the system and the way it slowed workflow. Training was intensive. Nonetheless, dissatisfaction was high.

The handwriting was on the wall, and I left the practice coincident with the implementation of the EHR. Sadly, my fears were realized for my ex-partners and my patients. Productivity dropped dramatically, and stays low to this day. The practice no longer sees walk-ins. The physicians barely see 20-22 patients per day, down about 20% from the number of patients seen before the EHR. The physicians are often there 2-4 hours after the office closes to finish typing their notes, whereas we used to leave within a half-hour of closing. One physician told me that he would only allow his patients to tell him one complaint per visit, because he didn’t feel he had time to document more. He also felt his notes in the EHR were much less complete than his dictated notes in the paper chart. Physician quality of life and family time has been dramatically impacted. Patients are angry and frustrated. Two other physicians ultimately left our practice as well and have been very hard to replace.

In my opinion, implementing EHR destroyed a healthy and happy practice that served its patients well, and filled a huge need in an underserved county. Three out of five physicians left the practice, leaving primary care for good. I do not feel that this was due to "poor implementation," as everyone in the practice had extensive training prior to going live. I see it more as a failure of the EHR vender to understand the workflow needs of physicians in a busy office setting.

Dr. Goldberg voices a point of view that, unfortunately, we’ve heard before – that EHRs change the way a practice runs, decrease productivity, and distance physicians from patients. The experience in his practice serves as a warning to others to be careful both with their expectations for their EHR, the selection of which EHR to purchase, and how to implement its use in their office.

Dr. Mel Chandler, a 66-year-old family physician from Edmonds, Wash., shared insights informed by seeing many changes to the practice of medicine over his long career:

I have had many experiences over the years including an elderly practice partner in my first 3 years who managed to keep all of his records on 3-by-5 cards in his desk. In the left-hand top drawer were his patient notes on these cards and in the right-top drawer, his 3-by-5 cards with records of the loans he made to his patients, often at no interest. It worked well for him, but not so well for those of us needing information when on call. For our records, we dictated a SOAP [subjective, objective, assessment, and plan] note. This worked well enough for years.

I believe the EHR may help with record keeping in a very limited fashion. The programs I have seen are complex, use templates, and make it difficult to enter information. I have resisted the use of templates previously so that I could freely think rather than have my thinking directed by a prescribed format. Over the last decade, I have changed my practice to focus purely on those who have severe mental illness. It is important for me to maintain eye contact or at minimum watch my clients at all times while they are in my presence. In my state of residence it is illegal to text and drive an automobile. This is because of the disastrous effects of the distraction of typing. Is my interaction with my patients no less important to perform with full attention than driving? We meet with patients/clients to have a person-to-person interaction to problem solve, teach, and often console.

The major point of my note is that we must "protect" the patient/physician interaction. We must support the concept that the manner in which we take a history and perform an exam is important and cannot be "cut short" by electronic devices that require us to take our eyes from the road ahead.

We admire Dr. Chandler’s analogy relating the importance of full attention to patients to the driving experience and seeing what is on the road.

Keep those emails and comments coming.

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 editor-in-chief of Redi-Reference, a company that creates mobile apps. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

The response to our request for readers to share their experiences with electronic health records continues to be intense, with comments that generally recognize the advantages of EHRs but emphasize the challenges they have presented for workflow and patient interactions. Some responses are downright negative, and reflect a level of frustration and disappointment in a system that they feel is no longer working for them or their patients.

Mark Goldberg is a family doctor in Alpharetta, Ga. He has practiced in a variety of settings over the last 29 years, and recently moved to urgent care from traditional primary care medicine in large part because of EHR implementation in his office practice.

His practice, part of a large health system, was located in a rural, underserved county. He had been a part of that practice for 16 years, and worked in an office with four other physicians. He describes their practice as serving the community in all capacities, including walk-in, same-day appointments. As he says it, "If our patients needed us, we saw them." Their average appointment load per doctor was about 25-30 patients per day. Their practice used paper charts, which where often dictated. Dr. Goldberg, on making the transition to an EHR:

At large cost, the owners of the clinic implemented an EHR, and initial users were dissatisfied with both the difficulty of using the system and the way it slowed workflow. Training was intensive. Nonetheless, dissatisfaction was high.

The handwriting was on the wall, and I left the practice coincident with the implementation of the EHR. Sadly, my fears were realized for my ex-partners and my patients. Productivity dropped dramatically, and stays low to this day. The practice no longer sees walk-ins. The physicians barely see 20-22 patients per day, down about 20% from the number of patients seen before the EHR. The physicians are often there 2-4 hours after the office closes to finish typing their notes, whereas we used to leave within a half-hour of closing. One physician told me that he would only allow his patients to tell him one complaint per visit, because he didn’t feel he had time to document more. He also felt his notes in the EHR were much less complete than his dictated notes in the paper chart. Physician quality of life and family time has been dramatically impacted. Patients are angry and frustrated. Two other physicians ultimately left our practice as well and have been very hard to replace.

In my opinion, implementing EHR destroyed a healthy and happy practice that served its patients well, and filled a huge need in an underserved county. Three out of five physicians left the practice, leaving primary care for good. I do not feel that this was due to "poor implementation," as everyone in the practice had extensive training prior to going live. I see it more as a failure of the EHR vender to understand the workflow needs of physicians in a busy office setting.

Dr. Goldberg voices a point of view that, unfortunately, we’ve heard before – that EHRs change the way a practice runs, decrease productivity, and distance physicians from patients. The experience in his practice serves as a warning to others to be careful both with their expectations for their EHR, the selection of which EHR to purchase, and how to implement its use in their office.

Dr. Mel Chandler, a 66-year-old family physician from Edmonds, Wash., shared insights informed by seeing many changes to the practice of medicine over his long career:

I have had many experiences over the years including an elderly practice partner in my first 3 years who managed to keep all of his records on 3-by-5 cards in his desk. In the left-hand top drawer were his patient notes on these cards and in the right-top drawer, his 3-by-5 cards with records of the loans he made to his patients, often at no interest. It worked well for him, but not so well for those of us needing information when on call. For our records, we dictated a SOAP [subjective, objective, assessment, and plan] note. This worked well enough for years.

I believe the EHR may help with record keeping in a very limited fashion. The programs I have seen are complex, use templates, and make it difficult to enter information. I have resisted the use of templates previously so that I could freely think rather than have my thinking directed by a prescribed format. Over the last decade, I have changed my practice to focus purely on those who have severe mental illness. It is important for me to maintain eye contact or at minimum watch my clients at all times while they are in my presence. In my state of residence it is illegal to text and drive an automobile. This is because of the disastrous effects of the distraction of typing. Is my interaction with my patients no less important to perform with full attention than driving? We meet with patients/clients to have a person-to-person interaction to problem solve, teach, and often console.

The major point of my note is that we must "protect" the patient/physician interaction. We must support the concept that the manner in which we take a history and perform an exam is important and cannot be "cut short" by electronic devices that require us to take our eyes from the road ahead.

We admire Dr. Chandler’s analogy relating the importance of full attention to patients to the driving experience and seeing what is on the road.

Keep those emails and comments coming.

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 editor-in-chief of Redi-Reference, a company that creates mobile apps. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

The response to our request for readers to share their experiences with electronic health records continues to be intense, with comments that generally recognize the advantages of EHRs but emphasize the challenges they have presented for workflow and patient interactions. Some responses are downright negative, and reflect a level of frustration and disappointment in a system that they feel is no longer working for them or their patients.

Mark Goldberg is a family doctor in Alpharetta, Ga. He has practiced in a variety of settings over the last 29 years, and recently moved to urgent care from traditional primary care medicine in large part because of EHR implementation in his office practice.

His practice, part of a large health system, was located in a rural, underserved county. He had been a part of that practice for 16 years, and worked in an office with four other physicians. He describes their practice as serving the community in all capacities, including walk-in, same-day appointments. As he says it, "If our patients needed us, we saw them." Their average appointment load per doctor was about 25-30 patients per day. Their practice used paper charts, which where often dictated. Dr. Goldberg, on making the transition to an EHR:

At large cost, the owners of the clinic implemented an EHR, and initial users were dissatisfied with both the difficulty of using the system and the way it slowed workflow. Training was intensive. Nonetheless, dissatisfaction was high.

The handwriting was on the wall, and I left the practice coincident with the implementation of the EHR. Sadly, my fears were realized for my ex-partners and my patients. Productivity dropped dramatically, and stays low to this day. The practice no longer sees walk-ins. The physicians barely see 20-22 patients per day, down about 20% from the number of patients seen before the EHR. The physicians are often there 2-4 hours after the office closes to finish typing their notes, whereas we used to leave within a half-hour of closing. One physician told me that he would only allow his patients to tell him one complaint per visit, because he didn’t feel he had time to document more. He also felt his notes in the EHR were much less complete than his dictated notes in the paper chart. Physician quality of life and family time has been dramatically impacted. Patients are angry and frustrated. Two other physicians ultimately left our practice as well and have been very hard to replace.

In my opinion, implementing EHR destroyed a healthy and happy practice that served its patients well, and filled a huge need in an underserved county. Three out of five physicians left the practice, leaving primary care for good. I do not feel that this was due to "poor implementation," as everyone in the practice had extensive training prior to going live. I see it more as a failure of the EHR vender to understand the workflow needs of physicians in a busy office setting.

Dr. Goldberg voices a point of view that, unfortunately, we’ve heard before – that EHRs change the way a practice runs, decrease productivity, and distance physicians from patients. The experience in his practice serves as a warning to others to be careful both with their expectations for their EHR, the selection of which EHR to purchase, and how to implement its use in their office.

Dr. Mel Chandler, a 66-year-old family physician from Edmonds, Wash., shared insights informed by seeing many changes to the practice of medicine over his long career:

I have had many experiences over the years including an elderly practice partner in my first 3 years who managed to keep all of his records on 3-by-5 cards in his desk. In the left-hand top drawer were his patient notes on these cards and in the right-top drawer, his 3-by-5 cards with records of the loans he made to his patients, often at no interest. It worked well for him, but not so well for those of us needing information when on call. For our records, we dictated a SOAP [subjective, objective, assessment, and plan] note. This worked well enough for years.

I believe the EHR may help with record keeping in a very limited fashion. The programs I have seen are complex, use templates, and make it difficult to enter information. I have resisted the use of templates previously so that I could freely think rather than have my thinking directed by a prescribed format. Over the last decade, I have changed my practice to focus purely on those who have severe mental illness. It is important for me to maintain eye contact or at minimum watch my clients at all times while they are in my presence. In my state of residence it is illegal to text and drive an automobile. This is because of the disastrous effects of the distraction of typing. Is my interaction with my patients no less important to perform with full attention than driving? We meet with patients/clients to have a person-to-person interaction to problem solve, teach, and often console.

The major point of my note is that we must "protect" the patient/physician interaction. We must support the concept that the manner in which we take a history and perform an exam is important and cannot be "cut short" by electronic devices that require us to take our eyes from the road ahead.

We admire Dr. Chandler’s analogy relating the importance of full attention to patients to the driving experience and seeing what is on the road.

Keep those emails and comments coming.

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 editor-in-chief of Redi-Reference, a company that creates mobile apps. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

Acne is a common skin disorder among young people, affecting up to 85% of adolescents, often causing a significant amount of distress, and, when severe, it can have long-lasting effects.

Pathophysiology

Acne vulgaris involves four processes: sebaceous hyperplasia driven by increased androgen levels; alterations of follicular growth and differentiation; colonization of follicle by Propionibacterium acnes; and immune response and inflammation.

Categorization

Categorizing acne on the basis of morphology and severity of lesions is useful. The three basic morphologies are comedonal, inflammatory, and mixed. Comedones are closed (whitehead) or open (blackhead). Closed comedones result from cell proliferation mixing with sebum and partially clogging the follicular lumen. Open comedones result when the follicle has a broader opening with visible keratin buildup that darkens. Inflammation manifests as papules, pustules, nodules, or pseudocysts and may include scarring or sinus tracts. The inflammation results from P. acne colonization, with release of inflammatory mediators. Severity is classified as mild, moderate, and severe. This assessment is subjective but should be based on number and type of lesions, amount of skin involved, scarring, and risk of dyspigmentation, which is greater in darker skin.

Age-specific considerations

The differential diagnosis and work-up of acne varies by age group. Neonatal (birth-6 weeks) acne has a prevalence of 20%, though these lesions actually may represent acneiform conditions such as self-limited neonatal cephalic pustulosis or transient neonatal pustular melanosis.

Photo courtesy of Neil Skolnik, M.D.

Infantile (6 weeks to 12 months, or uncommonly up to a few years old) acne is more common in males, usually is comedonal and inflammatory, and presents with papules, pustules, or nodules. A work-up usually is not necessary unless growth is abnormal or signs of hirsutism/virilization exist, in which case referral to endocrinology is made for a possible hormonal anomaly. Of note, true infantile acne may portend an increased risk of severe adolescent acne.

Mid-childhood (1-7 years) acne is not common since this age group does not produce significant levels of adrenal or gonadal androgens. If it does occur, a work-up by an endocrinologist is recommended.

Preadolescent (7-12 years) acne is common and may be the first sign of pubertal maturation. Such acne usually is comedonal with a "T-zone" distribution (forehead and central face), and may appear on the ears. Inflammatory lesions are sparse. No work-up beyond history and physical is needed unless there is concern for endocrinologic abnormalities (for example, PCOS), which may manifest as very severe or refractory acne.

Treatment

Goals of treatment involve addressing pathogenic factors and using the least aggressive but effective regimen, while avoiding bacterial resistance development. Additionally, side effects and expectations of results (in other words, noticeable results may take 4-8 weeks for any acne treatment) should be discussed in order to enhance compliance.

Various over-the-counter (OTC) products and prescription agents are available for the treatment of acne. OTC agents that have been tested include salicylic acid and benzoyl peroxide (BP). BP is effective, safe, and inexpensive. It can be used as monotherapy and, when used in combination with topical or systemic antibiotics, may minimize antibiotic-resistant P. acnes development.

Prescription options include topical retinoids, topical antibiotics, topical dapsone, oral antibiotics (typically tetracycline, doxycycline, or minocycline), oral isotretinoin, fixed-dose combination topical agents (BP/topical antibiotic, BP/topical retinoid, and topical retinoid/antibiotic), and hormonal therapy. The recommendations address the treatment of mild, moderate, and severe pediatric acne.

Mild acne usually presents as comedonal or mixed. Initial treatment can include BP monotherapy, topical retinoids, or combinations of topical retinoids, antibiotics, and BP. In patients of color, where there is a greater risk of scarring and dyspigmentation, initial therapy might also include a topical or oral antibiotic. In cases of inadequate response, the concentration, type, or formulation of topical retinoid can be changed or the topical combination can be modified.

Moderate acne may require an aggressive regimen of combination topical therapy that includes a retinoid and BP with or without topical dapsone, with the likely addition of an oral antibiotic. If lesions are moderate to severe inflammatory or mixed, oral antibiotics are effective, with maximal response taking 3-6 months. If an inadequate response and adherence assured, the strength, type, and formulation of topical regimens can be adjusted, although referral to a specialist may be considered.

Severe acne requires prompt initiation of treatment to avoid scarring and permanent skin changes. Treatment should include oral antibiotics with topical retinoids plus BP, with or without topical antibiotics. Strong consideration should be given to adding hormonal therapy to the treatment regimen of young menstruating women who have severe acne. In addition, for both males and females, oral isotretinoin and referral to a specialist may be considered.

Some recommend refraining from oral contraceptives until 1 year after menarche because of concerns about growth and bone density. When considering oral isotretinoin, remember it is teratogenic and that it causes questionable changes to bone health, mood, and bowel disorders, which may cause more issues in the pediatric population.

If there is an inadequate response after combination therapy with isotretinoin, physicians can try oral antibiotics with topical retinoids plus BP. If acne persists, consideration can be given to switch to a different oral antibiotic to address possible resistant organisms.

Remember that tetracyclines should not be used in ages younger than 8 years. Erythromycin, azithromycin, and trimethoprim/sulfamethoxazole are options for children younger than 8 years or those with a tetracycline allergy, as long as there is close monitoring for adverse events with any oral antibiotics in children.

Bottom line

The diagnosis, work-up, and management of pediatric acne vary depending upon age and pubertal onset. When approaching acne therapy, the best treatment is determined by assessment of type and severity of lesions. Use of topical BP, retinoids, antibiotics, and oral antibiotics are the base of therapy, with strength and combination of agents determined by type and severity of the acne.

Reference

Eichenfield, L.F., Krakowski, A.C., Piggott, C., Del Rosso, J., Baldwin, H., Friedlander, S.F., Levy, M., Lucky, A., Mancini, A.J., Orlow, S.J., Yan, A.C., Vaux, K.K., Webster, G., Zaenglein, A.L., Thiboutot, D.M. (2013). Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne. (Pediatrics 2013;131:S163 [doi:10.1542/peds.2013-0490B]).

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. Lee is a third-year and chief resident in the family medicine residency program at Abington Memorial Hospital.

Acne is a common skin disorder among young people, affecting up to 85% of adolescents, often causing a significant amount of distress, and, when severe, it can have long-lasting effects.

Pathophysiology

Acne vulgaris involves four processes: sebaceous hyperplasia driven by increased androgen levels; alterations of follicular growth and differentiation; colonization of follicle by Propionibacterium acnes; and immune response and inflammation.

Categorization

Categorizing acne on the basis of morphology and severity of lesions is useful. The three basic morphologies are comedonal, inflammatory, and mixed. Comedones are closed (whitehead) or open (blackhead). Closed comedones result from cell proliferation mixing with sebum and partially clogging the follicular lumen. Open comedones result when the follicle has a broader opening with visible keratin buildup that darkens. Inflammation manifests as papules, pustules, nodules, or pseudocysts and may include scarring or sinus tracts. The inflammation results from P. acne colonization, with release of inflammatory mediators. Severity is classified as mild, moderate, and severe. This assessment is subjective but should be based on number and type of lesions, amount of skin involved, scarring, and risk of dyspigmentation, which is greater in darker skin.

Age-specific considerations

The differential diagnosis and work-up of acne varies by age group. Neonatal (birth-6 weeks) acne has a prevalence of 20%, though these lesions actually may represent acneiform conditions such as self-limited neonatal cephalic pustulosis or transient neonatal pustular melanosis.

Photo courtesy of Neil Skolnik, M.D.

Infantile (6 weeks to 12 months, or uncommonly up to a few years old) acne is more common in males, usually is comedonal and inflammatory, and presents with papules, pustules, or nodules. A work-up usually is not necessary unless growth is abnormal or signs of hirsutism/virilization exist, in which case referral to endocrinology is made for a possible hormonal anomaly. Of note, true infantile acne may portend an increased risk of severe adolescent acne.

Mid-childhood (1-7 years) acne is not common since this age group does not produce significant levels of adrenal or gonadal androgens. If it does occur, a work-up by an endocrinologist is recommended.

Preadolescent (7-12 years) acne is common and may be the first sign of pubertal maturation. Such acne usually is comedonal with a "T-zone" distribution (forehead and central face), and may appear on the ears. Inflammatory lesions are sparse. No work-up beyond history and physical is needed unless there is concern for endocrinologic abnormalities (for example, PCOS), which may manifest as very severe or refractory acne.

Treatment

Goals of treatment involve addressing pathogenic factors and using the least aggressive but effective regimen, while avoiding bacterial resistance development. Additionally, side effects and expectations of results (in other words, noticeable results may take 4-8 weeks for any acne treatment) should be discussed in order to enhance compliance.

Various over-the-counter (OTC) products and prescription agents are available for the treatment of acne. OTC agents that have been tested include salicylic acid and benzoyl peroxide (BP). BP is effective, safe, and inexpensive. It can be used as monotherapy and, when used in combination with topical or systemic antibiotics, may minimize antibiotic-resistant P. acnes development.

Prescription options include topical retinoids, topical antibiotics, topical dapsone, oral antibiotics (typically tetracycline, doxycycline, or minocycline), oral isotretinoin, fixed-dose combination topical agents (BP/topical antibiotic, BP/topical retinoid, and topical retinoid/antibiotic), and hormonal therapy. The recommendations address the treatment of mild, moderate, and severe pediatric acne.

Mild acne usually presents as comedonal or mixed. Initial treatment can include BP monotherapy, topical retinoids, or combinations of topical retinoids, antibiotics, and BP. In patients of color, where there is a greater risk of scarring and dyspigmentation, initial therapy might also include a topical or oral antibiotic. In cases of inadequate response, the concentration, type, or formulation of topical retinoid can be changed or the topical combination can be modified.

Moderate acne may require an aggressive regimen of combination topical therapy that includes a retinoid and BP with or without topical dapsone, with the likely addition of an oral antibiotic. If lesions are moderate to severe inflammatory or mixed, oral antibiotics are effective, with maximal response taking 3-6 months. If an inadequate response and adherence assured, the strength, type, and formulation of topical regimens can be adjusted, although referral to a specialist may be considered.

Severe acne requires prompt initiation of treatment to avoid scarring and permanent skin changes. Treatment should include oral antibiotics with topical retinoids plus BP, with or without topical antibiotics. Strong consideration should be given to adding hormonal therapy to the treatment regimen of young menstruating women who have severe acne. In addition, for both males and females, oral isotretinoin and referral to a specialist may be considered.

Some recommend refraining from oral contraceptives until 1 year after menarche because of concerns about growth and bone density. When considering oral isotretinoin, remember it is teratogenic and that it causes questionable changes to bone health, mood, and bowel disorders, which may cause more issues in the pediatric population.

If there is an inadequate response after combination therapy with isotretinoin, physicians can try oral antibiotics with topical retinoids plus BP. If acne persists, consideration can be given to switch to a different oral antibiotic to address possible resistant organisms.

Remember that tetracyclines should not be used in ages younger than 8 years. Erythromycin, azithromycin, and trimethoprim/sulfamethoxazole are options for children younger than 8 years or those with a tetracycline allergy, as long as there is close monitoring for adverse events with any oral antibiotics in children.

Bottom line

The diagnosis, work-up, and management of pediatric acne vary depending upon age and pubertal onset. When approaching acne therapy, the best treatment is determined by assessment of type and severity of lesions. Use of topical BP, retinoids, antibiotics, and oral antibiotics are the base of therapy, with strength and combination of agents determined by type and severity of the acne.

Reference

Eichenfield, L.F., Krakowski, A.C., Piggott, C., Del Rosso, J., Baldwin, H., Friedlander, S.F., Levy, M., Lucky, A., Mancini, A.J., Orlow, S.J., Yan, A.C., Vaux, K.K., Webster, G., Zaenglein, A.L., Thiboutot, D.M. (2013). Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne. (Pediatrics 2013;131:S163 [doi:10.1542/peds.2013-0490B]).

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. Lee is a third-year and chief resident in the family medicine residency program at Abington Memorial Hospital.

Acne is a common skin disorder among young people, affecting up to 85% of adolescents, often causing a significant amount of distress, and, when severe, it can have long-lasting effects.

Pathophysiology

Acne vulgaris involves four processes: sebaceous hyperplasia driven by increased androgen levels; alterations of follicular growth and differentiation; colonization of follicle by Propionibacterium acnes; and immune response and inflammation.

Categorization

Categorizing acne on the basis of morphology and severity of lesions is useful. The three basic morphologies are comedonal, inflammatory, and mixed. Comedones are closed (whitehead) or open (blackhead). Closed comedones result from cell proliferation mixing with sebum and partially clogging the follicular lumen. Open comedones result when the follicle has a broader opening with visible keratin buildup that darkens. Inflammation manifests as papules, pustules, nodules, or pseudocysts and may include scarring or sinus tracts. The inflammation results from P. acne colonization, with release of inflammatory mediators. Severity is classified as mild, moderate, and severe. This assessment is subjective but should be based on number and type of lesions, amount of skin involved, scarring, and risk of dyspigmentation, which is greater in darker skin.

Age-specific considerations

The differential diagnosis and work-up of acne varies by age group. Neonatal (birth-6 weeks) acne has a prevalence of 20%, though these lesions actually may represent acneiform conditions such as self-limited neonatal cephalic pustulosis or transient neonatal pustular melanosis.

Photo courtesy of Neil Skolnik, M.D.

Infantile (6 weeks to 12 months, or uncommonly up to a few years old) acne is more common in males, usually is comedonal and inflammatory, and presents with papules, pustules, or nodules. A work-up usually is not necessary unless growth is abnormal or signs of hirsutism/virilization exist, in which case referral to endocrinology is made for a possible hormonal anomaly. Of note, true infantile acne may portend an increased risk of severe adolescent acne.

Mid-childhood (1-7 years) acne is not common since this age group does not produce significant levels of adrenal or gonadal androgens. If it does occur, a work-up by an endocrinologist is recommended.

Preadolescent (7-12 years) acne is common and may be the first sign of pubertal maturation. Such acne usually is comedonal with a "T-zone" distribution (forehead and central face), and may appear on the ears. Inflammatory lesions are sparse. No work-up beyond history and physical is needed unless there is concern for endocrinologic abnormalities (for example, PCOS), which may manifest as very severe or refractory acne.

Treatment

Goals of treatment involve addressing pathogenic factors and using the least aggressive but effective regimen, while avoiding bacterial resistance development. Additionally, side effects and expectations of results (in other words, noticeable results may take 4-8 weeks for any acne treatment) should be discussed in order to enhance compliance.

Various over-the-counter (OTC) products and prescription agents are available for the treatment of acne. OTC agents that have been tested include salicylic acid and benzoyl peroxide (BP). BP is effective, safe, and inexpensive. It can be used as monotherapy and, when used in combination with topical or systemic antibiotics, may minimize antibiotic-resistant P. acnes development.

Prescription options include topical retinoids, topical antibiotics, topical dapsone, oral antibiotics (typically tetracycline, doxycycline, or minocycline), oral isotretinoin, fixed-dose combination topical agents (BP/topical antibiotic, BP/topical retinoid, and topical retinoid/antibiotic), and hormonal therapy. The recommendations address the treatment of mild, moderate, and severe pediatric acne.

Mild acne usually presents as comedonal or mixed. Initial treatment can include BP monotherapy, topical retinoids, or combinations of topical retinoids, antibiotics, and BP. In patients of color, where there is a greater risk of scarring and dyspigmentation, initial therapy might also include a topical or oral antibiotic. In cases of inadequate response, the concentration, type, or formulation of topical retinoid can be changed or the topical combination can be modified.

Moderate acne may require an aggressive regimen of combination topical therapy that includes a retinoid and BP with or without topical dapsone, with the likely addition of an oral antibiotic. If lesions are moderate to severe inflammatory or mixed, oral antibiotics are effective, with maximal response taking 3-6 months. If an inadequate response and adherence assured, the strength, type, and formulation of topical regimens can be adjusted, although referral to a specialist may be considered.

Severe acne requires prompt initiation of treatment to avoid scarring and permanent skin changes. Treatment should include oral antibiotics with topical retinoids plus BP, with or without topical antibiotics. Strong consideration should be given to adding hormonal therapy to the treatment regimen of young menstruating women who have severe acne. In addition, for both males and females, oral isotretinoin and referral to a specialist may be considered.

Some recommend refraining from oral contraceptives until 1 year after menarche because of concerns about growth and bone density. When considering oral isotretinoin, remember it is teratogenic and that it causes questionable changes to bone health, mood, and bowel disorders, which may cause more issues in the pediatric population.

If there is an inadequate response after combination therapy with isotretinoin, physicians can try oral antibiotics with topical retinoids plus BP. If acne persists, consideration can be given to switch to a different oral antibiotic to address possible resistant organisms.

Remember that tetracyclines should not be used in ages younger than 8 years. Erythromycin, azithromycin, and trimethoprim/sulfamethoxazole are options for children younger than 8 years or those with a tetracycline allergy, as long as there is close monitoring for adverse events with any oral antibiotics in children.

Bottom line

The diagnosis, work-up, and management of pediatric acne vary depending upon age and pubertal onset. When approaching acne therapy, the best treatment is determined by assessment of type and severity of lesions. Use of topical BP, retinoids, antibiotics, and oral antibiotics are the base of therapy, with strength and combination of agents determined by type and severity of the acne.

Reference

Eichenfield, L.F., Krakowski, A.C., Piggott, C., Del Rosso, J., Baldwin, H., Friedlander, S.F., Levy, M., Lucky, A., Mancini, A.J., Orlow, S.J., Yan, A.C., Vaux, K.K., Webster, G., Zaenglein, A.L., Thiboutot, D.M. (2013). Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne. (Pediatrics 2013;131:S163 [doi:10.1542/peds.2013-0490B]).

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. Lee is a third-year and chief resident in the family medicine residency program at Abington Memorial Hospital.

In Robert Frost’s poem "Stopping by Woods on a Snowy Evening," the speaker is tired and stops briefly to look at the beauty of the surrounding forest. He reflects on what he sees, then faces the reality of all he has to do and the need to move on. He states, "The woods are lovely, dark and deep. But I have promises to keep, and miles to go before I sleep." It strikes us that Frost is trying to teach the importance of balancing time for reflection with the necessity of getting done the work we need to do.

Each month we write on different aspects of electronic health records. We try to provide a balanced and reflective – albeit optimistic – perspective on the opportunities, promises, and challenges facing all of us as we integrate this new technology into our practice. We also try very hard to keep patient care, not technology, as the focus of our efforts. Regularly, we receive letters from readers – intelligent, hard-working doctors – who have taken time to reflect on their experience with EHRs. The comments are insightful and focus primarily on the difficulties and challenges that individual physicians have had with their electronic records. Since we all see things from different angles, we plan to periodically publish the thoughts and feeling of our colleagues who share their thoughts with us (with their permission, of course). Here are some of those thoughts:

"While I am not against the concept of EHR, I believe there are serious flaws in the current EHR systems. In our present system, the amount of information that we are required to put in makes it difficult for anyone to find promptly the most needed information due to the long, protracted details of everything being done, which ends up costing more time than anything else. In order to document accurately during office visits, the physician often concentrates on the computer and the template more than on making eye contact with the Patient, and that’s just wrong.

"Many Patients are complaining about that. I personally face each Patient and take notes on paper the old-fashioned way, using a paper template for a rough draft. Later, after hours, I dictate the notes into the system (I cannot type well). It takes me 1 to 2 hours, but I don’t mind doing it because it allows me to keep communication and direct eye contact with each Patient.

"The truth of the matter is that we have not been able to find yet a medically intuitive program. The more tasks that are included in a program, the less user-friendly and more confusing it becomes."

Pierre B. Turchi, M.D.

Chambersburg, Pa.

"I am writing in response to your column where you discuss EHRs, medicine, and humanism. You assert that since the computers will be doing all the work/thinking for us, our success will depend on our ability to connect with the patient-with ‘warmth, sensitivity, compassion, and empathy.’ Really? And how is the patient supposed to perceive that the doctor has these traits when he/she’s hunched over a computer with his/her back to the patient? How is the doctor supposed to look the patient in the eye, take her hand, see that tear welling in the corner of the patient’s eye? Just when we had arrived at some degree of choosing well-rounded young people [for admission] into our medical schools who could be taught the importance of developing good rapport with patients, the EHR and its odd placement in exam rooms will erase all the progress we have made.

"A doctor colleague relates his experience at a local teaching hospital where his aged mother was being admitted. As she lay in the hospital bed with the curtain closed around her, the intern took her history at a computer outside the curtain! ... I fear too many new doctors will take that route."

Francine Palma Long, M.D.

Edward Hospital

Naperville, Ill.

"I read your column with gritting teeth every time the ‘word’ EHR is printed. Embracing an EHR world, as you’ve suggested we do, that has NOT been validated by peer review and universal ‘physician’ endorsement, is like asking us to sail across the flat ocean and reassuring us that the world IS truly round and we won’t fall off. ... We are ‘sending the entire fleet’ ahead onto waters that are not known to be calm. Frankly, the commander and weathermen have not done their due diligence before committing us ALL to a voyage that is not even a 50/50 bet of success. And we (the ever so undervalued physicians, frequently now only referred to as ‘providers’) are mandated to shove off on our own dollar or be penalized for not complying. EHR costs physicians too much for any real benefit, and costs CMS/insurance payers too much for the ‘clicked up,’ fortified ‘document’ that is produced by the hand and mouse."

Todd A. Stastny, M.D.

Blue Springs, Mo.

In reviewing many letters, of which these excerpts are only a few, we are struck by two main observations. The first is that we as physicians – busy though we are – feel strongly enough about the process by which we provide care that we take the time to write well-crafted, often detailed responses to the challenges of integrating technology into our practices. The second, less encouraging observation is that the bulk of the letters we have received point out primarily the problems with electronic records, and that we truly have "miles to go before we sleep."

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 editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

In Robert Frost’s poem "Stopping by Woods on a Snowy Evening," the speaker is tired and stops briefly to look at the beauty of the surrounding forest. He reflects on what he sees, then faces the reality of all he has to do and the need to move on. He states, "The woods are lovely, dark and deep. But I have promises to keep, and miles to go before I sleep." It strikes us that Frost is trying to teach the importance of balancing time for reflection with the necessity of getting done the work we need to do.

Each month we write on different aspects of electronic health records. We try to provide a balanced and reflective – albeit optimistic – perspective on the opportunities, promises, and challenges facing all of us as we integrate this new technology into our practice. We also try very hard to keep patient care, not technology, as the focus of our efforts. Regularly, we receive letters from readers – intelligent, hard-working doctors – who have taken time to reflect on their experience with EHRs. The comments are insightful and focus primarily on the difficulties and challenges that individual physicians have had with their electronic records. Since we all see things from different angles, we plan to periodically publish the thoughts and feeling of our colleagues who share their thoughts with us (with their permission, of course). Here are some of those thoughts:

"While I am not against the concept of EHR, I believe there are serious flaws in the current EHR systems. In our present system, the amount of information that we are required to put in makes it difficult for anyone to find promptly the most needed information due to the long, protracted details of everything being done, which ends up costing more time than anything else. In order to document accurately during office visits, the physician often concentrates on the computer and the template more than on making eye contact with the Patient, and that’s just wrong.

"Many Patients are complaining about that. I personally face each Patient and take notes on paper the old-fashioned way, using a paper template for a rough draft. Later, after hours, I dictate the notes into the system (I cannot type well). It takes me 1 to 2 hours, but I don’t mind doing it because it allows me to keep communication and direct eye contact with each Patient.

"The truth of the matter is that we have not been able to find yet a medically intuitive program. The more tasks that are included in a program, the less user-friendly and more confusing it becomes."

Pierre B. Turchi, M.D.

Chambersburg, Pa.

"I am writing in response to your column where you discuss EHRs, medicine, and humanism. You assert that since the computers will be doing all the work/thinking for us, our success will depend on our ability to connect with the patient-with ‘warmth, sensitivity, compassion, and empathy.’ Really? And how is the patient supposed to perceive that the doctor has these traits when he/she’s hunched over a computer with his/her back to the patient? How is the doctor supposed to look the patient in the eye, take her hand, see that tear welling in the corner of the patient’s eye? Just when we had arrived at some degree of choosing well-rounded young people [for admission] into our medical schools who could be taught the importance of developing good rapport with patients, the EHR and its odd placement in exam rooms will erase all the progress we have made.

"A doctor colleague relates his experience at a local teaching hospital where his aged mother was being admitted. As she lay in the hospital bed with the curtain closed around her, the intern took her history at a computer outside the curtain! ... I fear too many new doctors will take that route."

Francine Palma Long, M.D.

Edward Hospital

Naperville, Ill.

"I read your column with gritting teeth every time the ‘word’ EHR is printed. Embracing an EHR world, as you’ve suggested we do, that has NOT been validated by peer review and universal ‘physician’ endorsement, is like asking us to sail across the flat ocean and reassuring us that the world IS truly round and we won’t fall off. ... We are ‘sending the entire fleet’ ahead onto waters that are not known to be calm. Frankly, the commander and weathermen have not done their due diligence before committing us ALL to a voyage that is not even a 50/50 bet of success. And we (the ever so undervalued physicians, frequently now only referred to as ‘providers’) are mandated to shove off on our own dollar or be penalized for not complying. EHR costs physicians too much for any real benefit, and costs CMS/insurance payers too much for the ‘clicked up,’ fortified ‘document’ that is produced by the hand and mouse."

Todd A. Stastny, M.D.

Blue Springs, Mo.

In reviewing many letters, of which these excerpts are only a few, we are struck by two main observations. The first is that we as physicians – busy though we are – feel strongly enough about the process by which we provide care that we take the time to write well-crafted, often detailed responses to the challenges of integrating technology into our practices. The second, less encouraging observation is that the bulk of the letters we have received point out primarily the problems with electronic records, and that we truly have "miles to go before we sleep."

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 editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

In Robert Frost’s poem "Stopping by Woods on a Snowy Evening," the speaker is tired and stops briefly to look at the beauty of the surrounding forest. He reflects on what he sees, then faces the reality of all he has to do and the need to move on. He states, "The woods are lovely, dark and deep. But I have promises to keep, and miles to go before I sleep." It strikes us that Frost is trying to teach the importance of balancing time for reflection with the necessity of getting done the work we need to do.

Each month we write on different aspects of electronic health records. We try to provide a balanced and reflective – albeit optimistic – perspective on the opportunities, promises, and challenges facing all of us as we integrate this new technology into our practice. We also try very hard to keep patient care, not technology, as the focus of our efforts. Regularly, we receive letters from readers – intelligent, hard-working doctors – who have taken time to reflect on their experience with EHRs. The comments are insightful and focus primarily on the difficulties and challenges that individual physicians have had with their electronic records. Since we all see things from different angles, we plan to periodically publish the thoughts and feeling of our colleagues who share their thoughts with us (with their permission, of course). Here are some of those thoughts:

"While I am not against the concept of EHR, I believe there are serious flaws in the current EHR systems. In our present system, the amount of information that we are required to put in makes it difficult for anyone to find promptly the most needed information due to the long, protracted details of everything being done, which ends up costing more time than anything else. In order to document accurately during office visits, the physician often concentrates on the computer and the template more than on making eye contact with the Patient, and that’s just wrong.

"Many Patients are complaining about that. I personally face each Patient and take notes on paper the old-fashioned way, using a paper template for a rough draft. Later, after hours, I dictate the notes into the system (I cannot type well). It takes me 1 to 2 hours, but I don’t mind doing it because it allows me to keep communication and direct eye contact with each Patient.

"The truth of the matter is that we have not been able to find yet a medically intuitive program. The more tasks that are included in a program, the less user-friendly and more confusing it becomes."

Pierre B. Turchi, M.D.

Chambersburg, Pa.

"I am writing in response to your column where you discuss EHRs, medicine, and humanism. You assert that since the computers will be doing all the work/thinking for us, our success will depend on our ability to connect with the patient-with ‘warmth, sensitivity, compassion, and empathy.’ Really? And how is the patient supposed to perceive that the doctor has these traits when he/she’s hunched over a computer with his/her back to the patient? How is the doctor supposed to look the patient in the eye, take her hand, see that tear welling in the corner of the patient’s eye? Just when we had arrived at some degree of choosing well-rounded young people [for admission] into our medical schools who could be taught the importance of developing good rapport with patients, the EHR and its odd placement in exam rooms will erase all the progress we have made.

"A doctor colleague relates his experience at a local teaching hospital where his aged mother was being admitted. As she lay in the hospital bed with the curtain closed around her, the intern took her history at a computer outside the curtain! ... I fear too many new doctors will take that route."

Francine Palma Long, M.D.

Edward Hospital

Naperville, Ill.

"I read your column with gritting teeth every time the ‘word’ EHR is printed. Embracing an EHR world, as you’ve suggested we do, that has NOT been validated by peer review and universal ‘physician’ endorsement, is like asking us to sail across the flat ocean and reassuring us that the world IS truly round and we won’t fall off. ... We are ‘sending the entire fleet’ ahead onto waters that are not known to be calm. Frankly, the commander and weathermen have not done their due diligence before committing us ALL to a voyage that is not even a 50/50 bet of success. And we (the ever so undervalued physicians, frequently now only referred to as ‘providers’) are mandated to shove off on our own dollar or be penalized for not complying. EHR costs physicians too much for any real benefit, and costs CMS/insurance payers too much for the ‘clicked up,’ fortified ‘document’ that is produced by the hand and mouse."

Todd A. Stastny, M.D.

Blue Springs, Mo.

In reviewing many letters, of which these excerpts are only a few, we are struck by two main observations. The first is that we as physicians – busy though we are – feel strongly enough about the process by which we provide care that we take the time to write well-crafted, often detailed responses to the challenges of integrating technology into our practices. The second, less encouraging observation is that the bulk of the letters we have received point out primarily the problems with electronic records, and that we truly have "miles to go before we sleep."

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 editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

Pharyngitis is the major concern for greater than 15 million annual visits to primary care physicians in the United States. Although group A Streptococcus (GAS) is the most common bacterial cause of acute pharyngitis, only 20%-30% of school-age children and only 5%-15% of adults who present to a physician with a sore throat will turn out to have GAS pharyngitis. Treatment of GAS pharyngitis with antibiotics helps to avoid suppurative complications (for example, peritonsillar abscesses, cervical lymphadenitis, etc.), prevent acute rheumatic fever, improve clinical symptoms, decrease contagious transmission to close contacts of the patient, and allow for rapid resumption of normal activities. However, routine empiric treatment of patients with pharyngitis or upper respiratory tract infections with antibiotics has contributed greatly to the worsening of antimicrobial resistance among many common pathogens while failing to provide clinical benefit to patients with pharyngitis that is not caused by GAS. Nationally up to 70% of patients seen in primary care settings for a sore throat are prescribed antibiotics, despite the much lower incidence of GAS pharyngitis. The IDSA guidelines on the diagnosis and management of group A streptococcal pharyngitis provide a comprehensive evidence based statement addressing questions discussed below.

How should the diagnosis of GAS pharyngitis be established?

Diagnosis should be made by throat swab and testing by rapid antigen detection test (RADT) and/or throat culture. Both tonsils, or tonsillar fossae, and posterior pharynx should be swabbed to provide an accurate and adequate sample. RADTs are approximately 95% specific and have a sensitivity of 70%-90%. This means that a positive rapid strep test is most likely a true positive, representing group A pharyngitis. There is no need for confirmatory culture to be performed. A negative rapid strep result, because of its lack of sensitivity, may reflect a false-negative result, meaning that there is a chance that the individual has strep even with a negative test. The likelihood of a false-negative test is highest in those with the greatest likelihood of having GAS: children or people whose clinical picture based on history, symptoms, and signs appear most likely to have strep. In children and adolescents, negative RADTs should have a throat culture performed because of the high incidence of GAS-causing pharyngitis in children, and the likelihood that a negative RADT is inaccurate. Adults with negative RADTs do not warrant additional testing as the incidence of GAS is much lower among adults than children. There is no role for using antistreptococcal antibody titers to help diagnose acute GAS pharyngitis.

Who should undergo testing for GAS pharyngitis?

GAS testing should be performed for individuals with a reasonable likelihood of their pharyngitis being caused by GAS. Testing is not indicated in patients with pharyngitis and symptoms strongly suggestive of viral infection (for example, cough, rhinorrhea, hoarseness, and oral ulcers). In children younger than 3 years old, the incidence of GAS pharyngitis is very low, and testing should be used only in patients who have other risk factors, such as a close household contact with GAS pharyngitis. While GAS causes only 5%-15% of pharyngitis cases in adults, adults with school age children and those who work around children are at an increased risk for GAS pharyngitis. The routine testing of asymptomatic household contacts of patients with GAS pharyngitis is not indicated.

What are the treatment recommendations for patients diagnosed with GAS pharyngitis?

Treatment recommendations for GAS start with narrow spectrum, inexpensive, beta-lactams. Once daily amoxicillin (50 mg/kg [max 1,000 mg]) given for 10 days has been shown to be effective for GAS pharyngitis and is now among the approved regimens. Additional regimens include 10 days of penicillin VK, 250 mg two to three times daily for children; 250 mg four times daily or 500 mg twice daily for adolescents and adults; or 10 days of amoxicillin, 25 mg/kg (max 500 mg) twice daily for adults. Treatment regimens for patients with penicillin allergy include cephalexin 20 mg/kg (max 500 mg) twice daily for 10 days; cefadroxil 30 mg/kg (max 1,000 mg) for 10 days; clindamycin 7 mg/kg per dose (max 300 mg/dose) three times daily for 10 days; or azithromycin 12 mg/kg (max 500 mg) once daily for 5 days; clarithromycin 7.5mg/kg per dose (max 250 mg/dose) twice daily for 10 days. Because of poorer evidence and broader spectrum, the IDSA does not recommended later-generation cephalosporins for the treatment of GAS pharyngitis. Some evidence suggests that because of developing macrolide resistance, 10 days of clarithromycin may be more effective treatment than the shorter 5-day course of azithromycin. Adjunctive therapy with an analgesic/antipyretic to control pain or fever is appropriate, but aspirin should be avoided in children, and corticosteroids are not recommended.

Is the patient with frequent recurrent episodes of apparent GAS pharyngitis likely to be a carrier of pharyngeal GAS?

Clinicians should consider the possibility that some patients with frequent recurrent episodes of GAS pharyngitis may be chronic carriers of GAS and may be experiencing frequent viral infections. Since GAS carriers are unlikely to spread or cause GAS pharyngitis in close contacts, identification of GAS carriers and treatment with the goal of eradication of GAS is not indicated. During winter and spring, as many as 20% of asymptomatic school-age children may be GAS carriers. Tonsillectomy is not recommended solely to reduce GAS pharyngitis episodes.

The bottom line

GAS pharyngitis should be diagnosed with RADTs or throat culture. Treatment options for GAS pharyngitis should start with narrow spectrum beta-lactams, with once-daily amoxicillin now recommended as a treatment option.

Shulman et al. "Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America" (Clin. Infect. Dis. 2012 [doi: 10.1093/cid/cis629]).

Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Guthrie is a third-year resident in the hospital’s family medicine program.

Pharyngitis is the major concern for greater than 15 million annual visits to primary care physicians in the United States. Although group A Streptococcus (GAS) is the most common bacterial cause of acute pharyngitis, only 20%-30% of school-age children and only 5%-15% of adults who present to a physician with a sore throat will turn out to have GAS pharyngitis. Treatment of GAS pharyngitis with antibiotics helps to avoid suppurative complications (for example, peritonsillar abscesses, cervical lymphadenitis, etc.), prevent acute rheumatic fever, improve clinical symptoms, decrease contagious transmission to close contacts of the patient, and allow for rapid resumption of normal activities. However, routine empiric treatment of patients with pharyngitis or upper respiratory tract infections with antibiotics has contributed greatly to the worsening of antimicrobial resistance among many common pathogens while failing to provide clinical benefit to patients with pharyngitis that is not caused by GAS. Nationally up to 70% of patients seen in primary care settings for a sore throat are prescribed antibiotics, despite the much lower incidence of GAS pharyngitis. The IDSA guidelines on the diagnosis and management of group A streptococcal pharyngitis provide a comprehensive evidence based statement addressing questions discussed below.

How should the diagnosis of GAS pharyngitis be established?

Diagnosis should be made by throat swab and testing by rapid antigen detection test (RADT) and/or throat culture. Both tonsils, or tonsillar fossae, and posterior pharynx should be swabbed to provide an accurate and adequate sample. RADTs are approximately 95% specific and have a sensitivity of 70%-90%. This means that a positive rapid strep test is most likely a true positive, representing group A pharyngitis. There is no need for confirmatory culture to be performed. A negative rapid strep result, because of its lack of sensitivity, may reflect a false-negative result, meaning that there is a chance that the individual has strep even with a negative test. The likelihood of a false-negative test is highest in those with the greatest likelihood of having GAS: children or people whose clinical picture based on history, symptoms, and signs appear most likely to have strep. In children and adolescents, negative RADTs should have a throat culture performed because of the high incidence of GAS-causing pharyngitis in children, and the likelihood that a negative RADT is inaccurate. Adults with negative RADTs do not warrant additional testing as the incidence of GAS is much lower among adults than children. There is no role for using antistreptococcal antibody titers to help diagnose acute GAS pharyngitis.

Who should undergo testing for GAS pharyngitis?

GAS testing should be performed for individuals with a reasonable likelihood of their pharyngitis being caused by GAS. Testing is not indicated in patients with pharyngitis and symptoms strongly suggestive of viral infection (for example, cough, rhinorrhea, hoarseness, and oral ulcers). In children younger than 3 years old, the incidence of GAS pharyngitis is very low, and testing should be used only in patients who have other risk factors, such as a close household contact with GAS pharyngitis. While GAS causes only 5%-15% of pharyngitis cases in adults, adults with school age children and those who work around children are at an increased risk for GAS pharyngitis. The routine testing of asymptomatic household contacts of patients with GAS pharyngitis is not indicated.

What are the treatment recommendations for patients diagnosed with GAS pharyngitis?

Treatment recommendations for GAS start with narrow spectrum, inexpensive, beta-lactams. Once daily amoxicillin (50 mg/kg [max 1,000 mg]) given for 10 days has been shown to be effective for GAS pharyngitis and is now among the approved regimens. Additional regimens include 10 days of penicillin VK, 250 mg two to three times daily for children; 250 mg four times daily or 500 mg twice daily for adolescents and adults; or 10 days of amoxicillin, 25 mg/kg (max 500 mg) twice daily for adults. Treatment regimens for patients with penicillin allergy include cephalexin 20 mg/kg (max 500 mg) twice daily for 10 days; cefadroxil 30 mg/kg (max 1,000 mg) for 10 days; clindamycin 7 mg/kg per dose (max 300 mg/dose) three times daily for 10 days; or azithromycin 12 mg/kg (max 500 mg) once daily for 5 days; clarithromycin 7.5mg/kg per dose (max 250 mg/dose) twice daily for 10 days. Because of poorer evidence and broader spectrum, the IDSA does not recommended later-generation cephalosporins for the treatment of GAS pharyngitis. Some evidence suggests that because of developing macrolide resistance, 10 days of clarithromycin may be more effective treatment than the shorter 5-day course of azithromycin. Adjunctive therapy with an analgesic/antipyretic to control pain or fever is appropriate, but aspirin should be avoided in children, and corticosteroids are not recommended.

Is the patient with frequent recurrent episodes of apparent GAS pharyngitis likely to be a carrier of pharyngeal GAS?

Clinicians should consider the possibility that some patients with frequent recurrent episodes of GAS pharyngitis may be chronic carriers of GAS and may be experiencing frequent viral infections. Since GAS carriers are unlikely to spread or cause GAS pharyngitis in close contacts, identification of GAS carriers and treatment with the goal of eradication of GAS is not indicated. During winter and spring, as many as 20% of asymptomatic school-age children may be GAS carriers. Tonsillectomy is not recommended solely to reduce GAS pharyngitis episodes.

The bottom line

GAS pharyngitis should be diagnosed with RADTs or throat culture. Treatment options for GAS pharyngitis should start with narrow spectrum beta-lactams, with once-daily amoxicillin now recommended as a treatment option.

Shulman et al. "Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America" (Clin. Infect. Dis. 2012 [doi: 10.1093/cid/cis629]).

Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Guthrie is a third-year resident in the hospital’s family medicine program.

Pharyngitis is the major concern for greater than 15 million annual visits to primary care physicians in the United States. Although group A Streptococcus (GAS) is the most common bacterial cause of acute pharyngitis, only 20%-30% of school-age children and only 5%-15% of adults who present to a physician with a sore throat will turn out to have GAS pharyngitis. Treatment of GAS pharyngitis with antibiotics helps to avoid suppurative complications (for example, peritonsillar abscesses, cervical lymphadenitis, etc.), prevent acute rheumatic fever, improve clinical symptoms, decrease contagious transmission to close contacts of the patient, and allow for rapid resumption of normal activities. However, routine empiric treatment of patients with pharyngitis or upper respiratory tract infections with antibiotics has contributed greatly to the worsening of antimicrobial resistance among many common pathogens while failing to provide clinical benefit to patients with pharyngitis that is not caused by GAS. Nationally up to 70% of patients seen in primary care settings for a sore throat are prescribed antibiotics, despite the much lower incidence of GAS pharyngitis. The IDSA guidelines on the diagnosis and management of group A streptococcal pharyngitis provide a comprehensive evidence based statement addressing questions discussed below.

How should the diagnosis of GAS pharyngitis be established?

Diagnosis should be made by throat swab and testing by rapid antigen detection test (RADT) and/or throat culture. Both tonsils, or tonsillar fossae, and posterior pharynx should be swabbed to provide an accurate and adequate sample. RADTs are approximately 95% specific and have a sensitivity of 70%-90%. This means that a positive rapid strep test is most likely a true positive, representing group A pharyngitis. There is no need for confirmatory culture to be performed. A negative rapid strep result, because of its lack of sensitivity, may reflect a false-negative result, meaning that there is a chance that the individual has strep even with a negative test. The likelihood of a false-negative test is highest in those with the greatest likelihood of having GAS: children or people whose clinical picture based on history, symptoms, and signs appear most likely to have strep. In children and adolescents, negative RADTs should have a throat culture performed because of the high incidence of GAS-causing pharyngitis in children, and the likelihood that a negative RADT is inaccurate. Adults with negative RADTs do not warrant additional testing as the incidence of GAS is much lower among adults than children. There is no role for using antistreptococcal antibody titers to help diagnose acute GAS pharyngitis.

Who should undergo testing for GAS pharyngitis?

GAS testing should be performed for individuals with a reasonable likelihood of their pharyngitis being caused by GAS. Testing is not indicated in patients with pharyngitis and symptoms strongly suggestive of viral infection (for example, cough, rhinorrhea, hoarseness, and oral ulcers). In children younger than 3 years old, the incidence of GAS pharyngitis is very low, and testing should be used only in patients who have other risk factors, such as a close household contact with GAS pharyngitis. While GAS causes only 5%-15% of pharyngitis cases in adults, adults with school age children and those who work around children are at an increased risk for GAS pharyngitis. The routine testing of asymptomatic household contacts of patients with GAS pharyngitis is not indicated.

What are the treatment recommendations for patients diagnosed with GAS pharyngitis?

Treatment recommendations for GAS start with narrow spectrum, inexpensive, beta-lactams. Once daily amoxicillin (50 mg/kg [max 1,000 mg]) given for 10 days has been shown to be effective for GAS pharyngitis and is now among the approved regimens. Additional regimens include 10 days of penicillin VK, 250 mg two to three times daily for children; 250 mg four times daily or 500 mg twice daily for adolescents and adults; or 10 days of amoxicillin, 25 mg/kg (max 500 mg) twice daily for adults. Treatment regimens for patients with penicillin allergy include cephalexin 20 mg/kg (max 500 mg) twice daily for 10 days; cefadroxil 30 mg/kg (max 1,000 mg) for 10 days; clindamycin 7 mg/kg per dose (max 300 mg/dose) three times daily for 10 days; or azithromycin 12 mg/kg (max 500 mg) once daily for 5 days; clarithromycin 7.5mg/kg per dose (max 250 mg/dose) twice daily for 10 days. Because of poorer evidence and broader spectrum, the IDSA does not recommended later-generation cephalosporins for the treatment of GAS pharyngitis. Some evidence suggests that because of developing macrolide resistance, 10 days of clarithromycin may be more effective treatment than the shorter 5-day course of azithromycin. Adjunctive therapy with an analgesic/antipyretic to control pain or fever is appropriate, but aspirin should be avoided in children, and corticosteroids are not recommended.

Is the patient with frequent recurrent episodes of apparent GAS pharyngitis likely to be a carrier of pharyngeal GAS?

Clinicians should consider the possibility that some patients with frequent recurrent episodes of GAS pharyngitis may be chronic carriers of GAS and may be experiencing frequent viral infections. Since GAS carriers are unlikely to spread or cause GAS pharyngitis in close contacts, identification of GAS carriers and treatment with the goal of eradication of GAS is not indicated. During winter and spring, as many as 20% of asymptomatic school-age children may be GAS carriers. Tonsillectomy is not recommended solely to reduce GAS pharyngitis episodes.

The bottom line

GAS pharyngitis should be diagnosed with RADTs or throat culture. Treatment options for GAS pharyngitis should start with narrow spectrum beta-lactams, with once-daily amoxicillin now recommended as a treatment option.

Shulman et al. "Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America" (Clin. Infect. Dis. 2012 [doi: 10.1093/cid/cis629]).

Dr. Skolnik is an associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Guthrie is a third-year resident in the hospital’s family medicine program.

Every month we try to write about something that is both timely and relevant, but in general we choose topics that interest us. In response to our columns, we are typically greeted with e-mailed comments – both negative and positive – that highlight issues we haven’t covered or challenge the opinions we’ve expressed about health IT. We greatly enjoy the response from readers and welcome the criticism. In fact, we want to encourage it.

Over the next few columns, we hope to publish some of our readers’ comments and respond to them. If you have e-mailed us in the past, we may be contacting you to request your permission to publish your thoughts. If you have not yet sent us any correspondence, we would encourage you to do so over the next few weeks. Reach us at [email protected] and be sure to indicate whether or not you give permission to publish your words.

Historically, most of the correspondence we have received has been negative toward electronic health records. We anticipate this trend will continue as we move forward, and we are okay with that. There is no question that the national dialogue is presently quite critical of EHRs, frequently highlighting physician frustration with current electronic health record systems.

In fact, a recent survey conducted by the American College of Physicians and AmericanEHR Partners found that physician satisfaction with EHRs across multiple specialties dropped 12% from 2010 to 2012 (data presented at the 2013 Healthcare Information and Management Systems Society [HIMSS] annual meeting. Furthermore, 39% of respondents stated that they would not recommend their current EHR to a colleague. But what would cause such a negative downturn?

Ironically, many feel the reason for this, in large part, is the Meaningful Use program. The very same program designed to incentivize physicians to invest in technology has become the source of their growing dissatisfaction with it. Essentially, this government-sponsored program has forced the process of EHR adoption to move very quickly. Physicians who would have never before considered themselves "early adopters" have been encouraged to purchase an electronic record while the technology is still – in many ways – in its infancy. They have been motivated not only by the promise of financial gain, but also by the fear of looming penalties if they fail to comply.

This phenomenon is fairly novel and completely atypical of technology adoption. Traditionally, when any new innovation is brought to market, it is immediately embraced by a select few who always want to be on the bleeding edge (admittedly, the two of us are self-proclaimed geeks and often count ourselves among this group). Most people, however, have little interest and might not even take notice until that which once was innovative becomes "old hat."

The Facebook phenomenon is a prime example of this. The success of the social networking giant truly exploded once it moved from an online "college hangout" to a tool that "everyone and their grandmother" (literally) began relying on for essential communication. This was a completely organic process, not one artificially cultivated by government involvement. In other words, people began using Facebook not because they had to but because they wanted to. It simply provided a better way of communicating and managing information in the social domain.

Interestingly enough, EHRs promise to bring the same utility to the field of medicine. They are intended to enhance communication among physicians and streamline care by improving data management and clinical decision support. This is possible and even obtainable today in certain circumstances, but there is a great deal of inconsistency in quality among the various products available and the market has not had time to weed out those that are failing to deliver on their promises. In many ways, even we would agree that artificial influences have encouraged the market to move too fast, and we can sympathize with those who have found reason to question the value of many current EHR offerings.

Thankfully, there are many influential voices who have recently spoken out about the speed at which the world of health IT is moving. Most notably, Dr. James L. Madara, CEO and executive vice president of the American Medical Association, filed formal comments with the Centers for Medicare and Medicaid Services earlier this year encouraging them to "slow down" development of Meaningful Use stage 3. In the letter, Dr. Madara stated "It makes no sense to add stages and requirements to a program when even savvy EHR users and specialists are having difficulty meeting the Stage 1 measures."

It seems that the CMS agrees with this, as acting administrator Marilyn Tavenner announced in March that there will be a hiatus prior to further rulemaking to examine the program’s impact so far and solicit comments from clinicians.

With that in mind, here is your opportunity to bring your thoughts and criticisms to a public forum. As stated above, we look forward to receiving any perspective or status updates you might wish to offer and will review and publish these over the next few months. We hope that this will prove to be constructive, informative, and useful, and will reflect where our fellow clinicians stand on issues from meaningful (or unmeaningful) use to optimization strategies and techniques.

We are convinced that the true success of EHR adoption will take time and only come through the collective wisdom and feedback of clinicians, but we remain confident that eventually it will offer a path to improved patient care. Whether you agree or not, here’s your chance to let us know.

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 editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

Every month we try to write about something that is both timely and relevant, but in general we choose topics that interest us. In response to our columns, we are typically greeted with e-mailed comments – both negative and positive – that highlight issues we haven’t covered or challenge the opinions we’ve expressed about health IT. We greatly enjoy the response from readers and welcome the criticism. In fact, we want to encourage it.

Over the next few columns, we hope to publish some of our readers’ comments and respond to them. If you have e-mailed us in the past, we may be contacting you to request your permission to publish your thoughts. If you have not yet sent us any correspondence, we would encourage you to do so over the next few weeks. Reach us at [email protected] and be sure to indicate whether or not you give permission to publish your words.

Historically, most of the correspondence we have received has been negative toward electronic health records. We anticipate this trend will continue as we move forward, and we are okay with that. There is no question that the national dialogue is presently quite critical of EHRs, frequently highlighting physician frustration with current electronic health record systems.

In fact, a recent survey conducted by the American College of Physicians and AmericanEHR Partners found that physician satisfaction with EHRs across multiple specialties dropped 12% from 2010 to 2012 (data presented at the 2013 Healthcare Information and Management Systems Society [HIMSS] annual meeting. Furthermore, 39% of respondents stated that they would not recommend their current EHR to a colleague. But what would cause such a negative downturn?

Ironically, many feel the reason for this, in large part, is the Meaningful Use program. The very same program designed to incentivize physicians to invest in technology has become the source of their growing dissatisfaction with it. Essentially, this government-sponsored program has forced the process of EHR adoption to move very quickly. Physicians who would have never before considered themselves "early adopters" have been encouraged to purchase an electronic record while the technology is still – in many ways – in its infancy. They have been motivated not only by the promise of financial gain, but also by the fear of looming penalties if they fail to comply.

This phenomenon is fairly novel and completely atypical of technology adoption. Traditionally, when any new innovation is brought to market, it is immediately embraced by a select few who always want to be on the bleeding edge (admittedly, the two of us are self-proclaimed geeks and often count ourselves among this group). Most people, however, have little interest and might not even take notice until that which once was innovative becomes "old hat."

The Facebook phenomenon is a prime example of this. The success of the social networking giant truly exploded once it moved from an online "college hangout" to a tool that "everyone and their grandmother" (literally) began relying on for essential communication. This was a completely organic process, not one artificially cultivated by government involvement. In other words, people began using Facebook not because they had to but because they wanted to. It simply provided a better way of communicating and managing information in the social domain.

Interestingly enough, EHRs promise to bring the same utility to the field of medicine. They are intended to enhance communication among physicians and streamline care by improving data management and clinical decision support. This is possible and even obtainable today in certain circumstances, but there is a great deal of inconsistency in quality among the various products available and the market has not had time to weed out those that are failing to deliver on their promises. In many ways, even we would agree that artificial influences have encouraged the market to move too fast, and we can sympathize with those who have found reason to question the value of many current EHR offerings.

Thankfully, there are many influential voices who have recently spoken out about the speed at which the world of health IT is moving. Most notably, Dr. James L. Madara, CEO and executive vice president of the American Medical Association, filed formal comments with the Centers for Medicare and Medicaid Services earlier this year encouraging them to "slow down" development of Meaningful Use stage 3. In the letter, Dr. Madara stated "It makes no sense to add stages and requirements to a program when even savvy EHR users and specialists are having difficulty meeting the Stage 1 measures."

It seems that the CMS agrees with this, as acting administrator Marilyn Tavenner announced in March that there will be a hiatus prior to further rulemaking to examine the program’s impact so far and solicit comments from clinicians.

With that in mind, here is your opportunity to bring your thoughts and criticisms to a public forum. As stated above, we look forward to receiving any perspective or status updates you might wish to offer and will review and publish these over the next few months. We hope that this will prove to be constructive, informative, and useful, and will reflect where our fellow clinicians stand on issues from meaningful (or unmeaningful) use to optimization strategies and techniques.

We are convinced that the true success of EHR adoption will take time and only come through the collective wisdom and feedback of clinicians, but we remain confident that eventually it will offer a path to improved patient care. Whether you agree or not, here’s your chance to let us know.

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 editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].

Every month we try to write about something that is both timely and relevant, but in general we choose topics that interest us. In response to our columns, we are typically greeted with e-mailed comments – both negative and positive – that highlight issues we haven’t covered or challenge the opinions we’ve expressed about health IT. We greatly enjoy the response from readers and welcome the criticism. In fact, we want to encourage it.

Over the next few columns, we hope to publish some of our readers’ comments and respond to them. If you have e-mailed us in the past, we may be contacting you to request your permission to publish your thoughts. If you have not yet sent us any correspondence, we would encourage you to do so over the next few weeks. Reach us at [email protected] and be sure to indicate whether or not you give permission to publish your words.

Historically, most of the correspondence we have received has been negative toward electronic health records. We anticipate this trend will continue as we move forward, and we are okay with that. There is no question that the national dialogue is presently quite critical of EHRs, frequently highlighting physician frustration with current electronic health record systems.

In fact, a recent survey conducted by the American College of Physicians and AmericanEHR Partners found that physician satisfaction with EHRs across multiple specialties dropped 12% from 2010 to 2012 (data presented at the 2013 Healthcare Information and Management Systems Society [HIMSS] annual meeting. Furthermore, 39% of respondents stated that they would not recommend their current EHR to a colleague. But what would cause such a negative downturn?

Ironically, many feel the reason for this, in large part, is the Meaningful Use program. The very same program designed to incentivize physicians to invest in technology has become the source of their growing dissatisfaction with it. Essentially, this government-sponsored program has forced the process of EHR adoption to move very quickly. Physicians who would have never before considered themselves "early adopters" have been encouraged to purchase an electronic record while the technology is still – in many ways – in its infancy. They have been motivated not only by the promise of financial gain, but also by the fear of looming penalties if they fail to comply.

This phenomenon is fairly novel and completely atypical of technology adoption. Traditionally, when any new innovation is brought to market, it is immediately embraced by a select few who always want to be on the bleeding edge (admittedly, the two of us are self-proclaimed geeks and often count ourselves among this group). Most people, however, have little interest and might not even take notice until that which once was innovative becomes "old hat."

The Facebook phenomenon is a prime example of this. The success of the social networking giant truly exploded once it moved from an online "college hangout" to a tool that "everyone and their grandmother" (literally) began relying on for essential communication. This was a completely organic process, not one artificially cultivated by government involvement. In other words, people began using Facebook not because they had to but because they wanted to. It simply provided a better way of communicating and managing information in the social domain.

Interestingly enough, EHRs promise to bring the same utility to the field of medicine. They are intended to enhance communication among physicians and streamline care by improving data management and clinical decision support. This is possible and even obtainable today in certain circumstances, but there is a great deal of inconsistency in quality among the various products available and the market has not had time to weed out those that are failing to deliver on their promises. In many ways, even we would agree that artificial influences have encouraged the market to move too fast, and we can sympathize with those who have found reason to question the value of many current EHR offerings.

Thankfully, there are many influential voices who have recently spoken out about the speed at which the world of health IT is moving. Most notably, Dr. James L. Madara, CEO and executive vice president of the American Medical Association, filed formal comments with the Centers for Medicare and Medicaid Services earlier this year encouraging them to "slow down" development of Meaningful Use stage 3. In the letter, Dr. Madara stated "It makes no sense to add stages and requirements to a program when even savvy EHR users and specialists are having difficulty meeting the Stage 1 measures."

It seems that the CMS agrees with this, as acting administrator Marilyn Tavenner announced in March that there will be a hiatus prior to further rulemaking to examine the program’s impact so far and solicit comments from clinicians.

With that in mind, here is your opportunity to bring your thoughts and criticisms to a public forum. As stated above, we look forward to receiving any perspective or status updates you might wish to offer and will review and publish these over the next few months. We hope that this will prove to be constructive, informative, and useful, and will reflect where our fellow clinicians stand on issues from meaningful (or unmeaningful) use to optimization strategies and techniques.

We are convinced that the true success of EHR adoption will take time and only come through the collective wisdom and feedback of clinicians, but we remain confident that eventually it will offer a path to improved patient care. Whether you agree or not, here’s your chance to let us know.

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 editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at [email protected].