Letters COMMENTS
AND
Annals of Internal Medicine RESPONSES
Disclaimer: Drs. Moriates, Shah, and Arora are affiliated with Costs of
Care, a nonprofit organization dedicated to reducing medical bills for patients.
Primary Nonadherence With Prescribed Medication
Disclosures: Disclosures can be viewed at www.acponline.org/authors /icmje/ConflictOfInterestForms.do?msNum⫽L14-0294.
TO THE EDITOR: As Tamblyn and colleagues (1) highlighted, the
out-of-pocket costs of medications have led many patients to forgo recommended treatments. Nearly 1 of every 3 new prescriptions is not filled by patients, further supporting the expansive scope of this problem. The authors appropriately call for policy initiatives, such as copayment waivers for medications needed for chronic conditions. Although these policies are important, clinicians must not wait for them to be enacted before helping patients navigate cost-related nonadherence. Teaching clinicians to address patients’ concerns about out-ofpocket drug costs is vital to improving their health and well-being. Although most patients report a desire to talk to their providers about these costs, only 15% of patients say that they have ever done so and only 16% believe that their physicians were aware of the magnitude of their out-of-pocket costs (2). Moreover, patients whose providers do not ask about the problem of medication costs have a more negative perception regarding their clinicians’ overall interest and potential ability to assist them (3). Lastly, physician discussion of drug costs with patients is strongly associated with switching to a medication that costs less (4). If clinicians strive to provide truly “patient-centered care,” they must no longer ignore a problem that is central to patient experience and their health. In our teaching, we recommend 3 specific questions to ask patients while taking a medication history to detect costrelated nonadherence: 1) Do your medications cost too much? 2) Have you ever cut back on medications because of cost? and 3) Have you ever cut back on other things (for example, food and leisure activities) because of high drug costs? (5). By proactively identifying patients who will have problems paying for their medications, clinicians can initiate a conversation about strategies to reduce out-ofpocket costs, including such potential alternatives as generic drugs or other therapeutic options. Making such screening routine, similar to what is done with preferences for advanced directives, could help alleviate patient or physician discomfort with this topic. The American College of Physicians’ High-Value Care curriculum (www.highvaluecarecurricu lum.org) and the Costs of Care Teaching Value Project (www .teachingvalue.org) offer free teaching modules for clinicians to provide strategies to address patients’ medication costs. It is time that we at least start talking about these costs with our patients. Christopher Moriates, MD University of California, San Francisco San Francisco, California Neel Shah, MD, MPP Harvard Medical School Boston, Massachusetts Vineet Arora, MD, MAPP University of Chicago Chicago, Illinois
References 1. Tamblyn R, Eguale T, Huang A, Winslade N, Doran P. The incidence and determinants of primary nonadherence with prescribed medication in primary care: a cohort study. Ann Intern Med. 2014;160:441-50. [PMID: 24687067] doi:10.7326/M13 -1705 2. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA. 2003;290:953-8. [PMID: 12928475] 3. Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Arch Intern Med. 2004;164:1749-55. [PMID: 15364667] 4. Wilson IB, Schoen C, Neuman P, Strollo MK, Rogers WH, Chang H, et al. Physician-patient communication about prescription medication nonadherence: a 50-state study of America’s seniors. J Gen Intern Med. 2007;22:6-12. [PMID: 17351835] 5. Arora V, Kumar R, Levy A, Saathoff M, Farnan J, Shah N. GOT MeDS: designing and piloting an interactive module for trainees on reducing drug costs. J Gen Intern Med. 2013;28 Suppl 1:S464-5.
Effectiveness of Combination Therapy With Statin and Another Lipid-Modifying Agent Compared With Intensified Statin Monotherapy TO THE EDITOR: Gudzune and colleagues (1) have reported a study
on the effect of combination therapy with statin and other lipidmodifying agents, such as bile acid sequestrants and ezetimibe. This study had several important findings about combination therapy but also had several substantial problems, and the results should be carefully interpreted from various perspectives. It, indeed, revealed that combination therapy significantly decreased low-density lipoprotein cholesterol levels compared with mid- to high-intensity statin monotherapy. However, this finding does not mean that combination therapy is better than statin monotherapy. Combination therapy may not be superior to high-intensity statin monotherapy at improving the outcomes of deaths and cardiovascular events (2). Whether combination therapy could achieve better targets for low-density lipoprotein cholesterol than statin monotherapy also is unclear. Moreover, low-intensity statins in combination therapy may have fewer pleiotropic effects than highintensity statins (3). In addition, the cost-effectiveness and long-term cancer risk associated with combination therapy with statins and ezetimibe should be assessed (4, 5). Therefore, it may be too early to predict the beneficial effects of combination therapy as a therapeutic option for patients at high risk for atherosclerotic cardiovascular disease. Further studies are required to elucidate strategies to better manage such patients. Tetsuro Tsujimoto, MD Ritsuko Yamamoto-Honda, MD, PhD National Center for Global Health and Medicine Tokyo, Japan
678 © 2014 American College of Physicians
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/931019/ by a Tufts University User on 07/26/2017
Letters Disclosures: Authors have disclosed no conflicts of interest. Forms can
be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0259. References 1. Gudzune KA, Monroe AK, Sharma R, Ranasinghe PD, Chelladurai Y, Robinson KA. Effectiveness of combination therapy with statin and another lipid-modifying agent compared with intensified statin monotherapy: a systematic review. Ann Intern Med. 2014;160:468-76. [PMID: 24514899] doi:10.7326/M13-2526 2. Sharma M, Ansari MT, Abou-Setta AM, Soares-Weiser K, Ooi TC, Sears M, et al. Systematic review: comparative effectiveness and harms of combination therapy and monotherapy for dyslipidemia. Ann Intern Med. 2009;151:622-30. [PMID: 19884623] doi:10.7326/0003-4819-151-9-200911030-00144 3. Davignon J. Beneficial cardiovascular pleiotropic effects of statins. Circulation. 2004;109:III39-43. [PMID: 15198965] 4. Pletcher MJ, Lazar L, Bibbins-Domingo K, Moran A, Rodondi N, Coxson P, et al. Comparing impact and cost-effectiveness of primary prevention strategies for lipidlowering. Ann Intern Med. 2009;150:243-54. [PMID: 19221376] 5. Peto R, Emberson J, Landray M, Baigent C, Collins R, Clare R, et al. Analyses of cancer data from three ezetimibe trials. N Engl J Med. 2008;359:1357-66. [PMID: 18765432] doi:10.1056/NEJMsa0806603
Electronic Health Records TO THE EDITOR: I could not agree more with Sinsky and colleagues’ (1) observations, premise, and proposed principles to support highervalue primary care through electronic health records (EHRs). My concern is that their recommendations come about 10 years too late! Where were the institutional leaders of primary care and internal medicine to promote the authors’ recommendations when first- and now second-generation EHRs were being designed and installed? The corporate axiom remains true: If you don’t have a seat at the table, you’ll find yourself on the menu. Organized medicine’s— and particularly primary care’s—strategy of reactive response (let’s see how commercially available EHRs function, then we can make changes) as opposed to demanding proactive involvement continues to leave us weakly positioned to effect such changes. Leadership requires a change in this failed strategy. After a year of preparation and a major financial investment, my institution has just “gone live” with a new, all-encompassing EHR from a company that has now acquired the largest share of the EHR market. It resembles our prior EHR, which was a constant source of frustration and aggravation, but on steroids! The authors’ proposals face numerous real obstacles. With many practices and institutions already heavily invested in nextgeneration EHRs, what will be their incentives to buy new systems? The root of the problem for physicians and their interests is that the primary purpose, design, and directive of the EHR from its inception (facilitating the transmission of clinically useful information) has been hijacked by economically driven interests and advanced by the mutually beneficial alliance of institutional health care providers as billers and the insurance industry (as well as Medicare), which has financial interests as payors. Organized medicine regrettably did not oppose this hijacking. Current EHRs still function primarily as systems for enacting billing and payment, grading physicians, and collecting “quality measures.” Where does that leave the EHR industry’s incentives to implement the authors’ proposals? More important, where do the www.annals.org
authors and their organizations and foundations find the leverage to implement their recommendations? Primary care providers bear the brunt of the “pain” inflicted by not only the EHR but also the major changes buffeting our onceproud specialty of internal medicine. In my practice, the medical home is viewed as the repository of all information to be provided to other (specialty) physicians, preoperative screening units, referral and network managers, health insurers, quality measurers, pharmacy benefit managers, prior authorizers, visiting nurses, home care providers, disability adjudicators, college health services, and a host of others and for attending physician statements for life and long-term care insurance. Providing this information involves time and expense, none of which is compensated except for the moment spent preparing an attending physician statement. My medical home is not a happy one, especially after spending at least 3 hours every day on administrative chores of dubious value after the last patient leaves. Primary care just doesn’t have the “juice” to enforce change. So, primary care physicians are moving away from this field in substantial numbers. It is telling that a cardiac surgeon whom I care for, and complain to, mentioned that he and his colleagues are “so insulated” from the EHR that they barely take note of it. The orthopedic surgeons “can’t be bothered” with the EHR; they dictate their notes or use a scribe. Some of the notes from our specialty colleagues are so heavily templated and identical that I read only the concluding, usually brief, assessment and plan, knowing that it is the only relevant information coming directly from them. The greater the reimbursement for the encounter, the less burdensome the involvement with the EHR. Not a good position for primary care. I appreciate the authors’ efforts, but it will take more than a declaration of principles to effect meaningful change. Strong and dedicated leadership, which is sorely missing, is essential. Unfortunately, I doubt that I’ll see it while I’m still practicing. Michael E. Miller, MD Boston University Affiliated Physicians Boston, Massachusetts Disclosures: Authors have disclosed no conflicts of interest. Forms can
be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0331.
Reference 1. Sinsky CA, Beasley JW, Simmons GE, Baron RJ. Electronic health records: design, implementation, and policy for higher-value primary care. Ann Intern Med. 2014;160: 727-8. [PMID: 24842418] doi:10.7326/M13-2589
TO THE EDITOR: I read Sinsky and colleagues’ (1) essay with great interest. My experience in observing physicians using the EHR has not been favorable or impressive. The physician often sits with his or her back to the patient, concentrates on pushing buttons, and does not connect with the patient. I think that the “busy work” of inputting information into the computer may so distract physicians that important questions may be omitted. I believe that the big push for EHRs has come from government. In my opinion, physicians functioned better without EHRs and patients communicated better with physicians who faced them, wrote notes while chatting with them, and were not trying to create 4 November 2014 Annals of Internal Medicine Volume 161 • Number 9 679
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/931019/ by a Tufts University User on 07/26/2017
Letters an EHR designed to fulfill insurance and/or government demands for billing and information. Alan W. Feld, MD Nevada Heart Institute Las Vegas, Nevada Disclosures: Disclosures can be viewed at www.acponline.org/authors /icmje/ConflictOfInterestForms.do?msNum⫽L14-0330. Reference 1. Sinsky CA, Beasley JW, Simmons GE, Baron RJ. Electronic health records: design, implementation, and policy for higher-value primary care. Ann Intern Med. 2014;160: 727-8. [PMID: 24842418] doi:10.7326/M13-2589
IN RESPONSE: We appreciate the comments on our essay and join
Dr. Miller in wishing that we had written it 10 years ago. Electronic health records were designed and implemented without a fundamental understanding of the real needs of primary care clinicians and staff or any systematic attempt to evaluate the effect on patients or caregivers. An analogy between implementing EHRs without understanding the needs of clinicians or potential hazards and introducing a new medication without understanding the cellular biology of patients or attempting postmarketing surveillance on effectiveness or adverse effects can be made. To understand the “basic science” of primary care and evaluate the effect of EHRs (some of which may be subtle and relate to such factors as break-in tasks), input from physicians alone will not be sufficient and outside expertise is needed. One attempt to do this is our collaboration between industrial and systems engineers and primary care clinicians (www.fammed.wisc.edu/i-practise). As our essay and Drs. Miller and Feld point out, the issues are derived from not only technical and interface design but also policy. Dr. Miller correctly notes that the fundamental purpose of EHRs may have been “hijacked.” We hope that recognition of the problems caused by EHRs, as highlighted by the RAND Corporation and American Medical Association’s joint research report (1), will bring the importance of these issues to organized medicine, payors, and regulators. Fundamental philosophical changes to guide policy and implementation are needed if we are to increase efficiency and reduce burnout—which is in the interest of all (2). We completely agree with Dr. Feld that clinicians need to take responsibility for appropriate EHR use and employ what limited evidence is available about patient interactions to guide their actions during encounters (3, 4). Again, this approach will require policy
and organizational changes. Our essay is a “call to action” for individual clinicians, organized medicine, health care organizations, payors, and policymakers—none of whom gain from the current dysfunctional system. John W. Beasley, MD University of Wisconsin School of Medicine and Public Health Madison, Wisconsin Christine A. Sinsky, MD Medical Associates Clinic and Health Plans Dubuque, Iowa Disclosures: Authors have disclosed no conflicts of interest. Forms can
be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽M13-2589. References 1. Friedberg MW, Chen PG, Van Busum KR, Aunon F, Pham C, Caloyeras K. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation; 2013. Accessed at www.rand.org/content/dam/rand/pubs/research_reports/RR400 /RR439/RAND_RR439.pdf on 28 September 2014. 2. Howard PK. The Rule of Nobody. New York: WW Norton; 2014. 3. Sinsky CA, Beasley JW. Texting while doctoring: a patient safety hazard. Ann Intern Med. 2013;159:782-3. [PMID: 24297196] doi:10.7326/0003-4819-159-11 -201312030-00012 4. Asan O, D Smith P, Montague E. More screen time, less face time - implications for EHR design. J Eval Clin Pract. 2014. [PMID: 24835678] doi:10.1111/jep.12182
CORRECTION Correction: Antiretroviral Regimens for Treatment-Naive, HIV-1–Infected Volunteers On page 462 at the end of the fifth line in the Statistical Analysis section of a recent article (1), the word “less” should be “greater.” This has been corrected in the online version. Reference 1. Lennox JL, Landovitz RJ, Ribaudo HJ, Ofotokun I, Na LH, Godfrey C, et al. Efficacy and tolerability of 3 nonnucleoside reverse transcriptase inhibitor–sparing antiretroviral regimens for treatment-naive volunteers infected with HIV-1. A randomized, controlled equivalence trial. Ann Intern Med. 2014;161:461-71. [PMID: 25285539] doi:10.7326/M14-1084
680 4 November 2014 Annals of Internal Medicine Volume 161 • Number 9
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/931019/ by a Tufts University User on 07/26/2017
www.annals.org
AND
Annals of Internal Medicine RESPONSES
Disclaimer: Drs. Moriates, Shah, and Arora are affiliated with Costs of
Care, a nonprofit organization dedicated to reducing medical bills for patients.
Primary Nonadherence With Prescribed Medication
Disclosures: Disclosures can be viewed at www.acponline.org/authors /icmje/ConflictOfInterestForms.do?msNum⫽L14-0294.
TO THE EDITOR: As Tamblyn and colleagues (1) highlighted, the
out-of-pocket costs of medications have led many patients to forgo recommended treatments. Nearly 1 of every 3 new prescriptions is not filled by patients, further supporting the expansive scope of this problem. The authors appropriately call for policy initiatives, such as copayment waivers for medications needed for chronic conditions. Although these policies are important, clinicians must not wait for them to be enacted before helping patients navigate cost-related nonadherence. Teaching clinicians to address patients’ concerns about out-ofpocket drug costs is vital to improving their health and well-being. Although most patients report a desire to talk to their providers about these costs, only 15% of patients say that they have ever done so and only 16% believe that their physicians were aware of the magnitude of their out-of-pocket costs (2). Moreover, patients whose providers do not ask about the problem of medication costs have a more negative perception regarding their clinicians’ overall interest and potential ability to assist them (3). Lastly, physician discussion of drug costs with patients is strongly associated with switching to a medication that costs less (4). If clinicians strive to provide truly “patient-centered care,” they must no longer ignore a problem that is central to patient experience and their health. In our teaching, we recommend 3 specific questions to ask patients while taking a medication history to detect costrelated nonadherence: 1) Do your medications cost too much? 2) Have you ever cut back on medications because of cost? and 3) Have you ever cut back on other things (for example, food and leisure activities) because of high drug costs? (5). By proactively identifying patients who will have problems paying for their medications, clinicians can initiate a conversation about strategies to reduce out-ofpocket costs, including such potential alternatives as generic drugs or other therapeutic options. Making such screening routine, similar to what is done with preferences for advanced directives, could help alleviate patient or physician discomfort with this topic. The American College of Physicians’ High-Value Care curriculum (www.highvaluecarecurricu lum.org) and the Costs of Care Teaching Value Project (www .teachingvalue.org) offer free teaching modules for clinicians to provide strategies to address patients’ medication costs. It is time that we at least start talking about these costs with our patients. Christopher Moriates, MD University of California, San Francisco San Francisco, California Neel Shah, MD, MPP Harvard Medical School Boston, Massachusetts Vineet Arora, MD, MAPP University of Chicago Chicago, Illinois
References 1. Tamblyn R, Eguale T, Huang A, Winslade N, Doran P. The incidence and determinants of primary nonadherence with prescribed medication in primary care: a cohort study. Ann Intern Med. 2014;160:441-50. [PMID: 24687067] doi:10.7326/M13 -1705 2. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA. 2003;290:953-8. [PMID: 12928475] 3. Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Arch Intern Med. 2004;164:1749-55. [PMID: 15364667] 4. Wilson IB, Schoen C, Neuman P, Strollo MK, Rogers WH, Chang H, et al. Physician-patient communication about prescription medication nonadherence: a 50-state study of America’s seniors. J Gen Intern Med. 2007;22:6-12. [PMID: 17351835] 5. Arora V, Kumar R, Levy A, Saathoff M, Farnan J, Shah N. GOT MeDS: designing and piloting an interactive module for trainees on reducing drug costs. J Gen Intern Med. 2013;28 Suppl 1:S464-5.
Effectiveness of Combination Therapy With Statin and Another Lipid-Modifying Agent Compared With Intensified Statin Monotherapy TO THE EDITOR: Gudzune and colleagues (1) have reported a study
on the effect of combination therapy with statin and other lipidmodifying agents, such as bile acid sequestrants and ezetimibe. This study had several important findings about combination therapy but also had several substantial problems, and the results should be carefully interpreted from various perspectives. It, indeed, revealed that combination therapy significantly decreased low-density lipoprotein cholesterol levels compared with mid- to high-intensity statin monotherapy. However, this finding does not mean that combination therapy is better than statin monotherapy. Combination therapy may not be superior to high-intensity statin monotherapy at improving the outcomes of deaths and cardiovascular events (2). Whether combination therapy could achieve better targets for low-density lipoprotein cholesterol than statin monotherapy also is unclear. Moreover, low-intensity statins in combination therapy may have fewer pleiotropic effects than highintensity statins (3). In addition, the cost-effectiveness and long-term cancer risk associated with combination therapy with statins and ezetimibe should be assessed (4, 5). Therefore, it may be too early to predict the beneficial effects of combination therapy as a therapeutic option for patients at high risk for atherosclerotic cardiovascular disease. Further studies are required to elucidate strategies to better manage such patients. Tetsuro Tsujimoto, MD Ritsuko Yamamoto-Honda, MD, PhD National Center for Global Health and Medicine Tokyo, Japan
678 © 2014 American College of Physicians
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/931019/ by a Tufts University User on 07/26/2017
Letters Disclosures: Authors have disclosed no conflicts of interest. Forms can
be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0259. References 1. Gudzune KA, Monroe AK, Sharma R, Ranasinghe PD, Chelladurai Y, Robinson KA. Effectiveness of combination therapy with statin and another lipid-modifying agent compared with intensified statin monotherapy: a systematic review. Ann Intern Med. 2014;160:468-76. [PMID: 24514899] doi:10.7326/M13-2526 2. Sharma M, Ansari MT, Abou-Setta AM, Soares-Weiser K, Ooi TC, Sears M, et al. Systematic review: comparative effectiveness and harms of combination therapy and monotherapy for dyslipidemia. Ann Intern Med. 2009;151:622-30. [PMID: 19884623] doi:10.7326/0003-4819-151-9-200911030-00144 3. Davignon J. Beneficial cardiovascular pleiotropic effects of statins. Circulation. 2004;109:III39-43. [PMID: 15198965] 4. Pletcher MJ, Lazar L, Bibbins-Domingo K, Moran A, Rodondi N, Coxson P, et al. Comparing impact and cost-effectiveness of primary prevention strategies for lipidlowering. Ann Intern Med. 2009;150:243-54. [PMID: 19221376] 5. Peto R, Emberson J, Landray M, Baigent C, Collins R, Clare R, et al. Analyses of cancer data from three ezetimibe trials. N Engl J Med. 2008;359:1357-66. [PMID: 18765432] doi:10.1056/NEJMsa0806603
Electronic Health Records TO THE EDITOR: I could not agree more with Sinsky and colleagues’ (1) observations, premise, and proposed principles to support highervalue primary care through electronic health records (EHRs). My concern is that their recommendations come about 10 years too late! Where were the institutional leaders of primary care and internal medicine to promote the authors’ recommendations when first- and now second-generation EHRs were being designed and installed? The corporate axiom remains true: If you don’t have a seat at the table, you’ll find yourself on the menu. Organized medicine’s— and particularly primary care’s—strategy of reactive response (let’s see how commercially available EHRs function, then we can make changes) as opposed to demanding proactive involvement continues to leave us weakly positioned to effect such changes. Leadership requires a change in this failed strategy. After a year of preparation and a major financial investment, my institution has just “gone live” with a new, all-encompassing EHR from a company that has now acquired the largest share of the EHR market. It resembles our prior EHR, which was a constant source of frustration and aggravation, but on steroids! The authors’ proposals face numerous real obstacles. With many practices and institutions already heavily invested in nextgeneration EHRs, what will be their incentives to buy new systems? The root of the problem for physicians and their interests is that the primary purpose, design, and directive of the EHR from its inception (facilitating the transmission of clinically useful information) has been hijacked by economically driven interests and advanced by the mutually beneficial alliance of institutional health care providers as billers and the insurance industry (as well as Medicare), which has financial interests as payors. Organized medicine regrettably did not oppose this hijacking. Current EHRs still function primarily as systems for enacting billing and payment, grading physicians, and collecting “quality measures.” Where does that leave the EHR industry’s incentives to implement the authors’ proposals? More important, where do the www.annals.org
authors and their organizations and foundations find the leverage to implement their recommendations? Primary care providers bear the brunt of the “pain” inflicted by not only the EHR but also the major changes buffeting our onceproud specialty of internal medicine. In my practice, the medical home is viewed as the repository of all information to be provided to other (specialty) physicians, preoperative screening units, referral and network managers, health insurers, quality measurers, pharmacy benefit managers, prior authorizers, visiting nurses, home care providers, disability adjudicators, college health services, and a host of others and for attending physician statements for life and long-term care insurance. Providing this information involves time and expense, none of which is compensated except for the moment spent preparing an attending physician statement. My medical home is not a happy one, especially after spending at least 3 hours every day on administrative chores of dubious value after the last patient leaves. Primary care just doesn’t have the “juice” to enforce change. So, primary care physicians are moving away from this field in substantial numbers. It is telling that a cardiac surgeon whom I care for, and complain to, mentioned that he and his colleagues are “so insulated” from the EHR that they barely take note of it. The orthopedic surgeons “can’t be bothered” with the EHR; they dictate their notes or use a scribe. Some of the notes from our specialty colleagues are so heavily templated and identical that I read only the concluding, usually brief, assessment and plan, knowing that it is the only relevant information coming directly from them. The greater the reimbursement for the encounter, the less burdensome the involvement with the EHR. Not a good position for primary care. I appreciate the authors’ efforts, but it will take more than a declaration of principles to effect meaningful change. Strong and dedicated leadership, which is sorely missing, is essential. Unfortunately, I doubt that I’ll see it while I’m still practicing. Michael E. Miller, MD Boston University Affiliated Physicians Boston, Massachusetts Disclosures: Authors have disclosed no conflicts of interest. Forms can
be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0331.
Reference 1. Sinsky CA, Beasley JW, Simmons GE, Baron RJ. Electronic health records: design, implementation, and policy for higher-value primary care. Ann Intern Med. 2014;160: 727-8. [PMID: 24842418] doi:10.7326/M13-2589
TO THE EDITOR: I read Sinsky and colleagues’ (1) essay with great interest. My experience in observing physicians using the EHR has not been favorable or impressive. The physician often sits with his or her back to the patient, concentrates on pushing buttons, and does not connect with the patient. I think that the “busy work” of inputting information into the computer may so distract physicians that important questions may be omitted. I believe that the big push for EHRs has come from government. In my opinion, physicians functioned better without EHRs and patients communicated better with physicians who faced them, wrote notes while chatting with them, and were not trying to create 4 November 2014 Annals of Internal Medicine Volume 161 • Number 9 679
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/931019/ by a Tufts University User on 07/26/2017
Letters an EHR designed to fulfill insurance and/or government demands for billing and information. Alan W. Feld, MD Nevada Heart Institute Las Vegas, Nevada Disclosures: Disclosures can be viewed at www.acponline.org/authors /icmje/ConflictOfInterestForms.do?msNum⫽L14-0330. Reference 1. Sinsky CA, Beasley JW, Simmons GE, Baron RJ. Electronic health records: design, implementation, and policy for higher-value primary care. Ann Intern Med. 2014;160: 727-8. [PMID: 24842418] doi:10.7326/M13-2589
IN RESPONSE: We appreciate the comments on our essay and join
Dr. Miller in wishing that we had written it 10 years ago. Electronic health records were designed and implemented without a fundamental understanding of the real needs of primary care clinicians and staff or any systematic attempt to evaluate the effect on patients or caregivers. An analogy between implementing EHRs without understanding the needs of clinicians or potential hazards and introducing a new medication without understanding the cellular biology of patients or attempting postmarketing surveillance on effectiveness or adverse effects can be made. To understand the “basic science” of primary care and evaluate the effect of EHRs (some of which may be subtle and relate to such factors as break-in tasks), input from physicians alone will not be sufficient and outside expertise is needed. One attempt to do this is our collaboration between industrial and systems engineers and primary care clinicians (www.fammed.wisc.edu/i-practise). As our essay and Drs. Miller and Feld point out, the issues are derived from not only technical and interface design but also policy. Dr. Miller correctly notes that the fundamental purpose of EHRs may have been “hijacked.” We hope that recognition of the problems caused by EHRs, as highlighted by the RAND Corporation and American Medical Association’s joint research report (1), will bring the importance of these issues to organized medicine, payors, and regulators. Fundamental philosophical changes to guide policy and implementation are needed if we are to increase efficiency and reduce burnout—which is in the interest of all (2). We completely agree with Dr. Feld that clinicians need to take responsibility for appropriate EHR use and employ what limited evidence is available about patient interactions to guide their actions during encounters (3, 4). Again, this approach will require policy
and organizational changes. Our essay is a “call to action” for individual clinicians, organized medicine, health care organizations, payors, and policymakers—none of whom gain from the current dysfunctional system. John W. Beasley, MD University of Wisconsin School of Medicine and Public Health Madison, Wisconsin Christine A. Sinsky, MD Medical Associates Clinic and Health Plans Dubuque, Iowa Disclosures: Authors have disclosed no conflicts of interest. Forms can
be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽M13-2589. References 1. Friedberg MW, Chen PG, Van Busum KR, Aunon F, Pham C, Caloyeras K. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation; 2013. Accessed at www.rand.org/content/dam/rand/pubs/research_reports/RR400 /RR439/RAND_RR439.pdf on 28 September 2014. 2. Howard PK. The Rule of Nobody. New York: WW Norton; 2014. 3. Sinsky CA, Beasley JW. Texting while doctoring: a patient safety hazard. Ann Intern Med. 2013;159:782-3. [PMID: 24297196] doi:10.7326/0003-4819-159-11 -201312030-00012 4. Asan O, D Smith P, Montague E. More screen time, less face time - implications for EHR design. J Eval Clin Pract. 2014. [PMID: 24835678] doi:10.1111/jep.12182
CORRECTION Correction: Antiretroviral Regimens for Treatment-Naive, HIV-1–Infected Volunteers On page 462 at the end of the fifth line in the Statistical Analysis section of a recent article (1), the word “less” should be “greater.” This has been corrected in the online version. Reference 1. Lennox JL, Landovitz RJ, Ribaudo HJ, Ofotokun I, Na LH, Godfrey C, et al. Efficacy and tolerability of 3 nonnucleoside reverse transcriptase inhibitor–sparing antiretroviral regimens for treatment-naive volunteers infected with HIV-1. A randomized, controlled equivalence trial. Ann Intern Med. 2014;161:461-71. [PMID: 25285539] doi:10.7326/M14-1084
680 4 November 2014 Annals of Internal Medicine Volume 161 • Number 9
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/931019/ by a Tufts University User on 07/26/2017
www.annals.org
