Commentary

I hate epilepsy drug levels.

Other neurologists know what I’m talking about: Dilantin, Tegretol, and Depakote are the main ones we deal with. Levels for newer medications aren’t checked much, and phenobarbital is fading into the background.

I rarely check levels because 90% of the time they’re immaterial. If the patient isn’t having seizures and isn’t having side effects, who cares what the level is? It’s obviously just right for that patient (sort of like Goldilocks) regardless of what a number tells me it is.

Certainly there are exceptions to this: the well-controlled patient who suddenly goes downhill, for example. But in most cases, routinely checking drug levels serves no purpose, and often causes more harm them good.

In medical school, I was taught that you should never order a test unless the results will affect your plan of care. In a stable seizure patient, are you going to base your medication adjustments on how they’re doing, or a number?

Worse still, these levels are often used by specialties that don’t understand them. How many times have you seen well-controlled patients who had an unneeded level ordered – along with their annual lipid profile or thyroid panel, or because they went to the emergency department with pneumonia – and then had a nonneurologist adjust their dose based solely on the result? You often don’t find out about it until the patient calls you to report they seized or are suddenly drug-toxic.

I’m not an internist. In fact, I stink at general medicine, and don’t even pretend to understand the many drugs they have to start, adjust, and stop on an everyday basis. I don’t expect them to know as much about seizure medications as I do, anymore than they expect me to understand treatments for hypertension or diabetes. So I tell my patients that unless it’s an emergency, don’t let anyone else adjust their seizure medications. Just have them fax me the lab report, and I’ll deal with it.

At first, I was afraid this approach would ruffle feathers, but it hasn’t. Local internists have told me they’re glad to be able to take something off their list of concerns and punt it to me.

Modern medicine is full of things we can do, even when they’re just minor drug levels from a lab. But it’s still important to focus on what we should do, and to me, routinely checking drug levels should always be questioned.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I hate epilepsy drug levels.

Other neurologists know what I’m talking about: Dilantin, Tegretol, and Depakote are the main ones we deal with. Levels for newer medications aren’t checked much, and phenobarbital is fading into the background.

I rarely check levels because 90% of the time they’re immaterial. If the patient isn’t having seizures and isn’t having side effects, who cares what the level is? It’s obviously just right for that patient (sort of like Goldilocks) regardless of what a number tells me it is.

Certainly there are exceptions to this: the well-controlled patient who suddenly goes downhill, for example. But in most cases, routinely checking drug levels serves no purpose, and often causes more harm them good.

In medical school, I was taught that you should never order a test unless the results will affect your plan of care. In a stable seizure patient, are you going to base your medication adjustments on how they’re doing, or a number?

Worse still, these levels are often used by specialties that don’t understand them. How many times have you seen well-controlled patients who had an unneeded level ordered – along with their annual lipid profile or thyroid panel, or because they went to the emergency department with pneumonia – and then had a nonneurologist adjust their dose based solely on the result? You often don’t find out about it until the patient calls you to report they seized or are suddenly drug-toxic.

I’m not an internist. In fact, I stink at general medicine, and don’t even pretend to understand the many drugs they have to start, adjust, and stop on an everyday basis. I don’t expect them to know as much about seizure medications as I do, anymore than they expect me to understand treatments for hypertension or diabetes. So I tell my patients that unless it’s an emergency, don’t let anyone else adjust their seizure medications. Just have them fax me the lab report, and I’ll deal with it.

At first, I was afraid this approach would ruffle feathers, but it hasn’t. Local internists have told me they’re glad to be able to take something off their list of concerns and punt it to me.

Modern medicine is full of things we can do, even when they’re just minor drug levels from a lab. But it’s still important to focus on what we should do, and to me, routinely checking drug levels should always be questioned.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I hate epilepsy drug levels.

Other neurologists know what I’m talking about: Dilantin, Tegretol, and Depakote are the main ones we deal with. Levels for newer medications aren’t checked much, and phenobarbital is fading into the background.

I rarely check levels because 90% of the time they’re immaterial. If the patient isn’t having seizures and isn’t having side effects, who cares what the level is? It’s obviously just right for that patient (sort of like Goldilocks) regardless of what a number tells me it is.

Certainly there are exceptions to this: the well-controlled patient who suddenly goes downhill, for example. But in most cases, routinely checking drug levels serves no purpose, and often causes more harm them good.

In medical school, I was taught that you should never order a test unless the results will affect your plan of care. In a stable seizure patient, are you going to base your medication adjustments on how they’re doing, or a number?

Worse still, these levels are often used by specialties that don’t understand them. How many times have you seen well-controlled patients who had an unneeded level ordered – along with their annual lipid profile or thyroid panel, or because they went to the emergency department with pneumonia – and then had a nonneurologist adjust their dose based solely on the result? You often don’t find out about it until the patient calls you to report they seized or are suddenly drug-toxic.

I’m not an internist. In fact, I stink at general medicine, and don’t even pretend to understand the many drugs they have to start, adjust, and stop on an everyday basis. I don’t expect them to know as much about seizure medications as I do, anymore than they expect me to understand treatments for hypertension or diabetes. So I tell my patients that unless it’s an emergency, don’t let anyone else adjust their seizure medications. Just have them fax me the lab report, and I’ll deal with it.

At first, I was afraid this approach would ruffle feathers, but it hasn’t. Local internists have told me they’re glad to be able to take something off their list of concerns and punt it to me.

Modern medicine is full of things we can do, even when they’re just minor drug levels from a lab. But it’s still important to focus on what we should do, and to me, routinely checking drug levels should always be questioned.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Most of you are no doubt familiar with the opening of Charles Dickens’ classic novel A Tale of Two Cities: “It was the best of times, it was the worst of times.” In many ways Dickens has presaged my current thinking about the new lipid guidelines that were recently issued. On the one hand, they are truly the very best guidelines that could possibly be produced at the present time; on the other hand, they may also be the worst set of guidelines that could possibly be promulgated on the practice community at the present moment.

Let’s first take a good look at what the new guidelines actually recommend. First, it’s important to understand that the parentage of the new guidelines has changed in a very important way from that of earlier recommendations. The previous lipid guidelines—the National Cholesterol Education Panel (NCEP) recommendations—were issued in 2001 and were sponsored and endorsed by the National Institutes of Health (NIH) as the federal government’s best effort at lipid recommendations for the general practice community. An update in 2004 further advised that a low-density lipoprotein cholesterol (LDL-C) goal of < 70 mg/dL is appropriate for many patients with preexisting vascular disease.

New guidelines were clearly overdue. Indeed, an expert panel had already been convened and was hard at work. However, a year or so ago the NIH made a critical strategic decision that it no longer wanted to be in the guideline business. The NIH rather abruptly decided that there would be no further iterations of the NCEP guidelines.

Fortunately the NIH did not simply drop the ball. Rather, it decided to pass the baton (mixed metaphor—sorry!) to a joint task force of the American Heart Association (AHA) and the American College of Cardiology (ACC). After all, who better to ponder lipid goals than the vascular experts who populate these 2 august societies? These 2 groups took a good look at the work that had been done by the expert panel, and decided that they would bless the new recommendations.

The fruit of the years of labor were finally presented at the annual meeting of the AHA held in Dallas in 2013. I didn’t make it to all of the heart sessions during that meeting. (I was distracted to a considerable extent by the 50th anniversary commemoration of President John F. Kennedy’s assassination going on just a few blocks away from the convention center at the Texas School Book Depository site.) But I can tell you I was definitely at the AHA session where the guidelines were formally presented, and it was indeed a lively and controversial session.

By far the biggest change in the new guidelines, representing both its greatest strength and its greatest weakness, is the new emphasis on overall cardiovascular risk assessment rather than on the attainment of a certain defined LDL-C goal. Indeed, a feature of the new guidelines, which many find disconcerting, is that there is no longer any mention whatsoever of LDL-C goals or targets!

The guidelines are also heavily statin-centric; other classes of lipid-lowering agents, such as fibrates or niacin, receive short shrift indeed. The recommendations are that statins should be prescribed routinely for each of the following “statin benefit groups”:

1. Patients who have clinical atherosclerotic cardiovascular disease and thus fall into the “secondary prevention” category.

2. Those with LDL-C levels of  ≥ 190 mg/dL and who have no secondary cause, such as certain medications or diseases such as hypothyroidism or nephrotic syndrome.

3. Patients with diabetes without established cardiovascular disease aged 40 to 75 years with LDL-C levels between 70 mg/dL and 189 mg/dL.

4. Patients without diabetes with established atherosclerotic cardiovascular disease aged 40 to 75 years with LDL-C levels from 70 mg/dL to 189 mg/dL and a calculated cardiovascular risk of at least 7.5% over the next 10 years.

The fourth category is potentially the most confusing for conscientious providers. The risk calculator that determines whether or not someone has a risk of > 7.5% over the next year is not the traditional Framingham risk calculator, with which many providers are familiar. Rather, it is a brand-new, improved risk calculator devised by the panel. The calculator can be found on both the AHA and ACC websites and in iOS and Android apps (See App Corner, p.38).

To make things even more confusing, once it has been determined that a statin is indicated, the dosing of the statin, either low, moderate, or high intensity, must be selected on the basis of determined risk level. Fortunately, the panel has given us a nice table defining which statins qualify for inclusion in each of these 3 intensity categories. As a general rule, the low-intensity statins should almost always be avoided. But the determination of whether moderate or high-intensity statins are indicated gets somewhat murky. The first two aforementioned classes both deserve high-intensity statins. However, patients with diabetes who haven’t had an event could go with either moderate- or high-intensity statins, and those patients without diabetes or LDL-C levels ≥ 190, but with a 10-year risk of at least 7.5%, can also receive either moderate- or high-intensity statins.

So there it is, and it all does make a certain amount of sense. You first determine the patient’s risk category, which determines whether or not statins are indicated. If they are, you then decide what level of potency your prescribed statin should possess. There is no need to go checking LDL-C levels later, because your therapy is not targeted at any particular LDL-C level. You might want to check occasionally, though, just as a way of assessing patient compliance.

So what should we make of all of this? From a purely scientific point of view, it seems abundantly clear that these are the most scientifically valid set of guidelines that have ever been produced, generated by genuine experts who bent over backward to examine every possible relevant study. The new risk calculator is clearly a broader-based tool than the Framingham calculator, which was based on now-dated data from a very narrow heavily-white population basis. Although the new risk calculator has been criticized by some as a very imperfect tool that overestimates risk in some subpopulations, I firmly believe it is considerably less imperfect than the Framingham tool. It is, quite frankly, the best risk calculator anyone could come up with at this time, and the cutoff for treatment at a risk of 7.5% or higher over 10 years seems eminently reasonable to me.

So what’s the problem with the new guidelines? I think you astute readers already know what the problem is: These guidelines simply represent way too radical a change for the huge bulk of busy, harried providers out there. The average primary care provider is currently struggling to complete a multifaceted patient encounter in 15 minutes or less and then document it in excruciating detail. He or she is going to be extremely hard-pressed to master and implement the new guidelines. The guidelines are indeed the most scientifically accurate and thorough guidelines that could be humanly produced, but they represent such a radical change from previous guidelines that a huge number of providers are going to be playing catch-up for a long time. I hope that their learning curve can be a very rapid one, but I worry that these scientifically pristine guidelines will be slow to find their way into general practice. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Most of you are no doubt familiar with the opening of Charles Dickens’ classic novel A Tale of Two Cities: “It was the best of times, it was the worst of times.” In many ways Dickens has presaged my current thinking about the new lipid guidelines that were recently issued. On the one hand, they are truly the very best guidelines that could possibly be produced at the present time; on the other hand, they may also be the worst set of guidelines that could possibly be promulgated on the practice community at the present moment.

Let’s first take a good look at what the new guidelines actually recommend. First, it’s important to understand that the parentage of the new guidelines has changed in a very important way from that of earlier recommendations. The previous lipid guidelines—the National Cholesterol Education Panel (NCEP) recommendations—were issued in 2001 and were sponsored and endorsed by the National Institutes of Health (NIH) as the federal government’s best effort at lipid recommendations for the general practice community. An update in 2004 further advised that a low-density lipoprotein cholesterol (LDL-C) goal of < 70 mg/dL is appropriate for many patients with preexisting vascular disease.

New guidelines were clearly overdue. Indeed, an expert panel had already been convened and was hard at work. However, a year or so ago the NIH made a critical strategic decision that it no longer wanted to be in the guideline business. The NIH rather abruptly decided that there would be no further iterations of the NCEP guidelines.

Fortunately the NIH did not simply drop the ball. Rather, it decided to pass the baton (mixed metaphor—sorry!) to a joint task force of the American Heart Association (AHA) and the American College of Cardiology (ACC). After all, who better to ponder lipid goals than the vascular experts who populate these 2 august societies? These 2 groups took a good look at the work that had been done by the expert panel, and decided that they would bless the new recommendations.

The fruit of the years of labor were finally presented at the annual meeting of the AHA held in Dallas in 2013. I didn’t make it to all of the heart sessions during that meeting. (I was distracted to a considerable extent by the 50th anniversary commemoration of President John F. Kennedy’s assassination going on just a few blocks away from the convention center at the Texas School Book Depository site.) But I can tell you I was definitely at the AHA session where the guidelines were formally presented, and it was indeed a lively and controversial session.

By far the biggest change in the new guidelines, representing both its greatest strength and its greatest weakness, is the new emphasis on overall cardiovascular risk assessment rather than on the attainment of a certain defined LDL-C goal. Indeed, a feature of the new guidelines, which many find disconcerting, is that there is no longer any mention whatsoever of LDL-C goals or targets!

The guidelines are also heavily statin-centric; other classes of lipid-lowering agents, such as fibrates or niacin, receive short shrift indeed. The recommendations are that statins should be prescribed routinely for each of the following “statin benefit groups”:

1. Patients who have clinical atherosclerotic cardiovascular disease and thus fall into the “secondary prevention” category.

2. Those with LDL-C levels of  ≥ 190 mg/dL and who have no secondary cause, such as certain medications or diseases such as hypothyroidism or nephrotic syndrome.

3. Patients with diabetes without established cardiovascular disease aged 40 to 75 years with LDL-C levels between 70 mg/dL and 189 mg/dL.

4. Patients without diabetes with established atherosclerotic cardiovascular disease aged 40 to 75 years with LDL-C levels from 70 mg/dL to 189 mg/dL and a calculated cardiovascular risk of at least 7.5% over the next 10 years.

The fourth category is potentially the most confusing for conscientious providers. The risk calculator that determines whether or not someone has a risk of > 7.5% over the next year is not the traditional Framingham risk calculator, with which many providers are familiar. Rather, it is a brand-new, improved risk calculator devised by the panel. The calculator can be found on both the AHA and ACC websites and in iOS and Android apps (See App Corner, p.38).

To make things even more confusing, once it has been determined that a statin is indicated, the dosing of the statin, either low, moderate, or high intensity, must be selected on the basis of determined risk level. Fortunately, the panel has given us a nice table defining which statins qualify for inclusion in each of these 3 intensity categories. As a general rule, the low-intensity statins should almost always be avoided. But the determination of whether moderate or high-intensity statins are indicated gets somewhat murky. The first two aforementioned classes both deserve high-intensity statins. However, patients with diabetes who haven’t had an event could go with either moderate- or high-intensity statins, and those patients without diabetes or LDL-C levels ≥ 190, but with a 10-year risk of at least 7.5%, can also receive either moderate- or high-intensity statins.

So there it is, and it all does make a certain amount of sense. You first determine the patient’s risk category, which determines whether or not statins are indicated. If they are, you then decide what level of potency your prescribed statin should possess. There is no need to go checking LDL-C levels later, because your therapy is not targeted at any particular LDL-C level. You might want to check occasionally, though, just as a way of assessing patient compliance.

So what should we make of all of this? From a purely scientific point of view, it seems abundantly clear that these are the most scientifically valid set of guidelines that have ever been produced, generated by genuine experts who bent over backward to examine every possible relevant study. The new risk calculator is clearly a broader-based tool than the Framingham calculator, which was based on now-dated data from a very narrow heavily-white population basis. Although the new risk calculator has been criticized by some as a very imperfect tool that overestimates risk in some subpopulations, I firmly believe it is considerably less imperfect than the Framingham tool. It is, quite frankly, the best risk calculator anyone could come up with at this time, and the cutoff for treatment at a risk of 7.5% or higher over 10 years seems eminently reasonable to me.

So what’s the problem with the new guidelines? I think you astute readers already know what the problem is: These guidelines simply represent way too radical a change for the huge bulk of busy, harried providers out there. The average primary care provider is currently struggling to complete a multifaceted patient encounter in 15 minutes or less and then document it in excruciating detail. He or she is going to be extremely hard-pressed to master and implement the new guidelines. The guidelines are indeed the most scientifically accurate and thorough guidelines that could be humanly produced, but they represent such a radical change from previous guidelines that a huge number of providers are going to be playing catch-up for a long time. I hope that their learning curve can be a very rapid one, but I worry that these scientifically pristine guidelines will be slow to find their way into general practice. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Most of you are no doubt familiar with the opening of Charles Dickens’ classic novel A Tale of Two Cities: “It was the best of times, it was the worst of times.” In many ways Dickens has presaged my current thinking about the new lipid guidelines that were recently issued. On the one hand, they are truly the very best guidelines that could possibly be produced at the present time; on the other hand, they may also be the worst set of guidelines that could possibly be promulgated on the practice community at the present moment.

Let’s first take a good look at what the new guidelines actually recommend. First, it’s important to understand that the parentage of the new guidelines has changed in a very important way from that of earlier recommendations. The previous lipid guidelines—the National Cholesterol Education Panel (NCEP) recommendations—were issued in 2001 and were sponsored and endorsed by the National Institutes of Health (NIH) as the federal government’s best effort at lipid recommendations for the general practice community. An update in 2004 further advised that a low-density lipoprotein cholesterol (LDL-C) goal of < 70 mg/dL is appropriate for many patients with preexisting vascular disease.

New guidelines were clearly overdue. Indeed, an expert panel had already been convened and was hard at work. However, a year or so ago the NIH made a critical strategic decision that it no longer wanted to be in the guideline business. The NIH rather abruptly decided that there would be no further iterations of the NCEP guidelines.

Fortunately the NIH did not simply drop the ball. Rather, it decided to pass the baton (mixed metaphor—sorry!) to a joint task force of the American Heart Association (AHA) and the American College of Cardiology (ACC). After all, who better to ponder lipid goals than the vascular experts who populate these 2 august societies? These 2 groups took a good look at the work that had been done by the expert panel, and decided that they would bless the new recommendations.

The fruit of the years of labor were finally presented at the annual meeting of the AHA held in Dallas in 2013. I didn’t make it to all of the heart sessions during that meeting. (I was distracted to a considerable extent by the 50th anniversary commemoration of President John F. Kennedy’s assassination going on just a few blocks away from the convention center at the Texas School Book Depository site.) But I can tell you I was definitely at the AHA session where the guidelines were formally presented, and it was indeed a lively and controversial session.

By far the biggest change in the new guidelines, representing both its greatest strength and its greatest weakness, is the new emphasis on overall cardiovascular risk assessment rather than on the attainment of a certain defined LDL-C goal. Indeed, a feature of the new guidelines, which many find disconcerting, is that there is no longer any mention whatsoever of LDL-C goals or targets!

The guidelines are also heavily statin-centric; other classes of lipid-lowering agents, such as fibrates or niacin, receive short shrift indeed. The recommendations are that statins should be prescribed routinely for each of the following “statin benefit groups”:

1. Patients who have clinical atherosclerotic cardiovascular disease and thus fall into the “secondary prevention” category.

2. Those with LDL-C levels of  ≥ 190 mg/dL and who have no secondary cause, such as certain medications or diseases such as hypothyroidism or nephrotic syndrome.

3. Patients with diabetes without established cardiovascular disease aged 40 to 75 years with LDL-C levels between 70 mg/dL and 189 mg/dL.

4. Patients without diabetes with established atherosclerotic cardiovascular disease aged 40 to 75 years with LDL-C levels from 70 mg/dL to 189 mg/dL and a calculated cardiovascular risk of at least 7.5% over the next 10 years.

The fourth category is potentially the most confusing for conscientious providers. The risk calculator that determines whether or not someone has a risk of > 7.5% over the next year is not the traditional Framingham risk calculator, with which many providers are familiar. Rather, it is a brand-new, improved risk calculator devised by the panel. The calculator can be found on both the AHA and ACC websites and in iOS and Android apps (See App Corner, p.38).

To make things even more confusing, once it has been determined that a statin is indicated, the dosing of the statin, either low, moderate, or high intensity, must be selected on the basis of determined risk level. Fortunately, the panel has given us a nice table defining which statins qualify for inclusion in each of these 3 intensity categories. As a general rule, the low-intensity statins should almost always be avoided. But the determination of whether moderate or high-intensity statins are indicated gets somewhat murky. The first two aforementioned classes both deserve high-intensity statins. However, patients with diabetes who haven’t had an event could go with either moderate- or high-intensity statins, and those patients without diabetes or LDL-C levels ≥ 190, but with a 10-year risk of at least 7.5%, can also receive either moderate- or high-intensity statins.

So there it is, and it all does make a certain amount of sense. You first determine the patient’s risk category, which determines whether or not statins are indicated. If they are, you then decide what level of potency your prescribed statin should possess. There is no need to go checking LDL-C levels later, because your therapy is not targeted at any particular LDL-C level. You might want to check occasionally, though, just as a way of assessing patient compliance.

So what should we make of all of this? From a purely scientific point of view, it seems abundantly clear that these are the most scientifically valid set of guidelines that have ever been produced, generated by genuine experts who bent over backward to examine every possible relevant study. The new risk calculator is clearly a broader-based tool than the Framingham calculator, which was based on now-dated data from a very narrow heavily-white population basis. Although the new risk calculator has been criticized by some as a very imperfect tool that overestimates risk in some subpopulations, I firmly believe it is considerably less imperfect than the Framingham tool. It is, quite frankly, the best risk calculator anyone could come up with at this time, and the cutoff for treatment at a risk of 7.5% or higher over 10 years seems eminently reasonable to me.

So what’s the problem with the new guidelines? I think you astute readers already know what the problem is: These guidelines simply represent way too radical a change for the huge bulk of busy, harried providers out there. The average primary care provider is currently struggling to complete a multifaceted patient encounter in 15 minutes or less and then document it in excruciating detail. He or she is going to be extremely hard-pressed to master and implement the new guidelines. The guidelines are indeed the most scientifically accurate and thorough guidelines that could be humanly produced, but they represent such a radical change from previous guidelines that a huge number of providers are going to be playing catch-up for a long time. I hope that their learning curve can be a very rapid one, but I worry that these scientifically pristine guidelines will be slow to find their way into general practice. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

There are hardly any infectious diseases that a little soap and water can’t help.

That old chestnut resurfaced when Dr. Keiji Fukuda of the World Health Organization announced on May 14 that while a special WHO panel had determined that the worldwide spread of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) did not yet constitute an international public health emergency, its spread right now seems to be driven largely by poor infection-control measures.

courtesy Centers for Disease Control and Prevention

"Hospital outbreaks have been a key feature of this virus," which has produced nearly 600 confirmed cases worldwide, mostly in Saudi Arabia and the United Arab Emirates, but also with at least two confirmed cases in the United States, Dr. Fukuda said.

The recent uptick in cases – half of all cases to date were diagnosed in April – as well as their spread to new countries led the WHO special panel on MERS-CoV to meet May 13-14.

The panel concluded that no emergency exists yet. And they urged hospitals to put a much greater emphasis on the principles of Infection Fighting 101: handwashing, using masks and gloves, and changing gloves between patients.

In late April and early May, WHO staffers inspected several Saudi Arabian hospitals where MERS-CoV clusters had appeared and found "infection control practices were not up to standards," and that issues such as overcrowded emergency departments "amplified" the spread of MERS-CoV, Dr. Fukuda, WHO assistant director general, said during a press conference in Geneva.

MERS-CoV cases in the community also increased in recent weeks, which may reflect a seasonal rise in infections, improved surveillance and case recognition, or increasing person-to-person transmission. But Dr. Fukuda stressed that for now there is "no convincing evidence" of any change in the transmissibility of MERS-CoV or of its genetic makeup, and no evidence that MERS-CoV is cutting infectious swaths through communities.

The WHO committee put all the MERS-CoV evidence "on the table to see how it adds up," to produce "a very sober and critical assessment," a process Dr. Fukuda said could not have happened even 10 years ago.

[email protected]

On Twitter @mitchelzoler

There are hardly any infectious diseases that a little soap and water can’t help.

That old chestnut resurfaced when Dr. Keiji Fukuda of the World Health Organization announced on May 14 that while a special WHO panel had determined that the worldwide spread of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) did not yet constitute an international public health emergency, its spread right now seems to be driven largely by poor infection-control measures.

courtesy Centers for Disease Control and Prevention

"Hospital outbreaks have been a key feature of this virus," which has produced nearly 600 confirmed cases worldwide, mostly in Saudi Arabia and the United Arab Emirates, but also with at least two confirmed cases in the United States, Dr. Fukuda said.

The recent uptick in cases – half of all cases to date were diagnosed in April – as well as their spread to new countries led the WHO special panel on MERS-CoV to meet May 13-14.

The panel concluded that no emergency exists yet. And they urged hospitals to put a much greater emphasis on the principles of Infection Fighting 101: handwashing, using masks and gloves, and changing gloves between patients.

In late April and early May, WHO staffers inspected several Saudi Arabian hospitals where MERS-CoV clusters had appeared and found "infection control practices were not up to standards," and that issues such as overcrowded emergency departments "amplified" the spread of MERS-CoV, Dr. Fukuda, WHO assistant director general, said during a press conference in Geneva.

MERS-CoV cases in the community also increased in recent weeks, which may reflect a seasonal rise in infections, improved surveillance and case recognition, or increasing person-to-person transmission. But Dr. Fukuda stressed that for now there is "no convincing evidence" of any change in the transmissibility of MERS-CoV or of its genetic makeup, and no evidence that MERS-CoV is cutting infectious swaths through communities.

The WHO committee put all the MERS-CoV evidence "on the table to see how it adds up," to produce "a very sober and critical assessment," a process Dr. Fukuda said could not have happened even 10 years ago.

[email protected]

On Twitter @mitchelzoler

There are hardly any infectious diseases that a little soap and water can’t help.

That old chestnut resurfaced when Dr. Keiji Fukuda of the World Health Organization announced on May 14 that while a special WHO panel had determined that the worldwide spread of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) did not yet constitute an international public health emergency, its spread right now seems to be driven largely by poor infection-control measures.

courtesy Centers for Disease Control and Prevention

"Hospital outbreaks have been a key feature of this virus," which has produced nearly 600 confirmed cases worldwide, mostly in Saudi Arabia and the United Arab Emirates, but also with at least two confirmed cases in the United States, Dr. Fukuda said.

The recent uptick in cases – half of all cases to date were diagnosed in April – as well as their spread to new countries led the WHO special panel on MERS-CoV to meet May 13-14.

The panel concluded that no emergency exists yet. And they urged hospitals to put a much greater emphasis on the principles of Infection Fighting 101: handwashing, using masks and gloves, and changing gloves between patients.

In late April and early May, WHO staffers inspected several Saudi Arabian hospitals where MERS-CoV clusters had appeared and found "infection control practices were not up to standards," and that issues such as overcrowded emergency departments "amplified" the spread of MERS-CoV, Dr. Fukuda, WHO assistant director general, said during a press conference in Geneva.

MERS-CoV cases in the community also increased in recent weeks, which may reflect a seasonal rise in infections, improved surveillance and case recognition, or increasing person-to-person transmission. But Dr. Fukuda stressed that for now there is "no convincing evidence" of any change in the transmissibility of MERS-CoV or of its genetic makeup, and no evidence that MERS-CoV is cutting infectious swaths through communities.

The WHO committee put all the MERS-CoV evidence "on the table to see how it adds up," to produce "a very sober and critical assessment," a process Dr. Fukuda said could not have happened even 10 years ago.

[email protected]

On Twitter @mitchelzoler

Peripheral interventions editorial

I read Dr. Samson’s recent critique of nonvascular surgeons foray into the world of peripheral vascular interventions with interest. He points out in his article how the American College of Cardiology has changed its guidelines for percutaneous coronary interventions.

Suddenly, what once lacked evidence-based medicine now becomes justified. Is it a surprise to anyone that these same "vascular specialists" use the "rarely appropriate" indication to justify countless unnecessary peripheral vascular interventions?

Until the advent of percutaneous endovascular interventions, these "vascular specialists" had little to no interest in the treatment of peripheral vascular disease. It is only within the past decade that we have seen the emergence of "vascular specialists" who portray themselves as experts in the field of peripheral vascular disease.

Even more astonishing is that hospitals have embraced the concept of "heart and vascular centers" to bring these "vascular specialists" into the mainstream treatment of what was once the domain of vascular surgery.

I think three factors have led to Dr. Samson’s poignant set of observations. First, the number of cardiology trainees continues to outpace the need for coronary interventions. Since our cardiology colleagues already have access to patients with peripheral vascular disease, it is only logical that there would be interest in peripheral interventions.

Second, industry-sponsored trials have sought out high-volume physicians to enroll patients. Vascular surgeons are generally a conservative group, which is comfortable with the medical management of intermittent claudication and asymptomatic carotid stenosis, to name just a few examples.

The medical device industry quickly moved to physicians with a more aggressive approach to peripheral vascular disease. Lastly, hospitals needed to maintain the lucrative revenue stream afforded by coronary interventions and cardiac surgery.

With declining revenue it made sense for hospitals to economically credential "vascular specialists" to be the spokespersons for their "heart and vascular centers."

Proponents of "vascular specialists" argue that with an aging population, we will need a substantial influx of providers who can manage peripheral vascular disease. The flaw in this argument is that all of these patients are going to need procedures. Most vascular surgeons would argue that substantial numbers of patients with peripheral vascular disease would do quite well with medical management alone.

Certainly, we need to deal with symptomatic carotid disease, large aneurysms, and critical limb ischemia, but these patients account for a small proportion of those with vascular disease. It may well be that with shrinking Medicare, Medicaid, and third-party insurance coffers, government regulations will finally put an end to the countless number of unnecessary endovascular procedures.

Unfortunately for Dr. Samson and the rest of us, the future is not bright. Whereas inside the university there may be harmony among vascular surgeons and "vascular specialists," that is surely not the case in the community where vascular surgeons are faced with increasing competition.

With the tacit approval of hospitals and their hired consulting firms – who champion profits over delivery of evidence-based vascular care – the role of vascular surgery is becoming marginalized.

I would suggest that there has been deafening silence from our societies about the unique role vascular surgery has in treating peripheral vascular disease.

Who else has the training and skill to treat vascular disease with the most appropriate open or endovascular procedures – and more importantly, knows when to apply each method?

Perhaps the unbiased observer might ask the obvious, who needs a "vascular specialist"?

Dr. Samson’s observations point us to the answer in my view – the hospital.

– Richard David Edrington, M.D. Raleigh, N.C.

Carotid screening

I read your commentary article published in the online Vascular Specialist re: carotid screening and I have to say that you nailed it. I would think that any conclusion must be suspect if it is drawn on the basis of studies that are poorly performed by technologists of questionable skills who are usually not RVT’s, then are interpreted (if we are lucky) by internists or radiologists with no particular expertise in vascular disease. Worst-case scenario is that the techs actually interpret the study, as you noted. These are the same people that perform a duplex scan of the leg arterial system to evaluate the significance of arterial occlusive disease – no pressure studies at all!

I have had the same experience you have noted many times of having a patient come into the office holding a carotid scan report claiming a critical stenosis and our RVT finds no significant disease at all. The opposite is also true.

As is your practice, we never initiate treatment based on results from an outside lab. I believe that the only way we’ll see any change in this "open season" on performing noninvasive studies is to make reimbursement contingent upon lab accreditation.

This whole situation is reminiscent of that in the ’90s when carotid endarterectomy came under assault from studies designed and conducted by neurologists who had already drawn their conclusions before they enrolled the first patients.

Good job. Keep up the fight to inject a bit of reason into this, so far, one-sided debate.

– William M. Blackshear Jr., M.D.

Director, Vascular Institute of Florida, St. Petersburg

Peripheral interventions editorial

I read Dr. Samson’s recent critique of nonvascular surgeons foray into the world of peripheral vascular interventions with interest. He points out in his article how the American College of Cardiology has changed its guidelines for percutaneous coronary interventions.

Suddenly, what once lacked evidence-based medicine now becomes justified. Is it a surprise to anyone that these same "vascular specialists" use the "rarely appropriate" indication to justify countless unnecessary peripheral vascular interventions?

Until the advent of percutaneous endovascular interventions, these "vascular specialists" had little to no interest in the treatment of peripheral vascular disease. It is only within the past decade that we have seen the emergence of "vascular specialists" who portray themselves as experts in the field of peripheral vascular disease.

Even more astonishing is that hospitals have embraced the concept of "heart and vascular centers" to bring these "vascular specialists" into the mainstream treatment of what was once the domain of vascular surgery.

I think three factors have led to Dr. Samson’s poignant set of observations. First, the number of cardiology trainees continues to outpace the need for coronary interventions. Since our cardiology colleagues already have access to patients with peripheral vascular disease, it is only logical that there would be interest in peripheral interventions.

Second, industry-sponsored trials have sought out high-volume physicians to enroll patients. Vascular surgeons are generally a conservative group, which is comfortable with the medical management of intermittent claudication and asymptomatic carotid stenosis, to name just a few examples.

The medical device industry quickly moved to physicians with a more aggressive approach to peripheral vascular disease. Lastly, hospitals needed to maintain the lucrative revenue stream afforded by coronary interventions and cardiac surgery.

With declining revenue it made sense for hospitals to economically credential "vascular specialists" to be the spokespersons for their "heart and vascular centers."

Proponents of "vascular specialists" argue that with an aging population, we will need a substantial influx of providers who can manage peripheral vascular disease. The flaw in this argument is that all of these patients are going to need procedures. Most vascular surgeons would argue that substantial numbers of patients with peripheral vascular disease would do quite well with medical management alone.

Certainly, we need to deal with symptomatic carotid disease, large aneurysms, and critical limb ischemia, but these patients account for a small proportion of those with vascular disease. It may well be that with shrinking Medicare, Medicaid, and third-party insurance coffers, government regulations will finally put an end to the countless number of unnecessary endovascular procedures.

Unfortunately for Dr. Samson and the rest of us, the future is not bright. Whereas inside the university there may be harmony among vascular surgeons and "vascular specialists," that is surely not the case in the community where vascular surgeons are faced with increasing competition.

With the tacit approval of hospitals and their hired consulting firms – who champion profits over delivery of evidence-based vascular care – the role of vascular surgery is becoming marginalized.

I would suggest that there has been deafening silence from our societies about the unique role vascular surgery has in treating peripheral vascular disease.

Who else has the training and skill to treat vascular disease with the most appropriate open or endovascular procedures – and more importantly, knows when to apply each method?

Perhaps the unbiased observer might ask the obvious, who needs a "vascular specialist"?

Dr. Samson’s observations point us to the answer in my view – the hospital.

– Richard David Edrington, M.D. Raleigh, N.C.

Carotid screening

I read your commentary article published in the online Vascular Specialist re: carotid screening and I have to say that you nailed it. I would think that any conclusion must be suspect if it is drawn on the basis of studies that are poorly performed by technologists of questionable skills who are usually not RVT’s, then are interpreted (if we are lucky) by internists or radiologists with no particular expertise in vascular disease. Worst-case scenario is that the techs actually interpret the study, as you noted. These are the same people that perform a duplex scan of the leg arterial system to evaluate the significance of arterial occlusive disease – no pressure studies at all!

I have had the same experience you have noted many times of having a patient come into the office holding a carotid scan report claiming a critical stenosis and our RVT finds no significant disease at all. The opposite is also true.

As is your practice, we never initiate treatment based on results from an outside lab. I believe that the only way we’ll see any change in this "open season" on performing noninvasive studies is to make reimbursement contingent upon lab accreditation.

This whole situation is reminiscent of that in the ’90s when carotid endarterectomy came under assault from studies designed and conducted by neurologists who had already drawn their conclusions before they enrolled the first patients.

Good job. Keep up the fight to inject a bit of reason into this, so far, one-sided debate.

– William M. Blackshear Jr., M.D.

Director, Vascular Institute of Florida, St. Petersburg

Peripheral interventions editorial

I read Dr. Samson’s recent critique of nonvascular surgeons foray into the world of peripheral vascular interventions with interest. He points out in his article how the American College of Cardiology has changed its guidelines for percutaneous coronary interventions.

Suddenly, what once lacked evidence-based medicine now becomes justified. Is it a surprise to anyone that these same "vascular specialists" use the "rarely appropriate" indication to justify countless unnecessary peripheral vascular interventions?

Until the advent of percutaneous endovascular interventions, these "vascular specialists" had little to no interest in the treatment of peripheral vascular disease. It is only within the past decade that we have seen the emergence of "vascular specialists" who portray themselves as experts in the field of peripheral vascular disease.

Even more astonishing is that hospitals have embraced the concept of "heart and vascular centers" to bring these "vascular specialists" into the mainstream treatment of what was once the domain of vascular surgery.

I think three factors have led to Dr. Samson’s poignant set of observations. First, the number of cardiology trainees continues to outpace the need for coronary interventions. Since our cardiology colleagues already have access to patients with peripheral vascular disease, it is only logical that there would be interest in peripheral interventions.

Second, industry-sponsored trials have sought out high-volume physicians to enroll patients. Vascular surgeons are generally a conservative group, which is comfortable with the medical management of intermittent claudication and asymptomatic carotid stenosis, to name just a few examples.

The medical device industry quickly moved to physicians with a more aggressive approach to peripheral vascular disease. Lastly, hospitals needed to maintain the lucrative revenue stream afforded by coronary interventions and cardiac surgery.

With declining revenue it made sense for hospitals to economically credential "vascular specialists" to be the spokespersons for their "heart and vascular centers."

Proponents of "vascular specialists" argue that with an aging population, we will need a substantial influx of providers who can manage peripheral vascular disease. The flaw in this argument is that all of these patients are going to need procedures. Most vascular surgeons would argue that substantial numbers of patients with peripheral vascular disease would do quite well with medical management alone.

Certainly, we need to deal with symptomatic carotid disease, large aneurysms, and critical limb ischemia, but these patients account for a small proportion of those with vascular disease. It may well be that with shrinking Medicare, Medicaid, and third-party insurance coffers, government regulations will finally put an end to the countless number of unnecessary endovascular procedures.

Unfortunately for Dr. Samson and the rest of us, the future is not bright. Whereas inside the university there may be harmony among vascular surgeons and "vascular specialists," that is surely not the case in the community where vascular surgeons are faced with increasing competition.

With the tacit approval of hospitals and their hired consulting firms – who champion profits over delivery of evidence-based vascular care – the role of vascular surgery is becoming marginalized.

I would suggest that there has been deafening silence from our societies about the unique role vascular surgery has in treating peripheral vascular disease.

Who else has the training and skill to treat vascular disease with the most appropriate open or endovascular procedures – and more importantly, knows when to apply each method?

Perhaps the unbiased observer might ask the obvious, who needs a "vascular specialist"?

Dr. Samson’s observations point us to the answer in my view – the hospital.

– Richard David Edrington, M.D. Raleigh, N.C.

Carotid screening

I read your commentary article published in the online Vascular Specialist re: carotid screening and I have to say that you nailed it. I would think that any conclusion must be suspect if it is drawn on the basis of studies that are poorly performed by technologists of questionable skills who are usually not RVT’s, then are interpreted (if we are lucky) by internists or radiologists with no particular expertise in vascular disease. Worst-case scenario is that the techs actually interpret the study, as you noted. These are the same people that perform a duplex scan of the leg arterial system to evaluate the significance of arterial occlusive disease – no pressure studies at all!

I have had the same experience you have noted many times of having a patient come into the office holding a carotid scan report claiming a critical stenosis and our RVT finds no significant disease at all. The opposite is also true.

As is your practice, we never initiate treatment based on results from an outside lab. I believe that the only way we’ll see any change in this "open season" on performing noninvasive studies is to make reimbursement contingent upon lab accreditation.

This whole situation is reminiscent of that in the ’90s when carotid endarterectomy came under assault from studies designed and conducted by neurologists who had already drawn their conclusions before they enrolled the first patients.

Good job. Keep up the fight to inject a bit of reason into this, so far, one-sided debate.

– William M. Blackshear Jr., M.D.

Director, Vascular Institute of Florida, St. Petersburg

Nearly a year after "starting out" on the inpatient wards as a new hospitalist, there has been one idiosyncrasy that I just can’t seem to understand: Hospitals and skilled nursing facilities decrease their staffing and services on the weekends. Though I was aware of this as a resident, because it was frustrating, now, as an attending, it’s nearly surreal. I am the one responsible for the length of stay, patient satisfaction scores, and health care cost savings, and it just doesn’t make sense to decrease available services because of the weekend. How can it be good for patient care?

While Saturdays and Sundays can be slower from an admitting standpoint, because there is no clinic activity to generate a percentage of admissions, Friday night is often one of the busiest admitting nights of the week; and those patients admitted then, along with everyone else who failed to discharge during the week, have to be cared for on the weekend. If there are sick patients, there should be services for those patients. This means that PICC teams, wound care, PT/OT, nutrition, MRI staff, consultant services, case managers, and even hospitalists should treat Saturday and Sunday like any other day, and that staffing should reflect that. How can I as a hospitalist meet the goals of the system and take care of the patient if I don’t have the resources?

©robuart/Thinkstock

What usually happens is that providers "cover" for each other, which in my opinion, leads to more stressed-out staff, decreased time spent with patients, and decreased quality of care. I bet patients can sense it. Consultants who are spread thin are more likely to bark at each other, and things are triaged to what can "wait until Monday." For the inpatient, should anything wait until Monday?

I think nothing is as compromised, from a hospitalist standpoint, as case management and discharge capabilities. On the hospital and skilled nursing facility sides, the stress and complexity of discharge situation drastically increases on the weekends, yet case management is reduced by more than half. Is it fair or even safe for patients to stay another expensive night in the hospital simply because it is a weekend or a holiday? As Fridays approach, I find myself planning discharges around the looming weekend. Sometimes, I am faced with choosing to either rush things to prepare for the Friday discharge or accepting that discharge will simply have to wait until Monday.

I suppose there are many reasons the system is the way it is, but the biggest factor, as always, is likely money.

Days off have to come from somewhere and if another provider is not going to "cover," the only other option is to hire more case managers, more hospitalists, more fellows, and more ancillary staff for PICC lines, physical therapy, MRIs, wound consults, and transition of care.

In the end, if our goals truly are to increase patient satisfaction, decrease complications, decrease length of stay, and decrease patient frustration, then we should start thinking of our inpatient health care system like we would the fire department or even Walmart: open and fully staffed 365 days a year. Because illness, like fire and capitalism, doesn’t take the weekend off.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Nearly a year after "starting out" on the inpatient wards as a new hospitalist, there has been one idiosyncrasy that I just can’t seem to understand: Hospitals and skilled nursing facilities decrease their staffing and services on the weekends. Though I was aware of this as a resident, because it was frustrating, now, as an attending, it’s nearly surreal. I am the one responsible for the length of stay, patient satisfaction scores, and health care cost savings, and it just doesn’t make sense to decrease available services because of the weekend. How can it be good for patient care?

While Saturdays and Sundays can be slower from an admitting standpoint, because there is no clinic activity to generate a percentage of admissions, Friday night is often one of the busiest admitting nights of the week; and those patients admitted then, along with everyone else who failed to discharge during the week, have to be cared for on the weekend. If there are sick patients, there should be services for those patients. This means that PICC teams, wound care, PT/OT, nutrition, MRI staff, consultant services, case managers, and even hospitalists should treat Saturday and Sunday like any other day, and that staffing should reflect that. How can I as a hospitalist meet the goals of the system and take care of the patient if I don’t have the resources?

©robuart/Thinkstock

What usually happens is that providers "cover" for each other, which in my opinion, leads to more stressed-out staff, decreased time spent with patients, and decreased quality of care. I bet patients can sense it. Consultants who are spread thin are more likely to bark at each other, and things are triaged to what can "wait until Monday." For the inpatient, should anything wait until Monday?

I think nothing is as compromised, from a hospitalist standpoint, as case management and discharge capabilities. On the hospital and skilled nursing facility sides, the stress and complexity of discharge situation drastically increases on the weekends, yet case management is reduced by more than half. Is it fair or even safe for patients to stay another expensive night in the hospital simply because it is a weekend or a holiday? As Fridays approach, I find myself planning discharges around the looming weekend. Sometimes, I am faced with choosing to either rush things to prepare for the Friday discharge or accepting that discharge will simply have to wait until Monday.

I suppose there are many reasons the system is the way it is, but the biggest factor, as always, is likely money.

Days off have to come from somewhere and if another provider is not going to "cover," the only other option is to hire more case managers, more hospitalists, more fellows, and more ancillary staff for PICC lines, physical therapy, MRIs, wound consults, and transition of care.

In the end, if our goals truly are to increase patient satisfaction, decrease complications, decrease length of stay, and decrease patient frustration, then we should start thinking of our inpatient health care system like we would the fire department or even Walmart: open and fully staffed 365 days a year. Because illness, like fire and capitalism, doesn’t take the weekend off.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Nearly a year after "starting out" on the inpatient wards as a new hospitalist, there has been one idiosyncrasy that I just can’t seem to understand: Hospitals and skilled nursing facilities decrease their staffing and services on the weekends. Though I was aware of this as a resident, because it was frustrating, now, as an attending, it’s nearly surreal. I am the one responsible for the length of stay, patient satisfaction scores, and health care cost savings, and it just doesn’t make sense to decrease available services because of the weekend. How can it be good for patient care?

While Saturdays and Sundays can be slower from an admitting standpoint, because there is no clinic activity to generate a percentage of admissions, Friday night is often one of the busiest admitting nights of the week; and those patients admitted then, along with everyone else who failed to discharge during the week, have to be cared for on the weekend. If there are sick patients, there should be services for those patients. This means that PICC teams, wound care, PT/OT, nutrition, MRI staff, consultant services, case managers, and even hospitalists should treat Saturday and Sunday like any other day, and that staffing should reflect that. How can I as a hospitalist meet the goals of the system and take care of the patient if I don’t have the resources?

©robuart/Thinkstock

What usually happens is that providers "cover" for each other, which in my opinion, leads to more stressed-out staff, decreased time spent with patients, and decreased quality of care. I bet patients can sense it. Consultants who are spread thin are more likely to bark at each other, and things are triaged to what can "wait until Monday." For the inpatient, should anything wait until Monday?

I think nothing is as compromised, from a hospitalist standpoint, as case management and discharge capabilities. On the hospital and skilled nursing facility sides, the stress and complexity of discharge situation drastically increases on the weekends, yet case management is reduced by more than half. Is it fair or even safe for patients to stay another expensive night in the hospital simply because it is a weekend or a holiday? As Fridays approach, I find myself planning discharges around the looming weekend. Sometimes, I am faced with choosing to either rush things to prepare for the Friday discharge or accepting that discharge will simply have to wait until Monday.

I suppose there are many reasons the system is the way it is, but the biggest factor, as always, is likely money.

Days off have to come from somewhere and if another provider is not going to "cover," the only other option is to hire more case managers, more hospitalists, more fellows, and more ancillary staff for PICC lines, physical therapy, MRIs, wound consults, and transition of care.

In the end, if our goals truly are to increase patient satisfaction, decrease complications, decrease length of stay, and decrease patient frustration, then we should start thinking of our inpatient health care system like we would the fire department or even Walmart: open and fully staffed 365 days a year. Because illness, like fire and capitalism, doesn’t take the weekend off.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

The Advisory Council for Rural Surgery will be 2 years old in June 2014. Its creation resulted from the realization of ACS Leaders such as J. David Richardson, Brent Eastman, Patricia Numann, and the Board of Regents that a crisis was in process regarding surgical access in rural America.

The recognized crises in rural surgery are of interest to all surgeons. The core of therural surgical crisis is not just the access to surgical care for the estimated 60 million people of North America living in rural environs, but the role and sustainability of general surgery as a specialty in itself. General surgery, the parent of almost every specialty, has suffered a gradual attrition of its field through abdication or specialization.

While not universal, the shift from surgical training to creating specialist surgeons who take care of limited areas of anatomy leaves the American public facing a fragmented surgical world and, in those places where there cannot be multiple surgical "superspecialists," patients’ lives and well-being will depend on well-trained general surgeons in small communities and rural areas.

The Rural Council is wrestling with these large and fundamental questions. How do we train and support surgeons who must work in geographically or temporally isolated areas? Of the 1,200 residents graduating from ACGME-accredited general surgical residencies, only 30% seek broad-based practice, which amounts to 360 surgeons per year. Of those 360, about 10% –-– 36 surgeons – will practice in rural areas. More than 500 hospitals are deemed Critical Access and do general surgery. On the ACS rural listserv, there are 1,000 rural-based surgeons; 52% of rural surgeons are within 10 years of retirement (not to mention attrition from other sources such as health or burnout). A simple calculation proves that not enough surgeons will be there for those rural patients. A helicopter or runway does not equal surgical access. It takes the cognitive skills of a general surgeon to know who truly requires surgical care and what type.

Given these facts, new approaches to retaining surgical access in rural areas are coming either through proactive planning by surgeons or as a result of other parties with other interests "solving" the crisis.

Centralization is attractive to policy makers, but not to the rural patient 50-100 miles away on a snowy night. In the Affordable Care Act legislation, the ACS was able to procure a 10% increase in reimbursement for surgeons in underserved rural areas, which is appreciated. However, the motivation to practice in rural locales is not and will not be driven solely by money, for the joy of rural practice lies in the fulfillment of doing a difficult job well for an entire community in which one becomes an integral part. Finding ways to make that sort of surgical life possible to young men and women is the best answer.

The Advisory Council for Rural Surgery therefore is touching many areas of surgery and the ACS. Like the rest of the College, we function in five pillars – Education, Optimal Care/Quality, Membership Services, Communications, and Advocacy. Each pillar is actively engaged. Education, under Karen Deveney, is working on templates for rural tracks in general surgery residency programs in alignment with ABS and RRC requirements as well as medical student and postresidency surgeon education. Optimal Care, under Don Nakayama, is developing infrastructure standards for rural hospitals as well as research mechanisms for rural surgeons to develop their data. Membership Service, under Mike Sarap, works on recruitment and retention of rural surgeons, call relief strategies, and community-based services on oncology issues. Advocacy is well guided by Mark Savaris, who in particular is working on repeal of the infamous 96-hour rule that threatens surgical access in some of our most-remote hospitals. The Communication pillar, under Phil Caropreso, has made enormous strides through the development of a rural listserv, which allows rural surgeons to communicate in real time on subjects ranging from case review to practice management. Through Dr. Caropreso’s tireless efforts, 1,000 surgeons communicate approximately 20-100 times a day. In total, more than 5 million e-mails have been distributed in 18 months. Soon, this will morph into the Rural Surgical Community, with much-improved software, which also will be used by the rest of the College Fellows in their respective fields of interest.

Rural surgeons, like most surgeons, pride themselves on being individualists who can solve problems with limited resources. The Advisory Council for Rural Surgery is helping these individuals find a common place for education, advocacy, quality care, communication, and fellowship. Rural surgery is transforming from disparate surgeons in isolated areas to a common group of Fellows dedicated to the highest principles of the American College of Surgeons.

Dr. Hughes, an ACS Fellow, is a general surgeon practicing in McPherson, Kan., and chair of the ACS Advisory Council for Rural Surgery.

The Advisory Council for Rural Surgery will be 2 years old in June 2014. Its creation resulted from the realization of ACS Leaders such as J. David Richardson, Brent Eastman, Patricia Numann, and the Board of Regents that a crisis was in process regarding surgical access in rural America.

The recognized crises in rural surgery are of interest to all surgeons. The core of therural surgical crisis is not just the access to surgical care for the estimated 60 million people of North America living in rural environs, but the role and sustainability of general surgery as a specialty in itself. General surgery, the parent of almost every specialty, has suffered a gradual attrition of its field through abdication or specialization.

While not universal, the shift from surgical training to creating specialist surgeons who take care of limited areas of anatomy leaves the American public facing a fragmented surgical world and, in those places where there cannot be multiple surgical "superspecialists," patients’ lives and well-being will depend on well-trained general surgeons in small communities and rural areas.

The Rural Council is wrestling with these large and fundamental questions. How do we train and support surgeons who must work in geographically or temporally isolated areas? Of the 1,200 residents graduating from ACGME-accredited general surgical residencies, only 30% seek broad-based practice, which amounts to 360 surgeons per year. Of those 360, about 10% –-– 36 surgeons – will practice in rural areas. More than 500 hospitals are deemed Critical Access and do general surgery. On the ACS rural listserv, there are 1,000 rural-based surgeons; 52% of rural surgeons are within 10 years of retirement (not to mention attrition from other sources such as health or burnout). A simple calculation proves that not enough surgeons will be there for those rural patients. A helicopter or runway does not equal surgical access. It takes the cognitive skills of a general surgeon to know who truly requires surgical care and what type.

Given these facts, new approaches to retaining surgical access in rural areas are coming either through proactive planning by surgeons or as a result of other parties with other interests "solving" the crisis.

Centralization is attractive to policy makers, but not to the rural patient 50-100 miles away on a snowy night. In the Affordable Care Act legislation, the ACS was able to procure a 10% increase in reimbursement for surgeons in underserved rural areas, which is appreciated. However, the motivation to practice in rural locales is not and will not be driven solely by money, for the joy of rural practice lies in the fulfillment of doing a difficult job well for an entire community in which one becomes an integral part. Finding ways to make that sort of surgical life possible to young men and women is the best answer.

The Advisory Council for Rural Surgery therefore is touching many areas of surgery and the ACS. Like the rest of the College, we function in five pillars – Education, Optimal Care/Quality, Membership Services, Communications, and Advocacy. Each pillar is actively engaged. Education, under Karen Deveney, is working on templates for rural tracks in general surgery residency programs in alignment with ABS and RRC requirements as well as medical student and postresidency surgeon education. Optimal Care, under Don Nakayama, is developing infrastructure standards for rural hospitals as well as research mechanisms for rural surgeons to develop their data. Membership Service, under Mike Sarap, works on recruitment and retention of rural surgeons, call relief strategies, and community-based services on oncology issues. Advocacy is well guided by Mark Savaris, who in particular is working on repeal of the infamous 96-hour rule that threatens surgical access in some of our most-remote hospitals. The Communication pillar, under Phil Caropreso, has made enormous strides through the development of a rural listserv, which allows rural surgeons to communicate in real time on subjects ranging from case review to practice management. Through Dr. Caropreso’s tireless efforts, 1,000 surgeons communicate approximately 20-100 times a day. In total, more than 5 million e-mails have been distributed in 18 months. Soon, this will morph into the Rural Surgical Community, with much-improved software, which also will be used by the rest of the College Fellows in their respective fields of interest.

Rural surgeons, like most surgeons, pride themselves on being individualists who can solve problems with limited resources. The Advisory Council for Rural Surgery is helping these individuals find a common place for education, advocacy, quality care, communication, and fellowship. Rural surgery is transforming from disparate surgeons in isolated areas to a common group of Fellows dedicated to the highest principles of the American College of Surgeons.

Dr. Hughes, an ACS Fellow, is a general surgeon practicing in McPherson, Kan., and chair of the ACS Advisory Council for Rural Surgery.

The Advisory Council for Rural Surgery will be 2 years old in June 2014. Its creation resulted from the realization of ACS Leaders such as J. David Richardson, Brent Eastman, Patricia Numann, and the Board of Regents that a crisis was in process regarding surgical access in rural America.

The recognized crises in rural surgery are of interest to all surgeons. The core of therural surgical crisis is not just the access to surgical care for the estimated 60 million people of North America living in rural environs, but the role and sustainability of general surgery as a specialty in itself. General surgery, the parent of almost every specialty, has suffered a gradual attrition of its field through abdication or specialization.

While not universal, the shift from surgical training to creating specialist surgeons who take care of limited areas of anatomy leaves the American public facing a fragmented surgical world and, in those places where there cannot be multiple surgical "superspecialists," patients’ lives and well-being will depend on well-trained general surgeons in small communities and rural areas.

The Rural Council is wrestling with these large and fundamental questions. How do we train and support surgeons who must work in geographically or temporally isolated areas? Of the 1,200 residents graduating from ACGME-accredited general surgical residencies, only 30% seek broad-based practice, which amounts to 360 surgeons per year. Of those 360, about 10% –-– 36 surgeons – will practice in rural areas. More than 500 hospitals are deemed Critical Access and do general surgery. On the ACS rural listserv, there are 1,000 rural-based surgeons; 52% of rural surgeons are within 10 years of retirement (not to mention attrition from other sources such as health or burnout). A simple calculation proves that not enough surgeons will be there for those rural patients. A helicopter or runway does not equal surgical access. It takes the cognitive skills of a general surgeon to know who truly requires surgical care and what type.

Given these facts, new approaches to retaining surgical access in rural areas are coming either through proactive planning by surgeons or as a result of other parties with other interests "solving" the crisis.

Centralization is attractive to policy makers, but not to the rural patient 50-100 miles away on a snowy night. In the Affordable Care Act legislation, the ACS was able to procure a 10% increase in reimbursement for surgeons in underserved rural areas, which is appreciated. However, the motivation to practice in rural locales is not and will not be driven solely by money, for the joy of rural practice lies in the fulfillment of doing a difficult job well for an entire community in which one becomes an integral part. Finding ways to make that sort of surgical life possible to young men and women is the best answer.

The Advisory Council for Rural Surgery therefore is touching many areas of surgery and the ACS. Like the rest of the College, we function in five pillars – Education, Optimal Care/Quality, Membership Services, Communications, and Advocacy. Each pillar is actively engaged. Education, under Karen Deveney, is working on templates for rural tracks in general surgery residency programs in alignment with ABS and RRC requirements as well as medical student and postresidency surgeon education. Optimal Care, under Don Nakayama, is developing infrastructure standards for rural hospitals as well as research mechanisms for rural surgeons to develop their data. Membership Service, under Mike Sarap, works on recruitment and retention of rural surgeons, call relief strategies, and community-based services on oncology issues. Advocacy is well guided by Mark Savaris, who in particular is working on repeal of the infamous 96-hour rule that threatens surgical access in some of our most-remote hospitals. The Communication pillar, under Phil Caropreso, has made enormous strides through the development of a rural listserv, which allows rural surgeons to communicate in real time on subjects ranging from case review to practice management. Through Dr. Caropreso’s tireless efforts, 1,000 surgeons communicate approximately 20-100 times a day. In total, more than 5 million e-mails have been distributed in 18 months. Soon, this will morph into the Rural Surgical Community, with much-improved software, which also will be used by the rest of the College Fellows in their respective fields of interest.

Rural surgeons, like most surgeons, pride themselves on being individualists who can solve problems with limited resources. The Advisory Council for Rural Surgery is helping these individuals find a common place for education, advocacy, quality care, communication, and fellowship. Rural surgery is transforming from disparate surgeons in isolated areas to a common group of Fellows dedicated to the highest principles of the American College of Surgeons.

Dr. Hughes, an ACS Fellow, is a general surgeon practicing in McPherson, Kan., and chair of the ACS Advisory Council for Rural Surgery.

Life is short, and the Art long to learn.

–Chaucer

If you are anything like us, you still hold firmly to the notion that medicine, at its core, is an art. Sure, medicine is informed by cutting-edge sciences, such as biochemistry and molecular biology. But one can’t capture the nuances of the patient interaction by studying the Krebs cycle, nor define the motivating forces driving physicians by looking through a microscope. On the contrary, physicians are artists, much like musicians, sculptors, or dancers. And, like any of these artists, it would seem that a physician’s craft should improve through "practice," not by studying data or using a computer. So how do we reconcile this in the era of "Big Data"? How can the "ones and zeros" living deep in the "guts" of our electronic health records (EHRs) promise to revolutionize an art that has relied solely on the judgment – or gut sense – of physicians for centuries? Here we will attempt to answer these questions and ponder whether or not we really can improve the art of medicine with the help of data.

It’s more than the ‘ones and zeros’

With the right information and the proper tools to analyze it, it is possible to conceive of an improvement in our ability to care for patients. Take, for example, the prevention of malignancies. Currently, early detection of cancer relies heavily on a physician’s knowledge of – and compliance with – current cancer screening guidelines. Success also depends on a patient’s willingness to come in for annual visits to receive the instruction. If the patient doesn’t show up for a physical, or if the provider neglects to mention the need for a colonoscopy when the patient does appear, the test may go unordered (much to the patient’s relief, perhaps!). But the right tools and analytics won’t let that happen. Instead, the technology will identify the highest-risk populations with ever-improving accuracy and notify both physician and patient of the need for action. With enough data, we may even be able to make observations in trends of cancer inheritance never before possible and predict cancer long before it might be detected by conventional screening protocols.

It pays to care about the data

Physicians may not realize it, but data can have a significant financial advantage, by improving reimbursement and decreasing the overall cost of care. This can be achieved in two ways. The first way is by using the data to paint a more accurate picture of patient complexity. Medicare assigns a risk-adjusted score to patient cohorts based on the severity of their diagnoses and reimburses Medicare Advantage plans based on that score: the higher the score, the better the reimbursement. Occasionally, those additional dollars are passed along to the treating physicians. But all too often physicians do not use ICD-9 codes properly on their claims, making their patients appear less complicated and thereby receiving lower reimbursement. Through emerging data collection tools, improper coding can be identified and corrected, and missed opportunities can be discovered early enough to capture additional funds.

The second way these tools can be used leads to direct benefit to the health care system in general, through improved medical cost management. By interfacing with insurers and analyzing claims, the software can identify patients who are high utilizers and can show trends in medical costs across a community or health system. This allows providers to target certain patients or disease states around which to build cost-containment strategies and create win-win scenarios that decrease hospital readmissions, limit cost, and improve patient quality of life.

We recently learned of a great example of this. Using a population management data tool, a community health system was able to identify a geographic area in their region with a large uninsured population. This group had a disproportionately high utilization of emergency medical services and very low care quality markers (such as diabetes control, vaccination rates, etc.). Through targeted outreach based on these data, the system was able to direct individuals into low-cost, high-quality primary care sites and reduce emergency service utilization to levels below the surrounding neighborhoods. Simultaneously, the health of the community improved through better disease management and care coordination. Finally, data analytics tools uncovered additional opportunities for savings by identifying expensive brand-name drug prescriptions that could be replaced with generic drug alternatives.

A reluctant revolution

As we have lamented on previous occasions, the adoption of health care information technology is often driven by artificial external forces, such as stimulus programs or regulatory requirements. The government has routinely used incentive payments and reimbursement adjustments in order to spur widespread acceptance of EHRs. Most infamously, the Meaningful Use Regulations program has become the poster child for government involvement in direct patient care. Through the use of annual payments over a 5-year period (combined with the threat of penalties for lack of compliance), Meaningful Use has almost single-handedly enabled the Big Data revolution in health care by requiring physicians to purchase electronic health records systems and use them for population management. While seemingly a good thing, most physicians would hardly regard these systems as "meaningful." In fact, many question if there is any value in having an electronic record at all.

Whether or not their detractors admit it, EHRs do form the backbone of a new and very powerful information network – one which many believe has the power to revolutionize health care. While we certainly do not view the "data revolution" as the panacea others have claimed it to be, we do recognize that the right tools are emerging to enable physicians to learn from data and implement new, novel, and "disruptive" strategies to improve patient care.

Art is not static; the canvas, the paints, and the viewpoints change over time as experience evolves. Leonardo da Vinci furthered the world’s understanding of perspective. Pablo Picasso led a revolution in modern art. Each was different from his predecessors, and each expressed a human need to understand and portray the world in a manner consistent with his age. The same is true of our age and the art of medicine. The science has changed, as has the viewpoint and perspective from which we provide care. Our ability to record, retrieve, and understand health and disease will never be the same. But the attention to the patient is ever present. The necessity of interpreting the shifting world of health and disease to provide an empathic understanding of each patient’s individual and unique place in the world will never go away. Therein lies the Art.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.

Life is short, and the Art long to learn.

–Chaucer

If you are anything like us, you still hold firmly to the notion that medicine, at its core, is an art. Sure, medicine is informed by cutting-edge sciences, such as biochemistry and molecular biology. But one can’t capture the nuances of the patient interaction by studying the Krebs cycle, nor define the motivating forces driving physicians by looking through a microscope. On the contrary, physicians are artists, much like musicians, sculptors, or dancers. And, like any of these artists, it would seem that a physician’s craft should improve through "practice," not by studying data or using a computer. So how do we reconcile this in the era of "Big Data"? How can the "ones and zeros" living deep in the "guts" of our electronic health records (EHRs) promise to revolutionize an art that has relied solely on the judgment – or gut sense – of physicians for centuries? Here we will attempt to answer these questions and ponder whether or not we really can improve the art of medicine with the help of data.

It’s more than the ‘ones and zeros’

With the right information and the proper tools to analyze it, it is possible to conceive of an improvement in our ability to care for patients. Take, for example, the prevention of malignancies. Currently, early detection of cancer relies heavily on a physician’s knowledge of – and compliance with – current cancer screening guidelines. Success also depends on a patient’s willingness to come in for annual visits to receive the instruction. If the patient doesn’t show up for a physical, or if the provider neglects to mention the need for a colonoscopy when the patient does appear, the test may go unordered (much to the patient’s relief, perhaps!). But the right tools and analytics won’t let that happen. Instead, the technology will identify the highest-risk populations with ever-improving accuracy and notify both physician and patient of the need for action. With enough data, we may even be able to make observations in trends of cancer inheritance never before possible and predict cancer long before it might be detected by conventional screening protocols.

It pays to care about the data

Physicians may not realize it, but data can have a significant financial advantage, by improving reimbursement and decreasing the overall cost of care. This can be achieved in two ways. The first way is by using the data to paint a more accurate picture of patient complexity. Medicare assigns a risk-adjusted score to patient cohorts based on the severity of their diagnoses and reimburses Medicare Advantage plans based on that score: the higher the score, the better the reimbursement. Occasionally, those additional dollars are passed along to the treating physicians. But all too often physicians do not use ICD-9 codes properly on their claims, making their patients appear less complicated and thereby receiving lower reimbursement. Through emerging data collection tools, improper coding can be identified and corrected, and missed opportunities can be discovered early enough to capture additional funds.

The second way these tools can be used leads to direct benefit to the health care system in general, through improved medical cost management. By interfacing with insurers and analyzing claims, the software can identify patients who are high utilizers and can show trends in medical costs across a community or health system. This allows providers to target certain patients or disease states around which to build cost-containment strategies and create win-win scenarios that decrease hospital readmissions, limit cost, and improve patient quality of life.

We recently learned of a great example of this. Using a population management data tool, a community health system was able to identify a geographic area in their region with a large uninsured population. This group had a disproportionately high utilization of emergency medical services and very low care quality markers (such as diabetes control, vaccination rates, etc.). Through targeted outreach based on these data, the system was able to direct individuals into low-cost, high-quality primary care sites and reduce emergency service utilization to levels below the surrounding neighborhoods. Simultaneously, the health of the community improved through better disease management and care coordination. Finally, data analytics tools uncovered additional opportunities for savings by identifying expensive brand-name drug prescriptions that could be replaced with generic drug alternatives.

A reluctant revolution

As we have lamented on previous occasions, the adoption of health care information technology is often driven by artificial external forces, such as stimulus programs or regulatory requirements. The government has routinely used incentive payments and reimbursement adjustments in order to spur widespread acceptance of EHRs. Most infamously, the Meaningful Use Regulations program has become the poster child for government involvement in direct patient care. Through the use of annual payments over a 5-year period (combined with the threat of penalties for lack of compliance), Meaningful Use has almost single-handedly enabled the Big Data revolution in health care by requiring physicians to purchase electronic health records systems and use them for population management. While seemingly a good thing, most physicians would hardly regard these systems as "meaningful." In fact, many question if there is any value in having an electronic record at all.

Whether or not their detractors admit it, EHRs do form the backbone of a new and very powerful information network – one which many believe has the power to revolutionize health care. While we certainly do not view the "data revolution" as the panacea others have claimed it to be, we do recognize that the right tools are emerging to enable physicians to learn from data and implement new, novel, and "disruptive" strategies to improve patient care.

Art is not static; the canvas, the paints, and the viewpoints change over time as experience evolves. Leonardo da Vinci furthered the world’s understanding of perspective. Pablo Picasso led a revolution in modern art. Each was different from his predecessors, and each expressed a human need to understand and portray the world in a manner consistent with his age. The same is true of our age and the art of medicine. The science has changed, as has the viewpoint and perspective from which we provide care. Our ability to record, retrieve, and understand health and disease will never be the same. But the attention to the patient is ever present. The necessity of interpreting the shifting world of health and disease to provide an empathic understanding of each patient’s individual and unique place in the world will never go away. Therein lies the Art.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.

Life is short, and the Art long to learn.

–Chaucer

If you are anything like us, you still hold firmly to the notion that medicine, at its core, is an art. Sure, medicine is informed by cutting-edge sciences, such as biochemistry and molecular biology. But one can’t capture the nuances of the patient interaction by studying the Krebs cycle, nor define the motivating forces driving physicians by looking through a microscope. On the contrary, physicians are artists, much like musicians, sculptors, or dancers. And, like any of these artists, it would seem that a physician’s craft should improve through "practice," not by studying data or using a computer. So how do we reconcile this in the era of "Big Data"? How can the "ones and zeros" living deep in the "guts" of our electronic health records (EHRs) promise to revolutionize an art that has relied solely on the judgment – or gut sense – of physicians for centuries? Here we will attempt to answer these questions and ponder whether or not we really can improve the art of medicine with the help of data.

It’s more than the ‘ones and zeros’

With the right information and the proper tools to analyze it, it is possible to conceive of an improvement in our ability to care for patients. Take, for example, the prevention of malignancies. Currently, early detection of cancer relies heavily on a physician’s knowledge of – and compliance with – current cancer screening guidelines. Success also depends on a patient’s willingness to come in for annual visits to receive the instruction. If the patient doesn’t show up for a physical, or if the provider neglects to mention the need for a colonoscopy when the patient does appear, the test may go unordered (much to the patient’s relief, perhaps!). But the right tools and analytics won’t let that happen. Instead, the technology will identify the highest-risk populations with ever-improving accuracy and notify both physician and patient of the need for action. With enough data, we may even be able to make observations in trends of cancer inheritance never before possible and predict cancer long before it might be detected by conventional screening protocols.

It pays to care about the data

Physicians may not realize it, but data can have a significant financial advantage, by improving reimbursement and decreasing the overall cost of care. This can be achieved in two ways. The first way is by using the data to paint a more accurate picture of patient complexity. Medicare assigns a risk-adjusted score to patient cohorts based on the severity of their diagnoses and reimburses Medicare Advantage plans based on that score: the higher the score, the better the reimbursement. Occasionally, those additional dollars are passed along to the treating physicians. But all too often physicians do not use ICD-9 codes properly on their claims, making their patients appear less complicated and thereby receiving lower reimbursement. Through emerging data collection tools, improper coding can be identified and corrected, and missed opportunities can be discovered early enough to capture additional funds.

The second way these tools can be used leads to direct benefit to the health care system in general, through improved medical cost management. By interfacing with insurers and analyzing claims, the software can identify patients who are high utilizers and can show trends in medical costs across a community or health system. This allows providers to target certain patients or disease states around which to build cost-containment strategies and create win-win scenarios that decrease hospital readmissions, limit cost, and improve patient quality of life.

We recently learned of a great example of this. Using a population management data tool, a community health system was able to identify a geographic area in their region with a large uninsured population. This group had a disproportionately high utilization of emergency medical services and very low care quality markers (such as diabetes control, vaccination rates, etc.). Through targeted outreach based on these data, the system was able to direct individuals into low-cost, high-quality primary care sites and reduce emergency service utilization to levels below the surrounding neighborhoods. Simultaneously, the health of the community improved through better disease management and care coordination. Finally, data analytics tools uncovered additional opportunities for savings by identifying expensive brand-name drug prescriptions that could be replaced with generic drug alternatives.

A reluctant revolution

As we have lamented on previous occasions, the adoption of health care information technology is often driven by artificial external forces, such as stimulus programs or regulatory requirements. The government has routinely used incentive payments and reimbursement adjustments in order to spur widespread acceptance of EHRs. Most infamously, the Meaningful Use Regulations program has become the poster child for government involvement in direct patient care. Through the use of annual payments over a 5-year period (combined with the threat of penalties for lack of compliance), Meaningful Use has almost single-handedly enabled the Big Data revolution in health care by requiring physicians to purchase electronic health records systems and use them for population management. While seemingly a good thing, most physicians would hardly regard these systems as "meaningful." In fact, many question if there is any value in having an electronic record at all.

Whether or not their detractors admit it, EHRs do form the backbone of a new and very powerful information network – one which many believe has the power to revolutionize health care. While we certainly do not view the "data revolution" as the panacea others have claimed it to be, we do recognize that the right tools are emerging to enable physicians to learn from data and implement new, novel, and "disruptive" strategies to improve patient care.

Art is not static; the canvas, the paints, and the viewpoints change over time as experience evolves. Leonardo da Vinci furthered the world’s understanding of perspective. Pablo Picasso led a revolution in modern art. Each was different from his predecessors, and each expressed a human need to understand and portray the world in a manner consistent with his age. The same is true of our age and the art of medicine. The science has changed, as has the viewpoint and perspective from which we provide care. Our ability to record, retrieve, and understand health and disease will never be the same. But the attention to the patient is ever present. The necessity of interpreting the shifting world of health and disease to provide an empathic understanding of each patient’s individual and unique place in the world will never go away. Therein lies the Art.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.