Letters
Annals of Internal Medicine COMMENTS
AND
RESPONSES
Meeting Meaningful Use Criteria and Managing Patient Populations TO THE EDITOR: DesRoches and colleagues’ survey (1) shows that
human behavior resists even beneficial change. I have 2 main disagreements with their conclusions. First, that “[f]ew physicians could meet meaningful use criteria in early 2012” at the beginning of adoption of these criteria is predictable and not due to physician influence alone. Second, that “perceived ease of use of systems that can help to manage patient populations should be of concern to policymakers” may be true, but the survey questions do not allow this conclusion. Gross (2) and Ryan and Gross (3) described and Rogers (4) popularized the idea that adoption of any new process follows a sigmoid-shaped curve. Adoption of electronic health records (EHRs) in general and meaningful use in particular is no different. Ford and associates (5) showed that quantification of internal and external factors enables us to predict the curve of EHR adoption. If we identify forces that influence adoption of meaningful use criteria and interoperability, we can predict their adoption rate. DesRoches and colleagues’ article fails to elucidate these internal and external factors. The authors surveyed physicians 14 months after the final regulations were published, early in the meaningful use attestation cycle before anyone had developed workflows or content to satisfy meaningful use criteria. Even for those who felt prepared, installation, configuration, and adoption took time. Only a few vendors had fully certified products; thus, only the most aggressive sites that had installed these products were in a position to qualify for stage 1 meaningful use criteria by October 2011. Such a low number is predictable by the analyses of Gross and Ryan and of Rogers. How can performing at the expected rate be surprising? The questions were not geared for common situations, such as working as a hospitalist. How accurate were the definitions of primary and specialist care? An important weakness that prevents assertion of cause and effect between usability and adoption is that no questions were included about training, support, or technical skills assessments; only participants’ impression of usability was included. Usability is critical, but without assessing training, one cannot make conclusions about it. DesRoches and colleagues’ conclusion about “ease of use” is no more than opinion fails to offer insight about reasons for slow adoption. Recently, the Centers for Medicare & Medicaid Services (6) confirmed that “more than half of all doctors and other eligible providers have received . . . payments for adopting or meaningfully using . . . EHRs.” DesRoches and colleagues’ study was published after this confirmation, but the data were collected when the accumulated adoption rate was barely one fifth that of the current rate. The results are therefore moot. It is no surprise that early adopters would give generally favorable, and the rest would give generally unfavorable, assessments. Of note, almost 50% of those who felt unready for meaningful use believed that it was not hard to perform the tasks in their EHR. Making widespread EHR meaningful use a reality requires interoperability standards; noncontradictory, harmonized regulations;
and usability criteria to which all vendors adhere. Rather than decry the failure of physicians to adopt EHRs, let us examine the roles of all facets of the health care industry—insurance companies, the pharmaceutical industry, and government itself—as well as physicians and hospitals, in terms of their responsibilities to promote EHRs. Rather than surveys, with all of their limitations, we need metrics of influential internal, external, and interactive forces. Let’s not confuse perception of adoption and usability with the actual accomplishment of attestation. Richard Schreiber, MD Holy Spirit Hospital Camp Hill, Pennsylvania Potential Conflicts of Interest: None disclosed. References 1. DesRoches CM, Audet AM, Painter M, Donelan K. Meeting meaningful use criteria and managing patient populations: a national survey of practicing physicians. Ann Intern Med. 2013;158:791-9. [PMID: 23732712] 2. Gross NC. The Diffusion of a Culture Trait in Two Iowa Townships [master’s thesis]. Ames, Iowa: Iowa State Coll; 1942. 3. Ryan B, Gross NC. The diffusion of hybrid seed corn in two Iowa communities. Rural Sociol. 1943;8:15-24. 4. Rogers EM. Diffusion of Innovations. Glencoe, Illinois: Free Pr; 1962. 5. Ford EW, Menachemi N, Peterson LT, Huerta TR. Resistance is futile: but it is slowing the pace of EHR adoption nonetheless. J Am Med Inform Assoc. 2009;16: 274-81. [PMID: 19261931] 6. U. S. Department of Health and Human Services. Doctors and hospitals’ use of health IT more than doubles since 2012 [press release]. Washington, DC: U.S. Department of Health and Human Services; 22 May 2013. Accessed at www.hhs.gov /news/press/2013pres/05/20130522a.html on 7 June 2013.
TO THE EDITOR: I read with interest DesRoches and colleagues’
article (1) on assessing physician use of EHRs and whether such use was meaningful, as outlined by the Centers for Medicare & Medicaid Services. The fundamental flaw in the authors’ research question (and in the Centers for Medicare & Medicaid Services’ misguided use of this metric) is that the meaningful use criteria pertain to patient care, but the commercially available EHRs are invariably designed to optimize billing and insurance reimbursement. Thus, the finding that fewer than 1 in 10 physicians reported being able to use their systems to meet meaningful use criteria is hardly surprising. The commercial EHR has resulted in more money in the pockets of physicians who use it, although it has failed to facilitate meaningful use or show overall cost-savings (2, 3). Further, one need only look at the U.S. Department of Veterans Affairs Veterans Health Information Systems and Technology Architecture (VistA) Computerized Patient Record System as an example of an EHR that was designed to optimize patient care and has successfully achieved meaningful use. The West Virginia Department of Health implemented a statewide modified VistA system for one tenth the cost of the introduction of the Epic system (Epic Systems, Verona, Wisconsin) at West Virginia University. The VistA system within the U.S. Department of Veterans Affairs allows easy exchange of information with physicians around the country because all of the hospital inpatient and outpatient sites are linked. Both Veterans Affairs and non–Veterans Affairs hospitals using the VistA system are among the few in the nation that achieve © 2013 American College of Physicians 717
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Letters measurable meaningful use according to the Healthcare Information and Management Systems Society (4). Finally, the VistA system has won repeated accolades over the past 2 decades for its ease of use and for improving efficiency and optimizing prescription accuracy (5). Why, then, would a physician or health system implement anything other than the VistA EHR if they seek to use an EHR in a meaningful way, as the Centers for Medicare & Medicaid Services mandates? Stated differently, and in parallel with our current health financing crisis, why do we pay so much more for a privately delivered product that is so much less effective than one developed with taxpayer dollars? Philip A. Verhoef, MD, PhD University of Chicago Chicago, Illinois Potential Conflicts of Interest: None disclosed.
References 1. DesRoches CM, Audet AM, Painter M, Donelan K. Meeting meaningful use criteria and managing patient populations: a national survey of practicing physicians. Ann Intern Med. 2013;158:791-9. [PMID: 23732712] 2. Gans DN. Going electronic pays off. New MGMA report links EHRs with higher medical revenue. MGMA Connex. 2010;10:21-2. [PMID: 21049812] 3. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Aff (Millwood). 2013;32:63-8. [PMID: 23297272]. 4. Healthcare Information and Management Systems Society. EMR Adoption Model: Stage 7 Hospitals. Accessed at www.himssanalytics.org/hc_providers/stage7hospitals .asp on 28 June 2013. 5. Evans DC, Nichol WP, Perlin JB. Effect of the implementation of an enterprisewide electronic health record on productivity in the Veterans Health Administration. Health Econ Policy Law. 2006;1:163-9. [PMID: 18634688]
Pressure Ulcer Risk Assessment and Prevention TO THE EDITOR: Chou and colleagues’ (1) comparative effectiveness
review of pressure ulcer prevention is important to U.S. hospitals with wound teams established for investigating implementation of a bundled evidence-based protocol for pressure ulcer prevention. Hospitals have been addressing pressure ulcer prevention since the Centers for Medicare & Medicaid Services enacted a nonpayment policy for hospital-acquired conditions in 2008 (2). The financial constraints of this policy directly affect clinicians who implement a pressure ulcer prevention protocol to protect patients from harm. Clinicians reference the 5-point evidence-based guideline developed by the National Pressure Ulcer Advisory Panel: risk assessment, skin care, nutrition, mechanical loading and support surfaces, and clinical education (3). This bundled protocol should be implemented consistently in its entirety to effectively prevent pressure ulcers. Because of the importance of preventing pressure ulcers since 2008, the field would benefit from studies developed since then rather than reviewing outdated literature. Studies reviewed by Chou and colleagues developed before the announcement of the Centers for Medicare & Medicaid Services policy did not incorporate the same incentives that exist today for clinicians to prevent avoidable pressure ulcers. This discrepancy may account for low-quality studies
on pressure ulcer prevention, as well as inconsistent bundling of prevention protocols before 2008 compared with current studies. Chou and colleagues assumed the challenging initiative to classify the effectiveness of individual components of the prevention protocol from a scarce literature base with few high-quality studies. Many trials and cohort studies that the investigators reviewed failed to incorporate all components of the prevention protocol with standard consistency but rather compared the significance of individual preventive interventions relative to each other. By including such studies in their review, Chou and colleagues’ results are biased toward ineffective preventive interventions because they are reviewed separately instead of bundled. The National Pressure Ulcer Advisory Panel guidelines are clear that pressure ulcer prevention is effective only through consistent implementation of a bundled protocol instead of selective implementation of individual components (3). This concept is analogous to the classic gestalt principle of the whole being greater than the sum of its parts. The best-practices framework for quality improvement in health care by Nelson and associates (4) supports this principle of practicing bundled evidence-based protocols that incorporate all domains of health services: leadership, staff, information technology, and performance and improvement. The National Pressure Ulcer Advisory Panel guideline as a whole is stronger because it engages each practice domain to achieve cost-effective patient outcomes (5). Reviews segregating or isolating components of the evidence-based protocol fall short of comparative effectiveness for pressure ulcer prevention. William V. Padula, PhD, MS University of Chicago Chicago, Illinois Heidi M. Wald, MD, MSPH Mary Beth F. Makic, PhD, RN University of Colorado Aurora, Colorado Potential Conflicts of Interest: None disclosed. References 1. Chou R, Dana T, Bougatsos C, Blazina I, Starmer AJ, Reitel K, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med. 2013;159:28-38. [PMID: 23817702] 2. Kurtzman ET, Buerhaus PI. New Medicare payment rules: danger or opportunity for nursing? Am J Nurs. 2008;108:30-5. [PMID: 18535440] 3. National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention Points. 2007. Accessed at www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer -prevention-points/ on 27 September 2013. 4. Nelson EC, Batalden PB, Huber TP, Johnson JK, Godfrey MM, Headrick LA, et al. Success characteristics of high-performing microsystems. In: Nelson EC, Batalden PB, Godfrey MM, eds. Quality by Design. San Francisco: Jossey-Bass; 2007:3-33. 5. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49:38592. [PMID: 21368685]
IN RESPONSE: To clarify, we did not exclude studies that evaluated
bundled protocols for pressure ulcer prevention. Any controlled clinical trial or cohort study that compared alternative interventions for pressure ulcer prevention—including bundled protocols—was in-
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Letters cluded. In fact, studies of pressure ulcer interventions did not evaluate single-component therapies in isolation but as part of multicomponent prevention strategies. However, details about these strategies were often limited, representing a shortcoming of the available literature. As noted in our review, it is important for future studies of pressure ulcer preventive interventions to better describe the other components of care that were provided. In addition, to understand what should be included in bundled pressure ulcer prevention protocols it is first necessary to understand the effectiveness of the individual components. Therefore, studies that evaluate the effects of adding a specific component to standard or usual care, such as many of those included in our review, are critical for understanding comparative effectiveness. We found no evidence to support Dr. Padula and colleagues’ hypothesis that recent studies were more likely to report positive results than older studies because of more consistent use of standardized bundled prevention protocols. Indeed, the only good-quality trial to compare the effects of using a pressure ulcer risk assessment instrument, with or without a protocolized intervention strategy based on assessed risk, was published in 2011 (1). It found no effect of using a pressure ulcer risk assessment instrument on incidence of pressure ulcers compared with less-standardized risk assessment based on nurses’ clinical judgment. Roger Chou, MD Oregon Health & Science University Portland, Oregon
The emergence of the women’s health movement in the 1970s and funding of the U.S. Department of Health and Human Services Centers of Excellence in Women’s Health, establishment of the National Institutes of Health Office of Research on Women’s Health, and publication of the Institute of Medicine’s Exploring the Biological Contributions to Human Health: Does Sex Matter? (4) expanded the body of knowledge of this subject beyond specific body parts. This approach has already yielded breakthroughs (for example, aspirin prophylaxis of cardiovascular disease in women) (4). The health care industry noticed that most health care consumers are women, and women’s health centers cropped up across the nation. Clinical programs and scientific journals focusing on men’s health began to emerge, perhaps because of the belief that the pendulum had swung too far toward women’s health. This development further entrenched the disparities and constrained men’s and women’s health into narrow, mutually exclusive definitions. To tear down this silo-based approach, an integrated sex-specific approach to medicine in medical education (5), research, and clinical care would benefit everyone. Marjorie Jenkins, MD Tedd L. Mitchell, MD Steven L. Berk, MD Texas Tech University Health Sciences Center Lubbock, Texas Potential Conflicts of Interest: Dr. Jenkins: Consultancy: Novo
Nordisk. Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum⫽M12 -2540. Reference 1. Webster J, Coleman K, Mudge A, Marquart L, Gardner G, Stankiewicz M, et al. Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ Qual Saf. 2011;20:297-306. [PMID: 21262791]
Update in Women’s Health TO THE EDITOR: We recognize that McNamara and Walsh (1) primarily categorized women’s health according to the standard topics of breast, bone, and reproductive health and screening. Focusing on customary women’s health topics reinforces the current ideology, which implies that human organ systems function similarly whether the patient is male or female. This view fails to include the emerging body of knowledge about sex and gender differences in health and disease, which evidence-based guidelines explain (2, 3). As such, approaching women’s health through the lens of gender-specific medicine is defined as the science of how typical human biology differs between men and women and how the manifestations, mechanisms, and treatment of disease vary as a function of sex (2). We recognize the value and important breakthroughs that women’s health researchers have made in osteoporosis and breast and gynecologic cancer. However, a broader approach through sex and gender medicine will further improve outcomes in women’s health by defining differences between men and women in all biological systems, thereby better addressing diagnosis and treatment of a wider range of disease processes. www.annals.org
References 1. McNamara M, Walsh JM. Update in women’s health: evidence published in 2012. Ann Intern Med. 2013;159:203-9. [PMID: 23579223] 2. Legato M. Principles of Gender-Specific Medicine. 2nd ed. Philadelphia: Elsevier; 2011. 3. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women— 2011 update: a guideline from the American Heart Association. Circulation. 2011;123: 1243-62. [PMID: 21325087] 4. Wizemann TM, Pardue M-L. Exploring the Biological Contributions to Human Health: Does Sex Matter? Washington, DC: National Academies Pr; 2001. 5. Texas Tech University Health Sciences Center. Sex and Gender-Based Medicine Curriculum. Accessed at www.ttuhsc.edu/som/curriculum/sgbm_curriculum.aspx on 31 August 2013.
IN RESPONSE: As practicing women’s health physicians and inter-
nists, we agree that a broad approach to sex-based differences in disease is essential for providing comprehensive primary care. In writing our update, we searched multiple journal articles to identify studies that were relevant to primary care in women’s health and could be practice-changing. Of note, we did not approach the review process with predefined categories in mind. Rather, we let the selected articles themselves define the groupings that we used to outline the update. We have previously written several updates in women’s health before (1, 2) using this approach and had identified practicechanging articles that focused on migraine and cardiovascular disease, as well as breast arterial calcification and coronary heart disease (3,4). For our current update, we did not identify any articles that met the above criteria in the areas of cardiovascular disease, diabetes, 19 November 2013 Annals of Internal Medicine Volume 159 • Number 10 719
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Letters or cancer. In our opinion, primary care for women should never be broken down into the silos of “breast and gynecologic care” and “everything else.” Women’s health providers should seek to understand the complex interactions between sex and health, both in regard to chronic disease as well as sex-specific diseases, and use a comprehensive and holistic approach in clinical, educational, and research activities. Megan C. McNamara, MD, MS Case Western Reserve University Cleveland, Ohio Judith M.E. Walsh, MD., MPH Women’s Health Clinical Research Center, University of California, San Francisco San Francisco, California Potential Conflicts of Interest: None disclosed. Forms can be viewed at
www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum ⫽M13-0263. References 1. Schwarz EB, McNamara M, Miller RG, Walsh JM. Update in women’s health for the general internist. J Gen Intern Med. 2011;26:207-13. [PMID: 20824360] 2. Walsh JM, McNamara M, Miller RG, Schwarz EB. Update in women’s health for the general internist. J Gen Intern Med. 2012;27:232-7. [PMID: 21993997] 3. Schu¨rks M, Rist PM, Bigal ME, Buring JE, Lipton RB, Kurth T. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ. 2009;339:b3914. [PMID: 19861375] 4. Schnatz PF, Marakovits KA, O’Sullivan DM. The association of breast arterial calcification and coronary heart disease. Obstet Gynecol. 2011;117:233-41. [PMID: 21252734]
The New Crisis of Confidence in Psychiatric Diagnosis TO THE EDITOR: Frances (1) is correct that changes in diagnostic
systems can lead to overdiagnosis and everyday life problems could be misclassified as illnesses. Physicians and patients do not like diagnostic uncertainty, the possibility of inaccurate diagnoses, and unnecessary or harmful “treatment.” We also know how the media can echo these sentiments. Readers should consider several aspects. Revising a diagnostic manual is not unique to psychiatry. The definition of and treatment recommendations for various diseases, such as hypertension, have been adjusted numerous times. Recent discussion on obesity shows that even having a biological measure does not always allow for the clear separation of what is “normal” and what is not and whether one or the other comes with health benefits (2). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, does not aim to pathologize grief or forgetfulness. However, every memory disorder clinic has too many patients with dementia whose health care providers told them for too many years that their memory problems would reflect normal aging. This cir-
cumstance prevents therapy, and as in every other medical specialty, psychiatric therapy is not always pharmacologic. Putting the interests of drug companies and the complex process of revising a diagnostic manual in the same context is misleading. The physician always establishes a diagnosis. We have to carefully consider given criteria, and we must judge whether they are met. Then we decide how to monitor, educate, or treat our patients. Psychiatrists who do not recognize the difference between normal grief and major depression should not consult a manual but rather ask themselves whether they are qualified to be a physician. Advances in neuroscience may ultimately contribute to but do not currently allow for the definition of causal categories for major psychiatric diseases. The emergence and disappearance of cause-oriented approaches to disease classification have always been a part of psychiatry, creating such categories as “organic,” “endogenous,” and “psychogenic” disorders in the early 20th century. These models reflect the desire for simplistic causal explanations, as well as a generation’s limited insight into the structure and function of the brain. In the search for causes and objective biological tests, we have to acknowledge, as Frances did, that we still know far too little about the brain to achieve this goal. Until then, descriptive classification systems will keep us open-minded. Markus Donix, MD University Hospital Carl Gustav Carus Dresden, Germany Potential Conflicts of Interest: None disclosed. References 1. Frances A. The new crisis of confidence in psychiatric diagnosis. Ann Intern Med. 2013;159:221-2. [PMID: 23685989] 2. Ahima RS, Lazar MA. Physiology. The health risk of obesity—better metrics imperative. Science. 2013;341:856-8. [PMID: 23970691]
IN RESPONSE: Although Dr. Donix and I agree on most points, I fear that he underestimates the risk that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, will cause harmful, unintended consequences. This manual certainly does not “aim to pathologize grief or forgetfulness,” but it will almost surely have this result—particularly because primary care physicians, not psychiatrists, do most of the diagnosis and prescription of psychiatric drugs. There are no effective treatments for grief or forgetfulness, and the false positives are much more common than missed cases. It is also naive to ignore the large influence of drug company marketing on physician practice.
Allen Frances, MD Duke University Durham, North Carolina Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum⫽M13 -0997.
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Annals of Internal Medicine COMMENTS
AND
RESPONSES
Meeting Meaningful Use Criteria and Managing Patient Populations TO THE EDITOR: DesRoches and colleagues’ survey (1) shows that
human behavior resists even beneficial change. I have 2 main disagreements with their conclusions. First, that “[f]ew physicians could meet meaningful use criteria in early 2012” at the beginning of adoption of these criteria is predictable and not due to physician influence alone. Second, that “perceived ease of use of systems that can help to manage patient populations should be of concern to policymakers” may be true, but the survey questions do not allow this conclusion. Gross (2) and Ryan and Gross (3) described and Rogers (4) popularized the idea that adoption of any new process follows a sigmoid-shaped curve. Adoption of electronic health records (EHRs) in general and meaningful use in particular is no different. Ford and associates (5) showed that quantification of internal and external factors enables us to predict the curve of EHR adoption. If we identify forces that influence adoption of meaningful use criteria and interoperability, we can predict their adoption rate. DesRoches and colleagues’ article fails to elucidate these internal and external factors. The authors surveyed physicians 14 months after the final regulations were published, early in the meaningful use attestation cycle before anyone had developed workflows or content to satisfy meaningful use criteria. Even for those who felt prepared, installation, configuration, and adoption took time. Only a few vendors had fully certified products; thus, only the most aggressive sites that had installed these products were in a position to qualify for stage 1 meaningful use criteria by October 2011. Such a low number is predictable by the analyses of Gross and Ryan and of Rogers. How can performing at the expected rate be surprising? The questions were not geared for common situations, such as working as a hospitalist. How accurate were the definitions of primary and specialist care? An important weakness that prevents assertion of cause and effect between usability and adoption is that no questions were included about training, support, or technical skills assessments; only participants’ impression of usability was included. Usability is critical, but without assessing training, one cannot make conclusions about it. DesRoches and colleagues’ conclusion about “ease of use” is no more than opinion fails to offer insight about reasons for slow adoption. Recently, the Centers for Medicare & Medicaid Services (6) confirmed that “more than half of all doctors and other eligible providers have received . . . payments for adopting or meaningfully using . . . EHRs.” DesRoches and colleagues’ study was published after this confirmation, but the data were collected when the accumulated adoption rate was barely one fifth that of the current rate. The results are therefore moot. It is no surprise that early adopters would give generally favorable, and the rest would give generally unfavorable, assessments. Of note, almost 50% of those who felt unready for meaningful use believed that it was not hard to perform the tasks in their EHR. Making widespread EHR meaningful use a reality requires interoperability standards; noncontradictory, harmonized regulations;
and usability criteria to which all vendors adhere. Rather than decry the failure of physicians to adopt EHRs, let us examine the roles of all facets of the health care industry—insurance companies, the pharmaceutical industry, and government itself—as well as physicians and hospitals, in terms of their responsibilities to promote EHRs. Rather than surveys, with all of their limitations, we need metrics of influential internal, external, and interactive forces. Let’s not confuse perception of adoption and usability with the actual accomplishment of attestation. Richard Schreiber, MD Holy Spirit Hospital Camp Hill, Pennsylvania Potential Conflicts of Interest: None disclosed. References 1. DesRoches CM, Audet AM, Painter M, Donelan K. Meeting meaningful use criteria and managing patient populations: a national survey of practicing physicians. Ann Intern Med. 2013;158:791-9. [PMID: 23732712] 2. Gross NC. The Diffusion of a Culture Trait in Two Iowa Townships [master’s thesis]. Ames, Iowa: Iowa State Coll; 1942. 3. Ryan B, Gross NC. The diffusion of hybrid seed corn in two Iowa communities. Rural Sociol. 1943;8:15-24. 4. Rogers EM. Diffusion of Innovations. Glencoe, Illinois: Free Pr; 1962. 5. Ford EW, Menachemi N, Peterson LT, Huerta TR. Resistance is futile: but it is slowing the pace of EHR adoption nonetheless. J Am Med Inform Assoc. 2009;16: 274-81. [PMID: 19261931] 6. U. S. Department of Health and Human Services. Doctors and hospitals’ use of health IT more than doubles since 2012 [press release]. Washington, DC: U.S. Department of Health and Human Services; 22 May 2013. Accessed at www.hhs.gov /news/press/2013pres/05/20130522a.html on 7 June 2013.
TO THE EDITOR: I read with interest DesRoches and colleagues’
article (1) on assessing physician use of EHRs and whether such use was meaningful, as outlined by the Centers for Medicare & Medicaid Services. The fundamental flaw in the authors’ research question (and in the Centers for Medicare & Medicaid Services’ misguided use of this metric) is that the meaningful use criteria pertain to patient care, but the commercially available EHRs are invariably designed to optimize billing and insurance reimbursement. Thus, the finding that fewer than 1 in 10 physicians reported being able to use their systems to meet meaningful use criteria is hardly surprising. The commercial EHR has resulted in more money in the pockets of physicians who use it, although it has failed to facilitate meaningful use or show overall cost-savings (2, 3). Further, one need only look at the U.S. Department of Veterans Affairs Veterans Health Information Systems and Technology Architecture (VistA) Computerized Patient Record System as an example of an EHR that was designed to optimize patient care and has successfully achieved meaningful use. The West Virginia Department of Health implemented a statewide modified VistA system for one tenth the cost of the introduction of the Epic system (Epic Systems, Verona, Wisconsin) at West Virginia University. The VistA system within the U.S. Department of Veterans Affairs allows easy exchange of information with physicians around the country because all of the hospital inpatient and outpatient sites are linked. Both Veterans Affairs and non–Veterans Affairs hospitals using the VistA system are among the few in the nation that achieve © 2013 American College of Physicians 717
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Letters measurable meaningful use according to the Healthcare Information and Management Systems Society (4). Finally, the VistA system has won repeated accolades over the past 2 decades for its ease of use and for improving efficiency and optimizing prescription accuracy (5). Why, then, would a physician or health system implement anything other than the VistA EHR if they seek to use an EHR in a meaningful way, as the Centers for Medicare & Medicaid Services mandates? Stated differently, and in parallel with our current health financing crisis, why do we pay so much more for a privately delivered product that is so much less effective than one developed with taxpayer dollars? Philip A. Verhoef, MD, PhD University of Chicago Chicago, Illinois Potential Conflicts of Interest: None disclosed.
References 1. DesRoches CM, Audet AM, Painter M, Donelan K. Meeting meaningful use criteria and managing patient populations: a national survey of practicing physicians. Ann Intern Med. 2013;158:791-9. [PMID: 23732712] 2. Gans DN. Going electronic pays off. New MGMA report links EHRs with higher medical revenue. MGMA Connex. 2010;10:21-2. [PMID: 21049812] 3. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Aff (Millwood). 2013;32:63-8. [PMID: 23297272]. 4. Healthcare Information and Management Systems Society. EMR Adoption Model: Stage 7 Hospitals. Accessed at www.himssanalytics.org/hc_providers/stage7hospitals .asp on 28 June 2013. 5. Evans DC, Nichol WP, Perlin JB. Effect of the implementation of an enterprisewide electronic health record on productivity in the Veterans Health Administration. Health Econ Policy Law. 2006;1:163-9. [PMID: 18634688]
Pressure Ulcer Risk Assessment and Prevention TO THE EDITOR: Chou and colleagues’ (1) comparative effectiveness
review of pressure ulcer prevention is important to U.S. hospitals with wound teams established for investigating implementation of a bundled evidence-based protocol for pressure ulcer prevention. Hospitals have been addressing pressure ulcer prevention since the Centers for Medicare & Medicaid Services enacted a nonpayment policy for hospital-acquired conditions in 2008 (2). The financial constraints of this policy directly affect clinicians who implement a pressure ulcer prevention protocol to protect patients from harm. Clinicians reference the 5-point evidence-based guideline developed by the National Pressure Ulcer Advisory Panel: risk assessment, skin care, nutrition, mechanical loading and support surfaces, and clinical education (3). This bundled protocol should be implemented consistently in its entirety to effectively prevent pressure ulcers. Because of the importance of preventing pressure ulcers since 2008, the field would benefit from studies developed since then rather than reviewing outdated literature. Studies reviewed by Chou and colleagues developed before the announcement of the Centers for Medicare & Medicaid Services policy did not incorporate the same incentives that exist today for clinicians to prevent avoidable pressure ulcers. This discrepancy may account for low-quality studies
on pressure ulcer prevention, as well as inconsistent bundling of prevention protocols before 2008 compared with current studies. Chou and colleagues assumed the challenging initiative to classify the effectiveness of individual components of the prevention protocol from a scarce literature base with few high-quality studies. Many trials and cohort studies that the investigators reviewed failed to incorporate all components of the prevention protocol with standard consistency but rather compared the significance of individual preventive interventions relative to each other. By including such studies in their review, Chou and colleagues’ results are biased toward ineffective preventive interventions because they are reviewed separately instead of bundled. The National Pressure Ulcer Advisory Panel guidelines are clear that pressure ulcer prevention is effective only through consistent implementation of a bundled protocol instead of selective implementation of individual components (3). This concept is analogous to the classic gestalt principle of the whole being greater than the sum of its parts. The best-practices framework for quality improvement in health care by Nelson and associates (4) supports this principle of practicing bundled evidence-based protocols that incorporate all domains of health services: leadership, staff, information technology, and performance and improvement. The National Pressure Ulcer Advisory Panel guideline as a whole is stronger because it engages each practice domain to achieve cost-effective patient outcomes (5). Reviews segregating or isolating components of the evidence-based protocol fall short of comparative effectiveness for pressure ulcer prevention. William V. Padula, PhD, MS University of Chicago Chicago, Illinois Heidi M. Wald, MD, MSPH Mary Beth F. Makic, PhD, RN University of Colorado Aurora, Colorado Potential Conflicts of Interest: None disclosed. References 1. Chou R, Dana T, Bougatsos C, Blazina I, Starmer AJ, Reitel K, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med. 2013;159:28-38. [PMID: 23817702] 2. Kurtzman ET, Buerhaus PI. New Medicare payment rules: danger or opportunity for nursing? Am J Nurs. 2008;108:30-5. [PMID: 18535440] 3. National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention Points. 2007. Accessed at www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer -prevention-points/ on 27 September 2013. 4. Nelson EC, Batalden PB, Huber TP, Johnson JK, Godfrey MM, Headrick LA, et al. Success characteristics of high-performing microsystems. In: Nelson EC, Batalden PB, Godfrey MM, eds. Quality by Design. San Francisco: Jossey-Bass; 2007:3-33. 5. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49:38592. [PMID: 21368685]
IN RESPONSE: To clarify, we did not exclude studies that evaluated
bundled protocols for pressure ulcer prevention. Any controlled clinical trial or cohort study that compared alternative interventions for pressure ulcer prevention—including bundled protocols—was in-
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Letters cluded. In fact, studies of pressure ulcer interventions did not evaluate single-component therapies in isolation but as part of multicomponent prevention strategies. However, details about these strategies were often limited, representing a shortcoming of the available literature. As noted in our review, it is important for future studies of pressure ulcer preventive interventions to better describe the other components of care that were provided. In addition, to understand what should be included in bundled pressure ulcer prevention protocols it is first necessary to understand the effectiveness of the individual components. Therefore, studies that evaluate the effects of adding a specific component to standard or usual care, such as many of those included in our review, are critical for understanding comparative effectiveness. We found no evidence to support Dr. Padula and colleagues’ hypothesis that recent studies were more likely to report positive results than older studies because of more consistent use of standardized bundled prevention protocols. Indeed, the only good-quality trial to compare the effects of using a pressure ulcer risk assessment instrument, with or without a protocolized intervention strategy based on assessed risk, was published in 2011 (1). It found no effect of using a pressure ulcer risk assessment instrument on incidence of pressure ulcers compared with less-standardized risk assessment based on nurses’ clinical judgment. Roger Chou, MD Oregon Health & Science University Portland, Oregon
The emergence of the women’s health movement in the 1970s and funding of the U.S. Department of Health and Human Services Centers of Excellence in Women’s Health, establishment of the National Institutes of Health Office of Research on Women’s Health, and publication of the Institute of Medicine’s Exploring the Biological Contributions to Human Health: Does Sex Matter? (4) expanded the body of knowledge of this subject beyond specific body parts. This approach has already yielded breakthroughs (for example, aspirin prophylaxis of cardiovascular disease in women) (4). The health care industry noticed that most health care consumers are women, and women’s health centers cropped up across the nation. Clinical programs and scientific journals focusing on men’s health began to emerge, perhaps because of the belief that the pendulum had swung too far toward women’s health. This development further entrenched the disparities and constrained men’s and women’s health into narrow, mutually exclusive definitions. To tear down this silo-based approach, an integrated sex-specific approach to medicine in medical education (5), research, and clinical care would benefit everyone. Marjorie Jenkins, MD Tedd L. Mitchell, MD Steven L. Berk, MD Texas Tech University Health Sciences Center Lubbock, Texas Potential Conflicts of Interest: Dr. Jenkins: Consultancy: Novo
Nordisk. Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum⫽M12 -2540. Reference 1. Webster J, Coleman K, Mudge A, Marquart L, Gardner G, Stankiewicz M, et al. Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ Qual Saf. 2011;20:297-306. [PMID: 21262791]
Update in Women’s Health TO THE EDITOR: We recognize that McNamara and Walsh (1) primarily categorized women’s health according to the standard topics of breast, bone, and reproductive health and screening. Focusing on customary women’s health topics reinforces the current ideology, which implies that human organ systems function similarly whether the patient is male or female. This view fails to include the emerging body of knowledge about sex and gender differences in health and disease, which evidence-based guidelines explain (2, 3). As such, approaching women’s health through the lens of gender-specific medicine is defined as the science of how typical human biology differs between men and women and how the manifestations, mechanisms, and treatment of disease vary as a function of sex (2). We recognize the value and important breakthroughs that women’s health researchers have made in osteoporosis and breast and gynecologic cancer. However, a broader approach through sex and gender medicine will further improve outcomes in women’s health by defining differences between men and women in all biological systems, thereby better addressing diagnosis and treatment of a wider range of disease processes. www.annals.org
References 1. McNamara M, Walsh JM. Update in women’s health: evidence published in 2012. Ann Intern Med. 2013;159:203-9. [PMID: 23579223] 2. Legato M. Principles of Gender-Specific Medicine. 2nd ed. Philadelphia: Elsevier; 2011. 3. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women— 2011 update: a guideline from the American Heart Association. Circulation. 2011;123: 1243-62. [PMID: 21325087] 4. Wizemann TM, Pardue M-L. Exploring the Biological Contributions to Human Health: Does Sex Matter? Washington, DC: National Academies Pr; 2001. 5. Texas Tech University Health Sciences Center. Sex and Gender-Based Medicine Curriculum. Accessed at www.ttuhsc.edu/som/curriculum/sgbm_curriculum.aspx on 31 August 2013.
IN RESPONSE: As practicing women’s health physicians and inter-
nists, we agree that a broad approach to sex-based differences in disease is essential for providing comprehensive primary care. In writing our update, we searched multiple journal articles to identify studies that were relevant to primary care in women’s health and could be practice-changing. Of note, we did not approach the review process with predefined categories in mind. Rather, we let the selected articles themselves define the groupings that we used to outline the update. We have previously written several updates in women’s health before (1, 2) using this approach and had identified practicechanging articles that focused on migraine and cardiovascular disease, as well as breast arterial calcification and coronary heart disease (3,4). For our current update, we did not identify any articles that met the above criteria in the areas of cardiovascular disease, diabetes, 19 November 2013 Annals of Internal Medicine Volume 159 • Number 10 719
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Letters or cancer. In our opinion, primary care for women should never be broken down into the silos of “breast and gynecologic care” and “everything else.” Women’s health providers should seek to understand the complex interactions between sex and health, both in regard to chronic disease as well as sex-specific diseases, and use a comprehensive and holistic approach in clinical, educational, and research activities. Megan C. McNamara, MD, MS Case Western Reserve University Cleveland, Ohio Judith M.E. Walsh, MD., MPH Women’s Health Clinical Research Center, University of California, San Francisco San Francisco, California Potential Conflicts of Interest: None disclosed. Forms can be viewed at
www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum ⫽M13-0263. References 1. Schwarz EB, McNamara M, Miller RG, Walsh JM. Update in women’s health for the general internist. J Gen Intern Med. 2011;26:207-13. [PMID: 20824360] 2. Walsh JM, McNamara M, Miller RG, Schwarz EB. Update in women’s health for the general internist. J Gen Intern Med. 2012;27:232-7. [PMID: 21993997] 3. Schu¨rks M, Rist PM, Bigal ME, Buring JE, Lipton RB, Kurth T. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ. 2009;339:b3914. [PMID: 19861375] 4. Schnatz PF, Marakovits KA, O’Sullivan DM. The association of breast arterial calcification and coronary heart disease. Obstet Gynecol. 2011;117:233-41. [PMID: 21252734]
The New Crisis of Confidence in Psychiatric Diagnosis TO THE EDITOR: Frances (1) is correct that changes in diagnostic
systems can lead to overdiagnosis and everyday life problems could be misclassified as illnesses. Physicians and patients do not like diagnostic uncertainty, the possibility of inaccurate diagnoses, and unnecessary or harmful “treatment.” We also know how the media can echo these sentiments. Readers should consider several aspects. Revising a diagnostic manual is not unique to psychiatry. The definition of and treatment recommendations for various diseases, such as hypertension, have been adjusted numerous times. Recent discussion on obesity shows that even having a biological measure does not always allow for the clear separation of what is “normal” and what is not and whether one or the other comes with health benefits (2). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, does not aim to pathologize grief or forgetfulness. However, every memory disorder clinic has too many patients with dementia whose health care providers told them for too many years that their memory problems would reflect normal aging. This cir-
cumstance prevents therapy, and as in every other medical specialty, psychiatric therapy is not always pharmacologic. Putting the interests of drug companies and the complex process of revising a diagnostic manual in the same context is misleading. The physician always establishes a diagnosis. We have to carefully consider given criteria, and we must judge whether they are met. Then we decide how to monitor, educate, or treat our patients. Psychiatrists who do not recognize the difference between normal grief and major depression should not consult a manual but rather ask themselves whether they are qualified to be a physician. Advances in neuroscience may ultimately contribute to but do not currently allow for the definition of causal categories for major psychiatric diseases. The emergence and disappearance of cause-oriented approaches to disease classification have always been a part of psychiatry, creating such categories as “organic,” “endogenous,” and “psychogenic” disorders in the early 20th century. These models reflect the desire for simplistic causal explanations, as well as a generation’s limited insight into the structure and function of the brain. In the search for causes and objective biological tests, we have to acknowledge, as Frances did, that we still know far too little about the brain to achieve this goal. Until then, descriptive classification systems will keep us open-minded. Markus Donix, MD University Hospital Carl Gustav Carus Dresden, Germany Potential Conflicts of Interest: None disclosed. References 1. Frances A. The new crisis of confidence in psychiatric diagnosis. Ann Intern Med. 2013;159:221-2. [PMID: 23685989] 2. Ahima RS, Lazar MA. Physiology. The health risk of obesity—better metrics imperative. Science. 2013;341:856-8. [PMID: 23970691]
IN RESPONSE: Although Dr. Donix and I agree on most points, I fear that he underestimates the risk that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, will cause harmful, unintended consequences. This manual certainly does not “aim to pathologize grief or forgetfulness,” but it will almost surely have this result—particularly because primary care physicians, not psychiatrists, do most of the diagnosis and prescription of psychiatric drugs. There are no effective treatments for grief or forgetfulness, and the false positives are much more common than missed cases. It is also naive to ignore the large influence of drug company marketing on physician practice.
Allen Frances, MD Duke University Durham, North Carolina Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum⫽M13 -0997.
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