Neil Skolnik

Helping Patients Who Drink Too Much

men who drink more than 4 standard drinks in a day (or more than 14 per week) and women who drink more than 3 in a day (or more than 7 per week) are at increased risk for alcohol-related problems.

Electronic medical records

Electronic Medical Record (EMR) relational database is considered to be a major component of any medical care information system. A major problem for researchers in medical informatics is finding the best way to use these databases to extract valued useful information to and about the patient’s diseases and treatments. Integrating different EMR databases is a great achievement that will improve health care systems. This paper presents an AI approach to extract generic EMR from different resources and transfer them to clinical cases. The utilized approach is based on retrieving different relationships between patients’ different data tables (files) and automatically generating EMRs in XML format, then building frame based medical cases to form a case repository that can be used in medical diagnostic systems. Index Terms Electronic medical records, frame knowledge representation, relational databases, XML.

A View from the Trenches: Primary Care Physicians on Electronic Health Records

It is one thing for pundits in ivory towers to describe the correct approach that practicing physicians should use in selecting and implementing an electronic health record system, for them to describe the essential reasons why it is to the physician’s advantage to change over as rapidly as possible to a computer-based system of healthcare. It is another thing to actually make that change. Generals talk about the “cloud of war,” by which they mean that even the most carefully developed plans, conceived of in the quiet of the planning room, have to be carried out in a radically different manner than they planned when they face the confusion, disclarity, and realities of the field. This shift from theory to practice is also true of complex systems in medical practice. In the cloud of the office, the physician is often running four patients behind and trying to integrate a patient’s psychosocial needs with their medical needs while another patient down the hall is getting an EKG for chest pain. This is occurring simultaneously with trying to understand and integrate the new electronic health record (EHR). It isn’t correct to say that knowledge and planning doesn’t help; it does and that is why we have written this book. It remains important though to acknowledge that there are different sources available for learning - one is expert opinion and knowledge, the other is experience, the experience of individuals with whom you have something in common and who have decided to implement a system like that which you are considering and to hear their experiences, good and bad, with those systems. The goal of this chapter is to provide readers with candid, first-person accounts of primary care physicians’ experiences with a variety of EMR systems from a variety of settings. This should provide a balance of inspiration and consolation regarding a transitional experience that is changing the way medicine is practiced.

Initiating Titratable Fixed-Ratio Combinations of Basal Insulin Analogs and Glucagon-Like Peptide-1 Receptor Agonists: What You Need to Know

IN BRIEF Titratable fixed-ratio combinations (FRCs) of a basal insulin and a glucagon-like peptide-1 (GLP-1) receptor agonist are new therapeutic options for people with type 2 diabetes. Two FRCs—insulin degludec/liraglutide and insulin glargine/lixisenatide—have been approved for use in the United States. The two components in these FRCs target different aspects of diabetes pathophysiology, working in a complementary manner to decrease blood glucose while mitigating the side effects associated with each component (hypoglycemia and weight gain with insulin and gastrointestinal side effects with GLP-1 receptor agonists). This article reviews these products and key considerations for their use.

A View from the Top: Reflections of Leaders in the Electronic Health Record Industry

This chapter is comprised of responses from chief executive officers and chief medical officers of some of the major EHR vendors addressing two questions – what should clinicians be looking for now as they consider purchasing an EHR for their practice and where they feel the industry is going, that is to say what changes will we be seeing over the next 5 years of which the practicing physician should be aware. The expectation was that their thoughts would be interesting, but fairly consistent, in their positive outlook of the EHR industry and the promises of what EHRs might do for patient care. After all, they are the leaders in a industry which will change the way that health care is delivered more than any other single invention or discovery of this generation. Instead, what you will see in this chapter is that while their views are positive about the potential for EHRs to improve care, their views are anything but consistent as they speak honestly of the potential promises and pitfalls facing both the industry and the individual practitioners in choosing and implementing EHRs.

Meaningful Use Criteria: What's Missing?

S ince the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in February 2009, there has been a tremendous amount of discussion about the idea of “meaningful use.” Associated with the meaningful use criteria are financial incentives for those who adopt an electronic health record and care for Medicare and Medicaid patients. Such incentives might total more than

Nontraditional Risk Factors in CHD Risk Assessment

40,000-

Lipid Screening in the Pediatric Population

60,000 per provider. Those who fail to meet the criteria will find their reimbursements reduced beginning in 2016. Despite the abundance of commentary and speculation over meaningful use, until recently the term had not actually been defined. And now that the full set of rules for meaningful use is available, it might surprise some to know what has actually been excluded from the criteria. In explaining the meaningful use concept at the beginning of this year, the U.S. Department of Health and Human Services laid out several objectives and priorities centered on improving the quality, safety, efficiency, and accessibility of care. Any aspects of electronic health record (EHR) implementation that do not meet those goals have been specifically left out of the criteria. In doing so, the intent is to challenge health care providers to move forward toward the goal of EHR implementation, while acknowledging the limitations of the technology currently available. The first and most fascinating exclusion is any requirement for encounter note generation. While most EHR products emphasize electronic note generation, the authors do not think this provides a significant benefit over handwritten charting in meeting the goals of HITECH (Federal Register 2010;75:18432010). Still, it might be difficult to implement an EHR without this piece, as once an office becomes dependent on the technology, workflow can be significantly hindered by searching for documentation that is not in the electronic record. To address this, some practices have chosen to scan in handwritten notes. Unfortunately, this might preclude critical data points from being captured by the system, and make it impossible to meet some of the quality reporting goals laid out elsewhere in HITECH. A second intentional omission in the criteria is the requirement that providers make educational resources available to patients. Although the authors admit that proper information and education are critical, they are reluctant to make this a necessity, saying “there is currently a paucity of knowledge resources that are integrated within EHRs, that are widely available, and that meet [our] criteria, particularly in multiple languages.” As it turns out, many EHR products do include integrated patient education resources, but these often are limited in quality and come at an additional fee. As an alternative, online resources available through Web sites such as familydoctor.org and emedicine.com provide numerous educational tools that are free and peer reviewed. Another anticipated requirement that’s been excluded from the criteria is the necessity for orders to be transmitted electronically from care provider to testing, diagnostic imaging, or treatment facilities. It should be noted that Computerized Physician Order Entry (CPOE) is greatly emphasized under HITECH, with the objective that 80% of orders be entered through the EHR. CPOE is defined as “the provider’s use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device.” But in the criteria released so far, the requirements “will not include the electronic transmittal of [those orders] to the pharmacy, laboratory, or diagnostic imaging center.” Seemingly contrary to this, the guidelines do require e-prescribing to meet criteria, so further clarification is needed to determine which orders must be sent electronically and which do not. A review of these exclusions makes it apparent that no one is completely sure how the meaningful use criteria will affect the day-to-day practice of medicine. But with the lofty goals of improving the quality and accessibility of care, the authors of the legislation have attempted to challenge the status quo and yet maintain a practical perspective on what is possible with the resources at hand. Many physicians will remain skeptical of any government intervention in health care but can at least now be assured that the financial incentives are attached to a fairly practical set of requirements. ■

ADA Standards of Care

C oronary heart disease is the leading cause of death in the United States. Numerous strategies exist for detection and treatment of asymptomatic persons at risk for CHD. Guides such as the ATP III and Framingham risk calculators consider factors including age, gender, blood pressure, total cholesterol, HDL level, and diabetes in determining an individual’s 10-year risk for a coronary event. Unfortunately, with traditional metrics, 31% of men and 7% of women (21 million people) are classified as intermediate risk for CHD (10%-20% risk over 10 years). Aggressive risk factor modification is clearly indicated for high-risk individuals and is definitely not indicated for low-risk individuals, but the decision regarding therapy in intermediate-risk persons is difficult given less-certain benefits to weigh against possible harms. The U.S. Preventive Services Task Force recently released guidelines evaluating the utility of nine nontraditional risk factors in CHD assessment. High-sensitivity C-reactive protein Of the tests evaluated by the USPSTF, hs-CRP is the most clinically promising. An elevated hs-CRP (greater than 3.0 mg/L) conveys a relative risk of 1.58 for CHD events. In addition, hs-CRP can reclassify intermediate-CHD-risk individuals, with 11% of men elevated to high risk and 12% of men dropped to low risk. No such reclassification was possible for intermediate-risk women. Statin studies in patients with normal LDL cholesterol and elevated hs-CRP show benefit, but it is unclear whether this the result of lowered hs-CRP or other statin effects. Therefore, hs-CRP remains a promising tool without a sufficient evidence base for USPSTF recommendation. Ankle-brachial index ABI, the ratio of dorsalis pedis to right brachial artery systolic blood pressure, is a marker of peripheral vascular disease (PVD), itself a high-risk CHD equivalent. Though 10% of females at intermediate risk for CHD can be increased to high risk based on a low ABI (< 0.9), no clinical outcome differences were noted related to this reclassification, leading the USPSTF to reject the use of ABI in establishing CHD risk. Leukocyte count The USPSTF found no relationship between elevated leukocyte count and CHD events. Furthermore, the clinical utility of any link would be limited by the lack of specific interventions to lower leukocyte level. Fasting blood glucose In nondiabetic patients, impaired fasting glucose (100-125 mg/dL) is a weak predictor of CHD risk. Only 1 of 10 studies evaluated by the USPSTF found even a weak association between elevated fasting blood glucose and CHD risk in nondiabetics. Glucose testing in nondiabetics, therefore, is not indicated in evaluating CHD risk. Periodontal disease Periodontal disease – including gingivitis, periodontitis, tooth loss, and bony loss – is a weak independent risk factor for CHD, likely due to chronic inflammation. The CHD relative risk of the various oral diseases ranges from 1.24 for periodontitis to 1.34 for significant tooth loss. However, largely because of the heterogeneity of periodontal disease processes, difficulty with classification schemes, and unclear evidence of treatment effect, the USPSTF does not recommend routine preventive or therapeutic dental care for reducing CHD events. Carotid intima-media thickness Carotid IMT is an independent CHD risk factor and can modestly improve the predictive value of traditional risk assessments. However, severe methodologic limitations prevent the USPSTF from recommending carotid IMT for CHD risk assessment. Most carotid IMT studies are in the research setting, leaving the accuracy of clinical measurements unknown. Furthermore, no evidence exists for a treatment effect of lowering carotid IMT or using carotid IMT for risk restratification. Carotid IMT, therefore, has a limited role in CHD risk prediction. Coronary artery calcification score CAC score has only poor to fair evidence as an independent marker for CHD risk, based on studies with poor methodologic quality. Furthermore, the clinical utility of CAC score is limited by unclear effects of treatment in lowering CHD risk, as well as the radiation exposure involved in measuring the score. Homocysteine There is conflicting evidence linking homocysteine levels to increased CHD risk, with some studies reporting a relative risk of 1.21 for each 5 mol/L increase. No attempt was made to risk stratify patients based on homocysteine levels with or without Framingham risk data. Studies evaluating folate, the treatment for elevated homocysteine levels in patients with known CHD, did not show prevention benefit, and studies for primary prevention using folate have not been performed. Lipoprotein(a) Evidence exists for lipoprotein(a) as an independent risk factor for CHD, but no stratification of intermediate-risk patients was performed. Furthermore, the treatment effect of lowering elevated lipoprotein(a) is unclear independent of lowering LDL.

Restless Legs Syndrome

A 75% of children who have total cholesterol levels above the 90th percentile continue to have total cholesterol levels higher than 200 mg/dL when they are in their early twenties. Currently, about 12% of children in the United States have total cholesterol levels above 200 mg/dL. The American Academy of Pediatrics has issued guidelines for the screening and management of childhood lipids (Pediatrics 2008;122:198-208). There are two approaches to decreasing pediatric cholesterol levels. In the population approach, dietary changes are not recommended for children younger than 2 years of age because they may need more fat in their diet for normal growth and development. For children older than age 2 years, a “prudent” low-fat diet is recommended, with an increase in the intake of fruits, vegetables, and fish and a commensurate decrease in the intake of fruit juices, high-salt foods, and sweetened sodas and foods. In addition, the importance of exercise and the achievement of appropriate body weight should be emphasized. The individual approach involves screening for increased lipid levels in defined high-risk populations, and then deciding on treatment based on the individual’s risk of developing cardiovascular disease (CVD).