Mary Ellen Schneider

With President Obama’s reelection and Democrats retaining their control of the U.S. Senate, the Affordable Care Act appears to be on firm footing.

But Americans are still very much divided over the law. In a Kaiser Family Foundation poll taken a week before the general election, 38% of likely voters favored the Affordable Care Act (ACA), and 43% opposed it, with the remainder undecided. That division was evident on Election Day when voters in three states – Alabama, Montana, and Wyoming – voted to nullify the federal insurance mandate in the health law. A similar measure was on the ballot in Florida, but was rejected by voters.

While the language differed slightly, voters in Alabama, Montana, and Wyoming approved ballot measures amending their state constitutions to effectively bar the government from requiring individuals or employers to obtain or provide health insurance coverage.

This is not a new trend. In 2010, voters in Arizona, Missouri, and Oklahoma approved ballot measures rejecting the ACA’s individual insurance mandate. And in 2011, Ohio joined that list.

But the ballot measures are only symbolic victories for opponents of the 2010 health law. States don’t have the legal authority to supercede federal law. The only way to invalidate the individual insurance mandate would be through the passage of federal legislation or a court challenge. And the U.S. Supreme Court upheld the constitutionality of the insurance mandate earlier this year.

Another element of the ACA – health insurance exchanges – was also on the general election ballot. Voters in Missouri approved Proposition E, which amends the state’s constitution to bar the creation of a health insurance exchange except through legislation, a ballot initiative, or a veto referendum. The measure, which was approved by more than 60% of voters in the state, seeks to block the governor from setting up an exchange. That measure too is also largely symbolic since under the ACA the federal government is required to create and operate an exchange if a state fails to do so on its own.

Other issues were addressed via ballot initiative in the recent election. In Massachusetts, voters made it legal to use marijuana for medical reasons, but narrowly rejected a proposal that would have legalized physician-assisted suicide for certain terminally ill patients.

Abortion was another hot topic this year. Florida voters rejected a proposed constitutional amendment that would have barred the use of public funds to pay for abortions or for health insurance that included coverage of abortion.

In Montana, voters approved a parental notification measure for minors seeking abortions. Under the ballot measure, physicians would be barred from performing an abortion on a girl under age 16 unless they notify a parent or legal guardian at least 48 hours prior to the procedure. Notice is not required in medical emergencies or when waived by a court.

With President Obama’s reelection and Democrats retaining their control of the U.S. Senate, the Affordable Care Act appears to be on firm footing.

But Americans are still very much divided over the law. In a Kaiser Family Foundation poll taken a week before the general election, 38% of likely voters favored the Affordable Care Act (ACA), and 43% opposed it, with the remainder undecided. That division was evident on Election Day when voters in three states – Alabama, Montana, and Wyoming – voted to nullify the federal insurance mandate in the health law. A similar measure was on the ballot in Florida, but was rejected by voters.

While the language differed slightly, voters in Alabama, Montana, and Wyoming approved ballot measures amending their state constitutions to effectively bar the government from requiring individuals or employers to obtain or provide health insurance coverage.

This is not a new trend. In 2010, voters in Arizona, Missouri, and Oklahoma approved ballot measures rejecting the ACA’s individual insurance mandate. And in 2011, Ohio joined that list.

But the ballot measures are only symbolic victories for opponents of the 2010 health law. States don’t have the legal authority to supercede federal law. The only way to invalidate the individual insurance mandate would be through the passage of federal legislation or a court challenge. And the U.S. Supreme Court upheld the constitutionality of the insurance mandate earlier this year.

Another element of the ACA – health insurance exchanges – was also on the general election ballot. Voters in Missouri approved Proposition E, which amends the state’s constitution to bar the creation of a health insurance exchange except through legislation, a ballot initiative, or a veto referendum. The measure, which was approved by more than 60% of voters in the state, seeks to block the governor from setting up an exchange. That measure too is also largely symbolic since under the ACA the federal government is required to create and operate an exchange if a state fails to do so on its own.

Other issues were addressed via ballot initiative in the recent election. In Massachusetts, voters made it legal to use marijuana for medical reasons, but narrowly rejected a proposal that would have legalized physician-assisted suicide for certain terminally ill patients.

Abortion was another hot topic this year. Florida voters rejected a proposed constitutional amendment that would have barred the use of public funds to pay for abortions or for health insurance that included coverage of abortion.

In Montana, voters approved a parental notification measure for minors seeking abortions. Under the ballot measure, physicians would be barred from performing an abortion on a girl under age 16 unless they notify a parent or legal guardian at least 48 hours prior to the procedure. Notice is not required in medical emergencies or when waived by a court.

With President Obama’s reelection and Democrats retaining their control of the U.S. Senate, the Affordable Care Act appears to be on firm footing.

But Americans are still very much divided over the law. In a Kaiser Family Foundation poll taken a week before the general election, 38% of likely voters favored the Affordable Care Act (ACA), and 43% opposed it, with the remainder undecided. That division was evident on Election Day when voters in three states – Alabama, Montana, and Wyoming – voted to nullify the federal insurance mandate in the health law. A similar measure was on the ballot in Florida, but was rejected by voters.

While the language differed slightly, voters in Alabama, Montana, and Wyoming approved ballot measures amending their state constitutions to effectively bar the government from requiring individuals or employers to obtain or provide health insurance coverage.

This is not a new trend. In 2010, voters in Arizona, Missouri, and Oklahoma approved ballot measures rejecting the ACA’s individual insurance mandate. And in 2011, Ohio joined that list.

But the ballot measures are only symbolic victories for opponents of the 2010 health law. States don’t have the legal authority to supercede federal law. The only way to invalidate the individual insurance mandate would be through the passage of federal legislation or a court challenge. And the U.S. Supreme Court upheld the constitutionality of the insurance mandate earlier this year.

Another element of the ACA – health insurance exchanges – was also on the general election ballot. Voters in Missouri approved Proposition E, which amends the state’s constitution to bar the creation of a health insurance exchange except through legislation, a ballot initiative, or a veto referendum. The measure, which was approved by more than 60% of voters in the state, seeks to block the governor from setting up an exchange. That measure too is also largely symbolic since under the ACA the federal government is required to create and operate an exchange if a state fails to do so on its own.

Other issues were addressed via ballot initiative in the recent election. In Massachusetts, voters made it legal to use marijuana for medical reasons, but narrowly rejected a proposal that would have legalized physician-assisted suicide for certain terminally ill patients.

Abortion was another hot topic this year. Florida voters rejected a proposed constitutional amendment that would have barred the use of public funds to pay for abortions or for health insurance that included coverage of abortion.

In Montana, voters approved a parental notification measure for minors seeking abortions. Under the ballot measure, physicians would be barred from performing an abortion on a girl under age 16 unless they notify a parent or legal guardian at least 48 hours prior to the procedure. Notice is not required in medical emergencies or when waived by a court.

The drugmaker Sanofi is cutting the price of its new colorectal cancer drug Zaltrap in half after physicians balked at the $11,000-a-month price tag.

Sanofi has not released official documentation detailing the specifics of the change, but in recent conversations with oncology experts, company officials laid out a plan to offer a 50% discount to anyone who purchases ziv-aflibercept (Zaltrap) from them on the wholesale market.

The move follows a New York Times op-ed column in which Dr. Leonard B. Saltz, chief of the gastrointestinal oncology service at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, and two colleagues announced that they would not use Zaltrap because of its high price. He said in an interview that there are some lingering questions about the newly announced price reduction.

Discount vs. Price Reduction

For instance, he expressed concern that the 50% discount given to physicians and hospitals may not translate into a reduction in either Medicare reimbursement or copayments for patients, both of which are tied to the wholesale acquisition cost (WAC) of the drug.

Another problem with offering a discount without changing the official price of the drug is that this could inadvertently create a financial inducement for providers to choose that drug, Dr. Saltz said. If the providers are getting a 50% discount but are still being reimbursed at the full price, they would make a significant profit for using Zaltrap.

Dr. Saltz said he and his colleagues at Memorial Sloan-Kettering raised these issues with Sanofi officials but didn’t get an immediate response.

The Oncology Report contacted Sanofi about the Zaltrap price reduction, but company officials declined to comment.

‘A Good Thing for Patients’

Dr. Roy Beveridge, chief medical officer for the US Oncology Network, supported by McKesson Specialty Health, said in an interview that he’s confident that Sanofi made the price reduction in a way that will benefit patients and payers eventually. And he applauded the company’s unprecedented move to slash the price.

"It’s a good thing for patients," Dr. Beveridge said. "It’s a good thing for the system."

At the 1,000-plus physician US Oncology Network, oncologists consider efficacy, toxicity, and price when making determinations about which drugs are placed on its Level I Pathways. If something is more effective, it’s the first choice on the treatment pathway, Dr. Beveridge said. But if treatments are comparable in terms of efficacy and toxicity, then cost is a major consideration.

"We, as oncologists, recognize that increases of 15% per year are just not sustainable," he said.

With Sanofi’s decision to drop the price, Dr. Beveridge said he thinks more companies will be under pressure not to debut drugs with sky-high prices if they don’t offer significant new benefits.

"For those companies that have true innovative products and have something which is completely different and better, you’ll still see cost pressure going up," he said. "But for those that have results that are more comparable to other treatments, there’s going to be huge price pressure to be equal or lower than others."

Zaltrap Compared With Avastin

In October, Dr. Saltz, along with two other physicians at Memorial Sloan-Kettering, penned the op-ed in the New York Times saying that they had decided not to give Zaltrap to their patients because the drug did not provide greater efficacy than Genentech’s bevacizumab (Avastin), which sells for about $5,000 a month or less than half the cost of Zaltrap.

It was a relatively easy decision to make, said Dr. Saltz, who has been a paid consultant for Genentech and an unpaid consultant to Sanofi this year. They found no evidence that Zaltrap offered any benefit over Avastin, which they could get for about half the price. But Dr. Saltz said there needs to be more discussion in the United States about what to do in those more complicated cases where drugs offer fractionally more benefit at substantially increased prices.

There’s been a sense in the country that everything in health care is so important that it’s wrong to discuss costs, Dr. Saltz said, but that attitude has to change.

"We can’t afford that," he said. "It’s a fantasy and it’s untrue. We can’t just say that because we’re talking about health care, money is no object."

The drugmaker Sanofi is cutting the price of its new colorectal cancer drug Zaltrap in half after physicians balked at the $11,000-a-month price tag.

Sanofi has not released official documentation detailing the specifics of the change, but in recent conversations with oncology experts, company officials laid out a plan to offer a 50% discount to anyone who purchases ziv-aflibercept (Zaltrap) from them on the wholesale market.

The move follows a New York Times op-ed column in which Dr. Leonard B. Saltz, chief of the gastrointestinal oncology service at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, and two colleagues announced that they would not use Zaltrap because of its high price. He said in an interview that there are some lingering questions about the newly announced price reduction.

Discount vs. Price Reduction

For instance, he expressed concern that the 50% discount given to physicians and hospitals may not translate into a reduction in either Medicare reimbursement or copayments for patients, both of which are tied to the wholesale acquisition cost (WAC) of the drug.

Another problem with offering a discount without changing the official price of the drug is that this could inadvertently create a financial inducement for providers to choose that drug, Dr. Saltz said. If the providers are getting a 50% discount but are still being reimbursed at the full price, they would make a significant profit for using Zaltrap.

Dr. Saltz said he and his colleagues at Memorial Sloan-Kettering raised these issues with Sanofi officials but didn’t get an immediate response.

The Oncology Report contacted Sanofi about the Zaltrap price reduction, but company officials declined to comment.

‘A Good Thing for Patients’

Dr. Roy Beveridge, chief medical officer for the US Oncology Network, supported by McKesson Specialty Health, said in an interview that he’s confident that Sanofi made the price reduction in a way that will benefit patients and payers eventually. And he applauded the company’s unprecedented move to slash the price.

"It’s a good thing for patients," Dr. Beveridge said. "It’s a good thing for the system."

At the 1,000-plus physician US Oncology Network, oncologists consider efficacy, toxicity, and price when making determinations about which drugs are placed on its Level I Pathways. If something is more effective, it’s the first choice on the treatment pathway, Dr. Beveridge said. But if treatments are comparable in terms of efficacy and toxicity, then cost is a major consideration.

"We, as oncologists, recognize that increases of 15% per year are just not sustainable," he said.

With Sanofi’s decision to drop the price, Dr. Beveridge said he thinks more companies will be under pressure not to debut drugs with sky-high prices if they don’t offer significant new benefits.

"For those companies that have true innovative products and have something which is completely different and better, you’ll still see cost pressure going up," he said. "But for those that have results that are more comparable to other treatments, there’s going to be huge price pressure to be equal or lower than others."

Zaltrap Compared With Avastin

In October, Dr. Saltz, along with two other physicians at Memorial Sloan-Kettering, penned the op-ed in the New York Times saying that they had decided not to give Zaltrap to their patients because the drug did not provide greater efficacy than Genentech’s bevacizumab (Avastin), which sells for about $5,000 a month or less than half the cost of Zaltrap.

It was a relatively easy decision to make, said Dr. Saltz, who has been a paid consultant for Genentech and an unpaid consultant to Sanofi this year. They found no evidence that Zaltrap offered any benefit over Avastin, which they could get for about half the price. But Dr. Saltz said there needs to be more discussion in the United States about what to do in those more complicated cases where drugs offer fractionally more benefit at substantially increased prices.

There’s been a sense in the country that everything in health care is so important that it’s wrong to discuss costs, Dr. Saltz said, but that attitude has to change.

"We can’t afford that," he said. "It’s a fantasy and it’s untrue. We can’t just say that because we’re talking about health care, money is no object."

The drugmaker Sanofi is cutting the price of its new colorectal cancer drug Zaltrap in half after physicians balked at the $11,000-a-month price tag.

Sanofi has not released official documentation detailing the specifics of the change, but in recent conversations with oncology experts, company officials laid out a plan to offer a 50% discount to anyone who purchases ziv-aflibercept (Zaltrap) from them on the wholesale market.

The move follows a New York Times op-ed column in which Dr. Leonard B. Saltz, chief of the gastrointestinal oncology service at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, and two colleagues announced that they would not use Zaltrap because of its high price. He said in an interview that there are some lingering questions about the newly announced price reduction.

Discount vs. Price Reduction

For instance, he expressed concern that the 50% discount given to physicians and hospitals may not translate into a reduction in either Medicare reimbursement or copayments for patients, both of which are tied to the wholesale acquisition cost (WAC) of the drug.

Another problem with offering a discount without changing the official price of the drug is that this could inadvertently create a financial inducement for providers to choose that drug, Dr. Saltz said. If the providers are getting a 50% discount but are still being reimbursed at the full price, they would make a significant profit for using Zaltrap.

Dr. Saltz said he and his colleagues at Memorial Sloan-Kettering raised these issues with Sanofi officials but didn’t get an immediate response.

The Oncology Report contacted Sanofi about the Zaltrap price reduction, but company officials declined to comment.

‘A Good Thing for Patients’

Dr. Roy Beveridge, chief medical officer for the US Oncology Network, supported by McKesson Specialty Health, said in an interview that he’s confident that Sanofi made the price reduction in a way that will benefit patients and payers eventually. And he applauded the company’s unprecedented move to slash the price.

"It’s a good thing for patients," Dr. Beveridge said. "It’s a good thing for the system."

At the 1,000-plus physician US Oncology Network, oncologists consider efficacy, toxicity, and price when making determinations about which drugs are placed on its Level I Pathways. If something is more effective, it’s the first choice on the treatment pathway, Dr. Beveridge said. But if treatments are comparable in terms of efficacy and toxicity, then cost is a major consideration.

"We, as oncologists, recognize that increases of 15% per year are just not sustainable," he said.

With Sanofi’s decision to drop the price, Dr. Beveridge said he thinks more companies will be under pressure not to debut drugs with sky-high prices if they don’t offer significant new benefits.

"For those companies that have true innovative products and have something which is completely different and better, you’ll still see cost pressure going up," he said. "But for those that have results that are more comparable to other treatments, there’s going to be huge price pressure to be equal or lower than others."

Zaltrap Compared With Avastin

In October, Dr. Saltz, along with two other physicians at Memorial Sloan-Kettering, penned the op-ed in the New York Times saying that they had decided not to give Zaltrap to their patients because the drug did not provide greater efficacy than Genentech’s bevacizumab (Avastin), which sells for about $5,000 a month or less than half the cost of Zaltrap.

It was a relatively easy decision to make, said Dr. Saltz, who has been a paid consultant for Genentech and an unpaid consultant to Sanofi this year. They found no evidence that Zaltrap offered any benefit over Avastin, which they could get for about half the price. But Dr. Saltz said there needs to be more discussion in the United States about what to do in those more complicated cases where drugs offer fractionally more benefit at substantially increased prices.

There’s been a sense in the country that everything in health care is so important that it’s wrong to discuss costs, Dr. Saltz said, but that attitude has to change.

"We can’t afford that," he said. "It’s a fantasy and it’s untrue. We can’t just say that because we’re talking about health care, money is no object."

Over the next several months, the Accreditation Council for Graduate Medical Education is scheduled to consider a proposal that would decrease the amount of time that child neurology residents spend on inpatient adult neurology training.

The proposal is currently being considered by the ACGME’s Neurology Residency Review Committee and could move to the Committee on Requirements next year.

Currently, residents spend 12 months in adult neurology training, with as much as 9 months working in an inpatient setting in some cases. The proposal would limit adult inpatient work to 6 months, and mandate that residents spend a certain amount of their adult training time working in outpatient clinics. The proposal would also offer more elective options for residents during the adult neurology year, giving them the chance to train in virtually any part of the specialty from neuroradiology to neuropathology.

If the ACGME approves the proposal in early 2013, the soonest it could go into effect would be July 2013, said Dr. Phillip L. Pearl, chief of neurology at Children’s National Medical Center in Washington and a member of the Neurology Residency Review Committee.

The proposal emerged in large part because of concerns that child neurology residents were spending too much of the adult training year functioning as interns on adult stroke services, Dr. Pearl said.

"I think we’ve come to agreement that we see the value of maintaining strong adult neurology training, but opening it up and diversifying it," said Dr. Pearl, who is also the president of the Professors of Child Neurology.

Keeping the year of adult neurology training intact is important, Dr. Pearl said, because it provides a foundation to create "child neurologists and not neurological pediatricians."

"Neurologists think differently than pediatricians," he said. "The child neurologist does need to be able to take care of strokes, and movement disorders, and multiple sclerosis in children, and be able to localize neurological deficits in children. The best way to learn that process is in adults, where the disorders and localizable deficits are much more common."

Maintaining the connection to adult neurology training is also critical because it allows child neurologists to remain boarded in both adult and child neurology, Dr. Pearl said.

But continuing with the full 12 months of training in adult neurology is controversial, even with the increased emphasis on outpatient work.

Courtesy Cincinnati Children's Hospital Medical Center

Dr. Donald L. Gilbert, the child neurology residency program director at Cincinnati Children’s Hospital Medical Center in Ohio, said the proposal under review by the Residency Review Committee is "inadequate." Instead, he wants to see the requirement for adult training reduced to 3 months, followed by an additional 3 months of electives.

"Flexibility is the way to go," he said.

The reasons for ratcheting down the adult requirement are practical, Dr. Gilbert said. Today’s child neurologist doesn’t see that many adult patients. Dr. Gilbert and his colleagues recently conducted a survey of 437 child neurologists who were certified between 2001 and 2010. Of the 179 who responded, only about 3% reported that they provided general adult neurology services in their practices. About two-thirds of those who responded said they provided no adult neurology services.

"We need to train people to take care of whom they are going to take care of," he said.

The other problem with requiring a full year of adult neurology training is that it takes time away from the child neurology side of training, Dr. Gilbert said.

"You miss getting to see those kids if you’re spending that time in the adult inpatient service managing strokes and high blood pressure, diabetes, and chronic lung disease from smoking," he said.

Dr. Keith R. Ridel, a child neurologist in private practice in Indianapolis, agrees that the requirement for 12 months of adult neurology is outdated.

"Everybody will agree that the adult training is helpful, but how much of that you apply to your practice is debatable," he said.

Dr. Ridel, who works in a large neurology practice, said about a quarter of his patients are adults aged 18-30 years. He estimates that even with such a large number of adult patients, he applies only about half of what he learned during his adult training year to his day-to-day practice.

But other leaders in the field said the adult training year has significant value in creating a foundation of analytical skills for the new neurologist.

Dr. Donna M. Ferriero, who is a neonatal neurologist, said what she learned in her adult neurology training helps her to elicit signs and symptoms in the newborn.

Dr. Ferriero, who chairs the department of pediatrics at the University of California, San Francisco, Benioff Children’s Hospital, said residents today probably don’t need a full year of adult neurology, but they do need to spend a substantial portion of that first year learning about adult neurologic diagnosis and treatment. That type of training could also be incorporated into elective rotations, provided the training spans the developmental spectrum from cradle to grave, she said.

"Fundamentally we’re neurologists and we need neurologic training," she said.

The adult neurology training year also helps residents to build their basic diagnostic skills on patients who are often less complex and more compliant before moving on to children, said Dr. Nina F. Schor, professor and chair of the department of pediatrics at the University of Rochester (N.Y.).

For example, a resident who tried to conduct her first mental status exam on a 3-month-old would likely have a much harder time than if she mastered her skills first on adults and then adapted the exam to make it developmentally and age appropriate, Dr. Schor said.

Dr. Scott Pomeroy, the chair of neurology at Boston Children’s Hospital, said the number of months of adult training is less important than the content. At Boston Children’s Hospital, they already limit residents’ adult inpatient time to 6 months. During the other 6 months, residents participate in an outpatient adult neurology rotation. That rotation gives the residents a fuller picture of adult neurology and knowledge that is applicable to pediatric patients, he said.

"The distinction between adult and pediatric neurology for some diseases is not as striking as it used to be," Dr. Pomeroy said. "We used to think of multiple sclerosis as an adult disease. We now know that’s not true. There’s lots of kids that have it."

Leaders in adult and child neurology need to work together to improve the curriculum, he said. Both adult and child neurology residents would benefit from greater knowledge about neurogenetics, for example.

"If cool minds sat down and hammered out some agreement, we could get out of this ‘how many months of adult neurology’ discussion and into the discussion of how can we jointly improve our training experience," Dr. Pomeroy said. "This other thing is a big distraction."

Over the next several months, the Accreditation Council for Graduate Medical Education is scheduled to consider a proposal that would decrease the amount of time that child neurology residents spend on inpatient adult neurology training.

The proposal is currently being considered by the ACGME’s Neurology Residency Review Committee and could move to the Committee on Requirements next year.

Currently, residents spend 12 months in adult neurology training, with as much as 9 months working in an inpatient setting in some cases. The proposal would limit adult inpatient work to 6 months, and mandate that residents spend a certain amount of their adult training time working in outpatient clinics. The proposal would also offer more elective options for residents during the adult neurology year, giving them the chance to train in virtually any part of the specialty from neuroradiology to neuropathology.

If the ACGME approves the proposal in early 2013, the soonest it could go into effect would be July 2013, said Dr. Phillip L. Pearl, chief of neurology at Children’s National Medical Center in Washington and a member of the Neurology Residency Review Committee.

The proposal emerged in large part because of concerns that child neurology residents were spending too much of the adult training year functioning as interns on adult stroke services, Dr. Pearl said.

"I think we’ve come to agreement that we see the value of maintaining strong adult neurology training, but opening it up and diversifying it," said Dr. Pearl, who is also the president of the Professors of Child Neurology.

Keeping the year of adult neurology training intact is important, Dr. Pearl said, because it provides a foundation to create "child neurologists and not neurological pediatricians."

"Neurologists think differently than pediatricians," he said. "The child neurologist does need to be able to take care of strokes, and movement disorders, and multiple sclerosis in children, and be able to localize neurological deficits in children. The best way to learn that process is in adults, where the disorders and localizable deficits are much more common."

Maintaining the connection to adult neurology training is also critical because it allows child neurologists to remain boarded in both adult and child neurology, Dr. Pearl said.

But continuing with the full 12 months of training in adult neurology is controversial, even with the increased emphasis on outpatient work.

Courtesy Cincinnati Children's Hospital Medical Center

Dr. Donald L. Gilbert, the child neurology residency program director at Cincinnati Children’s Hospital Medical Center in Ohio, said the proposal under review by the Residency Review Committee is "inadequate." Instead, he wants to see the requirement for adult training reduced to 3 months, followed by an additional 3 months of electives.

"Flexibility is the way to go," he said.

The reasons for ratcheting down the adult requirement are practical, Dr. Gilbert said. Today’s child neurologist doesn’t see that many adult patients. Dr. Gilbert and his colleagues recently conducted a survey of 437 child neurologists who were certified between 2001 and 2010. Of the 179 who responded, only about 3% reported that they provided general adult neurology services in their practices. About two-thirds of those who responded said they provided no adult neurology services.

"We need to train people to take care of whom they are going to take care of," he said.

The other problem with requiring a full year of adult neurology training is that it takes time away from the child neurology side of training, Dr. Gilbert said.

"You miss getting to see those kids if you’re spending that time in the adult inpatient service managing strokes and high blood pressure, diabetes, and chronic lung disease from smoking," he said.

Dr. Keith R. Ridel, a child neurologist in private practice in Indianapolis, agrees that the requirement for 12 months of adult neurology is outdated.

"Everybody will agree that the adult training is helpful, but how much of that you apply to your practice is debatable," he said.

Dr. Ridel, who works in a large neurology practice, said about a quarter of his patients are adults aged 18-30 years. He estimates that even with such a large number of adult patients, he applies only about half of what he learned during his adult training year to his day-to-day practice.

But other leaders in the field said the adult training year has significant value in creating a foundation of analytical skills for the new neurologist.

Dr. Donna M. Ferriero, who is a neonatal neurologist, said what she learned in her adult neurology training helps her to elicit signs and symptoms in the newborn.

Dr. Ferriero, who chairs the department of pediatrics at the University of California, San Francisco, Benioff Children’s Hospital, said residents today probably don’t need a full year of adult neurology, but they do need to spend a substantial portion of that first year learning about adult neurologic diagnosis and treatment. That type of training could also be incorporated into elective rotations, provided the training spans the developmental spectrum from cradle to grave, she said.

"Fundamentally we’re neurologists and we need neurologic training," she said.

The adult neurology training year also helps residents to build their basic diagnostic skills on patients who are often less complex and more compliant before moving on to children, said Dr. Nina F. Schor, professor and chair of the department of pediatrics at the University of Rochester (N.Y.).

For example, a resident who tried to conduct her first mental status exam on a 3-month-old would likely have a much harder time than if she mastered her skills first on adults and then adapted the exam to make it developmentally and age appropriate, Dr. Schor said.

Dr. Scott Pomeroy, the chair of neurology at Boston Children’s Hospital, said the number of months of adult training is less important than the content. At Boston Children’s Hospital, they already limit residents’ adult inpatient time to 6 months. During the other 6 months, residents participate in an outpatient adult neurology rotation. That rotation gives the residents a fuller picture of adult neurology and knowledge that is applicable to pediatric patients, he said.

"The distinction between adult and pediatric neurology for some diseases is not as striking as it used to be," Dr. Pomeroy said. "We used to think of multiple sclerosis as an adult disease. We now know that’s not true. There’s lots of kids that have it."

Leaders in adult and child neurology need to work together to improve the curriculum, he said. Both adult and child neurology residents would benefit from greater knowledge about neurogenetics, for example.

"If cool minds sat down and hammered out some agreement, we could get out of this ‘how many months of adult neurology’ discussion and into the discussion of how can we jointly improve our training experience," Dr. Pomeroy said. "This other thing is a big distraction."

Over the next several months, the Accreditation Council for Graduate Medical Education is scheduled to consider a proposal that would decrease the amount of time that child neurology residents spend on inpatient adult neurology training.

The proposal is currently being considered by the ACGME’s Neurology Residency Review Committee and could move to the Committee on Requirements next year.

Currently, residents spend 12 months in adult neurology training, with as much as 9 months working in an inpatient setting in some cases. The proposal would limit adult inpatient work to 6 months, and mandate that residents spend a certain amount of their adult training time working in outpatient clinics. The proposal would also offer more elective options for residents during the adult neurology year, giving them the chance to train in virtually any part of the specialty from neuroradiology to neuropathology.

If the ACGME approves the proposal in early 2013, the soonest it could go into effect would be July 2013, said Dr. Phillip L. Pearl, chief of neurology at Children’s National Medical Center in Washington and a member of the Neurology Residency Review Committee.

The proposal emerged in large part because of concerns that child neurology residents were spending too much of the adult training year functioning as interns on adult stroke services, Dr. Pearl said.

"I think we’ve come to agreement that we see the value of maintaining strong adult neurology training, but opening it up and diversifying it," said Dr. Pearl, who is also the president of the Professors of Child Neurology.

Keeping the year of adult neurology training intact is important, Dr. Pearl said, because it provides a foundation to create "child neurologists and not neurological pediatricians."

"Neurologists think differently than pediatricians," he said. "The child neurologist does need to be able to take care of strokes, and movement disorders, and multiple sclerosis in children, and be able to localize neurological deficits in children. The best way to learn that process is in adults, where the disorders and localizable deficits are much more common."

Maintaining the connection to adult neurology training is also critical because it allows child neurologists to remain boarded in both adult and child neurology, Dr. Pearl said.

But continuing with the full 12 months of training in adult neurology is controversial, even with the increased emphasis on outpatient work.

Courtesy Cincinnati Children's Hospital Medical Center

Dr. Donald L. Gilbert, the child neurology residency program director at Cincinnati Children’s Hospital Medical Center in Ohio, said the proposal under review by the Residency Review Committee is "inadequate." Instead, he wants to see the requirement for adult training reduced to 3 months, followed by an additional 3 months of electives.

"Flexibility is the way to go," he said.

The reasons for ratcheting down the adult requirement are practical, Dr. Gilbert said. Today’s child neurologist doesn’t see that many adult patients. Dr. Gilbert and his colleagues recently conducted a survey of 437 child neurologists who were certified between 2001 and 2010. Of the 179 who responded, only about 3% reported that they provided general adult neurology services in their practices. About two-thirds of those who responded said they provided no adult neurology services.

"We need to train people to take care of whom they are going to take care of," he said.

The other problem with requiring a full year of adult neurology training is that it takes time away from the child neurology side of training, Dr. Gilbert said.

"You miss getting to see those kids if you’re spending that time in the adult inpatient service managing strokes and high blood pressure, diabetes, and chronic lung disease from smoking," he said.

Dr. Keith R. Ridel, a child neurologist in private practice in Indianapolis, agrees that the requirement for 12 months of adult neurology is outdated.

"Everybody will agree that the adult training is helpful, but how much of that you apply to your practice is debatable," he said.

Dr. Ridel, who works in a large neurology practice, said about a quarter of his patients are adults aged 18-30 years. He estimates that even with such a large number of adult patients, he applies only about half of what he learned during his adult training year to his day-to-day practice.

But other leaders in the field said the adult training year has significant value in creating a foundation of analytical skills for the new neurologist.

Dr. Donna M. Ferriero, who is a neonatal neurologist, said what she learned in her adult neurology training helps her to elicit signs and symptoms in the newborn.

Dr. Ferriero, who chairs the department of pediatrics at the University of California, San Francisco, Benioff Children’s Hospital, said residents today probably don’t need a full year of adult neurology, but they do need to spend a substantial portion of that first year learning about adult neurologic diagnosis and treatment. That type of training could also be incorporated into elective rotations, provided the training spans the developmental spectrum from cradle to grave, she said.

"Fundamentally we’re neurologists and we need neurologic training," she said.

The adult neurology training year also helps residents to build their basic diagnostic skills on patients who are often less complex and more compliant before moving on to children, said Dr. Nina F. Schor, professor and chair of the department of pediatrics at the University of Rochester (N.Y.).

For example, a resident who tried to conduct her first mental status exam on a 3-month-old would likely have a much harder time than if she mastered her skills first on adults and then adapted the exam to make it developmentally and age appropriate, Dr. Schor said.

Dr. Scott Pomeroy, the chair of neurology at Boston Children’s Hospital, said the number of months of adult training is less important than the content. At Boston Children’s Hospital, they already limit residents’ adult inpatient time to 6 months. During the other 6 months, residents participate in an outpatient adult neurology rotation. That rotation gives the residents a fuller picture of adult neurology and knowledge that is applicable to pediatric patients, he said.

"The distinction between adult and pediatric neurology for some diseases is not as striking as it used to be," Dr. Pomeroy said. "We used to think of multiple sclerosis as an adult disease. We now know that’s not true. There’s lots of kids that have it."

Leaders in adult and child neurology need to work together to improve the curriculum, he said. Both adult and child neurology residents would benefit from greater knowledge about neurogenetics, for example.

"If cool minds sat down and hammered out some agreement, we could get out of this ‘how many months of adult neurology’ discussion and into the discussion of how can we jointly improve our training experience," Dr. Pomeroy said. "This other thing is a big distraction."

A coming, branded formulation of isotretinoin will offer compliance and efficacy advantages not previously available to U.S. dermatologists.

Absorica is a novel, patented brand formulation of isotretinoin marketed in the United States by Ranbaxy Pharmaceuticals Inc. *It will be available by the end of 2012 for the treatment of severe recalcitrant nodular acne.

The new drug, approved by the Food and Drug Administration in May, isn’t just another therapeutic option for dermatologists looking to treat acne – it’s a potential game changer in terms of improving efficacy and preventing relapse, according to Dr. Eric "Billy" Baum of the University of Alabama, Birmingham, who is a member of the speakers’ bureau for Ranbaxy.

Absorica is not rated as A-B equivalent to Accutane and the other isotretinoins, Dr. Baum said.

"I think that this is going to be a great advantage to dermatologists today," he said in an interview. "They’ll be able to have a type of isotretinoin that they know they are going to see really good results with. They are going to get the high blood levels that they need in order to get the maximum improvement, maximum absorption, and maximum efficacy."

Absorption is the key difference between how Absorica works and how other isotretinoins work, Dr. Baum explained at the meeting sponsored by Skin Disease Education Foundation. 

Isotretinoin is highly lipophilic and is a poorly solubilized molecule. As a result, patients don’t get the maximum benefit of the drug unless they take it with a high-fat meal, ideally about 50 grams of fat, according to Dr. Baum. That’s the equivalent of a breakfast of two fried eggs in butter, two strips of bacon, two slices of toast with butter, 4 ounces of hash brown potatoes, and 8 ounces of whole milk, he said. Since isotretinoin is taken twice daily, patients should also eat another high-fat meal at dinnertime, he said.

But most adolescent patients taking isotretinoin don’t eat that type of high-fat diet – in fact, about a third of adolescents don’t eat breakfast at all, he said.

With the traditional form of isotretinoin, only about 40% of the drug was absorbed when patients were fasting. In contrast, with Absorica nearly 70% is absorbed, Dr. Baum said. "There is now a greater likelihood for patients to achieve cumulative targeted doses of isotretinoin in the 20 weeks of treatment, thereby increasing success of treatment and lowering the risk of relapse."

The better absorption with Absorica is due to a patented drug delivery system, which delivers isotretinoin along with fatty molecules, optimizing absorption in the small intestine, Dr. Baum explained.

A phase III trial with more than 900 patients showed no statistical difference in efficacy at 20 weeks between Absorica and Accutane when patients have eaten a high-fat meal. "You get the results that were achieved with the original Accutane under fed conditions with less concern about what patients will actually eat," Dr. Baum said.

There was also no notable difference in psychiatric, gastrointestinal, vascular, cardiac, or ophthalmic side effects between the two formulations, Dr. Baum said, adding that like all isotretinoins, Absorica patients and prescribers are obligated to participate in the iPLEDGE risk management program.

"This is a medication that’s been very highly studied, the largest clinical study on isotretinoin ever completed," he said.

The better rate of absorption is this formulation’s big clinical advantage, which should result in fewer relapses, Dr. Baum said. That could also make the drug more cost effective, because it would cut down on subsequent treatments in the event of relapse.

"It is important to treat isotretinoin patients most effectively in one cycle, if possible," Dr. Baum said. "This is the time where the patient is most motivated and has the most family support to comply with the complicated instructions of isotretinoin and iPLEDGE."

SDEF and this news organization are owned by Frontline Medical Communications.

*CORRECTION (11/07/12): A previous version of this story incorrectly reported when Absorica will be available in the U.S. This version has been updated.

A coming, branded formulation of isotretinoin will offer compliance and efficacy advantages not previously available to U.S. dermatologists.

Absorica is a novel, patented brand formulation of isotretinoin marketed in the United States by Ranbaxy Pharmaceuticals Inc. *It will be available by the end of 2012 for the treatment of severe recalcitrant nodular acne.

The new drug, approved by the Food and Drug Administration in May, isn’t just another therapeutic option for dermatologists looking to treat acne – it’s a potential game changer in terms of improving efficacy and preventing relapse, according to Dr. Eric "Billy" Baum of the University of Alabama, Birmingham, who is a member of the speakers’ bureau for Ranbaxy.

Absorica is not rated as A-B equivalent to Accutane and the other isotretinoins, Dr. Baum said.

"I think that this is going to be a great advantage to dermatologists today," he said in an interview. "They’ll be able to have a type of isotretinoin that they know they are going to see really good results with. They are going to get the high blood levels that they need in order to get the maximum improvement, maximum absorption, and maximum efficacy."

Absorption is the key difference between how Absorica works and how other isotretinoins work, Dr. Baum explained at the meeting sponsored by Skin Disease Education Foundation. 

Isotretinoin is highly lipophilic and is a poorly solubilized molecule. As a result, patients don’t get the maximum benefit of the drug unless they take it with a high-fat meal, ideally about 50 grams of fat, according to Dr. Baum. That’s the equivalent of a breakfast of two fried eggs in butter, two strips of bacon, two slices of toast with butter, 4 ounces of hash brown potatoes, and 8 ounces of whole milk, he said. Since isotretinoin is taken twice daily, patients should also eat another high-fat meal at dinnertime, he said.

But most adolescent patients taking isotretinoin don’t eat that type of high-fat diet – in fact, about a third of adolescents don’t eat breakfast at all, he said.

With the traditional form of isotretinoin, only about 40% of the drug was absorbed when patients were fasting. In contrast, with Absorica nearly 70% is absorbed, Dr. Baum said. "There is now a greater likelihood for patients to achieve cumulative targeted doses of isotretinoin in the 20 weeks of treatment, thereby increasing success of treatment and lowering the risk of relapse."

The better absorption with Absorica is due to a patented drug delivery system, which delivers isotretinoin along with fatty molecules, optimizing absorption in the small intestine, Dr. Baum explained.

A phase III trial with more than 900 patients showed no statistical difference in efficacy at 20 weeks between Absorica and Accutane when patients have eaten a high-fat meal. "You get the results that were achieved with the original Accutane under fed conditions with less concern about what patients will actually eat," Dr. Baum said.

There was also no notable difference in psychiatric, gastrointestinal, vascular, cardiac, or ophthalmic side effects between the two formulations, Dr. Baum said, adding that like all isotretinoins, Absorica patients and prescribers are obligated to participate in the iPLEDGE risk management program.

"This is a medication that’s been very highly studied, the largest clinical study on isotretinoin ever completed," he said.

The better rate of absorption is this formulation’s big clinical advantage, which should result in fewer relapses, Dr. Baum said. That could also make the drug more cost effective, because it would cut down on subsequent treatments in the event of relapse.

"It is important to treat isotretinoin patients most effectively in one cycle, if possible," Dr. Baum said. "This is the time where the patient is most motivated and has the most family support to comply with the complicated instructions of isotretinoin and iPLEDGE."

SDEF and this news organization are owned by Frontline Medical Communications.

*CORRECTION (11/07/12): A previous version of this story incorrectly reported when Absorica will be available in the U.S. This version has been updated.

A coming, branded formulation of isotretinoin will offer compliance and efficacy advantages not previously available to U.S. dermatologists.

Absorica is a novel, patented brand formulation of isotretinoin marketed in the United States by Ranbaxy Pharmaceuticals Inc. *It will be available by the end of 2012 for the treatment of severe recalcitrant nodular acne.

The new drug, approved by the Food and Drug Administration in May, isn’t just another therapeutic option for dermatologists looking to treat acne – it’s a potential game changer in terms of improving efficacy and preventing relapse, according to Dr. Eric "Billy" Baum of the University of Alabama, Birmingham, who is a member of the speakers’ bureau for Ranbaxy.

Absorica is not rated as A-B equivalent to Accutane and the other isotretinoins, Dr. Baum said.

"I think that this is going to be a great advantage to dermatologists today," he said in an interview. "They’ll be able to have a type of isotretinoin that they know they are going to see really good results with. They are going to get the high blood levels that they need in order to get the maximum improvement, maximum absorption, and maximum efficacy."

Absorption is the key difference between how Absorica works and how other isotretinoins work, Dr. Baum explained at the meeting sponsored by Skin Disease Education Foundation. 

Isotretinoin is highly lipophilic and is a poorly solubilized molecule. As a result, patients don’t get the maximum benefit of the drug unless they take it with a high-fat meal, ideally about 50 grams of fat, according to Dr. Baum. That’s the equivalent of a breakfast of two fried eggs in butter, two strips of bacon, two slices of toast with butter, 4 ounces of hash brown potatoes, and 8 ounces of whole milk, he said. Since isotretinoin is taken twice daily, patients should also eat another high-fat meal at dinnertime, he said.

But most adolescent patients taking isotretinoin don’t eat that type of high-fat diet – in fact, about a third of adolescents don’t eat breakfast at all, he said.

With the traditional form of isotretinoin, only about 40% of the drug was absorbed when patients were fasting. In contrast, with Absorica nearly 70% is absorbed, Dr. Baum said. "There is now a greater likelihood for patients to achieve cumulative targeted doses of isotretinoin in the 20 weeks of treatment, thereby increasing success of treatment and lowering the risk of relapse."

The better absorption with Absorica is due to a patented drug delivery system, which delivers isotretinoin along with fatty molecules, optimizing absorption in the small intestine, Dr. Baum explained.

A phase III trial with more than 900 patients showed no statistical difference in efficacy at 20 weeks between Absorica and Accutane when patients have eaten a high-fat meal. "You get the results that were achieved with the original Accutane under fed conditions with less concern about what patients will actually eat," Dr. Baum said.

There was also no notable difference in psychiatric, gastrointestinal, vascular, cardiac, or ophthalmic side effects between the two formulations, Dr. Baum said, adding that like all isotretinoins, Absorica patients and prescribers are obligated to participate in the iPLEDGE risk management program.

"This is a medication that’s been very highly studied, the largest clinical study on isotretinoin ever completed," he said.

The better rate of absorption is this formulation’s big clinical advantage, which should result in fewer relapses, Dr. Baum said. That could also make the drug more cost effective, because it would cut down on subsequent treatments in the event of relapse.

"It is important to treat isotretinoin patients most effectively in one cycle, if possible," Dr. Baum said. "This is the time where the patient is most motivated and has the most family support to comply with the complicated instructions of isotretinoin and iPLEDGE."

SDEF and this news organization are owned by Frontline Medical Communications.

*CORRECTION (11/07/12): A previous version of this story incorrectly reported when Absorica will be available in the U.S. This version has been updated.

A series of inspections conducted in October at the New England Compounding Center – the facility at the heart of the investigation into a recent fungal meningitis outbreak – found nonsterile conditions and contaminated vials of the steroid methylprednisolone acetate.

Investigators with the Food and Drug Administration’s New England District Office visited the New England Compounding Center (NECC) facility in Framingham, Mass., during 7 days in October. The FDA released the observations from those inspections on Oct. 26.

On Oct. 2, the FDA investigators noticed what appeared to be "greenish-black foreign matter" in 83 vials of methylprednisolone acetate and "white filamentous material" among another 17 vials from the same bin. The vials were marked with the same lot number as a shipment that was sent to customers in August and September. Although a sample taken by the company in August found that lot of vials to be to be sterile, the FDA’s own laboratory analysis found the presence of viable microbial growth in 50 of the 50 unopened vials it tested.

The investigators also discovered problems in the NECC’s clean rooms, which are enclosed spaces used to help reduce the risk of microbial contamination when processing sterile drug products. For instance, the firm’s own environmental monitoring reports revealed that between January and September 2012, there was bacteria and mold in multiple locations, including on surfaces within the clean rooms. There was no documentation that the company attempted to correct these problem, even though the contamination was above acceptable limits, according to the FDA.

FDA officials refused to characterize the observations made by its investigators or to comment on any other details of the agency’s ongoing investigation of the NECC.

A series of inspections conducted in October at the New England Compounding Center – the facility at the heart of the investigation into a recent fungal meningitis outbreak – found nonsterile conditions and contaminated vials of the steroid methylprednisolone acetate.

Investigators with the Food and Drug Administration’s New England District Office visited the New England Compounding Center (NECC) facility in Framingham, Mass., during 7 days in October. The FDA released the observations from those inspections on Oct. 26.

On Oct. 2, the FDA investigators noticed what appeared to be "greenish-black foreign matter" in 83 vials of methylprednisolone acetate and "white filamentous material" among another 17 vials from the same bin. The vials were marked with the same lot number as a shipment that was sent to customers in August and September. Although a sample taken by the company in August found that lot of vials to be to be sterile, the FDA’s own laboratory analysis found the presence of viable microbial growth in 50 of the 50 unopened vials it tested.

The investigators also discovered problems in the NECC’s clean rooms, which are enclosed spaces used to help reduce the risk of microbial contamination when processing sterile drug products. For instance, the firm’s own environmental monitoring reports revealed that between January and September 2012, there was bacteria and mold in multiple locations, including on surfaces within the clean rooms. There was no documentation that the company attempted to correct these problem, even though the contamination was above acceptable limits, according to the FDA.

FDA officials refused to characterize the observations made by its investigators or to comment on any other details of the agency’s ongoing investigation of the NECC.

A series of inspections conducted in October at the New England Compounding Center – the facility at the heart of the investigation into a recent fungal meningitis outbreak – found nonsterile conditions and contaminated vials of the steroid methylprednisolone acetate.

Investigators with the Food and Drug Administration’s New England District Office visited the New England Compounding Center (NECC) facility in Framingham, Mass., during 7 days in October. The FDA released the observations from those inspections on Oct. 26.

On Oct. 2, the FDA investigators noticed what appeared to be "greenish-black foreign matter" in 83 vials of methylprednisolone acetate and "white filamentous material" among another 17 vials from the same bin. The vials were marked with the same lot number as a shipment that was sent to customers in August and September. Although a sample taken by the company in August found that lot of vials to be to be sterile, the FDA’s own laboratory analysis found the presence of viable microbial growth in 50 of the 50 unopened vials it tested.

The investigators also discovered problems in the NECC’s clean rooms, which are enclosed spaces used to help reduce the risk of microbial contamination when processing sterile drug products. For instance, the firm’s own environmental monitoring reports revealed that between January and September 2012, there was bacteria and mold in multiple locations, including on surfaces within the clean rooms. There was no documentation that the company attempted to correct these problem, even though the contamination was above acceptable limits, according to the FDA.

FDA officials refused to characterize the observations made by its investigators or to comment on any other details of the agency’s ongoing investigation of the NECC.

When Dr. Alexander Carbo joined the faculty at Beth Israel Deaconess Medical Center in Boston in 2001, straight out of his residency, he rushed to become a member of the department of medicine’s quality improvement committee. Little over a decade later, Dr. Carbo leads that committee. He has also helped continue the success of BIDMC’s Stoneman Patient Safety Rotation, which serves as a kind of patient safety boot camp for residents.

In an interview with Hospitalist News, Dr. Carbo discussed the importance of engaging front-line clinicians in quality improvement projects and why residents and staff need training on how to improve patient safety.

Question: You’ve said that engaging front-line providers is critical for quality improvement. Why?

Dr. Carbo: We have to have a culture of safety. The only way that we can actually make improvements is if somebody knows that improvements are needed. If people don’t call things out, there is no way to fix them. It’s key for people to be able to call things out and to do that in a way that is nonthreatening. We try to make it clear here, we’re not here to look at individuals. We’re not here to get anybody in trouble. We’re here to figure out if there’s either an adverse event with or without error or an error with or without an adverse event. What happened? And how can we prevent this from happening in the future. We just need to have people call things out. I think most of our folks do more than that, but that’s where you have to start. That is the key component. Once people call things out, the next step is actually having them try to solve the problem.

Question: You are the attending preceptor for the Stoneman Patient Safety Rotation at BIDMC. What are your residents exposed to during this rotation?

Dr. Carbo: This rotation was started a decade ago by Dr. Kenneth Sands, who is our senior vice president of healthcare quality, and organized by Dr. Anjala Tess, who is a hospitalist and one of my colleagues here. The two of them – and several others – started this rotation and we’ve now put through several hundred residents. It is a mandatory patient safety rotation for all BIDMC residents. They go through a didactic component, a root-cause analysis, and complete a group project.

In the didactic component, we give lectures on root-cause analysis and process improvement. And residents get a chance to go to high-level committee meetings within the hospital.

The second part is that each resident is given a live case to review and then present at the medical peer review committee, which I chair. It’s very interesting for them, because unlike most programs in which they only get to talk about a hypothetical case, they actually examine the cases that we review. We usually try to give the residents cases that focus on process, such as a delay in antibiotic administration.

They also do a group project. The last group worked on improving the death-reporting process. Another group is looking at telemetry use in the hospital.

Question: Why is it important to have this exposure during residency?

Dr. Carbo: It is so central to what we as physicians do. But it’s something that most of us were never explicitly taught in medical school. It’s interesting for me as a teacher, because it’s one of the few topics I can teach to a resident that’s 60% new material. If I were to teach them about cardiology or pneumonia care, I don’t think I could teach them as much new material as I can teach them in quality and safety. The nice thing about quality and safety is that it cuts across every single discipline. If I teach you about patient safety and quality improvement, regardless of what you do in your career, it is applicable.

Question: What about practicing clinicians. Are they getting enough training on how to improve patient safety?

Dr. Carbo: None of us have enough training on patient safety. Hospitalists should work locally within their community and talk to their patient safety officer or their boss to really identify something that’s important to them. They can partner with the nurses, or physicians, or pharmacists they work with. Try to start small and work from there. Not everyone needs to fix every quality improvement problem in their hospital all at once.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

When Dr. Alexander Carbo joined the faculty at Beth Israel Deaconess Medical Center in Boston in 2001, straight out of his residency, he rushed to become a member of the department of medicine’s quality improvement committee. Little over a decade later, Dr. Carbo leads that committee. He has also helped continue the success of BIDMC’s Stoneman Patient Safety Rotation, which serves as a kind of patient safety boot camp for residents.

In an interview with Hospitalist News, Dr. Carbo discussed the importance of engaging front-line clinicians in quality improvement projects and why residents and staff need training on how to improve patient safety.

Question: You’ve said that engaging front-line providers is critical for quality improvement. Why?

Dr. Carbo: We have to have a culture of safety. The only way that we can actually make improvements is if somebody knows that improvements are needed. If people don’t call things out, there is no way to fix them. It’s key for people to be able to call things out and to do that in a way that is nonthreatening. We try to make it clear here, we’re not here to look at individuals. We’re not here to get anybody in trouble. We’re here to figure out if there’s either an adverse event with or without error or an error with or without an adverse event. What happened? And how can we prevent this from happening in the future. We just need to have people call things out. I think most of our folks do more than that, but that’s where you have to start. That is the key component. Once people call things out, the next step is actually having them try to solve the problem.

Question: You are the attending preceptor for the Stoneman Patient Safety Rotation at BIDMC. What are your residents exposed to during this rotation?

Dr. Carbo: This rotation was started a decade ago by Dr. Kenneth Sands, who is our senior vice president of healthcare quality, and organized by Dr. Anjala Tess, who is a hospitalist and one of my colleagues here. The two of them – and several others – started this rotation and we’ve now put through several hundred residents. It is a mandatory patient safety rotation for all BIDMC residents. They go through a didactic component, a root-cause analysis, and complete a group project.

In the didactic component, we give lectures on root-cause analysis and process improvement. And residents get a chance to go to high-level committee meetings within the hospital.

The second part is that each resident is given a live case to review and then present at the medical peer review committee, which I chair. It’s very interesting for them, because unlike most programs in which they only get to talk about a hypothetical case, they actually examine the cases that we review. We usually try to give the residents cases that focus on process, such as a delay in antibiotic administration.

They also do a group project. The last group worked on improving the death-reporting process. Another group is looking at telemetry use in the hospital.

Question: Why is it important to have this exposure during residency?

Dr. Carbo: It is so central to what we as physicians do. But it’s something that most of us were never explicitly taught in medical school. It’s interesting for me as a teacher, because it’s one of the few topics I can teach to a resident that’s 60% new material. If I were to teach them about cardiology or pneumonia care, I don’t think I could teach them as much new material as I can teach them in quality and safety. The nice thing about quality and safety is that it cuts across every single discipline. If I teach you about patient safety and quality improvement, regardless of what you do in your career, it is applicable.

Question: What about practicing clinicians. Are they getting enough training on how to improve patient safety?

Dr. Carbo: None of us have enough training on patient safety. Hospitalists should work locally within their community and talk to their patient safety officer or their boss to really identify something that’s important to them. They can partner with the nurses, or physicians, or pharmacists they work with. Try to start small and work from there. Not everyone needs to fix every quality improvement problem in their hospital all at once.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

When Dr. Alexander Carbo joined the faculty at Beth Israel Deaconess Medical Center in Boston in 2001, straight out of his residency, he rushed to become a member of the department of medicine’s quality improvement committee. Little over a decade later, Dr. Carbo leads that committee. He has also helped continue the success of BIDMC’s Stoneman Patient Safety Rotation, which serves as a kind of patient safety boot camp for residents.

In an interview with Hospitalist News, Dr. Carbo discussed the importance of engaging front-line clinicians in quality improvement projects and why residents and staff need training on how to improve patient safety.

Question: You’ve said that engaging front-line providers is critical for quality improvement. Why?

Dr. Carbo: We have to have a culture of safety. The only way that we can actually make improvements is if somebody knows that improvements are needed. If people don’t call things out, there is no way to fix them. It’s key for people to be able to call things out and to do that in a way that is nonthreatening. We try to make it clear here, we’re not here to look at individuals. We’re not here to get anybody in trouble. We’re here to figure out if there’s either an adverse event with or without error or an error with or without an adverse event. What happened? And how can we prevent this from happening in the future. We just need to have people call things out. I think most of our folks do more than that, but that’s where you have to start. That is the key component. Once people call things out, the next step is actually having them try to solve the problem.

Question: You are the attending preceptor for the Stoneman Patient Safety Rotation at BIDMC. What are your residents exposed to during this rotation?

Dr. Carbo: This rotation was started a decade ago by Dr. Kenneth Sands, who is our senior vice president of healthcare quality, and organized by Dr. Anjala Tess, who is a hospitalist and one of my colleagues here. The two of them – and several others – started this rotation and we’ve now put through several hundred residents. It is a mandatory patient safety rotation for all BIDMC residents. They go through a didactic component, a root-cause analysis, and complete a group project.

In the didactic component, we give lectures on root-cause analysis and process improvement. And residents get a chance to go to high-level committee meetings within the hospital.

The second part is that each resident is given a live case to review and then present at the medical peer review committee, which I chair. It’s very interesting for them, because unlike most programs in which they only get to talk about a hypothetical case, they actually examine the cases that we review. We usually try to give the residents cases that focus on process, such as a delay in antibiotic administration.

They also do a group project. The last group worked on improving the death-reporting process. Another group is looking at telemetry use in the hospital.

Question: Why is it important to have this exposure during residency?

Dr. Carbo: It is so central to what we as physicians do. But it’s something that most of us were never explicitly taught in medical school. It’s interesting for me as a teacher, because it’s one of the few topics I can teach to a resident that’s 60% new material. If I were to teach them about cardiology or pneumonia care, I don’t think I could teach them as much new material as I can teach them in quality and safety. The nice thing about quality and safety is that it cuts across every single discipline. If I teach you about patient safety and quality improvement, regardless of what you do in your career, it is applicable.

Question: What about practicing clinicians. Are they getting enough training on how to improve patient safety?

Dr. Carbo: None of us have enough training on patient safety. Hospitalists should work locally within their community and talk to their patient safety officer or their boss to really identify something that’s important to them. They can partner with the nurses, or physicians, or pharmacists they work with. Try to start small and work from there. Not everyone needs to fix every quality improvement problem in their hospital all at once.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

A diverse group of dermatologists, patient advocates, and industry and government representatives, led by the American Academy of Dermatology, have identified cutaneous oncology, pruritus, and performance outcomes and measurement as the most critical research needs in the field of dermatology.

The consensus research agenda was hammered out during a 2-day conference in Washington, D.C., in June. Over the next few months, small groups of conference participants will formulate ideas for how to carry out the research plan, with the goal of bringing their recommendations to the AAD’s annual meeting in March 2013.

The AAD and its partners came up with the research topics after surveying 20 dermatology societies and 15 patient advocacy groups about their research priorities. Conference participants then narrowed the list of possible research areas down to three. Some of the areas that didn’t make the cut included drug reactions, pediatric vascular anomalies, and wound care, according to Dr. Henry W. Lim, chair of the Research Agenda Committee and professor and chairman of dermatology at Henry Ford Hospital in Detroit.

Some of the proposed areas already had robust research efforts underway, while others could fit under the broader topics of cutaneous oncology, pruritus, and performance measurement, Dr. Lim said.

Pruritus and cutaneous oncology rose to the top of the list because the conditions are common, yet have significant gaps in both basic and clinical research. "We all felt that there was a significant knowledge and research gap in these areas," Dr. Lim said. For example, even though pruritus is a condition that dermatologists see every day, there is not a uniform scoring system for ranking the severity of the condition.

The gaps in classification affect not only day-to-day treatment, but also drug evaluation efforts at the Food and Drug Administration, Dr. Lim said.

The group also saw a need for more cutaneous oncology research, ranging from treatment to public education. "Clearly a lot of research has been done, but it is one of the most common and one of the most expensive conditions that we deal with," Dr. Lim said. "There are still a lot of areas that we need to cover."

The group included the final topic – performance outcomes and measurement – because of the growing pressure from the federal government and other payers to measure health care quality, said AAD President Daniel M. Siegel.

But making performance measurement a focus of research will also support data collection in other research areas and the movement toward electronic health records, Dr. Lim said.

The AAD, which is spearheading efforts to create a dermatology research agenda, does not fund research. However, Dr. Siegel said the AAD can do a lot to promote the agenda. For instance, the AAD will consider these research priorities when developing clinical guidelines, patient care guidelines, and continuing medical education. And, the AAD can highlight the research gaps in hopes of getting more scientists interested in the topics.

Even if researchers don’t immediately begin studies on these topics, that is alright, Dr. Siegel said, because advances that benefit dermatology can certainly come from other areas of medicine.

"The goal that I think most of us have ... is that we want to see research," Dr. Siegel said. "We want to see everything funded. You just never know where the benefits are."

A diverse group of dermatologists, patient advocates, and industry and government representatives, led by the American Academy of Dermatology, have identified cutaneous oncology, pruritus, and performance outcomes and measurement as the most critical research needs in the field of dermatology.

The consensus research agenda was hammered out during a 2-day conference in Washington, D.C., in June. Over the next few months, small groups of conference participants will formulate ideas for how to carry out the research plan, with the goal of bringing their recommendations to the AAD’s annual meeting in March 2013.

The AAD and its partners came up with the research topics after surveying 20 dermatology societies and 15 patient advocacy groups about their research priorities. Conference participants then narrowed the list of possible research areas down to three. Some of the areas that didn’t make the cut included drug reactions, pediatric vascular anomalies, and wound care, according to Dr. Henry W. Lim, chair of the Research Agenda Committee and professor and chairman of dermatology at Henry Ford Hospital in Detroit.

Some of the proposed areas already had robust research efforts underway, while others could fit under the broader topics of cutaneous oncology, pruritus, and performance measurement, Dr. Lim said.

Pruritus and cutaneous oncology rose to the top of the list because the conditions are common, yet have significant gaps in both basic and clinical research. "We all felt that there was a significant knowledge and research gap in these areas," Dr. Lim said. For example, even though pruritus is a condition that dermatologists see every day, there is not a uniform scoring system for ranking the severity of the condition.

The gaps in classification affect not only day-to-day treatment, but also drug evaluation efforts at the Food and Drug Administration, Dr. Lim said.

The group also saw a need for more cutaneous oncology research, ranging from treatment to public education. "Clearly a lot of research has been done, but it is one of the most common and one of the most expensive conditions that we deal with," Dr. Lim said. "There are still a lot of areas that we need to cover."

The group included the final topic – performance outcomes and measurement – because of the growing pressure from the federal government and other payers to measure health care quality, said AAD President Daniel M. Siegel.

But making performance measurement a focus of research will also support data collection in other research areas and the movement toward electronic health records, Dr. Lim said.

The AAD, which is spearheading efforts to create a dermatology research agenda, does not fund research. However, Dr. Siegel said the AAD can do a lot to promote the agenda. For instance, the AAD will consider these research priorities when developing clinical guidelines, patient care guidelines, and continuing medical education. And, the AAD can highlight the research gaps in hopes of getting more scientists interested in the topics.

Even if researchers don’t immediately begin studies on these topics, that is alright, Dr. Siegel said, because advances that benefit dermatology can certainly come from other areas of medicine.

"The goal that I think most of us have ... is that we want to see research," Dr. Siegel said. "We want to see everything funded. You just never know where the benefits are."

A diverse group of dermatologists, patient advocates, and industry and government representatives, led by the American Academy of Dermatology, have identified cutaneous oncology, pruritus, and performance outcomes and measurement as the most critical research needs in the field of dermatology.

The consensus research agenda was hammered out during a 2-day conference in Washington, D.C., in June. Over the next few months, small groups of conference participants will formulate ideas for how to carry out the research plan, with the goal of bringing their recommendations to the AAD’s annual meeting in March 2013.

The AAD and its partners came up with the research topics after surveying 20 dermatology societies and 15 patient advocacy groups about their research priorities. Conference participants then narrowed the list of possible research areas down to three. Some of the areas that didn’t make the cut included drug reactions, pediatric vascular anomalies, and wound care, according to Dr. Henry W. Lim, chair of the Research Agenda Committee and professor and chairman of dermatology at Henry Ford Hospital in Detroit.

Some of the proposed areas already had robust research efforts underway, while others could fit under the broader topics of cutaneous oncology, pruritus, and performance measurement, Dr. Lim said.

Pruritus and cutaneous oncology rose to the top of the list because the conditions are common, yet have significant gaps in both basic and clinical research. "We all felt that there was a significant knowledge and research gap in these areas," Dr. Lim said. For example, even though pruritus is a condition that dermatologists see every day, there is not a uniform scoring system for ranking the severity of the condition.

The gaps in classification affect not only day-to-day treatment, but also drug evaluation efforts at the Food and Drug Administration, Dr. Lim said.

The group also saw a need for more cutaneous oncology research, ranging from treatment to public education. "Clearly a lot of research has been done, but it is one of the most common and one of the most expensive conditions that we deal with," Dr. Lim said. "There are still a lot of areas that we need to cover."

The group included the final topic – performance outcomes and measurement – because of the growing pressure from the federal government and other payers to measure health care quality, said AAD President Daniel M. Siegel.

But making performance measurement a focus of research will also support data collection in other research areas and the movement toward electronic health records, Dr. Lim said.

The AAD, which is spearheading efforts to create a dermatology research agenda, does not fund research. However, Dr. Siegel said the AAD can do a lot to promote the agenda. For instance, the AAD will consider these research priorities when developing clinical guidelines, patient care guidelines, and continuing medical education. And, the AAD can highlight the research gaps in hopes of getting more scientists interested in the topics.

Even if researchers don’t immediately begin studies on these topics, that is alright, Dr. Siegel said, because advances that benefit dermatology can certainly come from other areas of medicine.

"The goal that I think most of us have ... is that we want to see research," Dr. Siegel said. "We want to see everything funded. You just never know where the benefits are."

Technical barriers and costs are holding back electronic sharing of clinical data, according to the results of a recent survey conducted by a consortium of physician associations.

More than 70% of the physicians polled said that their electronic health record (EHR) system was unable to communicate electronically with other systems – a lack of interoperability that prevents electronic exchange of information. Another barrier is the cost of setting up and maintaining interfaces and exchanges to share information.

The survey findings are not surprising, Dr. Michael Barr, senior vice president in the division of medical practice, professionalism, and quality at the American College of Physicians, said during a forum sponsored by the Bipartisan Policy Center in Washington. They do, however, highlight the progress that physicians have made in embracing EHRs.

Several years ago, this type of survey might have shown that physicians wanted to keep the status quo or that they feared change, he said. Now, the barriers to exchanging information have more to do with technology than physician attitudes.

Making progress on interoperability will be essential as physicians move forward with different care delivery models such as the patient-centered medical home and the medical home neighborhood, which includes subspecialists, Dr. Barr said.

"The success of these new models will depend on health IT infrastructure that supports seamless coordination of care, patient engagement, and clinical information exchange," he said. "You can’t do team-based care unless everybody has access to the information appropriately."

Beyond interoperability, there are still challenges for physicians seeking to implement EHRs in their practices, said Dr. Robert M. Wah, immediate past chair of the board of trustees of the American Medical Association.

The money available through the Medicare and Medicaid Electronic Health Record Incentive Programs is beginning to change that equation, he said, but most physicians still say that the incentives offered aren’t sufficient to offset the loss in productivity, the change in their workflow, and the assorted other expenses of bringing on EHRs. "We’re still very concerned about that as a barrier," Dr. Wah said.

The physician survey was developed by the American College of Physicians and Doctors Helping Doctors Transform Health Care. The American College of Surgeons, the Association of Medical Directors of Information Systems, and the American Academy of Pediatrics also were involved with the survey. The groups circulated the survey to thousands of their members and received responses from more than 500 physicians.

About three-quarters of the respondents were using an EHR at the time of the survey, higher than the national average of about 55%, according to the National Center for Health Statistics. As a result, the survey developers cautioned that the results should not be used to reflect the view of U.S. physicians as a whole.

The respondents were mostly from small practices. Nearly three-quarters of the physicians surveyed worked in practices with 10 or fewer physicians and more than half were in practices of 5 or fewer physicians.

The survey also provides a more detailed picture of the type of EHR functionality that physicians say would help them better manage care transitions, such as when they refer a patient, when a patient is discharged from the hospital, and when a patient is referred by another physician. More than 80% of those surveyed said that medication lists, relevant laboratory test results, and results from relevant imaging tests were "very important" or "essential."

Physicians indicated that they wanted to have this type of essential patient data pushed to them, possibly though secure e-mail. They also wanted the ability to look up additional patient information in the electronic record.

The survey results could be helpful in accelerating the move toward interoperability in EHRs. A companion report from the Bipartisan Policy Center recommended that clinicians from across specialties and care settings develop a consensus on what types of clinical information should be shared, how they want to receive it, and reasonable timeframes for delivering the data. That consensus information could be used, along with technical standards, to help craft a national strategy for health IT interoperability, according to the report.

Technical barriers and costs are holding back electronic sharing of clinical data, according to the results of a recent survey conducted by a consortium of physician associations.

More than 70% of the physicians polled said that their electronic health record (EHR) system was unable to communicate electronically with other systems – a lack of interoperability that prevents electronic exchange of information. Another barrier is the cost of setting up and maintaining interfaces and exchanges to share information.

The survey findings are not surprising, Dr. Michael Barr, senior vice president in the division of medical practice, professionalism, and quality at the American College of Physicians, said during a forum sponsored by the Bipartisan Policy Center in Washington. They do, however, highlight the progress that physicians have made in embracing EHRs.

Several years ago, this type of survey might have shown that physicians wanted to keep the status quo or that they feared change, he said. Now, the barriers to exchanging information have more to do with technology than physician attitudes.

Making progress on interoperability will be essential as physicians move forward with different care delivery models such as the patient-centered medical home and the medical home neighborhood, which includes subspecialists, Dr. Barr said.

"The success of these new models will depend on health IT infrastructure that supports seamless coordination of care, patient engagement, and clinical information exchange," he said. "You can’t do team-based care unless everybody has access to the information appropriately."

Beyond interoperability, there are still challenges for physicians seeking to implement EHRs in their practices, said Dr. Robert M. Wah, immediate past chair of the board of trustees of the American Medical Association.

The money available through the Medicare and Medicaid Electronic Health Record Incentive Programs is beginning to change that equation, he said, but most physicians still say that the incentives offered aren’t sufficient to offset the loss in productivity, the change in their workflow, and the assorted other expenses of bringing on EHRs. "We’re still very concerned about that as a barrier," Dr. Wah said.

The physician survey was developed by the American College of Physicians and Doctors Helping Doctors Transform Health Care. The American College of Surgeons, the Association of Medical Directors of Information Systems, and the American Academy of Pediatrics also were involved with the survey. The groups circulated the survey to thousands of their members and received responses from more than 500 physicians.

About three-quarters of the respondents were using an EHR at the time of the survey, higher than the national average of about 55%, according to the National Center for Health Statistics. As a result, the survey developers cautioned that the results should not be used to reflect the view of U.S. physicians as a whole.

The respondents were mostly from small practices. Nearly three-quarters of the physicians surveyed worked in practices with 10 or fewer physicians and more than half were in practices of 5 or fewer physicians.

The survey also provides a more detailed picture of the type of EHR functionality that physicians say would help them better manage care transitions, such as when they refer a patient, when a patient is discharged from the hospital, and when a patient is referred by another physician. More than 80% of those surveyed said that medication lists, relevant laboratory test results, and results from relevant imaging tests were "very important" or "essential."

Physicians indicated that they wanted to have this type of essential patient data pushed to them, possibly though secure e-mail. They also wanted the ability to look up additional patient information in the electronic record.

The survey results could be helpful in accelerating the move toward interoperability in EHRs. A companion report from the Bipartisan Policy Center recommended that clinicians from across specialties and care settings develop a consensus on what types of clinical information should be shared, how they want to receive it, and reasonable timeframes for delivering the data. That consensus information could be used, along with technical standards, to help craft a national strategy for health IT interoperability, according to the report.

Technical barriers and costs are holding back electronic sharing of clinical data, according to the results of a recent survey conducted by a consortium of physician associations.

More than 70% of the physicians polled said that their electronic health record (EHR) system was unable to communicate electronically with other systems – a lack of interoperability that prevents electronic exchange of information. Another barrier is the cost of setting up and maintaining interfaces and exchanges to share information.

The survey findings are not surprising, Dr. Michael Barr, senior vice president in the division of medical practice, professionalism, and quality at the American College of Physicians, said during a forum sponsored by the Bipartisan Policy Center in Washington. They do, however, highlight the progress that physicians have made in embracing EHRs.

Several years ago, this type of survey might have shown that physicians wanted to keep the status quo or that they feared change, he said. Now, the barriers to exchanging information have more to do with technology than physician attitudes.

Making progress on interoperability will be essential as physicians move forward with different care delivery models such as the patient-centered medical home and the medical home neighborhood, which includes subspecialists, Dr. Barr said.

"The success of these new models will depend on health IT infrastructure that supports seamless coordination of care, patient engagement, and clinical information exchange," he said. "You can’t do team-based care unless everybody has access to the information appropriately."

Beyond interoperability, there are still challenges for physicians seeking to implement EHRs in their practices, said Dr. Robert M. Wah, immediate past chair of the board of trustees of the American Medical Association.

The money available through the Medicare and Medicaid Electronic Health Record Incentive Programs is beginning to change that equation, he said, but most physicians still say that the incentives offered aren’t sufficient to offset the loss in productivity, the change in their workflow, and the assorted other expenses of bringing on EHRs. "We’re still very concerned about that as a barrier," Dr. Wah said.

The physician survey was developed by the American College of Physicians and Doctors Helping Doctors Transform Health Care. The American College of Surgeons, the Association of Medical Directors of Information Systems, and the American Academy of Pediatrics also were involved with the survey. The groups circulated the survey to thousands of their members and received responses from more than 500 physicians.

About three-quarters of the respondents were using an EHR at the time of the survey, higher than the national average of about 55%, according to the National Center for Health Statistics. As a result, the survey developers cautioned that the results should not be used to reflect the view of U.S. physicians as a whole.

The respondents were mostly from small practices. Nearly three-quarters of the physicians surveyed worked in practices with 10 or fewer physicians and more than half were in practices of 5 or fewer physicians.

The survey also provides a more detailed picture of the type of EHR functionality that physicians say would help them better manage care transitions, such as when they refer a patient, when a patient is discharged from the hospital, and when a patient is referred by another physician. More than 80% of those surveyed said that medication lists, relevant laboratory test results, and results from relevant imaging tests were "very important" or "essential."

Physicians indicated that they wanted to have this type of essential patient data pushed to them, possibly though secure e-mail. They also wanted the ability to look up additional patient information in the electronic record.

The survey results could be helpful in accelerating the move toward interoperability in EHRs. A companion report from the Bipartisan Policy Center recommended that clinicians from across specialties and care settings develop a consensus on what types of clinical information should be shared, how they want to receive it, and reasonable timeframes for delivering the data. That consensus information could be used, along with technical standards, to help craft a national strategy for health IT interoperability, according to the report.

Paying physicians based on clinical outcomes can get complicated. Why? Because it involves holding you accountable not only for your actions, but for what your patients do as well.

Over the last several months, federal officials have been taking heat for tying incentive payments for the use of electronic health records (EHRs) to patient behavior.

Alicia Ault/IMNG Medical Media

Under Stage 2 requirements for the meaningful use of EHRs, physicians are required to use secure messaging to communicate with patients and to give them the ability to view, download, and transmit their health information online.

But you’ll only get paid if at least 5% of the patients you see log on to your portal.

Dr. Farzad Mostashari, National Coordinator for Health Information Technology, defended the new patient engagement requirements at a conference in Washington, D.C. While the push-back from doctors is understandable, he said, the only way that the U.S. health care system can achieve higher quality at lower cost is to get patients much more involved than they are today.

Patient engagement is one of the most underutilized resources in health care, he said. "If it were a drug, it would be a blockbuster," Dr. Mostashari said.

You have a significant influence over your patients’ engagement. With some tweaks to office work flow, you should be able to steer patients toward these new options, according to Dr. Mostashari. Quite simply: Remind patients about your portal and messaging system every time you see them. If you do so, you should not have a problem meeting the 5% threshold, he added.

And for those who are successful in getting patients to look at their health information online, there’s another reward: Patients make the best fact checkers, Dr. Mostashari said.

Paying physicians based on clinical outcomes can get complicated. Why? Because it involves holding you accountable not only for your actions, but for what your patients do as well.

Over the last several months, federal officials have been taking heat for tying incentive payments for the use of electronic health records (EHRs) to patient behavior.

Alicia Ault/IMNG Medical Media

Under Stage 2 requirements for the meaningful use of EHRs, physicians are required to use secure messaging to communicate with patients and to give them the ability to view, download, and transmit their health information online.

But you’ll only get paid if at least 5% of the patients you see log on to your portal.

Dr. Farzad Mostashari, National Coordinator for Health Information Technology, defended the new patient engagement requirements at a conference in Washington, D.C. While the push-back from doctors is understandable, he said, the only way that the U.S. health care system can achieve higher quality at lower cost is to get patients much more involved than they are today.

Patient engagement is one of the most underutilized resources in health care, he said. "If it were a drug, it would be a blockbuster," Dr. Mostashari said.

You have a significant influence over your patients’ engagement. With some tweaks to office work flow, you should be able to steer patients toward these new options, according to Dr. Mostashari. Quite simply: Remind patients about your portal and messaging system every time you see them. If you do so, you should not have a problem meeting the 5% threshold, he added.

And for those who are successful in getting patients to look at their health information online, there’s another reward: Patients make the best fact checkers, Dr. Mostashari said.

Paying physicians based on clinical outcomes can get complicated. Why? Because it involves holding you accountable not only for your actions, but for what your patients do as well.

Over the last several months, federal officials have been taking heat for tying incentive payments for the use of electronic health records (EHRs) to patient behavior.

Alicia Ault/IMNG Medical Media

Under Stage 2 requirements for the meaningful use of EHRs, physicians are required to use secure messaging to communicate with patients and to give them the ability to view, download, and transmit their health information online.

But you’ll only get paid if at least 5% of the patients you see log on to your portal.

Dr. Farzad Mostashari, National Coordinator for Health Information Technology, defended the new patient engagement requirements at a conference in Washington, D.C. While the push-back from doctors is understandable, he said, the only way that the U.S. health care system can achieve higher quality at lower cost is to get patients much more involved than they are today.

Patient engagement is one of the most underutilized resources in health care, he said. "If it were a drug, it would be a blockbuster," Dr. Mostashari said.

You have a significant influence over your patients’ engagement. With some tweaks to office work flow, you should be able to steer patients toward these new options, according to Dr. Mostashari. Quite simply: Remind patients about your portal and messaging system every time you see them. If you do so, you should not have a problem meeting the 5% threshold, he added.

And for those who are successful in getting patients to look at their health information online, there’s another reward: Patients make the best fact checkers, Dr. Mostashari said.

The American Board of Dermatology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Psychiatry and Neurology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available – at the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.

The American Board of Dermatology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Psychiatry and Neurology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available – at the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.

The American Board of Dermatology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Psychiatry and Neurology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available – at the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.