Neil Skolnik, MD

"I won’t insist that the patient is a soul,

But he’s a something, possibly laughable,

Or possibly sublime, but not quite graphable.

Not quite containable on a bed chart.

Where science touches man it turns to art."

–John Ciardi

The Saturday Review, Nov. 18, 1967

"Not quite graphable" is how John Ciardi described patients in a wonderful poem titled "Lines From the Beating End of the Stethoscope." In that poem, which he read at the inaugural for the new president of New York Medical College, he describes medicine, as the title suggests, from the patient’s point of view.

The poem was meant to be a reminder of the subtle needs that patients have during their encounters with doctors around some of the most important decisions and events in their life, their health, and their physical and mental well-being. It was a reminder to doctors that patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.

How Mr. Ciardi had such insight 45 years ago into the issues that we are all facing today is remarkable. It is a rare day in which I do not hear from one of my colleagues about how the computer screen is getting between them and their patient.

We talk in conferences about how we have become so focused on the needs of the computer that the needs of the patient get left behind. How we are so busy making sure that the "checklist" of tasks for meaningful use have been completed, that the meaningful encounter – that feeling that the patient keeps with them after they leave the doctor’s office that they have encountered someone who cares about them – recedes into the background, while the foreground is filled with clicks and navigated pages.

A recent commentary in JAMA displayed a crayon drawing by a 7-year-old girl, which was given to her doctor (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family.

The message implicit in the publication of this drawing is clear – that patients are now beginning to see us in ways that are different than how we have traditionally seen ourselves. Ways that are frankly embarrassing. I don’t think that any of us go to the office desiring to be the kind of doctor that a child or an aging adult perceives as hunched over a computer screen distractedly listening to their concerns while typing away with our back toward them.

Integrating the electronic record into the exam room brings with it certain inherent tensions that potentially interfere with the interaction of patients and their physicians. These tensions are consistent with the tensions imposed by the necessity of documenting the patient encounter, and this tension exists whether the physician is using paper or electronic media.

Once this fact is understood, and the importance of maintaining an empathic interpersonal encounter with the patient is accepted as something that cannot be compromised, we can begin to thoughtfully and honestly develop methods that allow us to keep the encounter personal while integrating the electronic medical record into our office.

Sometimes, simple things can make a big difference. Attention to ergonomics of the exam room is important to minimize the negative impact that using an EMR can have on physician-patient interaction.

This may seem obvious, but a large multispecialty practice that we have visited has had significant problems, as well as physician and patient dissatisfaction, simply because they chose to use desktop computers located on small tables or desks in each exam room.

This initially seems like a clear and easy decision. The costly equipment was secure, and physicians did not have to carry laptops with them from room to room.

Unfortunately, because the desks are located against the wall in the exam room, the physician has to have his or her back to the patient in order to fill in a note during the visit. Alternatively, the physician can face the computer screen and keep turning her neck to look over her shoulder to maintain eye contact with the patient, then turn back to look at the computer to record the encounter. This behavior is awkward interpersonally and leads to physical discomfort for the physician.

Another helpful hint can be drawn directly from observations of physicians who use electronic health records.

Many physicians, particularly older physicians, never learned how to type well. They peck away at the keyboard, staring at the computer screen – or, even worse, the keyboard itself – while slowly entering a patient’s history. However, we have also noticed that some physicians are able to type their history of present illness while maintaining eye contact with their patient, only occasionally looking down at the screen.

Even though it requires an investment of time, physicians who do not have sufficient typing skills might consider acquiring this new skill so they can be more productive in their office.

Plenty of effort is given to improving workflow in the office – but if a physician cannot get information easily into the chart, the biggest funnel for office workflow is occurring right at the beginning of the patient encounter. And that interferes with everything downstream, including the quality of the note, the time taken for the encounter, and ultimately the physician’s relationship with their patient.

If learning how to type does not seem like a reasonable use of time, or if it seems too daunting a task to learn, then we would encourage these physicians to explore the use of voice recognition software. The software is now sophisticated enough to be useful and accurate, and allows us to look at the patient while dictating a note in front of them in a timely fashion.

Recognizing the challenges inherent in electronic documentation, and keeping in mind the importance of our goal of maintaining empathic relationships, allows us to critically look at our encounters. This critical, analytical eye allows us to creatively pursue the elusive ideal so persuasively described by Mr. Ciardi more than 40 years ago: "Where science touches man, it turns to art."

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

"I won’t insist that the patient is a soul,

But he’s a something, possibly laughable,

Or possibly sublime, but not quite graphable.

Not quite containable on a bed chart.

Where science touches man it turns to art."

–John Ciardi

The Saturday Review, Nov. 18, 1967

"Not quite graphable" is how John Ciardi described patients in a wonderful poem titled "Lines From the Beating End of the Stethoscope." In that poem, which he read at the inaugural for the new president of New York Medical College, he describes medicine, as the title suggests, from the patient’s point of view.

The poem was meant to be a reminder of the subtle needs that patients have during their encounters with doctors around some of the most important decisions and events in their life, their health, and their physical and mental well-being. It was a reminder to doctors that patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.

How Mr. Ciardi had such insight 45 years ago into the issues that we are all facing today is remarkable. It is a rare day in which I do not hear from one of my colleagues about how the computer screen is getting between them and their patient.

We talk in conferences about how we have become so focused on the needs of the computer that the needs of the patient get left behind. How we are so busy making sure that the "checklist" of tasks for meaningful use have been completed, that the meaningful encounter – that feeling that the patient keeps with them after they leave the doctor’s office that they have encountered someone who cares about them – recedes into the background, while the foreground is filled with clicks and navigated pages.

A recent commentary in JAMA displayed a crayon drawing by a 7-year-old girl, which was given to her doctor (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family.

The message implicit in the publication of this drawing is clear – that patients are now beginning to see us in ways that are different than how we have traditionally seen ourselves. Ways that are frankly embarrassing. I don’t think that any of us go to the office desiring to be the kind of doctor that a child or an aging adult perceives as hunched over a computer screen distractedly listening to their concerns while typing away with our back toward them.

Integrating the electronic record into the exam room brings with it certain inherent tensions that potentially interfere with the interaction of patients and their physicians. These tensions are consistent with the tensions imposed by the necessity of documenting the patient encounter, and this tension exists whether the physician is using paper or electronic media.

Once this fact is understood, and the importance of maintaining an empathic interpersonal encounter with the patient is accepted as something that cannot be compromised, we can begin to thoughtfully and honestly develop methods that allow us to keep the encounter personal while integrating the electronic medical record into our office.

Sometimes, simple things can make a big difference. Attention to ergonomics of the exam room is important to minimize the negative impact that using an EMR can have on physician-patient interaction.

This may seem obvious, but a large multispecialty practice that we have visited has had significant problems, as well as physician and patient dissatisfaction, simply because they chose to use desktop computers located on small tables or desks in each exam room.

This initially seems like a clear and easy decision. The costly equipment was secure, and physicians did not have to carry laptops with them from room to room.

Unfortunately, because the desks are located against the wall in the exam room, the physician has to have his or her back to the patient in order to fill in a note during the visit. Alternatively, the physician can face the computer screen and keep turning her neck to look over her shoulder to maintain eye contact with the patient, then turn back to look at the computer to record the encounter. This behavior is awkward interpersonally and leads to physical discomfort for the physician.

Another helpful hint can be drawn directly from observations of physicians who use electronic health records.

Many physicians, particularly older physicians, never learned how to type well. They peck away at the keyboard, staring at the computer screen – or, even worse, the keyboard itself – while slowly entering a patient’s history. However, we have also noticed that some physicians are able to type their history of present illness while maintaining eye contact with their patient, only occasionally looking down at the screen.

Even though it requires an investment of time, physicians who do not have sufficient typing skills might consider acquiring this new skill so they can be more productive in their office.

Plenty of effort is given to improving workflow in the office – but if a physician cannot get information easily into the chart, the biggest funnel for office workflow is occurring right at the beginning of the patient encounter. And that interferes with everything downstream, including the quality of the note, the time taken for the encounter, and ultimately the physician’s relationship with their patient.

If learning how to type does not seem like a reasonable use of time, or if it seems too daunting a task to learn, then we would encourage these physicians to explore the use of voice recognition software. The software is now sophisticated enough to be useful and accurate, and allows us to look at the patient while dictating a note in front of them in a timely fashion.

Recognizing the challenges inherent in electronic documentation, and keeping in mind the importance of our goal of maintaining empathic relationships, allows us to critically look at our encounters. This critical, analytical eye allows us to creatively pursue the elusive ideal so persuasively described by Mr. Ciardi more than 40 years ago: "Where science touches man, it turns to art."

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

"I won’t insist that the patient is a soul,

But he’s a something, possibly laughable,

Or possibly sublime, but not quite graphable.

Not quite containable on a bed chart.

Where science touches man it turns to art."

–John Ciardi

The Saturday Review, Nov. 18, 1967

"Not quite graphable" is how John Ciardi described patients in a wonderful poem titled "Lines From the Beating End of the Stethoscope." In that poem, which he read at the inaugural for the new president of New York Medical College, he describes medicine, as the title suggests, from the patient’s point of view.

The poem was meant to be a reminder of the subtle needs that patients have during their encounters with doctors around some of the most important decisions and events in their life, their health, and their physical and mental well-being. It was a reminder to doctors that patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.

How Mr. Ciardi had such insight 45 years ago into the issues that we are all facing today is remarkable. It is a rare day in which I do not hear from one of my colleagues about how the computer screen is getting between them and their patient.

We talk in conferences about how we have become so focused on the needs of the computer that the needs of the patient get left behind. How we are so busy making sure that the "checklist" of tasks for meaningful use have been completed, that the meaningful encounter – that feeling that the patient keeps with them after they leave the doctor’s office that they have encountered someone who cares about them – recedes into the background, while the foreground is filled with clicks and navigated pages.

A recent commentary in JAMA displayed a crayon drawing by a 7-year-old girl, which was given to her doctor (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family.

The message implicit in the publication of this drawing is clear – that patients are now beginning to see us in ways that are different than how we have traditionally seen ourselves. Ways that are frankly embarrassing. I don’t think that any of us go to the office desiring to be the kind of doctor that a child or an aging adult perceives as hunched over a computer screen distractedly listening to their concerns while typing away with our back toward them.

Integrating the electronic record into the exam room brings with it certain inherent tensions that potentially interfere with the interaction of patients and their physicians. These tensions are consistent with the tensions imposed by the necessity of documenting the patient encounter, and this tension exists whether the physician is using paper or electronic media.

Once this fact is understood, and the importance of maintaining an empathic interpersonal encounter with the patient is accepted as something that cannot be compromised, we can begin to thoughtfully and honestly develop methods that allow us to keep the encounter personal while integrating the electronic medical record into our office.

Sometimes, simple things can make a big difference. Attention to ergonomics of the exam room is important to minimize the negative impact that using an EMR can have on physician-patient interaction.

This may seem obvious, but a large multispecialty practice that we have visited has had significant problems, as well as physician and patient dissatisfaction, simply because they chose to use desktop computers located on small tables or desks in each exam room.

This initially seems like a clear and easy decision. The costly equipment was secure, and physicians did not have to carry laptops with them from room to room.

Unfortunately, because the desks are located against the wall in the exam room, the physician has to have his or her back to the patient in order to fill in a note during the visit. Alternatively, the physician can face the computer screen and keep turning her neck to look over her shoulder to maintain eye contact with the patient, then turn back to look at the computer to record the encounter. This behavior is awkward interpersonally and leads to physical discomfort for the physician.

Another helpful hint can be drawn directly from observations of physicians who use electronic health records.

Many physicians, particularly older physicians, never learned how to type well. They peck away at the keyboard, staring at the computer screen – or, even worse, the keyboard itself – while slowly entering a patient’s history. However, we have also noticed that some physicians are able to type their history of present illness while maintaining eye contact with their patient, only occasionally looking down at the screen.

Even though it requires an investment of time, physicians who do not have sufficient typing skills might consider acquiring this new skill so they can be more productive in their office.

Plenty of effort is given to improving workflow in the office – but if a physician cannot get information easily into the chart, the biggest funnel for office workflow is occurring right at the beginning of the patient encounter. And that interferes with everything downstream, including the quality of the note, the time taken for the encounter, and ultimately the physician’s relationship with their patient.

If learning how to type does not seem like a reasonable use of time, or if it seems too daunting a task to learn, then we would encourage these physicians to explore the use of voice recognition software. The software is now sophisticated enough to be useful and accurate, and allows us to look at the patient while dictating a note in front of them in a timely fashion.

Recognizing the challenges inherent in electronic documentation, and keeping in mind the importance of our goal of maintaining empathic relationships, allows us to critically look at our encounters. This critical, analytical eye allows us to creatively pursue the elusive ideal so persuasively described by Mr. Ciardi more than 40 years ago: "Where science touches man, it turns to art."

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

The old cliché "When it rains, it pours," is hardly more appropriate than in the world of health care. Every day, the industry changes, and we are forced to adapt to new regulations and expectations from the government, insurance companies, and patients that dramatically affect the way we practice.

Recently, the storms have been raging in the area of health IT. As an example, consider the initiative that began with a simple requirement for e-prescribing and then developed into a huge undertaking called "meaningful use."

It begs the question: Why is it that electronic health records, which were sold on the idea of making our lives easier, have only seemed to complicate things?

While there are certainly no easy answers, one thing is clear: Electronic records are here to stay, and they have had a significant impact on physician practice and patient care.

This month, we’ll explore the idea of implementing a patient portal, that is, granting patients immediate access to their medical records through the Web. This has evoked a tremendous amount of anxiety among physicians – and while these concerns are significant, they have not slowed the adoption of the new technology.

Unsealing the Sacred Book

There are a number of issues raised anytime a practice or health system decides to install a patient portal.

First and foremost, physicians become quite concerned about what a patient will see in their personal records, and how this will affect the doctor-patient relationship. This is particularly salient in areas such as mental health, social history, and life-altering diagnoses. A care provider may document something in a problem list or differential diagnosis that the patient could find shocking or offensive. Issues such as "morbid obesity" or "bipolar disorder," while perfectly legitimate and accurate, can be viewed as judgmental and insulting. Other comments, such as "possible malignancy" or "suspicious for multiple sclerosis," could be devastating to a patient who has not had time to process them with his or her physician.

It is critical, therefore, that providers are aware of what parts of the record will be available to the patient, and how to document sensitive issues appropriately. Most Web portals allow for customization and limits to be placed on what a patient can access. While it is true that patients have a right to the entirety of their record, it is not necessary to provide them with information they have not requested.

We would argue, however, that the standard should be to provide as much access as possible – a standard that has been adopted by many major health systems across the country. The onus is then placed on the doctor to be prudent in how he or she documents in the record, with full knowledge that patients can and will be reviewing it.

Why More Is (Usually) Better

Many of the people we speak to ask us whether or not we believe that sharing health records with our patients is a good thing. Until recently, we had only our own opinion, and had limited to no data to back it up. This all changed this month with an article by Dr. Tom Delbanco entitled "Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead" (Ann. Intern. Med. 2012;157:461-70).

In this study, more than 13,000 patients at multiple medical centers were given access to their physicians’ notes to see how reviewing them affected "behaviors, benefits, and negative consequences."

The results are quite interesting. Of the patients who reviewed their notes and answered follow-up surveys, 77%-87% felt more in control of their care, and 60%-78% reported better medication adherence. Only about a quarter of those surveyed had privacy concerns, and just 1%-8% reported that the notes caused "confusion, worry, or offense."

This study also examined physician behavior. Of the 105 primary care physicians involved across three states, 3%-36% reported changing documentation content, and many reported taking more time to write their notes.

In the end, the authors report that "99% of patients wanted open notes to continue, and no doctor elected to stop." Clearly, the process seemed to be beneficial for both physician and patient, and the benefits outweighed the risks.

Managing Liabilities

As our column last month pointed out ("How to Avoid EMR Legal Pitfalls," Sept. 15, p. 40), the use of electronic health records has unearthed some new legal pitfalls, and the realities of a patient portal further underscore this unfortunate fact. Patients – and their attorneys – are able to scrutinize their medical record, and any missed lab result or diagnostic error is available for anyone to see. This is a significant fear for many physicians, but so far history has proven the opposite to be true.

As we noted above, when patients feel more ownership of their health care, they perceive they are being better cared for, and fewer important details get overlooked. Abnormal lab values that may slip by a physician in the deluge of the daily mail are easily caught by a patient who is anxiously anticipating them.

But what about patients who will trouble their doctor over less than concerning results? While the cost might be a panicked phone call from someone with a slightly elevated BUN or low MCH, the reward could be a providential request to reevaluate the results of a CT scan showing a mass the primary care physician somehow missed.

We are hopeful that in the end, EHR technology will fulfill its touted promises, and that the downpour of new challenges will actually make the landscape more fertile to the growth of better patient care.

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

The old cliché "When it rains, it pours," is hardly more appropriate than in the world of health care. Every day, the industry changes, and we are forced to adapt to new regulations and expectations from the government, insurance companies, and patients that dramatically affect the way we practice.

Recently, the storms have been raging in the area of health IT. As an example, consider the initiative that began with a simple requirement for e-prescribing and then developed into a huge undertaking called "meaningful use."

It begs the question: Why is it that electronic health records, which were sold on the idea of making our lives easier, have only seemed to complicate things?

While there are certainly no easy answers, one thing is clear: Electronic records are here to stay, and they have had a significant impact on physician practice and patient care.

This month, we’ll explore the idea of implementing a patient portal, that is, granting patients immediate access to their medical records through the Web. This has evoked a tremendous amount of anxiety among physicians – and while these concerns are significant, they have not slowed the adoption of the new technology.

Unsealing the Sacred Book

There are a number of issues raised anytime a practice or health system decides to install a patient portal.

First and foremost, physicians become quite concerned about what a patient will see in their personal records, and how this will affect the doctor-patient relationship. This is particularly salient in areas such as mental health, social history, and life-altering diagnoses. A care provider may document something in a problem list or differential diagnosis that the patient could find shocking or offensive. Issues such as "morbid obesity" or "bipolar disorder," while perfectly legitimate and accurate, can be viewed as judgmental and insulting. Other comments, such as "possible malignancy" or "suspicious for multiple sclerosis," could be devastating to a patient who has not had time to process them with his or her physician.

It is critical, therefore, that providers are aware of what parts of the record will be available to the patient, and how to document sensitive issues appropriately. Most Web portals allow for customization and limits to be placed on what a patient can access. While it is true that patients have a right to the entirety of their record, it is not necessary to provide them with information they have not requested.

We would argue, however, that the standard should be to provide as much access as possible – a standard that has been adopted by many major health systems across the country. The onus is then placed on the doctor to be prudent in how he or she documents in the record, with full knowledge that patients can and will be reviewing it.

Why More Is (Usually) Better

Many of the people we speak to ask us whether or not we believe that sharing health records with our patients is a good thing. Until recently, we had only our own opinion, and had limited to no data to back it up. This all changed this month with an article by Dr. Tom Delbanco entitled "Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead" (Ann. Intern. Med. 2012;157:461-70).

In this study, more than 13,000 patients at multiple medical centers were given access to their physicians’ notes to see how reviewing them affected "behaviors, benefits, and negative consequences."

The results are quite interesting. Of the patients who reviewed their notes and answered follow-up surveys, 77%-87% felt more in control of their care, and 60%-78% reported better medication adherence. Only about a quarter of those surveyed had privacy concerns, and just 1%-8% reported that the notes caused "confusion, worry, or offense."

This study also examined physician behavior. Of the 105 primary care physicians involved across three states, 3%-36% reported changing documentation content, and many reported taking more time to write their notes.

In the end, the authors report that "99% of patients wanted open notes to continue, and no doctor elected to stop." Clearly, the process seemed to be beneficial for both physician and patient, and the benefits outweighed the risks.

Managing Liabilities

As our column last month pointed out ("How to Avoid EMR Legal Pitfalls," Sept. 15, p. 40), the use of electronic health records has unearthed some new legal pitfalls, and the realities of a patient portal further underscore this unfortunate fact. Patients – and their attorneys – are able to scrutinize their medical record, and any missed lab result or diagnostic error is available for anyone to see. This is a significant fear for many physicians, but so far history has proven the opposite to be true.

As we noted above, when patients feel more ownership of their health care, they perceive they are being better cared for, and fewer important details get overlooked. Abnormal lab values that may slip by a physician in the deluge of the daily mail are easily caught by a patient who is anxiously anticipating them.

But what about patients who will trouble their doctor over less than concerning results? While the cost might be a panicked phone call from someone with a slightly elevated BUN or low MCH, the reward could be a providential request to reevaluate the results of a CT scan showing a mass the primary care physician somehow missed.

We are hopeful that in the end, EHR technology will fulfill its touted promises, and that the downpour of new challenges will actually make the landscape more fertile to the growth of better patient care.

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

The old cliché "When it rains, it pours," is hardly more appropriate than in the world of health care. Every day, the industry changes, and we are forced to adapt to new regulations and expectations from the government, insurance companies, and patients that dramatically affect the way we practice.

Recently, the storms have been raging in the area of health IT. As an example, consider the initiative that began with a simple requirement for e-prescribing and then developed into a huge undertaking called "meaningful use."

It begs the question: Why is it that electronic health records, which were sold on the idea of making our lives easier, have only seemed to complicate things?

While there are certainly no easy answers, one thing is clear: Electronic records are here to stay, and they have had a significant impact on physician practice and patient care.

This month, we’ll explore the idea of implementing a patient portal, that is, granting patients immediate access to their medical records through the Web. This has evoked a tremendous amount of anxiety among physicians – and while these concerns are significant, they have not slowed the adoption of the new technology.

Unsealing the Sacred Book

There are a number of issues raised anytime a practice or health system decides to install a patient portal.

First and foremost, physicians become quite concerned about what a patient will see in their personal records, and how this will affect the doctor-patient relationship. This is particularly salient in areas such as mental health, social history, and life-altering diagnoses. A care provider may document something in a problem list or differential diagnosis that the patient could find shocking or offensive. Issues such as "morbid obesity" or "bipolar disorder," while perfectly legitimate and accurate, can be viewed as judgmental and insulting. Other comments, such as "possible malignancy" or "suspicious for multiple sclerosis," could be devastating to a patient who has not had time to process them with his or her physician.

It is critical, therefore, that providers are aware of what parts of the record will be available to the patient, and how to document sensitive issues appropriately. Most Web portals allow for customization and limits to be placed on what a patient can access. While it is true that patients have a right to the entirety of their record, it is not necessary to provide them with information they have not requested.

We would argue, however, that the standard should be to provide as much access as possible – a standard that has been adopted by many major health systems across the country. The onus is then placed on the doctor to be prudent in how he or she documents in the record, with full knowledge that patients can and will be reviewing it.

Why More Is (Usually) Better

Many of the people we speak to ask us whether or not we believe that sharing health records with our patients is a good thing. Until recently, we had only our own opinion, and had limited to no data to back it up. This all changed this month with an article by Dr. Tom Delbanco entitled "Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead" (Ann. Intern. Med. 2012;157:461-70).

In this study, more than 13,000 patients at multiple medical centers were given access to their physicians’ notes to see how reviewing them affected "behaviors, benefits, and negative consequences."

The results are quite interesting. Of the patients who reviewed their notes and answered follow-up surveys, 77%-87% felt more in control of their care, and 60%-78% reported better medication adherence. Only about a quarter of those surveyed had privacy concerns, and just 1%-8% reported that the notes caused "confusion, worry, or offense."

This study also examined physician behavior. Of the 105 primary care physicians involved across three states, 3%-36% reported changing documentation content, and many reported taking more time to write their notes.

In the end, the authors report that "99% of patients wanted open notes to continue, and no doctor elected to stop." Clearly, the process seemed to be beneficial for both physician and patient, and the benefits outweighed the risks.

Managing Liabilities

As our column last month pointed out ("How to Avoid EMR Legal Pitfalls," Sept. 15, p. 40), the use of electronic health records has unearthed some new legal pitfalls, and the realities of a patient portal further underscore this unfortunate fact. Patients – and their attorneys – are able to scrutinize their medical record, and any missed lab result or diagnostic error is available for anyone to see. This is a significant fear for many physicians, but so far history has proven the opposite to be true.

As we noted above, when patients feel more ownership of their health care, they perceive they are being better cared for, and fewer important details get overlooked. Abnormal lab values that may slip by a physician in the deluge of the daily mail are easily caught by a patient who is anxiously anticipating them.

But what about patients who will trouble their doctor over less than concerning results? While the cost might be a panicked phone call from someone with a slightly elevated BUN or low MCH, the reward could be a providential request to reevaluate the results of a CT scan showing a mass the primary care physician somehow missed.

We are hopeful that in the end, EHR technology will fulfill its touted promises, and that the downpour of new challenges will actually make the landscape more fertile to the growth of better patient care.

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

Approximately 4,000 women in the United States die every year of cervical cancer. Fifty percent of women with cervical cancer have never been screened, and another 10% were not screened within the previous 5 years. Papanicolaou (Pap) testing has markedly reduced mortality from cervical cancer, helping lower it from first to 14th on the list of causes of cancer deaths in women.

New guidelines from the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology address age-appropriate screening strategies, use of cytology and high-risk human papillomavirus (HPV) testing, follow-up, age to cease screening, and the approach to the HPV-vaccinated patient.

Nearly 100% of cervical cancers are caused by HPV. "High-risk HPV" is a term used to identify approximately 15 carcinogenic HPV genotypes, including HPV 16 and HPV 18. Most HPV infections are cleared by the body within 2 years; those that remain have a higher risk of developing precancerous lesions.

Cervical intraepithelial neoplasia (CIN) are precancerous lesions found on the cervix and are classified as CIN 1, 2, or 3, depending on degree of abnormality in the epithelium. CIN 1-2 have a 10%-15% likelihood of progressing to CIN 3 and a 1%-5% risk of becoming cancer. The Bethesda system uses the nomenclature low-grade and high-grade squamous intraepithelial lesion (LSIL and HSIL), which correspond to CIN 1 and CIN 2-3, respectively.

Screening Recommendations

• Initiation of screening: Screening in adolescents and young women has led to unnecessary evaluation and overtreatment of preinvasive cervical lesions that have a high probability of regressing spontaneously.

Recommendation: Cervical cancer screening should begin at age 21 years regardless of age of sexual initiation or other risk factors.

• Periodic screening: Evidence has shown that annual screening leads to a small increase in cancers prevented, at the cost of a large excess of procedures and treatments. Most HPV infections are benign and transient, and lesions will usually regress within 2 years. At worst, these lesions are usually years from causing cancer.

Recommendation: Screening should be periodic, based on age and clinical history, regardless of previous HPV vaccination.

• Screening, 21-29 years: There is a high prevalence of HPV in this age group – mostly benign cases that will regress spontaneously. Studies show no significant difference in cancer reduction between a 2-year and 3-year screening interval. However, there is a tripling in the number of colposcopy referrals in this age group when screening occurs every 2 years.

Recommendation: Women should be screened with cytology alone every 3 years. HPV testing should not be used to screen women in this age group.

• Screening, 30-65 years: There are two types of testing that are appropriate in this age group; one is recommended over the other if available. "Co-testing" refers to the combination of cytology and HPV testing, which increases the ability to detect CIN 3 and allows for a decrease in the interval of screening because of the low risk associated with a negative screen. Co-testing also increases the ability to detect adenocarcinoma. Cytology alone is also acceptable, but there is insufficient evidence to support a longer screening interval, even with previous successive negative screens.

Recommendation: In this age range, co-test screening should be performed every 5 years, or cytology alone every 3 years.

• Screening, older than 65 years: Women who have had CIN 2+ in the past 20 years have a 5- to 10-fold greater risk of developing cervical cancer than does the general population.

Recommendation: Discontinue screening in women older than 65 years who have had no diagnosis of CIN 2+ in the previous 20 years, regardless of sexual activity. For a woman who has been diagnosed or treated for CIN 2+ or adenocarcinoma in situ, routine screening should continue for 20 years, even past age 65 years.

• Screening, women after hysterectomy: Women who have had hysterectomy with removal of the cervix who have no history of CIN 2+ should not be screened.

Management of Abnormal Results

• HPV positive, cytology negative: It is not recommended to send these women immediately for colposcopy. Instead, there are two options: Either repeat co-testing in 12 months, or perform genotype-specific HPV testing for HPV 16 alone or HPV 16/18.

If co-testing is repeated in 12 months, women testing positive on either test (HPV positive or LSIL [low-grade squamous intraepithelial lesion] or greater) should be referred for colposcopy. If genotype testing is performed, then women testing positive for HPV 16 or HPV 16/18 also should be referred for colposcopy. If genotype is negative for HPV 16 or HPV 16/18, then repeat co-testing in 12 months. This is the only situation in which genotype-specific HPV testing is recommended.

• ASC-US, HPV negative: Atypical cells of undetermined significance (ASC-US) is a cytology testing finding that is not diagnostic and is clinically ambiguous, because it doesn’t represent a specific cytologic interpretation. Studies have shown that the risk of developing precancerous lesions from ASC-US is not different enough from a negative co-test to alter management. Thus, the recommendation is to continue screening per age-specific guidelines.

• ASC-US, HPV positive; LSIL; or more severe cytologic result regardless of HPV status: Conduct a colposcopic evaluation.

The Bottom Line:

Cervical cancer screening is an essential part of well-woman care. However, new recommendations stress maximizing benefit and minimizing harm by starting screening at age 21 years and by having screening intervals that are longer than annually and are determined by a woman’s age and previous cytology results. Screening recommendations do not change based on history of HPV vaccination.

Reference

• American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer (J. Low. Genit. Tract Dis. 2012;16:175-204).

Management guidelines and algorithms can be found at www.asccp.org.

Dr. Ward is a third-year resident in the ob.gyn. residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Approximately 4,000 women in the United States die every year of cervical cancer. Fifty percent of women with cervical cancer have never been screened, and another 10% were not screened within the previous 5 years. Papanicolaou (Pap) testing has markedly reduced mortality from cervical cancer, helping lower it from first to 14th on the list of causes of cancer deaths in women.

New guidelines from the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology address age-appropriate screening strategies, use of cytology and high-risk human papillomavirus (HPV) testing, follow-up, age to cease screening, and the approach to the HPV-vaccinated patient.

Nearly 100% of cervical cancers are caused by HPV. "High-risk HPV" is a term used to identify approximately 15 carcinogenic HPV genotypes, including HPV 16 and HPV 18. Most HPV infections are cleared by the body within 2 years; those that remain have a higher risk of developing precancerous lesions.

Cervical intraepithelial neoplasia (CIN) are precancerous lesions found on the cervix and are classified as CIN 1, 2, or 3, depending on degree of abnormality in the epithelium. CIN 1-2 have a 10%-15% likelihood of progressing to CIN 3 and a 1%-5% risk of becoming cancer. The Bethesda system uses the nomenclature low-grade and high-grade squamous intraepithelial lesion (LSIL and HSIL), which correspond to CIN 1 and CIN 2-3, respectively.

Screening Recommendations

• Initiation of screening: Screening in adolescents and young women has led to unnecessary evaluation and overtreatment of preinvasive cervical lesions that have a high probability of regressing spontaneously.

Recommendation: Cervical cancer screening should begin at age 21 years regardless of age of sexual initiation or other risk factors.

• Periodic screening: Evidence has shown that annual screening leads to a small increase in cancers prevented, at the cost of a large excess of procedures and treatments. Most HPV infections are benign and transient, and lesions will usually regress within 2 years. At worst, these lesions are usually years from causing cancer.

Recommendation: Screening should be periodic, based on age and clinical history, regardless of previous HPV vaccination.

• Screening, 21-29 years: There is a high prevalence of HPV in this age group – mostly benign cases that will regress spontaneously. Studies show no significant difference in cancer reduction between a 2-year and 3-year screening interval. However, there is a tripling in the number of colposcopy referrals in this age group when screening occurs every 2 years.

Recommendation: Women should be screened with cytology alone every 3 years. HPV testing should not be used to screen women in this age group.

• Screening, 30-65 years: There are two types of testing that are appropriate in this age group; one is recommended over the other if available. "Co-testing" refers to the combination of cytology and HPV testing, which increases the ability to detect CIN 3 and allows for a decrease in the interval of screening because of the low risk associated with a negative screen. Co-testing also increases the ability to detect adenocarcinoma. Cytology alone is also acceptable, but there is insufficient evidence to support a longer screening interval, even with previous successive negative screens.

Recommendation: In this age range, co-test screening should be performed every 5 years, or cytology alone every 3 years.

• Screening, older than 65 years: Women who have had CIN 2+ in the past 20 years have a 5- to 10-fold greater risk of developing cervical cancer than does the general population.

Recommendation: Discontinue screening in women older than 65 years who have had no diagnosis of CIN 2+ in the previous 20 years, regardless of sexual activity. For a woman who has been diagnosed or treated for CIN 2+ or adenocarcinoma in situ, routine screening should continue for 20 years, even past age 65 years.

• Screening, women after hysterectomy: Women who have had hysterectomy with removal of the cervix who have no history of CIN 2+ should not be screened.

Management of Abnormal Results

• HPV positive, cytology negative: It is not recommended to send these women immediately for colposcopy. Instead, there are two options: Either repeat co-testing in 12 months, or perform genotype-specific HPV testing for HPV 16 alone or HPV 16/18.

If co-testing is repeated in 12 months, women testing positive on either test (HPV positive or LSIL [low-grade squamous intraepithelial lesion] or greater) should be referred for colposcopy. If genotype testing is performed, then women testing positive for HPV 16 or HPV 16/18 also should be referred for colposcopy. If genotype is negative for HPV 16 or HPV 16/18, then repeat co-testing in 12 months. This is the only situation in which genotype-specific HPV testing is recommended.

• ASC-US, HPV negative: Atypical cells of undetermined significance (ASC-US) is a cytology testing finding that is not diagnostic and is clinically ambiguous, because it doesn’t represent a specific cytologic interpretation. Studies have shown that the risk of developing precancerous lesions from ASC-US is not different enough from a negative co-test to alter management. Thus, the recommendation is to continue screening per age-specific guidelines.

• ASC-US, HPV positive; LSIL; or more severe cytologic result regardless of HPV status: Conduct a colposcopic evaluation.

The Bottom Line:

Cervical cancer screening is an essential part of well-woman care. However, new recommendations stress maximizing benefit and minimizing harm by starting screening at age 21 years and by having screening intervals that are longer than annually and are determined by a woman’s age and previous cytology results. Screening recommendations do not change based on history of HPV vaccination.

Reference

• American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer (J. Low. Genit. Tract Dis. 2012;16:175-204).

Management guidelines and algorithms can be found at www.asccp.org.

Dr. Ward is a third-year resident in the ob.gyn. residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Approximately 4,000 women in the United States die every year of cervical cancer. Fifty percent of women with cervical cancer have never been screened, and another 10% were not screened within the previous 5 years. Papanicolaou (Pap) testing has markedly reduced mortality from cervical cancer, helping lower it from first to 14th on the list of causes of cancer deaths in women.

New guidelines from the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology address age-appropriate screening strategies, use of cytology and high-risk human papillomavirus (HPV) testing, follow-up, age to cease screening, and the approach to the HPV-vaccinated patient.

Nearly 100% of cervical cancers are caused by HPV. "High-risk HPV" is a term used to identify approximately 15 carcinogenic HPV genotypes, including HPV 16 and HPV 18. Most HPV infections are cleared by the body within 2 years; those that remain have a higher risk of developing precancerous lesions.

Cervical intraepithelial neoplasia (CIN) are precancerous lesions found on the cervix and are classified as CIN 1, 2, or 3, depending on degree of abnormality in the epithelium. CIN 1-2 have a 10%-15% likelihood of progressing to CIN 3 and a 1%-5% risk of becoming cancer. The Bethesda system uses the nomenclature low-grade and high-grade squamous intraepithelial lesion (LSIL and HSIL), which correspond to CIN 1 and CIN 2-3, respectively.

Screening Recommendations

• Initiation of screening: Screening in adolescents and young women has led to unnecessary evaluation and overtreatment of preinvasive cervical lesions that have a high probability of regressing spontaneously.

Recommendation: Cervical cancer screening should begin at age 21 years regardless of age of sexual initiation or other risk factors.

• Periodic screening: Evidence has shown that annual screening leads to a small increase in cancers prevented, at the cost of a large excess of procedures and treatments. Most HPV infections are benign and transient, and lesions will usually regress within 2 years. At worst, these lesions are usually years from causing cancer.

Recommendation: Screening should be periodic, based on age and clinical history, regardless of previous HPV vaccination.

• Screening, 21-29 years: There is a high prevalence of HPV in this age group – mostly benign cases that will regress spontaneously. Studies show no significant difference in cancer reduction between a 2-year and 3-year screening interval. However, there is a tripling in the number of colposcopy referrals in this age group when screening occurs every 2 years.

Recommendation: Women should be screened with cytology alone every 3 years. HPV testing should not be used to screen women in this age group.

• Screening, 30-65 years: There are two types of testing that are appropriate in this age group; one is recommended over the other if available. "Co-testing" refers to the combination of cytology and HPV testing, which increases the ability to detect CIN 3 and allows for a decrease in the interval of screening because of the low risk associated with a negative screen. Co-testing also increases the ability to detect adenocarcinoma. Cytology alone is also acceptable, but there is insufficient evidence to support a longer screening interval, even with previous successive negative screens.

Recommendation: In this age range, co-test screening should be performed every 5 years, or cytology alone every 3 years.

• Screening, older than 65 years: Women who have had CIN 2+ in the past 20 years have a 5- to 10-fold greater risk of developing cervical cancer than does the general population.

Recommendation: Discontinue screening in women older than 65 years who have had no diagnosis of CIN 2+ in the previous 20 years, regardless of sexual activity. For a woman who has been diagnosed or treated for CIN 2+ or adenocarcinoma in situ, routine screening should continue for 20 years, even past age 65 years.

• Screening, women after hysterectomy: Women who have had hysterectomy with removal of the cervix who have no history of CIN 2+ should not be screened.

Management of Abnormal Results

• HPV positive, cytology negative: It is not recommended to send these women immediately for colposcopy. Instead, there are two options: Either repeat co-testing in 12 months, or perform genotype-specific HPV testing for HPV 16 alone or HPV 16/18.

If co-testing is repeated in 12 months, women testing positive on either test (HPV positive or LSIL [low-grade squamous intraepithelial lesion] or greater) should be referred for colposcopy. If genotype testing is performed, then women testing positive for HPV 16 or HPV 16/18 also should be referred for colposcopy. If genotype is negative for HPV 16 or HPV 16/18, then repeat co-testing in 12 months. This is the only situation in which genotype-specific HPV testing is recommended.

• ASC-US, HPV negative: Atypical cells of undetermined significance (ASC-US) is a cytology testing finding that is not diagnostic and is clinically ambiguous, because it doesn’t represent a specific cytologic interpretation. Studies have shown that the risk of developing precancerous lesions from ASC-US is not different enough from a negative co-test to alter management. Thus, the recommendation is to continue screening per age-specific guidelines.

• ASC-US, HPV positive; LSIL; or more severe cytologic result regardless of HPV status: Conduct a colposcopic evaluation.

The Bottom Line:

Cervical cancer screening is an essential part of well-woman care. However, new recommendations stress maximizing benefit and minimizing harm by starting screening at age 21 years and by having screening intervals that are longer than annually and are determined by a woman’s age and previous cytology results. Screening recommendations do not change based on history of HPV vaccination.

Reference

• American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer (J. Low. Genit. Tract Dis. 2012;16:175-204).

Management guidelines and algorithms can be found at www.asccp.org.

Dr. Ward is a third-year resident in the ob.gyn. residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Although implementation of the electronic medical record is a work in progress, its capabilities clearly are endless. What’s less certain is the EMR’s impact on a crucial aspect of physician practice: medical liability.

For physicians’ defense attorneys, the days of reviewing the original handwritten medical record are fading. The arduous task of deciphering illegible entries and uncovering tidbits of information that proved to be critical to the successful defense of a claim is sorely missed.

Now, we sift through reams of printed data hoping to locate the coveted "free-text" note as we strive to breathe some life into a lifeless document. The satisfaction of finding that rare note quickly turns to frustration when it is later repeated throughout the record; a byproduct of the "cut and paste" feature favored by many. Any significance of the note is lost if there are errors or other data to establish obvious changes in the patient’s condition. The intimacy of the physician-patient relationship is lost with the EMR.

Increasingly, we are dealing with the problem of the information hidden behind the EMR. It can be more significant to the claim or defense of a claim than the information that appears on the record.

Allegations of record alterations, once debated by ink and handwriting experts who poked pin-sized holes in charts to obtain samples for ink dating or analyzed impressions and indentations to prove the timing of an entry, are now fodder for forensic computer experts. The "metadata" provide tangible electronic evidence of changes, additions, and deletions.

One of the biggest challenges has been the translation of the interactive live documentation systems into static documents to produce during the discovery phase of a case.

Electronic storage of information adds a new dimension to reproduction of the EMR. A simple request for a copy of the medical record has become a document production nightmare. What formerly constituted the "official" medical record now may incorporate much more. And, there is no such thing as a "user-friendly" printed version of the EMR; it looks nothing like the "live" system and proves to be notoriously more burdensome to navigate. We are also finding that the periodic system upgrades can hinder access to prior documentation, in some cases making it virtually impossible. Addressing these problems requires resources.

Yet, we all need to embrace the technology and learn to use it to our advantage, in health care and in litigation. In order to maximize the benefits of the EMR and minimize the potential legal pitfalls, health care providers need to be aware of a few of the basics.

• First and foremost, the EMR should never be deleted or altered. The EMR needs to be preserved in accordance with the applicable laws in your state.

Keep in mind that the simple act of logging into a patient’s chart creates a permanent record, even if no entry was made. While you may have no recollection of doing so, an audit will identify when you were in a patient’s EMR. In fact, it will disclose every person who accessed the patient’s record, along with the date, time, computer from which the record was accessed, and whether the record was created, modified, or deleted. HIPAA permits an individual to receive an accounting of disclosures of his or her protected health information upon request for up to 6 years.

• Before you succumb to the urge to "cut and paste" a prior note, pause. Read the note first; you might find that it no longer accurately reflects the patient’s condition. The note needs to reflect the patient’s current status. As the clinical condition of the patient changes, so should the note.

If the documentation system allows for "free text" notes, seize the opportunity. Consider capturing the visit in a more meaningful way to reflect your interaction with the patient. Although it can be faster to check off the boxes and move on to the next task, you are more likely to recall a patient or situation if you take the time to make a note.

• The nuances of a patient encounter are frequently missed by a computer. When you do "click" through documentation screens, click cautiously. Be careful with screens that offer drop-down options, and confirm that you are selecting the proper response. It only takes a slip of the mouse to make a mistake. We all know that typing can be onerous for those who lack keyboard skills, but try to catch the "typos."

• Make certain that your documentation addresses the actual evaluation you performed. There should be no documentation of an examination that was not done – that is called fraud.

• Be mindful to time your entry, especially in those cases when it is well after the treatment. The precise time can be determined, and disputes or discrepancies over timing of the entry can be resolved.

• Take the time to familiarize yourself with the documentation system in place. The next time you sign off on an entry, remember that the document created is only as good as the information entered.

An awareness of the potential pitfalls of the EMR is the first step to making the changes that will ultimately benefit everyone involved – your patient, you, and sometimes even your attorney.

Ms. Ford is a shareholder in the law firm of Marshall, Dennehey, Warner, Coleman, & Goggin, King of Prussia, Pa., and specializes in medical malpractice litigation. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also a partner in EHR Practice Consultants, helping practices move to EHR systems. Contact him at [email protected]

Although implementation of the electronic medical record is a work in progress, its capabilities clearly are endless. What’s less certain is the EMR’s impact on a crucial aspect of physician practice: medical liability.

For physicians’ defense attorneys, the days of reviewing the original handwritten medical record are fading. The arduous task of deciphering illegible entries and uncovering tidbits of information that proved to be critical to the successful defense of a claim is sorely missed.

Now, we sift through reams of printed data hoping to locate the coveted "free-text" note as we strive to breathe some life into a lifeless document. The satisfaction of finding that rare note quickly turns to frustration when it is later repeated throughout the record; a byproduct of the "cut and paste" feature favored by many. Any significance of the note is lost if there are errors or other data to establish obvious changes in the patient’s condition. The intimacy of the physician-patient relationship is lost with the EMR.

Increasingly, we are dealing with the problem of the information hidden behind the EMR. It can be more significant to the claim or defense of a claim than the information that appears on the record.

Allegations of record alterations, once debated by ink and handwriting experts who poked pin-sized holes in charts to obtain samples for ink dating or analyzed impressions and indentations to prove the timing of an entry, are now fodder for forensic computer experts. The "metadata" provide tangible electronic evidence of changes, additions, and deletions.

One of the biggest challenges has been the translation of the interactive live documentation systems into static documents to produce during the discovery phase of a case.

Electronic storage of information adds a new dimension to reproduction of the EMR. A simple request for a copy of the medical record has become a document production nightmare. What formerly constituted the "official" medical record now may incorporate much more. And, there is no such thing as a "user-friendly" printed version of the EMR; it looks nothing like the "live" system and proves to be notoriously more burdensome to navigate. We are also finding that the periodic system upgrades can hinder access to prior documentation, in some cases making it virtually impossible. Addressing these problems requires resources.

Yet, we all need to embrace the technology and learn to use it to our advantage, in health care and in litigation. In order to maximize the benefits of the EMR and minimize the potential legal pitfalls, health care providers need to be aware of a few of the basics.

• First and foremost, the EMR should never be deleted or altered. The EMR needs to be preserved in accordance with the applicable laws in your state.

Keep in mind that the simple act of logging into a patient’s chart creates a permanent record, even if no entry was made. While you may have no recollection of doing so, an audit will identify when you were in a patient’s EMR. In fact, it will disclose every person who accessed the patient’s record, along with the date, time, computer from which the record was accessed, and whether the record was created, modified, or deleted. HIPAA permits an individual to receive an accounting of disclosures of his or her protected health information upon request for up to 6 years.

• Before you succumb to the urge to "cut and paste" a prior note, pause. Read the note first; you might find that it no longer accurately reflects the patient’s condition. The note needs to reflect the patient’s current status. As the clinical condition of the patient changes, so should the note.

If the documentation system allows for "free text" notes, seize the opportunity. Consider capturing the visit in a more meaningful way to reflect your interaction with the patient. Although it can be faster to check off the boxes and move on to the next task, you are more likely to recall a patient or situation if you take the time to make a note.

• The nuances of a patient encounter are frequently missed by a computer. When you do "click" through documentation screens, click cautiously. Be careful with screens that offer drop-down options, and confirm that you are selecting the proper response. It only takes a slip of the mouse to make a mistake. We all know that typing can be onerous for those who lack keyboard skills, but try to catch the "typos."

• Make certain that your documentation addresses the actual evaluation you performed. There should be no documentation of an examination that was not done – that is called fraud.

• Be mindful to time your entry, especially in those cases when it is well after the treatment. The precise time can be determined, and disputes or discrepancies over timing of the entry can be resolved.

• Take the time to familiarize yourself with the documentation system in place. The next time you sign off on an entry, remember that the document created is only as good as the information entered.

An awareness of the potential pitfalls of the EMR is the first step to making the changes that will ultimately benefit everyone involved – your patient, you, and sometimes even your attorney.

Ms. Ford is a shareholder in the law firm of Marshall, Dennehey, Warner, Coleman, & Goggin, King of Prussia, Pa., and specializes in medical malpractice litigation. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also a partner in EHR Practice Consultants, helping practices move to EHR systems. Contact him at [email protected]

Although implementation of the electronic medical record is a work in progress, its capabilities clearly are endless. What’s less certain is the EMR’s impact on a crucial aspect of physician practice: medical liability.

For physicians’ defense attorneys, the days of reviewing the original handwritten medical record are fading. The arduous task of deciphering illegible entries and uncovering tidbits of information that proved to be critical to the successful defense of a claim is sorely missed.

Now, we sift through reams of printed data hoping to locate the coveted "free-text" note as we strive to breathe some life into a lifeless document. The satisfaction of finding that rare note quickly turns to frustration when it is later repeated throughout the record; a byproduct of the "cut and paste" feature favored by many. Any significance of the note is lost if there are errors or other data to establish obvious changes in the patient’s condition. The intimacy of the physician-patient relationship is lost with the EMR.

Increasingly, we are dealing with the problem of the information hidden behind the EMR. It can be more significant to the claim or defense of a claim than the information that appears on the record.

Allegations of record alterations, once debated by ink and handwriting experts who poked pin-sized holes in charts to obtain samples for ink dating or analyzed impressions and indentations to prove the timing of an entry, are now fodder for forensic computer experts. The "metadata" provide tangible electronic evidence of changes, additions, and deletions.

One of the biggest challenges has been the translation of the interactive live documentation systems into static documents to produce during the discovery phase of a case.

Electronic storage of information adds a new dimension to reproduction of the EMR. A simple request for a copy of the medical record has become a document production nightmare. What formerly constituted the "official" medical record now may incorporate much more. And, there is no such thing as a "user-friendly" printed version of the EMR; it looks nothing like the "live" system and proves to be notoriously more burdensome to navigate. We are also finding that the periodic system upgrades can hinder access to prior documentation, in some cases making it virtually impossible. Addressing these problems requires resources.

Yet, we all need to embrace the technology and learn to use it to our advantage, in health care and in litigation. In order to maximize the benefits of the EMR and minimize the potential legal pitfalls, health care providers need to be aware of a few of the basics.

• First and foremost, the EMR should never be deleted or altered. The EMR needs to be preserved in accordance with the applicable laws in your state.

Keep in mind that the simple act of logging into a patient’s chart creates a permanent record, even if no entry was made. While you may have no recollection of doing so, an audit will identify when you were in a patient’s EMR. In fact, it will disclose every person who accessed the patient’s record, along with the date, time, computer from which the record was accessed, and whether the record was created, modified, or deleted. HIPAA permits an individual to receive an accounting of disclosures of his or her protected health information upon request for up to 6 years.

• Before you succumb to the urge to "cut and paste" a prior note, pause. Read the note first; you might find that it no longer accurately reflects the patient’s condition. The note needs to reflect the patient’s current status. As the clinical condition of the patient changes, so should the note.

If the documentation system allows for "free text" notes, seize the opportunity. Consider capturing the visit in a more meaningful way to reflect your interaction with the patient. Although it can be faster to check off the boxes and move on to the next task, you are more likely to recall a patient or situation if you take the time to make a note.

• The nuances of a patient encounter are frequently missed by a computer. When you do "click" through documentation screens, click cautiously. Be careful with screens that offer drop-down options, and confirm that you are selecting the proper response. It only takes a slip of the mouse to make a mistake. We all know that typing can be onerous for those who lack keyboard skills, but try to catch the "typos."

• Make certain that your documentation addresses the actual evaluation you performed. There should be no documentation of an examination that was not done – that is called fraud.

• Be mindful to time your entry, especially in those cases when it is well after the treatment. The precise time can be determined, and disputes or discrepancies over timing of the entry can be resolved.

• Take the time to familiarize yourself with the documentation system in place. The next time you sign off on an entry, remember that the document created is only as good as the information entered.

An awareness of the potential pitfalls of the EMR is the first step to making the changes that will ultimately benefit everyone involved – your patient, you, and sometimes even your attorney.

Ms. Ford is a shareholder in the law firm of Marshall, Dennehey, Warner, Coleman, & Goggin, King of Prussia, Pa., and specializes in medical malpractice litigation. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also a partner in EHR Practice Consultants, helping practices move to EHR systems. Contact him at [email protected]

The new joint position statement from the American Diabetes Association and the European Association for the Study of Diabetes emphasizes an individualized, patient-centered approach that is less prescriptive and algorithmic than previous guidelines.

Goals

The guidelines recommend lowering HbA_1c to less than 7% in most patients. More important, however, is establishing an individual goal for each patient, taking into account the benefit and risk of tight glycemic control, and the patient’s ability to comply with recommended regimens.

For example, a patient who is newly diagnosed with type 2 diabetes, is highly motivated, is at low risk of hypoglycemic complications, and has a long life expectancy with no significant comorbidities may be encouraged to achieve an HbA_1c of less than 6.5%.

Conversely, a patient with longstanding disease, at high risk of hypoglycemic complications, with a short life span, and having established vascular complications should have a goal of 7.5%-8.0%, or even higher. The guidelines discourage using the percentage of patients with an HbA_1c of less than 7% as a quality indicator, because it undermines individualization of treatment goals.

Therapeutic Options

Lifestyle intervention forms the foundation of treatment for all patients with type 2 diabetes. Weight loss, or at least weight maintenance, should be encouraged through dietary, medical, or surgical means. Weight loss of 5%-10% can contribute to glycemic control. The physical activity goal is at least 150 minutes of moderate activity per week, or as much as possible – noting that any increase in activity level is beneficial.

Metformin is recommended as the usual first-line medical therapy for diabetes. It decreases hepatic gluconeogenesis, is generally weight neutral, and has a low risk of hypoglycemia. Sulfonylureas stimulate insulin release from the pancreas and carry a risk of weight gain and hypoglycemia. The meglinitides, also secretagogues, have less risk of hypoglycemia. Thiazolidinediones (TZDs) improve insulin sensitivity in muscle tissue and decrease hepatic gluconeogenesis. Side effects include weight gain, edema and heart failure, increased risk of bone fractures, and a possible increased risk of bladder cancer.

The injectable GLP-1 (glucagon-like peptide 1) receptor agonists increase insulin and decrease glucagon secretion, slow gastric emptying, and decrease appetite. They stimulate weight loss but also can cause nausea and vomiting. The DPP-4 (dipeptidyl peptidase 4) inhibitors decrease breakdown of GLP-1 and similarly lead to increased insulin and decreased glucagon secretion. Insulin, having many forms and regimens, becomes an option for patients with more severe disease; but it carries the risk of hypoglycemia and weight gain.

Implementation

Newly diagnosed patients near their HbA_1c goal who are highly motivated can be offered a 3- to 6-month period of lifestyle-only intervention before starting pharmacologic therapy. Lifestyle intervention will not be enough for most patients to achieve target HbA_1c goals, however, and oral, noninsulin injectable therapies and insulin therapies should then be added.

Initial drug monotherapy with metformin is appropriate for most patients. If target goals have not been reached after 3 months of titrating up from a low dose, then a second agent from a different class should be added, followed after another 3 months by a third agent.

Because of a relative lack of comparative long-term data about other oral and noninsulin injectable therapies, the next agent to be added will be determined based on the characteristics of a given class of medication, along with how those characteristics match a patient’s needs.

To help choose an individualized regimen, the guidelines outline five factors for each of the other drug categories: efficacy, risk of hypoglycemia, weight change, major side effects, and cost.

For example, sulfonylureas have high efficacy, a moderate risk of hypoglycemia, and low cost, while the TZDs have high efficacy, side effects of heart failure and edema, and high cost.

Adding a second agent will decrease HbA_1c an average of 1%. If a medication has been added as a second- or third-line agent, and there has been no noticeable decrease in glycemic measures after 3 months, the patient should be considered a nonresponder. A drug from a different class should then be substituted.

If a patient has a high initial HbA_1c (9.0%-10%), dual drug therapy may be appropriate from the start. If hyperglycemia is severe (fasting plasma glucose is greater than 300 mg/dL or HbA_1c is greater than 10%), strong consideration should be given to starting therapy with insulin.

Transitioning to insulin often will be required, as progressive beta-cell destruction is a hallmark of the disease. The simplest approach is adding once-daily basal insulin, with patients taught to uptitrate their own insulin in a small incremental manner once or twice weekly based on the results of their daily fasting blood glucose values.

When fasting glucose levels are controlled but HbA_1c is not at goal, it is likely due to postprandial glucose excursions, and prandial insulin is indicated. Short-acting bolus insulin may be started before the evening meal, which usually has the largest carbohydrate content. Then, if needed, add it to other meals. Another option is twice-daily premixed insulin, given before morning and evening meals. This regimen lowers HbA_1c more, but it also has a greater risk of hypoglycemia and weight gain.

Metformin may be continued with basal insulin, and may allow less weight gain than insulin alone. Continuing secretagogues initially when insulin is started minimizes initial deterioration of control. But it offers little advantage after that, and thus should then be stopped. It also needs to be discontinued if prandial insulin therapy is added. TZDs should generally be stopped when starting insulin, while the GLP-1 receptor agonists may be helpful with insulin.

Summary

The clear message of these guidelines is to individualize therapy to maximize adherence and benefit. Establish a target HbA_1c goal and start with lifestyle modification with or without metformin. If HbA_1c is not at goal after 3 months, add a second and then possibly a third oral or noninsulin injectable agent from different classes based on efficacy, side effects, weight change, and cost.

Reference

• Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach. Diabetes Care 2012;35:1364-79.

To listen to an interview with Dr. Skolnik and the chair of the guidelines committee, Dr. Silvio Inzucchi, going over the details of the guidelines, click here, or search for "Diabetes Core Update" in iTunes for the special June 1, 2012, issue.

Dr. Olson is a third-year resident and chief resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

The new joint position statement from the American Diabetes Association and the European Association for the Study of Diabetes emphasizes an individualized, patient-centered approach that is less prescriptive and algorithmic than previous guidelines.

Goals

The guidelines recommend lowering HbA_1c to less than 7% in most patients. More important, however, is establishing an individual goal for each patient, taking into account the benefit and risk of tight glycemic control, and the patient’s ability to comply with recommended regimens.

For example, a patient who is newly diagnosed with type 2 diabetes, is highly motivated, is at low risk of hypoglycemic complications, and has a long life expectancy with no significant comorbidities may be encouraged to achieve an HbA_1c of less than 6.5%.

Conversely, a patient with longstanding disease, at high risk of hypoglycemic complications, with a short life span, and having established vascular complications should have a goal of 7.5%-8.0%, or even higher. The guidelines discourage using the percentage of patients with an HbA_1c of less than 7% as a quality indicator, because it undermines individualization of treatment goals.

Therapeutic Options

Lifestyle intervention forms the foundation of treatment for all patients with type 2 diabetes. Weight loss, or at least weight maintenance, should be encouraged through dietary, medical, or surgical means. Weight loss of 5%-10% can contribute to glycemic control. The physical activity goal is at least 150 minutes of moderate activity per week, or as much as possible – noting that any increase in activity level is beneficial.

Metformin is recommended as the usual first-line medical therapy for diabetes. It decreases hepatic gluconeogenesis, is generally weight neutral, and has a low risk of hypoglycemia. Sulfonylureas stimulate insulin release from the pancreas and carry a risk of weight gain and hypoglycemia. The meglinitides, also secretagogues, have less risk of hypoglycemia. Thiazolidinediones (TZDs) improve insulin sensitivity in muscle tissue and decrease hepatic gluconeogenesis. Side effects include weight gain, edema and heart failure, increased risk of bone fractures, and a possible increased risk of bladder cancer.

The injectable GLP-1 (glucagon-like peptide 1) receptor agonists increase insulin and decrease glucagon secretion, slow gastric emptying, and decrease appetite. They stimulate weight loss but also can cause nausea and vomiting. The DPP-4 (dipeptidyl peptidase 4) inhibitors decrease breakdown of GLP-1 and similarly lead to increased insulin and decreased glucagon secretion. Insulin, having many forms and regimens, becomes an option for patients with more severe disease; but it carries the risk of hypoglycemia and weight gain.

Implementation

Newly diagnosed patients near their HbA_1c goal who are highly motivated can be offered a 3- to 6-month period of lifestyle-only intervention before starting pharmacologic therapy. Lifestyle intervention will not be enough for most patients to achieve target HbA_1c goals, however, and oral, noninsulin injectable therapies and insulin therapies should then be added.

Initial drug monotherapy with metformin is appropriate for most patients. If target goals have not been reached after 3 months of titrating up from a low dose, then a second agent from a different class should be added, followed after another 3 months by a third agent.

Because of a relative lack of comparative long-term data about other oral and noninsulin injectable therapies, the next agent to be added will be determined based on the characteristics of a given class of medication, along with how those characteristics match a patient’s needs.

To help choose an individualized regimen, the guidelines outline five factors for each of the other drug categories: efficacy, risk of hypoglycemia, weight change, major side effects, and cost.

For example, sulfonylureas have high efficacy, a moderate risk of hypoglycemia, and low cost, while the TZDs have high efficacy, side effects of heart failure and edema, and high cost.

Adding a second agent will decrease HbA_1c an average of 1%. If a medication has been added as a second- or third-line agent, and there has been no noticeable decrease in glycemic measures after 3 months, the patient should be considered a nonresponder. A drug from a different class should then be substituted.

If a patient has a high initial HbA_1c (9.0%-10%), dual drug therapy may be appropriate from the start. If hyperglycemia is severe (fasting plasma glucose is greater than 300 mg/dL or HbA_1c is greater than 10%), strong consideration should be given to starting therapy with insulin.

Transitioning to insulin often will be required, as progressive beta-cell destruction is a hallmark of the disease. The simplest approach is adding once-daily basal insulin, with patients taught to uptitrate their own insulin in a small incremental manner once or twice weekly based on the results of their daily fasting blood glucose values.

When fasting glucose levels are controlled but HbA_1c is not at goal, it is likely due to postprandial glucose excursions, and prandial insulin is indicated. Short-acting bolus insulin may be started before the evening meal, which usually has the largest carbohydrate content. Then, if needed, add it to other meals. Another option is twice-daily premixed insulin, given before morning and evening meals. This regimen lowers HbA_1c more, but it also has a greater risk of hypoglycemia and weight gain.

Metformin may be continued with basal insulin, and may allow less weight gain than insulin alone. Continuing secretagogues initially when insulin is started minimizes initial deterioration of control. But it offers little advantage after that, and thus should then be stopped. It also needs to be discontinued if prandial insulin therapy is added. TZDs should generally be stopped when starting insulin, while the GLP-1 receptor agonists may be helpful with insulin.

Summary

The clear message of these guidelines is to individualize therapy to maximize adherence and benefit. Establish a target HbA_1c goal and start with lifestyle modification with or without metformin. If HbA_1c is not at goal after 3 months, add a second and then possibly a third oral or noninsulin injectable agent from different classes based on efficacy, side effects, weight change, and cost.

Reference

• Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach. Diabetes Care 2012;35:1364-79.

To listen to an interview with Dr. Skolnik and the chair of the guidelines committee, Dr. Silvio Inzucchi, going over the details of the guidelines, click here, or search for "Diabetes Core Update" in iTunes for the special June 1, 2012, issue.

Dr. Olson is a third-year resident and chief resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

The new joint position statement from the American Diabetes Association and the European Association for the Study of Diabetes emphasizes an individualized, patient-centered approach that is less prescriptive and algorithmic than previous guidelines.

Goals

The guidelines recommend lowering HbA_1c to less than 7% in most patients. More important, however, is establishing an individual goal for each patient, taking into account the benefit and risk of tight glycemic control, and the patient’s ability to comply with recommended regimens.

For example, a patient who is newly diagnosed with type 2 diabetes, is highly motivated, is at low risk of hypoglycemic complications, and has a long life expectancy with no significant comorbidities may be encouraged to achieve an HbA_1c of less than 6.5%.

Conversely, a patient with longstanding disease, at high risk of hypoglycemic complications, with a short life span, and having established vascular complications should have a goal of 7.5%-8.0%, or even higher. The guidelines discourage using the percentage of patients with an HbA_1c of less than 7% as a quality indicator, because it undermines individualization of treatment goals.

Therapeutic Options

Lifestyle intervention forms the foundation of treatment for all patients with type 2 diabetes. Weight loss, or at least weight maintenance, should be encouraged through dietary, medical, or surgical means. Weight loss of 5%-10% can contribute to glycemic control. The physical activity goal is at least 150 minutes of moderate activity per week, or as much as possible – noting that any increase in activity level is beneficial.

Metformin is recommended as the usual first-line medical therapy for diabetes. It decreases hepatic gluconeogenesis, is generally weight neutral, and has a low risk of hypoglycemia. Sulfonylureas stimulate insulin release from the pancreas and carry a risk of weight gain and hypoglycemia. The meglinitides, also secretagogues, have less risk of hypoglycemia. Thiazolidinediones (TZDs) improve insulin sensitivity in muscle tissue and decrease hepatic gluconeogenesis. Side effects include weight gain, edema and heart failure, increased risk of bone fractures, and a possible increased risk of bladder cancer.

The injectable GLP-1 (glucagon-like peptide 1) receptor agonists increase insulin and decrease glucagon secretion, slow gastric emptying, and decrease appetite. They stimulate weight loss but also can cause nausea and vomiting. The DPP-4 (dipeptidyl peptidase 4) inhibitors decrease breakdown of GLP-1 and similarly lead to increased insulin and decreased glucagon secretion. Insulin, having many forms and regimens, becomes an option for patients with more severe disease; but it carries the risk of hypoglycemia and weight gain.

Implementation

Newly diagnosed patients near their HbA_1c goal who are highly motivated can be offered a 3- to 6-month period of lifestyle-only intervention before starting pharmacologic therapy. Lifestyle intervention will not be enough for most patients to achieve target HbA_1c goals, however, and oral, noninsulin injectable therapies and insulin therapies should then be added.

Initial drug monotherapy with metformin is appropriate for most patients. If target goals have not been reached after 3 months of titrating up from a low dose, then a second agent from a different class should be added, followed after another 3 months by a third agent.

Because of a relative lack of comparative long-term data about other oral and noninsulin injectable therapies, the next agent to be added will be determined based on the characteristics of a given class of medication, along with how those characteristics match a patient’s needs.

To help choose an individualized regimen, the guidelines outline five factors for each of the other drug categories: efficacy, risk of hypoglycemia, weight change, major side effects, and cost.

For example, sulfonylureas have high efficacy, a moderate risk of hypoglycemia, and low cost, while the TZDs have high efficacy, side effects of heart failure and edema, and high cost.

Adding a second agent will decrease HbA_1c an average of 1%. If a medication has been added as a second- or third-line agent, and there has been no noticeable decrease in glycemic measures after 3 months, the patient should be considered a nonresponder. A drug from a different class should then be substituted.

If a patient has a high initial HbA_1c (9.0%-10%), dual drug therapy may be appropriate from the start. If hyperglycemia is severe (fasting plasma glucose is greater than 300 mg/dL or HbA_1c is greater than 10%), strong consideration should be given to starting therapy with insulin.

Transitioning to insulin often will be required, as progressive beta-cell destruction is a hallmark of the disease. The simplest approach is adding once-daily basal insulin, with patients taught to uptitrate their own insulin in a small incremental manner once or twice weekly based on the results of their daily fasting blood glucose values.

When fasting glucose levels are controlled but HbA_1c is not at goal, it is likely due to postprandial glucose excursions, and prandial insulin is indicated. Short-acting bolus insulin may be started before the evening meal, which usually has the largest carbohydrate content. Then, if needed, add it to other meals. Another option is twice-daily premixed insulin, given before morning and evening meals. This regimen lowers HbA_1c more, but it also has a greater risk of hypoglycemia and weight gain.

Metformin may be continued with basal insulin, and may allow less weight gain than insulin alone. Continuing secretagogues initially when insulin is started minimizes initial deterioration of control. But it offers little advantage after that, and thus should then be stopped. It also needs to be discontinued if prandial insulin therapy is added. TZDs should generally be stopped when starting insulin, while the GLP-1 receptor agonists may be helpful with insulin.

Summary

The clear message of these guidelines is to individualize therapy to maximize adherence and benefit. Establish a target HbA_1c goal and start with lifestyle modification with or without metformin. If HbA_1c is not at goal after 3 months, add a second and then possibly a third oral or noninsulin injectable agent from different classes based on efficacy, side effects, weight change, and cost.

Reference

• Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach. Diabetes Care 2012;35:1364-79.

To listen to an interview with Dr. Skolnik and the chair of the guidelines committee, Dr. Silvio Inzucchi, going over the details of the guidelines, click here, or search for "Diabetes Core Update" in iTunes for the special June 1, 2012, issue.

Dr. Olson is a third-year resident and chief resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

While we often mention the government incentives offered for meaningful use compliance, we frequently get questions about the specifics of each program, who is eligible for which incentives, and when the actual checks will arrive in the mail. Admittedly, it can be somewhat mystifying, so here we will help to lay out what to expect.

Let’s start with the basics:

– Which program do I qualify for?

By now, you likely know that the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as a part of the American Reinvestment and Recovery Act of 2009, promises financial incentives for hospitals and clinicians who meet the requirements for meaningful use. There are two separate programs under which institutions and "eligible providers" (EPs) can qualify for a payout: Medicare and Medicaid. We won’t cover the hospital programs here, but will focus just on the incentives for EPs.

First, under the Medicare Program, any doctor (which includes any MD or DO, dentist, podiatrist, optometrist, or chiropractor) who treats Medicare patients can qualify as an eligible provider. EPs who adopt a certified electronic health record and comply with an extensive set of rules defining how they use it will receive up to $44,000 in increased Medicare payments over a 5-year period.

Below, we will discuss in detail how the money is allocated, but it is worth noting here that EPs who do not charge a defined minimum annual dollar amount to Medicare will not receive the full incentive. Instead, they will receive a percentage of their total billing.

Also worth noting is the absence of care extenders such as nurse practitioners (NPs) and physician assistants (PAs) from the list of eligible providers under the Medicare program. The Medicaid program is quite different.

Fewer providers will qualify for the Medicaid incentive, but there is greater financial benefit and flexibility for those who do fall under this program. To be eligible, any physician (MD or DO), nurse practitioner, certified nurse-midwife, or dentist must have a minimum of 30% Medicaid patient volume (or 20% if the provider is a pediatrician). Physician assistants can also be eligible if he or she provides care in a federally qualified health center or rural health clinic that is led by a physician assistant.

The maximum financial incentive is raised to $63,750; but unfortunately, the Medicaid incentive program is not available in every state. Currently absent from the list of participating states are Hawaii, Minnesota, Nevada, New Hampshire, and Virginia. One additional note: A provider eligible under both Medicare and Medicaid will need to choose just one program in which to participate, but may switch once during the total duration of the incentive initiative.

– How does the money get paid out?

As mentioned above, the Medicare incentive program pays out a maximum of $44,000 over a 5-year period. It is not divided equally over each year, and several factors may affect the total amount.

First, only providers who adopt a certified EHR and begin attesting by the 2012 incentive year can receive the maximum benefit. To receive any benefit at all, an EP must begin attesting by 2014. To give a more tangible example, if one were to successfully attest starting in 2012 and continue to successfully attest every year, he or she would receive the following annual payments: $18,000 in 2012, $12,000 in 2013, $8,000 in 2014, $4,000 in 2015, and $2,000 in 2016, for a total of $44,000.

If he or she were to delay attesting by just 1 year, the maximal payout amount would decrease to $39,000, as the first payment drops to $15,000 and final year incentive is lost.

As mentioned earlier, any EP not meeting a minimum threshold in Medicare charges will not be eligible for the full incentive, but instead will receive a percentage of their billing. For example, in year 1, any EP not submitting at least $24,000 in Medicare charges will receive 75% of their billing as their incentive.

Thankfully, a provider need not wait to attest until that $24,000 is reached. Medicare will hold the payment until the threshold is met or until the end of the calendar year, whichever is first. At that point, an EP can expect to see the incentive check within 4-8 weeks, according to CMS statements.

The Medicaid program works a bit differently. First, the EP may receive an incentive payment in year 1 of the 6-year attestation period for simply adopting, implementing, or upgrading to a certified electronic health record. (Following the initial year, that provider will need to follow the same guidelines outlined under the Medicare program).

Second, delaying implementation does not limit the amount of incentive money available to the EP – so a provider who waits to begin the process in 2016 can receive the same $63,750 incentive as one who begins in 2012.

Finally, the CMS requires that states disburse the payments within 45 days of attestation, and there are no billing thresholds to meet.

– What about the penalties?

Providers who are eligible under the Medicare program will begin to see "payment adjustments" if they fail to comply with meaningful use by 2015. This amounts to a 1% penalty per year, and will max out at 5%. Under the Medicaid program, there is no penalty for not adopting an EHR.

Either way, the timeline should provide plenty of time for anyone who is serious about switching to electronic health records. Those who eschew technology and refuse to make the jump can decide on their own if the outlined penalties are a reasonable price to pay.

This column, EHR Report, appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

While we often mention the government incentives offered for meaningful use compliance, we frequently get questions about the specifics of each program, who is eligible for which incentives, and when the actual checks will arrive in the mail. Admittedly, it can be somewhat mystifying, so here we will help to lay out what to expect.

Let’s start with the basics:

– Which program do I qualify for?

By now, you likely know that the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as a part of the American Reinvestment and Recovery Act of 2009, promises financial incentives for hospitals and clinicians who meet the requirements for meaningful use. There are two separate programs under which institutions and "eligible providers" (EPs) can qualify for a payout: Medicare and Medicaid. We won’t cover the hospital programs here, but will focus just on the incentives for EPs.

First, under the Medicare Program, any doctor (which includes any MD or DO, dentist, podiatrist, optometrist, or chiropractor) who treats Medicare patients can qualify as an eligible provider. EPs who adopt a certified electronic health record and comply with an extensive set of rules defining how they use it will receive up to $44,000 in increased Medicare payments over a 5-year period.

Below, we will discuss in detail how the money is allocated, but it is worth noting here that EPs who do not charge a defined minimum annual dollar amount to Medicare will not receive the full incentive. Instead, they will receive a percentage of their total billing.

Also worth noting is the absence of care extenders such as nurse practitioners (NPs) and physician assistants (PAs) from the list of eligible providers under the Medicare program. The Medicaid program is quite different.

Fewer providers will qualify for the Medicaid incentive, but there is greater financial benefit and flexibility for those who do fall under this program. To be eligible, any physician (MD or DO), nurse practitioner, certified nurse-midwife, or dentist must have a minimum of 30% Medicaid patient volume (or 20% if the provider is a pediatrician). Physician assistants can also be eligible if he or she provides care in a federally qualified health center or rural health clinic that is led by a physician assistant.

The maximum financial incentive is raised to $63,750; but unfortunately, the Medicaid incentive program is not available in every state. Currently absent from the list of participating states are Hawaii, Minnesota, Nevada, New Hampshire, and Virginia. One additional note: A provider eligible under both Medicare and Medicaid will need to choose just one program in which to participate, but may switch once during the total duration of the incentive initiative.

– How does the money get paid out?

As mentioned above, the Medicare incentive program pays out a maximum of $44,000 over a 5-year period. It is not divided equally over each year, and several factors may affect the total amount.

First, only providers who adopt a certified EHR and begin attesting by the 2012 incentive year can receive the maximum benefit. To receive any benefit at all, an EP must begin attesting by 2014. To give a more tangible example, if one were to successfully attest starting in 2012 and continue to successfully attest every year, he or she would receive the following annual payments: $18,000 in 2012, $12,000 in 2013, $8,000 in 2014, $4,000 in 2015, and $2,000 in 2016, for a total of $44,000.

If he or she were to delay attesting by just 1 year, the maximal payout amount would decrease to $39,000, as the first payment drops to $15,000 and final year incentive is lost.

As mentioned earlier, any EP not meeting a minimum threshold in Medicare charges will not be eligible for the full incentive, but instead will receive a percentage of their billing. For example, in year 1, any EP not submitting at least $24,000 in Medicare charges will receive 75% of their billing as their incentive.

Thankfully, a provider need not wait to attest until that $24,000 is reached. Medicare will hold the payment until the threshold is met or until the end of the calendar year, whichever is first. At that point, an EP can expect to see the incentive check within 4-8 weeks, according to CMS statements.

The Medicaid program works a bit differently. First, the EP may receive an incentive payment in year 1 of the 6-year attestation period for simply adopting, implementing, or upgrading to a certified electronic health record. (Following the initial year, that provider will need to follow the same guidelines outlined under the Medicare program).

Second, delaying implementation does not limit the amount of incentive money available to the EP – so a provider who waits to begin the process in 2016 can receive the same $63,750 incentive as one who begins in 2012.

Finally, the CMS requires that states disburse the payments within 45 days of attestation, and there are no billing thresholds to meet.

– What about the penalties?

Providers who are eligible under the Medicare program will begin to see "payment adjustments" if they fail to comply with meaningful use by 2015. This amounts to a 1% penalty per year, and will max out at 5%. Under the Medicaid program, there is no penalty for not adopting an EHR.

Either way, the timeline should provide plenty of time for anyone who is serious about switching to electronic health records. Those who eschew technology and refuse to make the jump can decide on their own if the outlined penalties are a reasonable price to pay.

This column, EHR Report, appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

While we often mention the government incentives offered for meaningful use compliance, we frequently get questions about the specifics of each program, who is eligible for which incentives, and when the actual checks will arrive in the mail. Admittedly, it can be somewhat mystifying, so here we will help to lay out what to expect.

Let’s start with the basics:

– Which program do I qualify for?

By now, you likely know that the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as a part of the American Reinvestment and Recovery Act of 2009, promises financial incentives for hospitals and clinicians who meet the requirements for meaningful use. There are two separate programs under which institutions and "eligible providers" (EPs) can qualify for a payout: Medicare and Medicaid. We won’t cover the hospital programs here, but will focus just on the incentives for EPs.

First, under the Medicare Program, any doctor (which includes any MD or DO, dentist, podiatrist, optometrist, or chiropractor) who treats Medicare patients can qualify as an eligible provider. EPs who adopt a certified electronic health record and comply with an extensive set of rules defining how they use it will receive up to $44,000 in increased Medicare payments over a 5-year period.

Below, we will discuss in detail how the money is allocated, but it is worth noting here that EPs who do not charge a defined minimum annual dollar amount to Medicare will not receive the full incentive. Instead, they will receive a percentage of their total billing.

Also worth noting is the absence of care extenders such as nurse practitioners (NPs) and physician assistants (PAs) from the list of eligible providers under the Medicare program. The Medicaid program is quite different.

Fewer providers will qualify for the Medicaid incentive, but there is greater financial benefit and flexibility for those who do fall under this program. To be eligible, any physician (MD or DO), nurse practitioner, certified nurse-midwife, or dentist must have a minimum of 30% Medicaid patient volume (or 20% if the provider is a pediatrician). Physician assistants can also be eligible if he or she provides care in a federally qualified health center or rural health clinic that is led by a physician assistant.

The maximum financial incentive is raised to $63,750; but unfortunately, the Medicaid incentive program is not available in every state. Currently absent from the list of participating states are Hawaii, Minnesota, Nevada, New Hampshire, and Virginia. One additional note: A provider eligible under both Medicare and Medicaid will need to choose just one program in which to participate, but may switch once during the total duration of the incentive initiative.

– How does the money get paid out?

As mentioned above, the Medicare incentive program pays out a maximum of $44,000 over a 5-year period. It is not divided equally over each year, and several factors may affect the total amount.

First, only providers who adopt a certified EHR and begin attesting by the 2012 incentive year can receive the maximum benefit. To receive any benefit at all, an EP must begin attesting by 2014. To give a more tangible example, if one were to successfully attest starting in 2012 and continue to successfully attest every year, he or she would receive the following annual payments: $18,000 in 2012, $12,000 in 2013, $8,000 in 2014, $4,000 in 2015, and $2,000 in 2016, for a total of $44,000.

If he or she were to delay attesting by just 1 year, the maximal payout amount would decrease to $39,000, as the first payment drops to $15,000 and final year incentive is lost.

As mentioned earlier, any EP not meeting a minimum threshold in Medicare charges will not be eligible for the full incentive, but instead will receive a percentage of their billing. For example, in year 1, any EP not submitting at least $24,000 in Medicare charges will receive 75% of their billing as their incentive.

Thankfully, a provider need not wait to attest until that $24,000 is reached. Medicare will hold the payment until the threshold is met or until the end of the calendar year, whichever is first. At that point, an EP can expect to see the incentive check within 4-8 weeks, according to CMS statements.

The Medicaid program works a bit differently. First, the EP may receive an incentive payment in year 1 of the 6-year attestation period for simply adopting, implementing, or upgrading to a certified electronic health record. (Following the initial year, that provider will need to follow the same guidelines outlined under the Medicare program).

Second, delaying implementation does not limit the amount of incentive money available to the EP – so a provider who waits to begin the process in 2016 can receive the same $63,750 incentive as one who begins in 2012.

Finally, the CMS requires that states disburse the payments within 45 days of attestation, and there are no billing thresholds to meet.

– What about the penalties?

Providers who are eligible under the Medicare program will begin to see "payment adjustments" if they fail to comply with meaningful use by 2015. This amounts to a 1% penalty per year, and will max out at 5%. Under the Medicaid program, there is no penalty for not adopting an EHR.

Either way, the timeline should provide plenty of time for anyone who is serious about switching to electronic health records. Those who eschew technology and refuse to make the jump can decide on their own if the outlined penalties are a reasonable price to pay.

This column, EHR Report, appears regularly in Family Practice News, a publication of Elsevier. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at [email protected].

The American College of Physicians recently published guidelines on venous thromboembolism prophylaxis in hospitalized medical patients (Ann. Intern. Med. 2011;155:625-32).

Venous thromboembolism (VTE) – including pulmonary embolism (PE) and deep vein thrombosis (DVT) – is a cause of serious morbidity and mortality in hospitalized patients. Between 5% and 10% of all in-hospital deaths are a direct result of PE, and PE accounts for 200,000-300,000 hospitalizations per year.

Two main approaches to VTE prophylaxis exist. The first is heparin or related agents, including low-dose unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux, all given subcutaneously. The second option is mechanical leg compression, which primarily includes graduated compression stockings and intermittent pneumatic compression.

Studies from 1950 and 2011 were analyzed that compared heparin or related agents vs. no heparin; LMWH vs. UFH; and mechanical prophylaxis vs. no prophylaxis. The primary outcome for the extracted data was total mortality up to 120 days from randomization, whereas secondary outcomes included symptomatic DVT, all PE, fatal PE, all bleedings events, major bleeding events, and – for mechanical prophylaxis – skin damage.

Prophylaxis vs. No Prophylaxis

In nonstroke medical patients (10 trials, n = 20,717), heparin or related agent (UFH, LMWH, or fondaparinux) prophylaxis did not significantly reduce total mortality, compared with no prophylaxis. There was a statistically significant reduced risk of PE and an increased risk of bleeding events with heparin or related agents. There was an increase in major bleeding and a reduction in symptomatic DVT with heparin that was not statistically significant.

Heparin prophylaxis in acute stroke patients (eight trials, n = 15,405) did not show a significant reduction in mortality, PE, or symptomatic DVT, although there was a nonsignificant increased risk for major bleeding events. Most of the evidence for this group came from one large study that also showed a significant increase in 14-day hemorrhagic stroke or serious extracranial hemorrhage, as well as a significant decrease in 14-day recurrent ischemic stroke with heparin prophylaxis.

Analyzing combined data from acute stroke and nonstroke medical patients, heparin prophylaxis decreased mortality to a borderline but not to a statistically significant degree (relative risk, 93%). There was a significant reduction in risk of PE (RR, 0.70) but no significant decrease in symptomatic DVT with heparin prophylaxis. With heparin, there was a significantly increased risk of all bleeding events (RR, 1.28) and major bleeding events (RR, 1.61).

LMWH vs. UFH

In a comparison of LMWH vs. UFH, nonstroke medical patients (nine trials, n = 11,650) and acute stroke patients showed no significant difference in mortality, PE, symptomatic DVT, or major bleeding. Combined data from acute stroke and nonstroke medical patients also showed no significant difference for any outcome.

Mechanical vs. No Prophylaxis

Most data come from one large study of acute stroke patients that compared graduated compression stockings vs. no prophylaxis. There was not a significant difference in mortality, symptomatic DVT, or PE. There was, however, a significant increase in skin damage with compression stockings. There are insufficient data to evaluate benefit and risk of intermittent pneumatic compression in medical patients. Based on data from surgical patients, intermittent pneumatic compression may be used for VTE prophylaxis in medical patients when bleeding risk makes heparin contraindicated for prophylaxis.

Recommendations

• Assess all medical inpatients for the risk for thromboembolism and bleeding prior to initiation of prophylaxis. A thoughtful assessment of benefit to risk should be done for each patient, and then a decision should be made about initiating prophylaxis.

• Pharmacologic prophylaxis with heparin or a related drug for VTE in medical (including stroke) patients is usually beneficial, unless the assessed risk for bleeding outweighs the likely benefits. In medical inpatients, prophylaxis leads to a statistically significant reduction in PE (four events per 1,000 people treated) and an increase in all bleeding events (nine per 1,000 people) and a nonstatistically significant increase in major bleeding events (one per 1,000 people). There is no effect on mortality or DVT. The increased risk for major bleeding is greater in patients with stroke (six per 1,000). For most people, the reduction in PE outweighs the harm of increased bleeding. The evidence in patients with stroke is weaker than for medical inpatients in general.

• Recommend against the use of mechanical prophylaxis with graduated compression stockings for prevention of VTE.

Notably, the guidelines do not support the application in hospitals of quality performance measures that encourage universal VTE prophylaxis, because such measures would encourage increased use of prophylaxis without regard to risk stratification and assessment. The evidence simply does not support routine prophylaxis of all medical inpatients.

Risk factors for thromboembolism include inherited conditions (such as protein C and protein S deficiencies and the factor V Leiden mutation), and acquired-risk factors (such as cancer, immobilization, presence of central venous catheters, heart failure, smoking, chronic kidney disease, and history of thromboembolism). Risk factors for bleeding with anticoagulant therapy include hypertension, cancer, prior stroke, diabetes, a bleeding disorder, and use of NSAIDs, aspirin, or antiplatelet agents. Unfortunately, these conditions exist together in many hospitalized patients, and there are no validated tools to formally assess risk and benefit of VTE prophylaxis.

Bottom Line

Assess risk for venous thromboembolism as well as bleeding risk in all hospitalized medical patients. Heparin or related agent prophylaxis does not decrease total mortality, but it does decrease the risk of PE while increasing risk of bleeding. For most people, the reduction in PE outweighs the harm of increased bleeding. When benefit outweighs risk, use subcutaneous low-dose UFH, LMWH, or fondaparinux for VTE prophylaxis. Graduated compression stockings are not recommended for VTE prophylaxis.

Dr. Olsen is a chief resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

The American College of Physicians recently published guidelines on venous thromboembolism prophylaxis in hospitalized medical patients (Ann. Intern. Med. 2011;155:625-32).

Venous thromboembolism (VTE) – including pulmonary embolism (PE) and deep vein thrombosis (DVT) – is a cause of serious morbidity and mortality in hospitalized patients. Between 5% and 10% of all in-hospital deaths are a direct result of PE, and PE accounts for 200,000-300,000 hospitalizations per year.

Two main approaches to VTE prophylaxis exist. The first is heparin or related agents, including low-dose unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux, all given subcutaneously. The second option is mechanical leg compression, which primarily includes graduated compression stockings and intermittent pneumatic compression.

Studies from 1950 and 2011 were analyzed that compared heparin or related agents vs. no heparin; LMWH vs. UFH; and mechanical prophylaxis vs. no prophylaxis. The primary outcome for the extracted data was total mortality up to 120 days from randomization, whereas secondary outcomes included symptomatic DVT, all PE, fatal PE, all bleedings events, major bleeding events, and – for mechanical prophylaxis – skin damage.

Prophylaxis vs. No Prophylaxis

In nonstroke medical patients (10 trials, n = 20,717), heparin or related agent (UFH, LMWH, or fondaparinux) prophylaxis did not significantly reduce total mortality, compared with no prophylaxis. There was a statistically significant reduced risk of PE and an increased risk of bleeding events with heparin or related agents. There was an increase in major bleeding and a reduction in symptomatic DVT with heparin that was not statistically significant.

Heparin prophylaxis in acute stroke patients (eight trials, n = 15,405) did not show a significant reduction in mortality, PE, or symptomatic DVT, although there was a nonsignificant increased risk for major bleeding events. Most of the evidence for this group came from one large study that also showed a significant increase in 14-day hemorrhagic stroke or serious extracranial hemorrhage, as well as a significant decrease in 14-day recurrent ischemic stroke with heparin prophylaxis.

Analyzing combined data from acute stroke and nonstroke medical patients, heparin prophylaxis decreased mortality to a borderline but not to a statistically significant degree (relative risk, 93%). There was a significant reduction in risk of PE (RR, 0.70) but no significant decrease in symptomatic DVT with heparin prophylaxis. With heparin, there was a significantly increased risk of all bleeding events (RR, 1.28) and major bleeding events (RR, 1.61).

LMWH vs. UFH

In a comparison of LMWH vs. UFH, nonstroke medical patients (nine trials, n = 11,650) and acute stroke patients showed no significant difference in mortality, PE, symptomatic DVT, or major bleeding. Combined data from acute stroke and nonstroke medical patients also showed no significant difference for any outcome.

Mechanical vs. No Prophylaxis

Most data come from one large study of acute stroke patients that compared graduated compression stockings vs. no prophylaxis. There was not a significant difference in mortality, symptomatic DVT, or PE. There was, however, a significant increase in skin damage with compression stockings. There are insufficient data to evaluate benefit and risk of intermittent pneumatic compression in medical patients. Based on data from surgical patients, intermittent pneumatic compression may be used for VTE prophylaxis in medical patients when bleeding risk makes heparin contraindicated for prophylaxis.

Recommendations

• Assess all medical inpatients for the risk for thromboembolism and bleeding prior to initiation of prophylaxis. A thoughtful assessment of benefit to risk should be done for each patient, and then a decision should be made about initiating prophylaxis.

• Pharmacologic prophylaxis with heparin or a related drug for VTE in medical (including stroke) patients is usually beneficial, unless the assessed risk for bleeding outweighs the likely benefits. In medical inpatients, prophylaxis leads to a statistically significant reduction in PE (four events per 1,000 people treated) and an increase in all bleeding events (nine per 1,000 people) and a nonstatistically significant increase in major bleeding events (one per 1,000 people). There is no effect on mortality or DVT. The increased risk for major bleeding is greater in patients with stroke (six per 1,000). For most people, the reduction in PE outweighs the harm of increased bleeding. The evidence in patients with stroke is weaker than for medical inpatients in general.

• Recommend against the use of mechanical prophylaxis with graduated compression stockings for prevention of VTE.

Notably, the guidelines do not support the application in hospitals of quality performance measures that encourage universal VTE prophylaxis, because such measures would encourage increased use of prophylaxis without regard to risk stratification and assessment. The evidence simply does not support routine prophylaxis of all medical inpatients.

Risk factors for thromboembolism include inherited conditions (such as protein C and protein S deficiencies and the factor V Leiden mutation), and acquired-risk factors (such as cancer, immobilization, presence of central venous catheters, heart failure, smoking, chronic kidney disease, and history of thromboembolism). Risk factors for bleeding with anticoagulant therapy include hypertension, cancer, prior stroke, diabetes, a bleeding disorder, and use of NSAIDs, aspirin, or antiplatelet agents. Unfortunately, these conditions exist together in many hospitalized patients, and there are no validated tools to formally assess risk and benefit of VTE prophylaxis.

Bottom Line

Assess risk for venous thromboembolism as well as bleeding risk in all hospitalized medical patients. Heparin or related agent prophylaxis does not decrease total mortality, but it does decrease the risk of PE while increasing risk of bleeding. For most people, the reduction in PE outweighs the harm of increased bleeding. When benefit outweighs risk, use subcutaneous low-dose UFH, LMWH, or fondaparinux for VTE prophylaxis. Graduated compression stockings are not recommended for VTE prophylaxis.

Dr. Olsen is a chief resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

The American College of Physicians recently published guidelines on venous thromboembolism prophylaxis in hospitalized medical patients (Ann. Intern. Med. 2011;155:625-32).

Venous thromboembolism (VTE) – including pulmonary embolism (PE) and deep vein thrombosis (DVT) – is a cause of serious morbidity and mortality in hospitalized patients. Between 5% and 10% of all in-hospital deaths are a direct result of PE, and PE accounts for 200,000-300,000 hospitalizations per year.

Two main approaches to VTE prophylaxis exist. The first is heparin or related agents, including low-dose unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux, all given subcutaneously. The second option is mechanical leg compression, which primarily includes graduated compression stockings and intermittent pneumatic compression.

Studies from 1950 and 2011 were analyzed that compared heparin or related agents vs. no heparin; LMWH vs. UFH; and mechanical prophylaxis vs. no prophylaxis. The primary outcome for the extracted data was total mortality up to 120 days from randomization, whereas secondary outcomes included symptomatic DVT, all PE, fatal PE, all bleedings events, major bleeding events, and – for mechanical prophylaxis – skin damage.

Prophylaxis vs. No Prophylaxis

In nonstroke medical patients (10 trials, n = 20,717), heparin or related agent (UFH, LMWH, or fondaparinux) prophylaxis did not significantly reduce total mortality, compared with no prophylaxis. There was a statistically significant reduced risk of PE and an increased risk of bleeding events with heparin or related agents. There was an increase in major bleeding and a reduction in symptomatic DVT with heparin that was not statistically significant.

Heparin prophylaxis in acute stroke patients (eight trials, n = 15,405) did not show a significant reduction in mortality, PE, or symptomatic DVT, although there was a nonsignificant increased risk for major bleeding events. Most of the evidence for this group came from one large study that also showed a significant increase in 14-day hemorrhagic stroke or serious extracranial hemorrhage, as well as a significant decrease in 14-day recurrent ischemic stroke with heparin prophylaxis.

Analyzing combined data from acute stroke and nonstroke medical patients, heparin prophylaxis decreased mortality to a borderline but not to a statistically significant degree (relative risk, 93%). There was a significant reduction in risk of PE (RR, 0.70) but no significant decrease in symptomatic DVT with heparin prophylaxis. With heparin, there was a significantly increased risk of all bleeding events (RR, 1.28) and major bleeding events (RR, 1.61).

LMWH vs. UFH

In a comparison of LMWH vs. UFH, nonstroke medical patients (nine trials, n = 11,650) and acute stroke patients showed no significant difference in mortality, PE, symptomatic DVT, or major bleeding. Combined data from acute stroke and nonstroke medical patients also showed no significant difference for any outcome.

Mechanical vs. No Prophylaxis

Most data come from one large study of acute stroke patients that compared graduated compression stockings vs. no prophylaxis. There was not a significant difference in mortality, symptomatic DVT, or PE. There was, however, a significant increase in skin damage with compression stockings. There are insufficient data to evaluate benefit and risk of intermittent pneumatic compression in medical patients. Based on data from surgical patients, intermittent pneumatic compression may be used for VTE prophylaxis in medical patients when bleeding risk makes heparin contraindicated for prophylaxis.

Recommendations

• Assess all medical inpatients for the risk for thromboembolism and bleeding prior to initiation of prophylaxis. A thoughtful assessment of benefit to risk should be done for each patient, and then a decision should be made about initiating prophylaxis.

• Pharmacologic prophylaxis with heparin or a related drug for VTE in medical (including stroke) patients is usually beneficial, unless the assessed risk for bleeding outweighs the likely benefits. In medical inpatients, prophylaxis leads to a statistically significant reduction in PE (four events per 1,000 people treated) and an increase in all bleeding events (nine per 1,000 people) and a nonstatistically significant increase in major bleeding events (one per 1,000 people). There is no effect on mortality or DVT. The increased risk for major bleeding is greater in patients with stroke (six per 1,000). For most people, the reduction in PE outweighs the harm of increased bleeding. The evidence in patients with stroke is weaker than for medical inpatients in general.

• Recommend against the use of mechanical prophylaxis with graduated compression stockings for prevention of VTE.

Notably, the guidelines do not support the application in hospitals of quality performance measures that encourage universal VTE prophylaxis, because such measures would encourage increased use of prophylaxis without regard to risk stratification and assessment. The evidence simply does not support routine prophylaxis of all medical inpatients.

Risk factors for thromboembolism include inherited conditions (such as protein C and protein S deficiencies and the factor V Leiden mutation), and acquired-risk factors (such as cancer, immobilization, presence of central venous catheters, heart failure, smoking, chronic kidney disease, and history of thromboembolism). Risk factors for bleeding with anticoagulant therapy include hypertension, cancer, prior stroke, diabetes, a bleeding disorder, and use of NSAIDs, aspirin, or antiplatelet agents. Unfortunately, these conditions exist together in many hospitalized patients, and there are no validated tools to formally assess risk and benefit of VTE prophylaxis.

Bottom Line

Assess risk for venous thromboembolism as well as bleeding risk in all hospitalized medical patients. Heparin or related agent prophylaxis does not decrease total mortality, but it does decrease the risk of PE while increasing risk of bleeding. For most people, the reduction in PE outweighs the harm of increased bleeding. When benefit outweighs risk, use subcutaneous low-dose UFH, LMWH, or fondaparinux for VTE prophylaxis. Graduated compression stockings are not recommended for VTE prophylaxis.

Dr. Olsen is a chief resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Okay, we admit it – even we are becoming a bit jaded with all of the attention being paid to meaningful use. So we thought we’d give ourselves and our readers a break this month and instead write about a topic that gets far too little attention: optimization.

This is the concept of using electronic health records in ways that actually fulfill their intended promises of increased efficiency and improved patient care.

Often, the mere mention of optimization is met with looks of speculation and incredulity. This is followed with a question like, "Have you ever actually tried to use this thing?" or a definitive statement such as, "Impossible!"

We would argue, however, that if a practice has done its homework and invested in a high-quality, well-regarded EHR, there is no reason to doubt that real advantages eventually can be realized. In fact, if priority is given to optimal use early on in the implementation of an electronic record, government incentive and quality initiatives (such as meaningful use, PQRS/PQRI, etc.), can be far less painful to manage.

Here we focus on a few simple tools providers can use to increase – or at least maintain – their productivity.

Start With the Right Information

The most valuable step in ensuring optimal use of an EHR is timely and relevant education. Unfortunately, this is where many vendors fall short, as most training is done by individuals who do not actually care for patients. As a result, a great deal of emphasis is placed on what each button or checkbox does instead of how to make it through the day as efficiently as possible.

Instead, we encourage all providers to view the use of an electronic record through the lens of a workflow process. From beginning to end, interacting with the EHR should follow a logical progression and make sense to the user. If there is functionality that is unnecessary and only slows the provider down, it should be avoided in favor of elements that streamline the documentation process.

To put it another way, when learning the software, we should always be looking to the goal of an efficiently completed visit.

Preplan Your Visits

A great advantage of an electronic health record can be the ability to look into the future and "preplan" visits. It may be a novel concept to most, but adjusting to this model can greatly increase efficiency in the long run.

As an example, providers might look ahead at which patients will be coming in for a visit and preorder lab tests, in-office diagnostic studies, or routine health maintenance items. This way, the staff can properly prepare in advance and increase the speed of patient flow through the office. This also will reduce the amount of "clicking" and documentation the provider will need to do while the patient is in the exam room.

Avoid Duplicate Work

Most electronic health records include the ability to create timesaving templates or macros that can dramatically increase documentation efficiency. Templates created for common encounters (such as sinusitis, headache, or hypertension follow-up) allow providers to call up a mostly completed note and simply fill in the blanks to make it accurate and specific to an individual patient.

Templates also can be created for unique patients. For example, if Mrs. Jones comes in regularly for a diabetic check but her care plan always remains the same, a template specific to her will greatly decrease the documentation burden each time she visits. Likewise, macros that contain commonly used language can be created.

To illustrate, instructions for a hypertensive patient to avoid salt intake and increase exercise are typically provided. This text can be saved as a macro, and then, with a few keystrokes, can be inserted whenever deemed appropriate.

These invaluable tools are always helpful and well received, though it’s surprising how few physicians actually take advantage of them.

Think Like a Coder

Before taking offense to this section’s heading, consider this: Most of us are paid based on our documentation and coding. While far from a perfect – or even fair – system, it is the current reality. As a result, the way we create our notes should be informed by this fact.

It is important, therefore, to include documentation to support the way you are billing, and an EHR makes this a much easier thing to do.

Once they’re comfortable with the workflow, it is common for physicians to develop a sort of muscle memory – a pattern of documenting that insures all of the required elements for better evaluation and management coding are being hit. It is essential, however, not to fall into the trap of overdocumentation – including history points or exam elements in a note out of habit when they were not actually obtained. This is fraudulent and becomes obvious through repeated abuse.

Bottom line: Be sure to get paid for the work you are already doing through robust, but honest and accurate, documentation.

Summing Up

Unfortunately, it often seems that the government’s EHR incentive program has completely backfired. Instead of making our use of health information technology more meaningful, it has instead only resulted in additional mouse clicks and less efficient workflow. It is possible, though, to optimize the way we use health information technology and increase our efficiency with it.

Who knows? This might even make using it more meaningful at the same time!

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

Okay, we admit it – even we are becoming a bit jaded with all of the attention being paid to meaningful use. So we thought we’d give ourselves and our readers a break this month and instead write about a topic that gets far too little attention: optimization.

This is the concept of using electronic health records in ways that actually fulfill their intended promises of increased efficiency and improved patient care.

Often, the mere mention of optimization is met with looks of speculation and incredulity. This is followed with a question like, "Have you ever actually tried to use this thing?" or a definitive statement such as, "Impossible!"

We would argue, however, that if a practice has done its homework and invested in a high-quality, well-regarded EHR, there is no reason to doubt that real advantages eventually can be realized. In fact, if priority is given to optimal use early on in the implementation of an electronic record, government incentive and quality initiatives (such as meaningful use, PQRS/PQRI, etc.), can be far less painful to manage.

Here we focus on a few simple tools providers can use to increase – or at least maintain – their productivity.

Start With the Right Information

The most valuable step in ensuring optimal use of an EHR is timely and relevant education. Unfortunately, this is where many vendors fall short, as most training is done by individuals who do not actually care for patients. As a result, a great deal of emphasis is placed on what each button or checkbox does instead of how to make it through the day as efficiently as possible.

Instead, we encourage all providers to view the use of an electronic record through the lens of a workflow process. From beginning to end, interacting with the EHR should follow a logical progression and make sense to the user. If there is functionality that is unnecessary and only slows the provider down, it should be avoided in favor of elements that streamline the documentation process.

To put it another way, when learning the software, we should always be looking to the goal of an efficiently completed visit.

Preplan Your Visits

A great advantage of an electronic health record can be the ability to look into the future and "preplan" visits. It may be a novel concept to most, but adjusting to this model can greatly increase efficiency in the long run.

As an example, providers might look ahead at which patients will be coming in for a visit and preorder lab tests, in-office diagnostic studies, or routine health maintenance items. This way, the staff can properly prepare in advance and increase the speed of patient flow through the office. This also will reduce the amount of "clicking" and documentation the provider will need to do while the patient is in the exam room.

Avoid Duplicate Work

Most electronic health records include the ability to create timesaving templates or macros that can dramatically increase documentation efficiency. Templates created for common encounters (such as sinusitis, headache, or hypertension follow-up) allow providers to call up a mostly completed note and simply fill in the blanks to make it accurate and specific to an individual patient.

Templates also can be created for unique patients. For example, if Mrs. Jones comes in regularly for a diabetic check but her care plan always remains the same, a template specific to her will greatly decrease the documentation burden each time she visits. Likewise, macros that contain commonly used language can be created.

To illustrate, instructions for a hypertensive patient to avoid salt intake and increase exercise are typically provided. This text can be saved as a macro, and then, with a few keystrokes, can be inserted whenever deemed appropriate.

These invaluable tools are always helpful and well received, though it’s surprising how few physicians actually take advantage of them.

Think Like a Coder

Before taking offense to this section’s heading, consider this: Most of us are paid based on our documentation and coding. While far from a perfect – or even fair – system, it is the current reality. As a result, the way we create our notes should be informed by this fact.

It is important, therefore, to include documentation to support the way you are billing, and an EHR makes this a much easier thing to do.

Once they’re comfortable with the workflow, it is common for physicians to develop a sort of muscle memory – a pattern of documenting that insures all of the required elements for better evaluation and management coding are being hit. It is essential, however, not to fall into the trap of overdocumentation – including history points or exam elements in a note out of habit when they were not actually obtained. This is fraudulent and becomes obvious through repeated abuse.

Bottom line: Be sure to get paid for the work you are already doing through robust, but honest and accurate, documentation.

Summing Up

Unfortunately, it often seems that the government’s EHR incentive program has completely backfired. Instead of making our use of health information technology more meaningful, it has instead only resulted in additional mouse clicks and less efficient workflow. It is possible, though, to optimize the way we use health information technology and increase our efficiency with it.

Who knows? This might even make using it more meaningful at the same time!

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

Okay, we admit it – even we are becoming a bit jaded with all of the attention being paid to meaningful use. So we thought we’d give ourselves and our readers a break this month and instead write about a topic that gets far too little attention: optimization.

This is the concept of using electronic health records in ways that actually fulfill their intended promises of increased efficiency and improved patient care.

Often, the mere mention of optimization is met with looks of speculation and incredulity. This is followed with a question like, "Have you ever actually tried to use this thing?" or a definitive statement such as, "Impossible!"

We would argue, however, that if a practice has done its homework and invested in a high-quality, well-regarded EHR, there is no reason to doubt that real advantages eventually can be realized. In fact, if priority is given to optimal use early on in the implementation of an electronic record, government incentive and quality initiatives (such as meaningful use, PQRS/PQRI, etc.), can be far less painful to manage.

Here we focus on a few simple tools providers can use to increase – or at least maintain – their productivity.

Start With the Right Information

The most valuable step in ensuring optimal use of an EHR is timely and relevant education. Unfortunately, this is where many vendors fall short, as most training is done by individuals who do not actually care for patients. As a result, a great deal of emphasis is placed on what each button or checkbox does instead of how to make it through the day as efficiently as possible.

Instead, we encourage all providers to view the use of an electronic record through the lens of a workflow process. From beginning to end, interacting with the EHR should follow a logical progression and make sense to the user. If there is functionality that is unnecessary and only slows the provider down, it should be avoided in favor of elements that streamline the documentation process.

To put it another way, when learning the software, we should always be looking to the goal of an efficiently completed visit.

Preplan Your Visits

A great advantage of an electronic health record can be the ability to look into the future and "preplan" visits. It may be a novel concept to most, but adjusting to this model can greatly increase efficiency in the long run.

As an example, providers might look ahead at which patients will be coming in for a visit and preorder lab tests, in-office diagnostic studies, or routine health maintenance items. This way, the staff can properly prepare in advance and increase the speed of patient flow through the office. This also will reduce the amount of "clicking" and documentation the provider will need to do while the patient is in the exam room.

Avoid Duplicate Work

Most electronic health records include the ability to create timesaving templates or macros that can dramatically increase documentation efficiency. Templates created for common encounters (such as sinusitis, headache, or hypertension follow-up) allow providers to call up a mostly completed note and simply fill in the blanks to make it accurate and specific to an individual patient.

Templates also can be created for unique patients. For example, if Mrs. Jones comes in regularly for a diabetic check but her care plan always remains the same, a template specific to her will greatly decrease the documentation burden each time she visits. Likewise, macros that contain commonly used language can be created.

To illustrate, instructions for a hypertensive patient to avoid salt intake and increase exercise are typically provided. This text can be saved as a macro, and then, with a few keystrokes, can be inserted whenever deemed appropriate.

These invaluable tools are always helpful and well received, though it’s surprising how few physicians actually take advantage of them.

Think Like a Coder

Before taking offense to this section’s heading, consider this: Most of us are paid based on our documentation and coding. While far from a perfect – or even fair – system, it is the current reality. As a result, the way we create our notes should be informed by this fact.

It is important, therefore, to include documentation to support the way you are billing, and an EHR makes this a much easier thing to do.

Once they’re comfortable with the workflow, it is common for physicians to develop a sort of muscle memory – a pattern of documenting that insures all of the required elements for better evaluation and management coding are being hit. It is essential, however, not to fall into the trap of overdocumentation – including history points or exam elements in a note out of habit when they were not actually obtained. This is fraudulent and becomes obvious through repeated abuse.

Bottom line: Be sure to get paid for the work you are already doing through robust, but honest and accurate, documentation.

Summing Up

Unfortunately, it often seems that the government’s EHR incentive program has completely backfired. Instead of making our use of health information technology more meaningful, it has instead only resulted in additional mouse clicks and less efficient workflow. It is possible, though, to optimize the way we use health information technology and increase our efficiency with it.

Who knows? This might even make using it more meaningful at the same time!

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

By now, you’ve certainly heard the news: The "meaningful use" freight train has continued rolling forward and has finally arrived at the proposed criteria for stage 2. The specifics are available online for review and comment, and already – even in the pages of this newspaper – the medical world is abuzz with speculation about what they’ll really mean for docs.

Many wonder if the authors of the guidelines have overstepped and are proposing standards simply too cumbersome to meet. Others have described them as "a logical progression" to follow stage 1. Either way, the proposed rules certainly point to themes that will resonate across the medical world, and it is worth taking a moment to reflect upon the key elements and their potential impact.

So, What’s the Big Deal?

If you’re among the 39% of physicians who have collected meaningful use incentive payments so far (or are planning to be one of them soon), you’re likely aware of the stakes: $44,000 per provider in increased Medicare reimbursements for those who comply, with penalties starting in 2015 for any laggards who have not jumped on board.

You are probably also intimately aware of the requirements for stage 1. Included among these are specific goals for common and sometimes uncommon workflow items, such as entering electronic orders and providing clinical summaries for each visit.

A cursory review of the stage 2 requirements reveals more of the same, but with higher target goals. For instance, in the case of e-prescribing, the required percentage has risen from 40% of eligible prescriptions to 65%. In addition, measures that previously just required a "test" of ability now find themselves with target percentages of their own.

One clear example of this is the new requirement that physicians must transmit a summary of care record for more than 10% of referrals or transitions of care. This highlights the underlying core of the new measures: better communication.

Communication Is Key

Reading through the proposed rule, it doesn’t take long to recognize its emphasis on the sharing of health information. This is not limited just to information exchange among care providers in different settings, but also includes improved communication between physicians and patients.

For example, the new guidelines really put pressure on providers to have a secure and interactive web portal for electronic correspondence with their patients. Certain measures underscore this, such as the reduced time allowed to provide patients with a clinical visit summary (down from 3 days to just 24 hours).

The ability to publish this information through a Web portal will really become a necessity to comply with the tightened schedule. In addition, having a portal will pave the way for other measures, including those that provide for immediate patient access to labs and test results.

Of course, this also presents a unique challenge, as it may raise significant questions about patients’ studies prior to the physician’s opportunity to review the results with them. Most patients don’t have the luxury of a medical education with which to interpret their own results, and this could introduce significant anxiety and unnecessary phone calls to their physicians.

One final note about communication is the emphasis on sharing information with vaccine and syndromic data registries. Although practices were only required to perform a test in stage 1, stage 2 requires practices to carry out this process regularly. This, combined with the routine use of transition of care records, will begin to lay the groundwork for robust data exchange and population management.

Quality Matters

Stage 1 required providers to implement one clinical decision support rule to help insure best practice at the point of care. With the dawn of stage 2, the proposed number of such interventions is now up to five. In addition, the Centers for Medicare and Medicaid Services (CMS) will be looking for providers to report on 12 clinical quality measures, up from the current 6.

Reporting these should probably be taken quite seriously; some experts have postulated that, while stage 1 was a test of the EHR’s ability to collect the data, stage 2 is a test of the doctor.

It is not entirely clear what CMS is doing with the data being captured, but one thing is definitely worth observing: These quality measures are the same as those required for other government programs such as the Physician Quality Reporting System, and at some point the data will likely be used to determine physician reimbursement. This is no different from what is being expected from many private insurers, so it’s not surprising that CMS would capitalize on the power of the EHR to collect information and analyze physician performance.

Be Prepared

As stated previously, many of the rules proposed for stage 2 expand upon those already expected in stage 1. If providers choose to be proactive and exceed the stage 1 targets wherever possible in advance of 2014, they’ll likely find the transition a very reasonable undertaking. Those who have done the bare minimum to skate by in stage 1 will be far more challenged.

Either way, we encourage all physicians to continue to investigate the changes and engage their EHR vendor to see how the software may be updated to accommodate the new rules. As with most things, a better understanding of what’s to come will aid in framing the issues constructively and hopefully allay the concerns that many of us have any time the government gets more involved in health care.

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

By now, you’ve certainly heard the news: The "meaningful use" freight train has continued rolling forward and has finally arrived at the proposed criteria for stage 2. The specifics are available online for review and comment, and already – even in the pages of this newspaper – the medical world is abuzz with speculation about what they’ll really mean for docs.

Many wonder if the authors of the guidelines have overstepped and are proposing standards simply too cumbersome to meet. Others have described them as "a logical progression" to follow stage 1. Either way, the proposed rules certainly point to themes that will resonate across the medical world, and it is worth taking a moment to reflect upon the key elements and their potential impact.

So, What’s the Big Deal?

If you’re among the 39% of physicians who have collected meaningful use incentive payments so far (or are planning to be one of them soon), you’re likely aware of the stakes: $44,000 per provider in increased Medicare reimbursements for those who comply, with penalties starting in 2015 for any laggards who have not jumped on board.

You are probably also intimately aware of the requirements for stage 1. Included among these are specific goals for common and sometimes uncommon workflow items, such as entering electronic orders and providing clinical summaries for each visit.

A cursory review of the stage 2 requirements reveals more of the same, but with higher target goals. For instance, in the case of e-prescribing, the required percentage has risen from 40% of eligible prescriptions to 65%. In addition, measures that previously just required a "test" of ability now find themselves with target percentages of their own.

One clear example of this is the new requirement that physicians must transmit a summary of care record for more than 10% of referrals or transitions of care. This highlights the underlying core of the new measures: better communication.

Communication Is Key

Reading through the proposed rule, it doesn’t take long to recognize its emphasis on the sharing of health information. This is not limited just to information exchange among care providers in different settings, but also includes improved communication between physicians and patients.

For example, the new guidelines really put pressure on providers to have a secure and interactive web portal for electronic correspondence with their patients. Certain measures underscore this, such as the reduced time allowed to provide patients with a clinical visit summary (down from 3 days to just 24 hours).

The ability to publish this information through a Web portal will really become a necessity to comply with the tightened schedule. In addition, having a portal will pave the way for other measures, including those that provide for immediate patient access to labs and test results.

Of course, this also presents a unique challenge, as it may raise significant questions about patients’ studies prior to the physician’s opportunity to review the results with them. Most patients don’t have the luxury of a medical education with which to interpret their own results, and this could introduce significant anxiety and unnecessary phone calls to their physicians.

One final note about communication is the emphasis on sharing information with vaccine and syndromic data registries. Although practices were only required to perform a test in stage 1, stage 2 requires practices to carry out this process regularly. This, combined with the routine use of transition of care records, will begin to lay the groundwork for robust data exchange and population management.

Quality Matters

Stage 1 required providers to implement one clinical decision support rule to help insure best practice at the point of care. With the dawn of stage 2, the proposed number of such interventions is now up to five. In addition, the Centers for Medicare and Medicaid Services (CMS) will be looking for providers to report on 12 clinical quality measures, up from the current 6.

Reporting these should probably be taken quite seriously; some experts have postulated that, while stage 1 was a test of the EHR’s ability to collect the data, stage 2 is a test of the doctor.

It is not entirely clear what CMS is doing with the data being captured, but one thing is definitely worth observing: These quality measures are the same as those required for other government programs such as the Physician Quality Reporting System, and at some point the data will likely be used to determine physician reimbursement. This is no different from what is being expected from many private insurers, so it’s not surprising that CMS would capitalize on the power of the EHR to collect information and analyze physician performance.

Be Prepared

As stated previously, many of the rules proposed for stage 2 expand upon those already expected in stage 1. If providers choose to be proactive and exceed the stage 1 targets wherever possible in advance of 2014, they’ll likely find the transition a very reasonable undertaking. Those who have done the bare minimum to skate by in stage 1 will be far more challenged.

Either way, we encourage all physicians to continue to investigate the changes and engage their EHR vendor to see how the software may be updated to accommodate the new rules. As with most things, a better understanding of what’s to come will aid in framing the issues constructively and hopefully allay the concerns that many of us have any time the government gets more involved in health care.

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

By now, you’ve certainly heard the news: The "meaningful use" freight train has continued rolling forward and has finally arrived at the proposed criteria for stage 2. The specifics are available online for review and comment, and already – even in the pages of this newspaper – the medical world is abuzz with speculation about what they’ll really mean for docs.

Many wonder if the authors of the guidelines have overstepped and are proposing standards simply too cumbersome to meet. Others have described them as "a logical progression" to follow stage 1. Either way, the proposed rules certainly point to themes that will resonate across the medical world, and it is worth taking a moment to reflect upon the key elements and their potential impact.

So, What’s the Big Deal?

If you’re among the 39% of physicians who have collected meaningful use incentive payments so far (or are planning to be one of them soon), you’re likely aware of the stakes: $44,000 per provider in increased Medicare reimbursements for those who comply, with penalties starting in 2015 for any laggards who have not jumped on board.

You are probably also intimately aware of the requirements for stage 1. Included among these are specific goals for common and sometimes uncommon workflow items, such as entering electronic orders and providing clinical summaries for each visit.

A cursory review of the stage 2 requirements reveals more of the same, but with higher target goals. For instance, in the case of e-prescribing, the required percentage has risen from 40% of eligible prescriptions to 65%. In addition, measures that previously just required a "test" of ability now find themselves with target percentages of their own.

One clear example of this is the new requirement that physicians must transmit a summary of care record for more than 10% of referrals or transitions of care. This highlights the underlying core of the new measures: better communication.

Communication Is Key

Reading through the proposed rule, it doesn’t take long to recognize its emphasis on the sharing of health information. This is not limited just to information exchange among care providers in different settings, but also includes improved communication between physicians and patients.

For example, the new guidelines really put pressure on providers to have a secure and interactive web portal for electronic correspondence with their patients. Certain measures underscore this, such as the reduced time allowed to provide patients with a clinical visit summary (down from 3 days to just 24 hours).

The ability to publish this information through a Web portal will really become a necessity to comply with the tightened schedule. In addition, having a portal will pave the way for other measures, including those that provide for immediate patient access to labs and test results.

Of course, this also presents a unique challenge, as it may raise significant questions about patients’ studies prior to the physician’s opportunity to review the results with them. Most patients don’t have the luxury of a medical education with which to interpret their own results, and this could introduce significant anxiety and unnecessary phone calls to their physicians.

One final note about communication is the emphasis on sharing information with vaccine and syndromic data registries. Although practices were only required to perform a test in stage 1, stage 2 requires practices to carry out this process regularly. This, combined with the routine use of transition of care records, will begin to lay the groundwork for robust data exchange and population management.

Quality Matters

Stage 1 required providers to implement one clinical decision support rule to help insure best practice at the point of care. With the dawn of stage 2, the proposed number of such interventions is now up to five. In addition, the Centers for Medicare and Medicaid Services (CMS) will be looking for providers to report on 12 clinical quality measures, up from the current 6.

Reporting these should probably be taken quite seriously; some experts have postulated that, while stage 1 was a test of the EHR’s ability to collect the data, stage 2 is a test of the doctor.

It is not entirely clear what CMS is doing with the data being captured, but one thing is definitely worth observing: These quality measures are the same as those required for other government programs such as the Physician Quality Reporting System, and at some point the data will likely be used to determine physician reimbursement. This is no different from what is being expected from many private insurers, so it’s not surprising that CMS would capitalize on the power of the EHR to collect information and analyze physician performance.

Be Prepared

As stated previously, many of the rules proposed for stage 2 expand upon those already expected in stage 1. If providers choose to be proactive and exceed the stage 1 targets wherever possible in advance of 2014, they’ll likely find the transition a very reasonable undertaking. Those who have done the bare minimum to skate by in stage 1 will be far more challenged.

Either way, we encourage all physicians to continue to investigate the changes and engage their EHR vendor to see how the software may be updated to accommodate the new rules. As with most things, a better understanding of what’s to come will aid in framing the issues constructively and hopefully allay the concerns that many of us have any time the government gets more involved in health care.

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

The need to improve the quality of care while lowering its cost is at the root of every major initiative in health care today. While new models of care are evolving to meet this need, new technology applications are being developed simultaneously to make these models viable. The electronic health record is both the means and the end of these revolutionary processes.

An EHR’s raison d’être is to collect and share data important for the treatment of patients. This seemingly simple function, however, rests on complex, multifaceted relationships that seek to balance caregivers’ needs against information systems’ capabilities. Driven forward by federal government mandates, the next several years promise to bring issues of EHR standardization, usability, and interoperability to the forefront of practicing physicians’ collective awareness.

EHR Development: Where Is It Going, and Why

While change is constant in health care – and exponential in technology – three EHR developmental imperatives are emerging in response to industry trends, as well as existing and imminent federal requirements:

• Interoperability. Standardization – the prerequisite for sharing records between and among IT systems – has been an important, though hard-to-achieve, goal of EHR development since 1991, when the Institute of Medicine’s report, "The Computer-Based Patient Record: An Essential Technology for Health Care," introduced the idea of "an electronic patient record ... specifically designed to support users through availability of complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids."

Since that time, several organizations have worked to further the development of standards, with some success as evidenced by standardization of lab results, medication names, allergies, and demographic data. Other data elements, such as physician progress notes that require multiple concepts to express, are proving more problematic. The challenge: ensuring interoperability for public health reporting and research without hindering or further complicating the physician "conversation." Meeting this challenge demands ongoing, industry-level standards development.

• Usability. As federal mandates increase quality and reporting requirements, EHR solutions must evolve to help rather than hinder physicians’ efforts to meet them. For example, an EHR that requires numerous "clicks" to order a single medication is not going to streamline a physician’s workflow. The problem is finding ways to objectively measure something as seemingly subjective as usability.

However, the issue is now on the federal radar and fast becoming a must-have for EHR products. Certification organizations increasingly are looking for ways to measure and mandate usability of EHR products, from the National Institute of Standards and Technology’s (NIST) search for sources "to fully develop and execute a project to create a usability framework for health information technology (HIT) systems" to the Certification Commission for Healthcare Information Systems’ (CCHIT) 2011 Usability Testing Guide for Comprehensive Ambulatory EHRs.

• Care coordination. Despite spending one-sixth of our entire gross domestic product on health care, the United States falls far short of being the healthiest society in the world. One reason: We spend the vast majority of our resources treating the symptoms rather than the causes of disease. Care coordination across all elements of the complex health care system (for example, subspecialty care, hospitals, home health agencies, nursing homes, etc.) and the patient’s community is essential to creating a shift from treatment to prevention – and EHRs are essential to care coordination.

In addition, care coordination is a key characteristic of the patient-centered medical home, an emerging care concept based on evidence, driven by data, focused on health and wellness, and centered on the needs of the patient.

These three imperatives – interoperability, usability, and care coordination – are driving EHR development. As such, they also are key considerations in the selection of an EHR solution.

Functional Matters: Choosing an EHR Solution

The 2009 American Recovery and Reinvestment Act’s (ARRA) HITECH Act may have brought EHRs to the forefront of health care discussion, but it did not alter their primary function – improving the quality of care. To ensure this result, physicians should look for the following in an EHR product:

• Certification: Certification assures a product has met core criteria considered essential by a broad range of stakeholders, which is key to maximizing the system’s value. One-time certification is not enough; annual certification evidences the continual development necessary for the product’s ongoing viability.

The sole organization designated by the Department of Health and Human Services (HHS) since 2006, CCHIT is the industry’s leading EHR certification body and the de facto standard for usability and other criteria. However, with the advent of ARRA and the resulting need to preclude any conflict of interest, HHS now will oversee multiple certification organizations. The Office of the National Coordinator (ONC) for Health Information Technology is developing its own certification criteria with NIST, which will assess conformity and accredit certification bodies.

Still, those that now possess CCHIT usability ratings and certification have positioned themselves in the forefront of the certification process.

• Structured data: Structured data reside in fixed fields within a record or file. These discrete data fields (for example, blood pressure, body mass index, and height/weight) establish the predetermined data types and understood relationships necessary for efficient quality reporting. Since 2008, the Centers for Medicare and Medicaid Services has allowed reporting of quality measures data to a qualified registry. As early as this year, CMS could begin accepting direct EHR-based quality reporting. As early as 2012, CMS could mandate it. EHRs built on unstructured data (as is found in many transcription/dictation systems) will not support compliance.

• Meaningful use guarantees: Incentives should not be the sole reason why physicians deploy EHRs, but the ability to secure incentives must not be overlooked. EHR vendors with a commitment to – and a plan for – meeting meaningful use criteria as they are established will offer guarantees to that effect.

• Clinical decision support: Evidence-based practice is the inevitable future of health care. EHRs with clinical prompts and reminders support best practice and systemize the use of evidence at the point of care.

• Support for coordinated care: Increasingly, EHRs will serve as the foundation for data registries, health information exchange, and other means to assure patients get the indicated care when and where they need and want it, and in a culturally and linguistically appropriate manner. Expanded patient data access – via secure communication portals, for instance – also will require more robust data controls to ensure secure data exchange. However, it will enable patient-centric care through greater patient involvement.

Health care is a dynamic industry, driven by the needs – changing and continuous – of its stakeholders. Developing, choosing, and deploying EHRs will continue to challenge. Keeping standardization, usability, and interoperability as the prime focus of all development and purchase decisions ultimately will smooth the path for everyone.

Dr. Corley is the chief medical officer for NextGen Healthcare Information Systems, an electronic health record vendor. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references.

References

1. The Computer-Based Patient Record: An Essential Technology for Health Care Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine Richard S. Dick, Elaine B. Steen; eds. 190 pages. Washington, D.C.: National Academy Press; 1991.

2. National Institute of Standards and Technology. Health Information Technology Usability Framework. Federal Business Opportunity. Solicitation Number: AMD-10-SS39 Web.

The need to improve the quality of care while lowering its cost is at the root of every major initiative in health care today. While new models of care are evolving to meet this need, new technology applications are being developed simultaneously to make these models viable. The electronic health record is both the means and the end of these revolutionary processes.

An EHR’s raison d’être is to collect and share data important for the treatment of patients. This seemingly simple function, however, rests on complex, multifaceted relationships that seek to balance caregivers’ needs against information systems’ capabilities. Driven forward by federal government mandates, the next several years promise to bring issues of EHR standardization, usability, and interoperability to the forefront of practicing physicians’ collective awareness.

EHR Development: Where Is It Going, and Why

While change is constant in health care – and exponential in technology – three EHR developmental imperatives are emerging in response to industry trends, as well as existing and imminent federal requirements:

• Interoperability. Standardization – the prerequisite for sharing records between and among IT systems – has been an important, though hard-to-achieve, goal of EHR development since 1991, when the Institute of Medicine’s report, "The Computer-Based Patient Record: An Essential Technology for Health Care," introduced the idea of "an electronic patient record ... specifically designed to support users through availability of complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids."

Since that time, several organizations have worked to further the development of standards, with some success as evidenced by standardization of lab results, medication names, allergies, and demographic data. Other data elements, such as physician progress notes that require multiple concepts to express, are proving more problematic. The challenge: ensuring interoperability for public health reporting and research without hindering or further complicating the physician "conversation." Meeting this challenge demands ongoing, industry-level standards development.

• Usability. As federal mandates increase quality and reporting requirements, EHR solutions must evolve to help rather than hinder physicians’ efforts to meet them. For example, an EHR that requires numerous "clicks" to order a single medication is not going to streamline a physician’s workflow. The problem is finding ways to objectively measure something as seemingly subjective as usability.

However, the issue is now on the federal radar and fast becoming a must-have for EHR products. Certification organizations increasingly are looking for ways to measure and mandate usability of EHR products, from the National Institute of Standards and Technology’s (NIST) search for sources "to fully develop and execute a project to create a usability framework for health information technology (HIT) systems" to the Certification Commission for Healthcare Information Systems’ (CCHIT) 2011 Usability Testing Guide for Comprehensive Ambulatory EHRs.

• Care coordination. Despite spending one-sixth of our entire gross domestic product on health care, the United States falls far short of being the healthiest society in the world. One reason: We spend the vast majority of our resources treating the symptoms rather than the causes of disease. Care coordination across all elements of the complex health care system (for example, subspecialty care, hospitals, home health agencies, nursing homes, etc.) and the patient’s community is essential to creating a shift from treatment to prevention – and EHRs are essential to care coordination.

In addition, care coordination is a key characteristic of the patient-centered medical home, an emerging care concept based on evidence, driven by data, focused on health and wellness, and centered on the needs of the patient.

These three imperatives – interoperability, usability, and care coordination – are driving EHR development. As such, they also are key considerations in the selection of an EHR solution.

Functional Matters: Choosing an EHR Solution

The 2009 American Recovery and Reinvestment Act’s (ARRA) HITECH Act may have brought EHRs to the forefront of health care discussion, but it did not alter their primary function – improving the quality of care. To ensure this result, physicians should look for the following in an EHR product:

• Certification: Certification assures a product has met core criteria considered essential by a broad range of stakeholders, which is key to maximizing the system’s value. One-time certification is not enough; annual certification evidences the continual development necessary for the product’s ongoing viability.

The sole organization designated by the Department of Health and Human Services (HHS) since 2006, CCHIT is the industry’s leading EHR certification body and the de facto standard for usability and other criteria. However, with the advent of ARRA and the resulting need to preclude any conflict of interest, HHS now will oversee multiple certification organizations. The Office of the National Coordinator (ONC) for Health Information Technology is developing its own certification criteria with NIST, which will assess conformity and accredit certification bodies.

Still, those that now possess CCHIT usability ratings and certification have positioned themselves in the forefront of the certification process.

• Structured data: Structured data reside in fixed fields within a record or file. These discrete data fields (for example, blood pressure, body mass index, and height/weight) establish the predetermined data types and understood relationships necessary for efficient quality reporting. Since 2008, the Centers for Medicare and Medicaid Services has allowed reporting of quality measures data to a qualified registry. As early as this year, CMS could begin accepting direct EHR-based quality reporting. As early as 2012, CMS could mandate it. EHRs built on unstructured data (as is found in many transcription/dictation systems) will not support compliance.

• Meaningful use guarantees: Incentives should not be the sole reason why physicians deploy EHRs, but the ability to secure incentives must not be overlooked. EHR vendors with a commitment to – and a plan for – meeting meaningful use criteria as they are established will offer guarantees to that effect.

• Clinical decision support: Evidence-based practice is the inevitable future of health care. EHRs with clinical prompts and reminders support best practice and systemize the use of evidence at the point of care.

• Support for coordinated care: Increasingly, EHRs will serve as the foundation for data registries, health information exchange, and other means to assure patients get the indicated care when and where they need and want it, and in a culturally and linguistically appropriate manner. Expanded patient data access – via secure communication portals, for instance – also will require more robust data controls to ensure secure data exchange. However, it will enable patient-centric care through greater patient involvement.

Health care is a dynamic industry, driven by the needs – changing and continuous – of its stakeholders. Developing, choosing, and deploying EHRs will continue to challenge. Keeping standardization, usability, and interoperability as the prime focus of all development and purchase decisions ultimately will smooth the path for everyone.

Dr. Corley is the chief medical officer for NextGen Healthcare Information Systems, an electronic health record vendor. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references.

References

1. The Computer-Based Patient Record: An Essential Technology for Health Care Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine Richard S. Dick, Elaine B. Steen; eds. 190 pages. Washington, D.C.: National Academy Press; 1991.

2. National Institute of Standards and Technology. Health Information Technology Usability Framework. Federal Business Opportunity. Solicitation Number: AMD-10-SS39 Web.

The need to improve the quality of care while lowering its cost is at the root of every major initiative in health care today. While new models of care are evolving to meet this need, new technology applications are being developed simultaneously to make these models viable. The electronic health record is both the means and the end of these revolutionary processes.

An EHR’s raison d’être is to collect and share data important for the treatment of patients. This seemingly simple function, however, rests on complex, multifaceted relationships that seek to balance caregivers’ needs against information systems’ capabilities. Driven forward by federal government mandates, the next several years promise to bring issues of EHR standardization, usability, and interoperability to the forefront of practicing physicians’ collective awareness.

EHR Development: Where Is It Going, and Why

While change is constant in health care – and exponential in technology – three EHR developmental imperatives are emerging in response to industry trends, as well as existing and imminent federal requirements:

• Interoperability. Standardization – the prerequisite for sharing records between and among IT systems – has been an important, though hard-to-achieve, goal of EHR development since 1991, when the Institute of Medicine’s report, "The Computer-Based Patient Record: An Essential Technology for Health Care," introduced the idea of "an electronic patient record ... specifically designed to support users through availability of complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids."

Since that time, several organizations have worked to further the development of standards, with some success as evidenced by standardization of lab results, medication names, allergies, and demographic data. Other data elements, such as physician progress notes that require multiple concepts to express, are proving more problematic. The challenge: ensuring interoperability for public health reporting and research without hindering or further complicating the physician "conversation." Meeting this challenge demands ongoing, industry-level standards development.

• Usability. As federal mandates increase quality and reporting requirements, EHR solutions must evolve to help rather than hinder physicians’ efforts to meet them. For example, an EHR that requires numerous "clicks" to order a single medication is not going to streamline a physician’s workflow. The problem is finding ways to objectively measure something as seemingly subjective as usability.

However, the issue is now on the federal radar and fast becoming a must-have for EHR products. Certification organizations increasingly are looking for ways to measure and mandate usability of EHR products, from the National Institute of Standards and Technology’s (NIST) search for sources "to fully develop and execute a project to create a usability framework for health information technology (HIT) systems" to the Certification Commission for Healthcare Information Systems’ (CCHIT) 2011 Usability Testing Guide for Comprehensive Ambulatory EHRs.

• Care coordination. Despite spending one-sixth of our entire gross domestic product on health care, the United States falls far short of being the healthiest society in the world. One reason: We spend the vast majority of our resources treating the symptoms rather than the causes of disease. Care coordination across all elements of the complex health care system (for example, subspecialty care, hospitals, home health agencies, nursing homes, etc.) and the patient’s community is essential to creating a shift from treatment to prevention – and EHRs are essential to care coordination.

In addition, care coordination is a key characteristic of the patient-centered medical home, an emerging care concept based on evidence, driven by data, focused on health and wellness, and centered on the needs of the patient.

These three imperatives – interoperability, usability, and care coordination – are driving EHR development. As such, they also are key considerations in the selection of an EHR solution.

Functional Matters: Choosing an EHR Solution

The 2009 American Recovery and Reinvestment Act’s (ARRA) HITECH Act may have brought EHRs to the forefront of health care discussion, but it did not alter their primary function – improving the quality of care. To ensure this result, physicians should look for the following in an EHR product:

• Certification: Certification assures a product has met core criteria considered essential by a broad range of stakeholders, which is key to maximizing the system’s value. One-time certification is not enough; annual certification evidences the continual development necessary for the product’s ongoing viability.

The sole organization designated by the Department of Health and Human Services (HHS) since 2006, CCHIT is the industry’s leading EHR certification body and the de facto standard for usability and other criteria. However, with the advent of ARRA and the resulting need to preclude any conflict of interest, HHS now will oversee multiple certification organizations. The Office of the National Coordinator (ONC) for Health Information Technology is developing its own certification criteria with NIST, which will assess conformity and accredit certification bodies.

Still, those that now possess CCHIT usability ratings and certification have positioned themselves in the forefront of the certification process.

• Structured data: Structured data reside in fixed fields within a record or file. These discrete data fields (for example, blood pressure, body mass index, and height/weight) establish the predetermined data types and understood relationships necessary for efficient quality reporting. Since 2008, the Centers for Medicare and Medicaid Services has allowed reporting of quality measures data to a qualified registry. As early as this year, CMS could begin accepting direct EHR-based quality reporting. As early as 2012, CMS could mandate it. EHRs built on unstructured data (as is found in many transcription/dictation systems) will not support compliance.

• Meaningful use guarantees: Incentives should not be the sole reason why physicians deploy EHRs, but the ability to secure incentives must not be overlooked. EHR vendors with a commitment to – and a plan for – meeting meaningful use criteria as they are established will offer guarantees to that effect.

• Clinical decision support: Evidence-based practice is the inevitable future of health care. EHRs with clinical prompts and reminders support best practice and systemize the use of evidence at the point of care.

• Support for coordinated care: Increasingly, EHRs will serve as the foundation for data registries, health information exchange, and other means to assure patients get the indicated care when and where they need and want it, and in a culturally and linguistically appropriate manner. Expanded patient data access – via secure communication portals, for instance – also will require more robust data controls to ensure secure data exchange. However, it will enable patient-centric care through greater patient involvement.

Health care is a dynamic industry, driven by the needs – changing and continuous – of its stakeholders. Developing, choosing, and deploying EHRs will continue to challenge. Keeping standardization, usability, and interoperability as the prime focus of all development and purchase decisions ultimately will smooth the path for everyone.

Dr. Corley is the chief medical officer for NextGen Healthcare Information Systems, an electronic health record vendor. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references.

References

1. The Computer-Based Patient Record: An Essential Technology for Health Care Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine Richard S. Dick, Elaine B. Steen; eds. 190 pages. Washington, D.C.: National Academy Press; 1991.

2. National Institute of Standards and Technology. Health Information Technology Usability Framework. Federal Business Opportunity. Solicitation Number: AMD-10-SS39 Web.