Mary Ellen Schneider

NEW YORK — Screening for the human papillomavirus in adolescent females is not cost effective because of the high rate of infection in that population, Dr. Edyta C. Pirog said at a gynecology conference sponsored by Mount Sinai School of Medicine.

Since the majority of low-grade squamous intraepithelial lesions will regress spontaneously in adolescent females, most treatment guidelines allow for the observation of these lesions through repeated cytology, said Dr. Pirog, of Weill Cornell Medical College, New York. However, immunosuppressed adolescents, who have a high rate of progression to high-grade squamous intraepithelial lesions, require careful follow-up by physicians, Dr. Pirog said.

The American College of Obstetricians and Gynecologists recently released a new committee opinion advising physicians to take a less aggressive approach to treating abnormal pap test results and benign lesions in adolescents, compared with the approach used in adults (Obstet. Gynecol. 2006;107:963–8). ACOG recommends a noninvasive approach because of the potential risk of cervical incompetence after surgical excision. Adolescent patients who follow their physician's instructions can be treated effectively through follow-up cytology screening at either two 6-month follow-ups or one 12-month follow-up in most cases, according to ACOG. There is a high prevalence of HPV in women aged 15–35 years, even among those with normal pap smears. About 20%–40% of women aged 15–35 with normal pap smears have HPV, Dr. Pirog reported.

Most infections are transient and asymptomatic. About half of women of all ages will clear an HPV infection within 8 months, and 90% of women clear the infection within 2 years, she said. In one study of adolescents aged 14–17 years, the cumulative incidence of HPV infection was more than 80% but the infections cleared within a matter of months (J. Infect. Dis. 2005;191:182–92).

Adolescents also have a different progression of squamous intraepithelial lesions, compared with adults. More than half of low-grade squamous intraepithelial lesions in adolescents have regressed at 12 months; 91% regress by 36 months (Lancet 2004;364:1678–83). This study found that only 3% of low-grade lesions have progressed to high-grade lesions at 36 months in adolescents, compared with about 10% in other age groups. However, researchers have shown that the risk of progression is greater in HIV-positive adolescents. A study of females aged 13–18 years found that the incidence of high-grade squamous intraepithelial lesions at the end of the 4-year follow-up was 21.5% in HIV-positive girls, compared with 4.8% in HIV-negative girls (J. Infect. Dis. 2004;190:1413–21).

NEW YORK — Screening for the human papillomavirus in adolescent females is not cost effective because of the high rate of infection in that population, Dr. Edyta C. Pirog said at a gynecology conference sponsored by Mount Sinai School of Medicine.

Since the majority of low-grade squamous intraepithelial lesions will regress spontaneously in adolescent females, most treatment guidelines allow for the observation of these lesions through repeated cytology, said Dr. Pirog, of Weill Cornell Medical College, New York. However, immunosuppressed adolescents, who have a high rate of progression to high-grade squamous intraepithelial lesions, require careful follow-up by physicians, Dr. Pirog said.

The American College of Obstetricians and Gynecologists recently released a new committee opinion advising physicians to take a less aggressive approach to treating abnormal pap test results and benign lesions in adolescents, compared with the approach used in adults (Obstet. Gynecol. 2006;107:963–8). ACOG recommends a noninvasive approach because of the potential risk of cervical incompetence after surgical excision. Adolescent patients who follow their physician's instructions can be treated effectively through follow-up cytology screening at either two 6-month follow-ups or one 12-month follow-up in most cases, according to ACOG. There is a high prevalence of HPV in women aged 15–35 years, even among those with normal pap smears. About 20%–40% of women aged 15–35 with normal pap smears have HPV, Dr. Pirog reported.

Most infections are transient and asymptomatic. About half of women of all ages will clear an HPV infection within 8 months, and 90% of women clear the infection within 2 years, she said. In one study of adolescents aged 14–17 years, the cumulative incidence of HPV infection was more than 80% but the infections cleared within a matter of months (J. Infect. Dis. 2005;191:182–92).

Adolescents also have a different progression of squamous intraepithelial lesions, compared with adults. More than half of low-grade squamous intraepithelial lesions in adolescents have regressed at 12 months; 91% regress by 36 months (Lancet 2004;364:1678–83). This study found that only 3% of low-grade lesions have progressed to high-grade lesions at 36 months in adolescents, compared with about 10% in other age groups. However, researchers have shown that the risk of progression is greater in HIV-positive adolescents. A study of females aged 13–18 years found that the incidence of high-grade squamous intraepithelial lesions at the end of the 4-year follow-up was 21.5% in HIV-positive girls, compared with 4.8% in HIV-negative girls (J. Infect. Dis. 2004;190:1413–21).

NEW YORK — Screening for the human papillomavirus in adolescent females is not cost effective because of the high rate of infection in that population, Dr. Edyta C. Pirog said at a gynecology conference sponsored by Mount Sinai School of Medicine.

Since the majority of low-grade squamous intraepithelial lesions will regress spontaneously in adolescent females, most treatment guidelines allow for the observation of these lesions through repeated cytology, said Dr. Pirog, of Weill Cornell Medical College, New York. However, immunosuppressed adolescents, who have a high rate of progression to high-grade squamous intraepithelial lesions, require careful follow-up by physicians, Dr. Pirog said.

The American College of Obstetricians and Gynecologists recently released a new committee opinion advising physicians to take a less aggressive approach to treating abnormal pap test results and benign lesions in adolescents, compared with the approach used in adults (Obstet. Gynecol. 2006;107:963–8). ACOG recommends a noninvasive approach because of the potential risk of cervical incompetence after surgical excision. Adolescent patients who follow their physician's instructions can be treated effectively through follow-up cytology screening at either two 6-month follow-ups or one 12-month follow-up in most cases, according to ACOG. There is a high prevalence of HPV in women aged 15–35 years, even among those with normal pap smears. About 20%–40% of women aged 15–35 with normal pap smears have HPV, Dr. Pirog reported.

Most infections are transient and asymptomatic. About half of women of all ages will clear an HPV infection within 8 months, and 90% of women clear the infection within 2 years, she said. In one study of adolescents aged 14–17 years, the cumulative incidence of HPV infection was more than 80% but the infections cleared within a matter of months (J. Infect. Dis. 2005;191:182–92).

Adolescents also have a different progression of squamous intraepithelial lesions, compared with adults. More than half of low-grade squamous intraepithelial lesions in adolescents have regressed at 12 months; 91% regress by 36 months (Lancet 2004;364:1678–83). This study found that only 3% of low-grade lesions have progressed to high-grade lesions at 36 months in adolescents, compared with about 10% in other age groups. However, researchers have shown that the risk of progression is greater in HIV-positive adolescents. A study of females aged 13–18 years found that the incidence of high-grade squamous intraepithelial lesions at the end of the 4-year follow-up was 21.5% in HIV-positive girls, compared with 4.8% in HIV-negative girls (J. Infect. Dis. 2004;190:1413–21).

NEW YORK — When evaluating a breast mass in an adolescent, keep in mind that breast cancer is rare in this population and imaging should be limited, Dr. Patricia Simmons advised physicians at a gynecology conference sponsored by Mount Sinai School of Medicine.

Studies of the histopathology of young patients who have had surgery for a breast mass show that the most consistent finding is fibroadenoma, though some had fibrocystic changes, abscess, and infection, and in very rare cases, malignant diseases, said Dr. Simmons, professor of pediatrics at the Mayo Clinic in Rochester, Minn.

In the rare case of a malignant mass, it is likely to be the type of tumor found more commonly in young patients, such as primary or metastatic rhabdomyosarcoma, metastatic neuroblastoma, or lymphoma, she said.

In those cases, patients did not discover the masses through self-breast exam but generally presented with constitutional symptoms such as fever, night sweats, and weight loss.

The clinical experience in breast masses in adolescents is largely anecdotal, and the surgical experience is limited, Dr. Simmons said. But for the most part, breast masses in adolescent women are benign, cancer is rare, and when cancer occurs, it is generally not carcinoma, she said.

When looking at a breast mass in adolescents, physicians should consider the duration, the constitutional symptoms, and the risk factors for malignancy. Keep in mind that in young women, the risk factors are different, because the patient hasn't lived long enough to develop most of the factors considered in adults, Dr. Simmons said. The risk factors in adolescents are generally cancer history and whether the patient has had chest radiation.

During the physical exam, the mass size and character, breast skin changes, nodes, and organomegaly should be assessed.

In cases in which the diagnosis is uncertain, imaging will be necessary. However, while a mammogram is the go-to test in adults, this type of imaging is ineffective in adolescents because the young breast is denser and firmer, Dr. Simmons said. An ultrasound will be much more sensitive, she said.

Surgery may be indicated in cases such as a recurring cyst that is symptomatic; a growing, disfiguring mass; suspected cystosarcoma phyllodes; suspected papilloma; suspected papillomatosis; or an abscess.

When considering surgery for a fibroadenoma, physicians should assess the course, the certainty of the diagnosis, any worrisome features, size and distortion, and tolerance, Dr. Simmons said. In a case in which the mass is distorting the breast, surgery is probably the right choice, because it is interfering with normal life, she said. However, she cautioned physicians not to opt for surgery just because the mass is worrisome to the mother.

“I think we need to arm our patients with the facts, and we should be able to alleviate anxiety if that anxiety is misplaced and not take [the fibroadenoma] out just because it's there,” she said.

In many cases, it is fine to watch a fibroadenoma in an adolescent patient since most will be benign and not progressive, Dr. Simmons said. “We should be conservative with this population to preserve breast architecture and breast-feeding to the extent we can,” she said.

NEW YORK — When evaluating a breast mass in an adolescent, keep in mind that breast cancer is rare in this population and imaging should be limited, Dr. Patricia Simmons advised physicians at a gynecology conference sponsored by Mount Sinai School of Medicine.

Studies of the histopathology of young patients who have had surgery for a breast mass show that the most consistent finding is fibroadenoma, though some had fibrocystic changes, abscess, and infection, and in very rare cases, malignant diseases, said Dr. Simmons, professor of pediatrics at the Mayo Clinic in Rochester, Minn.

In the rare case of a malignant mass, it is likely to be the type of tumor found more commonly in young patients, such as primary or metastatic rhabdomyosarcoma, metastatic neuroblastoma, or lymphoma, she said.

In those cases, patients did not discover the masses through self-breast exam but generally presented with constitutional symptoms such as fever, night sweats, and weight loss.

The clinical experience in breast masses in adolescents is largely anecdotal, and the surgical experience is limited, Dr. Simmons said. But for the most part, breast masses in adolescent women are benign, cancer is rare, and when cancer occurs, it is generally not carcinoma, she said.

When looking at a breast mass in adolescents, physicians should consider the duration, the constitutional symptoms, and the risk factors for malignancy. Keep in mind that in young women, the risk factors are different, because the patient hasn't lived long enough to develop most of the factors considered in adults, Dr. Simmons said. The risk factors in adolescents are generally cancer history and whether the patient has had chest radiation.

During the physical exam, the mass size and character, breast skin changes, nodes, and organomegaly should be assessed.

In cases in which the diagnosis is uncertain, imaging will be necessary. However, while a mammogram is the go-to test in adults, this type of imaging is ineffective in adolescents because the young breast is denser and firmer, Dr. Simmons said. An ultrasound will be much more sensitive, she said.

Surgery may be indicated in cases such as a recurring cyst that is symptomatic; a growing, disfiguring mass; suspected cystosarcoma phyllodes; suspected papilloma; suspected papillomatosis; or an abscess.

When considering surgery for a fibroadenoma, physicians should assess the course, the certainty of the diagnosis, any worrisome features, size and distortion, and tolerance, Dr. Simmons said. In a case in which the mass is distorting the breast, surgery is probably the right choice, because it is interfering with normal life, she said. However, she cautioned physicians not to opt for surgery just because the mass is worrisome to the mother.

“I think we need to arm our patients with the facts, and we should be able to alleviate anxiety if that anxiety is misplaced and not take [the fibroadenoma] out just because it's there,” she said.

In many cases, it is fine to watch a fibroadenoma in an adolescent patient since most will be benign and not progressive, Dr. Simmons said. “We should be conservative with this population to preserve breast architecture and breast-feeding to the extent we can,” she said.

NEW YORK — When evaluating a breast mass in an adolescent, keep in mind that breast cancer is rare in this population and imaging should be limited, Dr. Patricia Simmons advised physicians at a gynecology conference sponsored by Mount Sinai School of Medicine.

Studies of the histopathology of young patients who have had surgery for a breast mass show that the most consistent finding is fibroadenoma, though some had fibrocystic changes, abscess, and infection, and in very rare cases, malignant diseases, said Dr. Simmons, professor of pediatrics at the Mayo Clinic in Rochester, Minn.

In the rare case of a malignant mass, it is likely to be the type of tumor found more commonly in young patients, such as primary or metastatic rhabdomyosarcoma, metastatic neuroblastoma, or lymphoma, she said.

In those cases, patients did not discover the masses through self-breast exam but generally presented with constitutional symptoms such as fever, night sweats, and weight loss.

The clinical experience in breast masses in adolescents is largely anecdotal, and the surgical experience is limited, Dr. Simmons said. But for the most part, breast masses in adolescent women are benign, cancer is rare, and when cancer occurs, it is generally not carcinoma, she said.

When looking at a breast mass in adolescents, physicians should consider the duration, the constitutional symptoms, and the risk factors for malignancy. Keep in mind that in young women, the risk factors are different, because the patient hasn't lived long enough to develop most of the factors considered in adults, Dr. Simmons said. The risk factors in adolescents are generally cancer history and whether the patient has had chest radiation.

During the physical exam, the mass size and character, breast skin changes, nodes, and organomegaly should be assessed.

In cases in which the diagnosis is uncertain, imaging will be necessary. However, while a mammogram is the go-to test in adults, this type of imaging is ineffective in adolescents because the young breast is denser and firmer, Dr. Simmons said. An ultrasound will be much more sensitive, she said.

Surgery may be indicated in cases such as a recurring cyst that is symptomatic; a growing, disfiguring mass; suspected cystosarcoma phyllodes; suspected papilloma; suspected papillomatosis; or an abscess.

When considering surgery for a fibroadenoma, physicians should assess the course, the certainty of the diagnosis, any worrisome features, size and distortion, and tolerance, Dr. Simmons said. In a case in which the mass is distorting the breast, surgery is probably the right choice, because it is interfering with normal life, she said. However, she cautioned physicians not to opt for surgery just because the mass is worrisome to the mother.

“I think we need to arm our patients with the facts, and we should be able to alleviate anxiety if that anxiety is misplaced and not take [the fibroadenoma] out just because it's there,” she said.

In many cases, it is fine to watch a fibroadenoma in an adolescent patient since most will be benign and not progressive, Dr. Simmons said. “We should be conservative with this population to preserve breast architecture and breast-feeding to the extent we can,” she said.

NEW YORK — Adolescents are disproportionately affected by sexually transmitted diseases because of biologic, psychological, cognitive, and behavioral factors, as well as poor access to health care, Dr. Robin Recant said at a gynecology conference sponsored by Mount Sinai School of Medicine.

Female adolescents are biologically at higher risk for STDs such as chlamydia and gonorrhea because of the columnar epithelium on their ectocervix, said Dr. Recant, of the New York City Department of Health and Mental Hygiene Bureau of Sexually Transmitted Disease Control.

Both chlamydia and gonorrhea preferentially attach to the columnar epithelium, she said. Also, HIV acquisition and shedding may be increased with cervical ectopy.

Mucus production in the adolescent female is increased, but the mucus is thinner than in older women, which may make it easier for pathogens to attach to the epithelium. Adolescent females also have lower vaginal pH, though there are no studies on the significance of this in terms of STD infection, Dr. Recant said.

Psychological and cognitive factors also make both female and male adolescents more vulnerable. For instance, these young adults may not appreciate the consequences of their actions. “Their lack of foresight is often compounded by the use of drugs and alcohol,” Dr. Recant said.

Adolescents also may have difficulty with complex, ordered tasks, such as correct condom use. And they may use sexual activity as a form of rebellion against their parents. Adolescents are likely to experiment both with relationships and sexual behaviors. And since they are going through a formative stage of social development, it may be hard for them to negotiate with older sex partners, she said.

On the behavioral front, sexually active adolescents frequently have multiple sex partners, putting them at greater risk for STDs. Adolescents are frequently serial monogamists who have a series of short-lived sexual relationships, Dr. Recant said.

The 2003 results of the Youth Risk Behavior Survey show that 53% of male high school students in New York City had had sexual intercourse and that 39% of female high school students had. In addition, the survey finds that 8% of female high school students and 25% of male high school students in New York City have had four or more sexual partners in their lifetime.

Trends over the past 10 years show an overall increase in the use of condoms by adolescents, Dr. Recant said, but that use decreases with the duration of the relationship and with age. Similar trends appear in data from the 2003 Youth Risk Behavior Survey. The survey shows that among females, condom use dropped from 78% among 9th graders to 64% among 12th graders. Condom use was higher in males but dropped from a high of 90% in 10th graders to 82% in 12th graders.

Adolescents may face greater risk from inadequate access to health care, and generally obtain health care services less often than older or younger individuals, Dr. Recant said. Also, some may not recognize the symptoms of a sexually transmitted disease or may be too embarrassed to seek care.

“Adolescents may not even be able to distinguish whether aspects of their health are physically normal or abnormal because their bodies are changing so rapidly,” Dr. Recant said.

Confidentiality is another issue. Adolescents are more likely to seek care from physicians and other providers who ensure confidentiality, she said.

Some physicians contribute to the problem because they may not be comfortable discussing sexual behavior with adolescents. Sometimes physicians and other providers fail to take a sexual history or screen as recommended, she said.

Cost can be a barrier for adolescents. Those with insurance coverage may be afraid that their parents will see the diagnosis when they get the bill for the appointment, Dr. Recent said.

NEW YORK — Adolescents are disproportionately affected by sexually transmitted diseases because of biologic, psychological, cognitive, and behavioral factors, as well as poor access to health care, Dr. Robin Recant said at a gynecology conference sponsored by Mount Sinai School of Medicine.

Female adolescents are biologically at higher risk for STDs such as chlamydia and gonorrhea because of the columnar epithelium on their ectocervix, said Dr. Recant, of the New York City Department of Health and Mental Hygiene Bureau of Sexually Transmitted Disease Control.

Both chlamydia and gonorrhea preferentially attach to the columnar epithelium, she said. Also, HIV acquisition and shedding may be increased with cervical ectopy.

Mucus production in the adolescent female is increased, but the mucus is thinner than in older women, which may make it easier for pathogens to attach to the epithelium. Adolescent females also have lower vaginal pH, though there are no studies on the significance of this in terms of STD infection, Dr. Recant said.

Psychological and cognitive factors also make both female and male adolescents more vulnerable. For instance, these young adults may not appreciate the consequences of their actions. “Their lack of foresight is often compounded by the use of drugs and alcohol,” Dr. Recant said.

Adolescents also may have difficulty with complex, ordered tasks, such as correct condom use. And they may use sexual activity as a form of rebellion against their parents. Adolescents are likely to experiment both with relationships and sexual behaviors. And since they are going through a formative stage of social development, it may be hard for them to negotiate with older sex partners, she said.

On the behavioral front, sexually active adolescents frequently have multiple sex partners, putting them at greater risk for STDs. Adolescents are frequently serial monogamists who have a series of short-lived sexual relationships, Dr. Recant said.

The 2003 results of the Youth Risk Behavior Survey show that 53% of male high school students in New York City had had sexual intercourse and that 39% of female high school students had. In addition, the survey finds that 8% of female high school students and 25% of male high school students in New York City have had four or more sexual partners in their lifetime.

Trends over the past 10 years show an overall increase in the use of condoms by adolescents, Dr. Recant said, but that use decreases with the duration of the relationship and with age. Similar trends appear in data from the 2003 Youth Risk Behavior Survey. The survey shows that among females, condom use dropped from 78% among 9th graders to 64% among 12th graders. Condom use was higher in males but dropped from a high of 90% in 10th graders to 82% in 12th graders.

Adolescents may face greater risk from inadequate access to health care, and generally obtain health care services less often than older or younger individuals, Dr. Recant said. Also, some may not recognize the symptoms of a sexually transmitted disease or may be too embarrassed to seek care.

“Adolescents may not even be able to distinguish whether aspects of their health are physically normal or abnormal because their bodies are changing so rapidly,” Dr. Recant said.

Confidentiality is another issue. Adolescents are more likely to seek care from physicians and other providers who ensure confidentiality, she said.

Some physicians contribute to the problem because they may not be comfortable discussing sexual behavior with adolescents. Sometimes physicians and other providers fail to take a sexual history or screen as recommended, she said.

Cost can be a barrier for adolescents. Those with insurance coverage may be afraid that their parents will see the diagnosis when they get the bill for the appointment, Dr. Recent said.

NEW YORK — Adolescents are disproportionately affected by sexually transmitted diseases because of biologic, psychological, cognitive, and behavioral factors, as well as poor access to health care, Dr. Robin Recant said at a gynecology conference sponsored by Mount Sinai School of Medicine.

Female adolescents are biologically at higher risk for STDs such as chlamydia and gonorrhea because of the columnar epithelium on their ectocervix, said Dr. Recant, of the New York City Department of Health and Mental Hygiene Bureau of Sexually Transmitted Disease Control.

Both chlamydia and gonorrhea preferentially attach to the columnar epithelium, she said. Also, HIV acquisition and shedding may be increased with cervical ectopy.

Mucus production in the adolescent female is increased, but the mucus is thinner than in older women, which may make it easier for pathogens to attach to the epithelium. Adolescent females also have lower vaginal pH, though there are no studies on the significance of this in terms of STD infection, Dr. Recant said.

Psychological and cognitive factors also make both female and male adolescents more vulnerable. For instance, these young adults may not appreciate the consequences of their actions. “Their lack of foresight is often compounded by the use of drugs and alcohol,” Dr. Recant said.

Adolescents also may have difficulty with complex, ordered tasks, such as correct condom use. And they may use sexual activity as a form of rebellion against their parents. Adolescents are likely to experiment both with relationships and sexual behaviors. And since they are going through a formative stage of social development, it may be hard for them to negotiate with older sex partners, she said.

On the behavioral front, sexually active adolescents frequently have multiple sex partners, putting them at greater risk for STDs. Adolescents are frequently serial monogamists who have a series of short-lived sexual relationships, Dr. Recant said.

The 2003 results of the Youth Risk Behavior Survey show that 53% of male high school students in New York City had had sexual intercourse and that 39% of female high school students had. In addition, the survey finds that 8% of female high school students and 25% of male high school students in New York City have had four or more sexual partners in their lifetime.

Trends over the past 10 years show an overall increase in the use of condoms by adolescents, Dr. Recant said, but that use decreases with the duration of the relationship and with age. Similar trends appear in data from the 2003 Youth Risk Behavior Survey. The survey shows that among females, condom use dropped from 78% among 9th graders to 64% among 12th graders. Condom use was higher in males but dropped from a high of 90% in 10th graders to 82% in 12th graders.

Adolescents may face greater risk from inadequate access to health care, and generally obtain health care services less often than older or younger individuals, Dr. Recant said. Also, some may not recognize the symptoms of a sexually transmitted disease or may be too embarrassed to seek care.

“Adolescents may not even be able to distinguish whether aspects of their health are physically normal or abnormal because their bodies are changing so rapidly,” Dr. Recant said.

Confidentiality is another issue. Adolescents are more likely to seek care from physicians and other providers who ensure confidentiality, she said.

Some physicians contribute to the problem because they may not be comfortable discussing sexual behavior with adolescents. Sometimes physicians and other providers fail to take a sexual history or screen as recommended, she said.

Cost can be a barrier for adolescents. Those with insurance coverage may be afraid that their parents will see the diagnosis when they get the bill for the appointment, Dr. Recent said.

ORLANDO — Pregnant women who are not heavy smokers may be more likely to successfully quit, according to research presented at the annual meeting of the Society for Research on Nicotine and Tobacco.

Lower amounts of smoking, adequate prenatal care, and higher incomes were all associated with women being more likely to quit smoking during pregnancy, said Beth Nordstrom Bailey, Ph.D., of East Tennessee State University in Johnson City. She analyzed predictors of smoking cessation among women living in rural Tennessee and Virginia, a population with a historically high rate of smoking.

Dr. Bailey conducted a chart review of 221 women who received prenatal care at a family medicine clinic in 2002 and 2003. She considered sociodemographic factors, medical factors, and substance use history. Of those women, 148 were self-identified as prepregnancy smokers. More than 60% of these smoked a pack or more a day.

Only 27% of the prepregnancy smokers were able to quit during pregnancy, 43% reduced their smoking by a quarter of a pack per day, and about 30% continued smoking at the same level.

The amount of smoking had the highest association with ability to quit. Prenatal care accounted for about 12% of the variation in quitting, Dr. Bailey said. In addition, women were more likely to quit if they had fewer prior pregnancies. Other factors such as marital status, history of depression, education, and use of drugs were not related to cessation.

ORLANDO — Pregnant women who are not heavy smokers may be more likely to successfully quit, according to research presented at the annual meeting of the Society for Research on Nicotine and Tobacco.

Lower amounts of smoking, adequate prenatal care, and higher incomes were all associated with women being more likely to quit smoking during pregnancy, said Beth Nordstrom Bailey, Ph.D., of East Tennessee State University in Johnson City. She analyzed predictors of smoking cessation among women living in rural Tennessee and Virginia, a population with a historically high rate of smoking.

Dr. Bailey conducted a chart review of 221 women who received prenatal care at a family medicine clinic in 2002 and 2003. She considered sociodemographic factors, medical factors, and substance use history. Of those women, 148 were self-identified as prepregnancy smokers. More than 60% of these smoked a pack or more a day.

Only 27% of the prepregnancy smokers were able to quit during pregnancy, 43% reduced their smoking by a quarter of a pack per day, and about 30% continued smoking at the same level.

The amount of smoking had the highest association with ability to quit. Prenatal care accounted for about 12% of the variation in quitting, Dr. Bailey said. In addition, women were more likely to quit if they had fewer prior pregnancies. Other factors such as marital status, history of depression, education, and use of drugs were not related to cessation.

ORLANDO — Pregnant women who are not heavy smokers may be more likely to successfully quit, according to research presented at the annual meeting of the Society for Research on Nicotine and Tobacco.

Lower amounts of smoking, adequate prenatal care, and higher incomes were all associated with women being more likely to quit smoking during pregnancy, said Beth Nordstrom Bailey, Ph.D., of East Tennessee State University in Johnson City. She analyzed predictors of smoking cessation among women living in rural Tennessee and Virginia, a population with a historically high rate of smoking.

Dr. Bailey conducted a chart review of 221 women who received prenatal care at a family medicine clinic in 2002 and 2003. She considered sociodemographic factors, medical factors, and substance use history. Of those women, 148 were self-identified as prepregnancy smokers. More than 60% of these smoked a pack or more a day.

Only 27% of the prepregnancy smokers were able to quit during pregnancy, 43% reduced their smoking by a quarter of a pack per day, and about 30% continued smoking at the same level.

The amount of smoking had the highest association with ability to quit. Prenatal care accounted for about 12% of the variation in quitting, Dr. Bailey said. In addition, women were more likely to quit if they had fewer prior pregnancies. Other factors such as marital status, history of depression, education, and use of drugs were not related to cessation.

The Health and Human Services Office of Inspector General recently gave the green light to a redesigned patient assistance program from the drug maker Schering-Plough Corp.

The Inspector General issued a special advisory bulletin cautioning drug makers that continuing their patient assistance programs for people enrolled in the Medicare Part D prescription drug benefit could put them at risk for violating the federal antikickback statute. But the bulletin outlined some designs that would allow Medicare beneficiaries to continue to receive drug assistance from the companies outside of the Part D benefit.

The new advisory opinion (no. 06–03) states that the OIG will not impose administrative sanctions on Schering-Plough based on the specific design of the program's two patient assistance plans, which offer free drugs to financially needy patients taking hepatitis or cancer drugs, and to such patients taking other outpatient prescription drugs. The advisory opinion does not apply to any other arrangements.

Under the redesign, Part D beneficiaries are eligible for free drugs if they meet the income requirements for the patient assistance plans and have already spent at least 3% of their household income on outpatient prescription drugs that coverage year. The free drugs do not count toward the beneficiary's true out-of-pocket costs and will not be billed to either the Part D plan or Medicare.

“[W]e conclude that the arrangement contains safeguards sufficient to ensure that the [patient assistance plans] operate entirely outside the Part D benefit, and, therefore, there is minimal risk of fraud and abuse under the Part D program,” Lewis Morris, chief counsel to the OIG, wrote in the advisory opinion.

The OIG advisory opinion is available online at oig.hhs.gov/fraud/advisory opinions.html

The Health and Human Services Office of Inspector General recently gave the green light to a redesigned patient assistance program from the drug maker Schering-Plough Corp.

The Inspector General issued a special advisory bulletin cautioning drug makers that continuing their patient assistance programs for people enrolled in the Medicare Part D prescription drug benefit could put them at risk for violating the federal antikickback statute. But the bulletin outlined some designs that would allow Medicare beneficiaries to continue to receive drug assistance from the companies outside of the Part D benefit.

The new advisory opinion (no. 06–03) states that the OIG will not impose administrative sanctions on Schering-Plough based on the specific design of the program's two patient assistance plans, which offer free drugs to financially needy patients taking hepatitis or cancer drugs, and to such patients taking other outpatient prescription drugs. The advisory opinion does not apply to any other arrangements.

Under the redesign, Part D beneficiaries are eligible for free drugs if they meet the income requirements for the patient assistance plans and have already spent at least 3% of their household income on outpatient prescription drugs that coverage year. The free drugs do not count toward the beneficiary's true out-of-pocket costs and will not be billed to either the Part D plan or Medicare.

“[W]e conclude that the arrangement contains safeguards sufficient to ensure that the [patient assistance plans] operate entirely outside the Part D benefit, and, therefore, there is minimal risk of fraud and abuse under the Part D program,” Lewis Morris, chief counsel to the OIG, wrote in the advisory opinion.

The OIG advisory opinion is available online at oig.hhs.gov/fraud/advisory opinions.html

The Health and Human Services Office of Inspector General recently gave the green light to a redesigned patient assistance program from the drug maker Schering-Plough Corp.

The Inspector General issued a special advisory bulletin cautioning drug makers that continuing their patient assistance programs for people enrolled in the Medicare Part D prescription drug benefit could put them at risk for violating the federal antikickback statute. But the bulletin outlined some designs that would allow Medicare beneficiaries to continue to receive drug assistance from the companies outside of the Part D benefit.

The new advisory opinion (no. 06–03) states that the OIG will not impose administrative sanctions on Schering-Plough based on the specific design of the program's two patient assistance plans, which offer free drugs to financially needy patients taking hepatitis or cancer drugs, and to such patients taking other outpatient prescription drugs. The advisory opinion does not apply to any other arrangements.

Under the redesign, Part D beneficiaries are eligible for free drugs if they meet the income requirements for the patient assistance plans and have already spent at least 3% of their household income on outpatient prescription drugs that coverage year. The free drugs do not count toward the beneficiary's true out-of-pocket costs and will not be billed to either the Part D plan or Medicare.

“[W]e conclude that the arrangement contains safeguards sufficient to ensure that the [patient assistance plans] operate entirely outside the Part D benefit, and, therefore, there is minimal risk of fraud and abuse under the Part D program,” Lewis Morris, chief counsel to the OIG, wrote in the advisory opinion.

The OIG advisory opinion is available online at oig.hhs.gov/fraud/advisory opinions.html

Merck Faces Punitive Damages

Jurors in New Jersey last month awarded $9 million in punitive damages—and $4.5 million in compensatory damages—to John McDarby, 76, who claimed that his myocardial infarction was caused in part by his long-term use of Vioxx. However, the jury did not find in favor of the other plaintiff in the case—60-year-old Thomas Cona, who claimed his use of Vioxx for about 22 months contributed to his MI. Merck & Co., which manufactures Vioxx, plans to appeal both the compensatory and punitive damage awards. “We continue to believe that the heart attacks in both these cases were caused by the preexisting medical conditions of these two men, and not Vioxx,” Chuck Harrell, a member of the Merck defense team, said in a statement. To date, Merck has lost only one other Vioxx case. In 2005, a Texas jury awarded more than $250 million to the plaintiff and found that Merck had failed to warn doctors about the risks of the drugs, the drug was improperly designed, and that the company's negligence caused the death of Robert Ernst. Merck has won a federal case and another New Jersey case and plans on appealing the Texas verdict.

Importance of Exercise

Patients with arthritis still aren't getting the message that exercise can decrease pain and disability in that population, according to a study in the American Journal of Preventive Medicine. The researchers compared levels of activity among individuals with and without arthritis using data from the 2002 National Health Interview Survey and found that adults with arthritis were much less likely to engage in recommended levels of moderate to vigorous activity and that overall activity levels were low. They did not find significant differences between those with and without arthritis in terms of inactivity or in the participation in strengthening exercises. Future research should focus on targeting the groups at the greatest risk for inactivity such as women, the elderly, and minorities, the authors wrote.

Health Care Workforce Concerns

The number of new geriatricians in the United States is declining, even as the over-65 population is growing rapidly, according to a report from the Center for Health Workforce Studies at the University at Albany, part of the State University of New York system. The report, which was funded by the Health Resources and Services Administration, finds that while projections on the number of physicians entering practice each year is expected to be adequate to meet the “aggregate demand,” it may not be well matched to the needs of older Americans. And the report points to the need for more geriatricians, registered nurses, clinical psychologists, nursing home administrators, and other health care workers to meet the needs of the growing older population. The report also found that the demand for services by older adults is likely to be affected by health insurance reimbursement policies, emerging technology, new models of care, and changes in the profession-specific scope of practice. The full report is available online at

http://chws.albany.edu

Researching Psoriatic Arthritis

The National Psoriasis Foundation has awarded $120,000 in seed money to researchers trying to understand the mechanism of disease for psoriasis and psoriatic arthritis. The idea behind the program is to fund research that will generate preliminary data to be used in grant applications to the National Institutes of Health. The four grants—funded at $30,000 each—were awarded to researchers in Oregon, Utah, Colorado, and New York. One grant recipient at Columbia University will focus on understanding the environment of joints in psoriatic arthritis. The results of this type of research could lead to better therapeutic targets for psoriatic arthritis, according to the Psoriasis Foundation.

Decline in Charity Care

The decade-long decline in the proportion of physicians providing charity care continued in 2004–2005, according to a study by the Center for Studying Health System Change. The percentage of physicians providing any free or reduced-fee care decreased to 68% in 2004–2005, down from 72% in 2000–2001. “Declines in charity care were observed across most major specialties, practice types, practice income levels, and geographic regions,” study authors Peter J. Cunningham, Ph.D., and Jessica H. May wrote. “Increasing financial pressures and changes in practice arrangements may account in part for the continuing decrease in physician charity care.” More than 70% of physicians providing charity care reported that they typically did so in their own practice, while 14% provided it while on call in a hospital emergency department and 6% in another practice or clinic.

Vote of Low Confidence

Americans have a low level of trust and confidence in President Bush when it comes to improving the U.S. health care system, a Wall Street Journal Online/Harris Interactive poll found. Only 25% of adults are “confident or very confident” that the president can reduce the percentage of Americans without health insurance, according to the online survey of more than 2,400 adults. About half (49%) of Republicans expressed this level of confidence, compared with 7% of Democrats and 19% of Independents. Respondents expressed somewhat more trust in the Democrats (45%) and potential 2008 Democratic presidential candidate Sen. Hillary Clinton (D-N.Y.) (41%) to improve the health care system than in the Republicans (31%) and President Bush (30%).

Merck Faces Punitive Damages

Jurors in New Jersey last month awarded $9 million in punitive damages—and $4.5 million in compensatory damages—to John McDarby, 76, who claimed that his myocardial infarction was caused in part by his long-term use of Vioxx. However, the jury did not find in favor of the other plaintiff in the case—60-year-old Thomas Cona, who claimed his use of Vioxx for about 22 months contributed to his MI. Merck & Co., which manufactures Vioxx, plans to appeal both the compensatory and punitive damage awards. “We continue to believe that the heart attacks in both these cases were caused by the preexisting medical conditions of these two men, and not Vioxx,” Chuck Harrell, a member of the Merck defense team, said in a statement. To date, Merck has lost only one other Vioxx case. In 2005, a Texas jury awarded more than $250 million to the plaintiff and found that Merck had failed to warn doctors about the risks of the drugs, the drug was improperly designed, and that the company's negligence caused the death of Robert Ernst. Merck has won a federal case and another New Jersey case and plans on appealing the Texas verdict.

Importance of Exercise

Patients with arthritis still aren't getting the message that exercise can decrease pain and disability in that population, according to a study in the American Journal of Preventive Medicine. The researchers compared levels of activity among individuals with and without arthritis using data from the 2002 National Health Interview Survey and found that adults with arthritis were much less likely to engage in recommended levels of moderate to vigorous activity and that overall activity levels were low. They did not find significant differences between those with and without arthritis in terms of inactivity or in the participation in strengthening exercises. Future research should focus on targeting the groups at the greatest risk for inactivity such as women, the elderly, and minorities, the authors wrote.

Health Care Workforce Concerns

The number of new geriatricians in the United States is declining, even as the over-65 population is growing rapidly, according to a report from the Center for Health Workforce Studies at the University at Albany, part of the State University of New York system. The report, which was funded by the Health Resources and Services Administration, finds that while projections on the number of physicians entering practice each year is expected to be adequate to meet the “aggregate demand,” it may not be well matched to the needs of older Americans. And the report points to the need for more geriatricians, registered nurses, clinical psychologists, nursing home administrators, and other health care workers to meet the needs of the growing older population. The report also found that the demand for services by older adults is likely to be affected by health insurance reimbursement policies, emerging technology, new models of care, and changes in the profession-specific scope of practice. The full report is available online at

http://chws.albany.edu

Researching Psoriatic Arthritis

The National Psoriasis Foundation has awarded $120,000 in seed money to researchers trying to understand the mechanism of disease for psoriasis and psoriatic arthritis. The idea behind the program is to fund research that will generate preliminary data to be used in grant applications to the National Institutes of Health. The four grants—funded at $30,000 each—were awarded to researchers in Oregon, Utah, Colorado, and New York. One grant recipient at Columbia University will focus on understanding the environment of joints in psoriatic arthritis. The results of this type of research could lead to better therapeutic targets for psoriatic arthritis, according to the Psoriasis Foundation.

Decline in Charity Care

The decade-long decline in the proportion of physicians providing charity care continued in 2004–2005, according to a study by the Center for Studying Health System Change. The percentage of physicians providing any free or reduced-fee care decreased to 68% in 2004–2005, down from 72% in 2000–2001. “Declines in charity care were observed across most major specialties, practice types, practice income levels, and geographic regions,” study authors Peter J. Cunningham, Ph.D., and Jessica H. May wrote. “Increasing financial pressures and changes in practice arrangements may account in part for the continuing decrease in physician charity care.” More than 70% of physicians providing charity care reported that they typically did so in their own practice, while 14% provided it while on call in a hospital emergency department and 6% in another practice or clinic.

Vote of Low Confidence

Americans have a low level of trust and confidence in President Bush when it comes to improving the U.S. health care system, a Wall Street Journal Online/Harris Interactive poll found. Only 25% of adults are “confident or very confident” that the president can reduce the percentage of Americans without health insurance, according to the online survey of more than 2,400 adults. About half (49%) of Republicans expressed this level of confidence, compared with 7% of Democrats and 19% of Independents. Respondents expressed somewhat more trust in the Democrats (45%) and potential 2008 Democratic presidential candidate Sen. Hillary Clinton (D-N.Y.) (41%) to improve the health care system than in the Republicans (31%) and President Bush (30%).

Merck Faces Punitive Damages

Jurors in New Jersey last month awarded $9 million in punitive damages—and $4.5 million in compensatory damages—to John McDarby, 76, who claimed that his myocardial infarction was caused in part by his long-term use of Vioxx. However, the jury did not find in favor of the other plaintiff in the case—60-year-old Thomas Cona, who claimed his use of Vioxx for about 22 months contributed to his MI. Merck & Co., which manufactures Vioxx, plans to appeal both the compensatory and punitive damage awards. “We continue to believe that the heart attacks in both these cases were caused by the preexisting medical conditions of these two men, and not Vioxx,” Chuck Harrell, a member of the Merck defense team, said in a statement. To date, Merck has lost only one other Vioxx case. In 2005, a Texas jury awarded more than $250 million to the plaintiff and found that Merck had failed to warn doctors about the risks of the drugs, the drug was improperly designed, and that the company's negligence caused the death of Robert Ernst. Merck has won a federal case and another New Jersey case and plans on appealing the Texas verdict.

Importance of Exercise

Patients with arthritis still aren't getting the message that exercise can decrease pain and disability in that population, according to a study in the American Journal of Preventive Medicine. The researchers compared levels of activity among individuals with and without arthritis using data from the 2002 National Health Interview Survey and found that adults with arthritis were much less likely to engage in recommended levels of moderate to vigorous activity and that overall activity levels were low. They did not find significant differences between those with and without arthritis in terms of inactivity or in the participation in strengthening exercises. Future research should focus on targeting the groups at the greatest risk for inactivity such as women, the elderly, and minorities, the authors wrote.

Health Care Workforce Concerns

The number of new geriatricians in the United States is declining, even as the over-65 population is growing rapidly, according to a report from the Center for Health Workforce Studies at the University at Albany, part of the State University of New York system. The report, which was funded by the Health Resources and Services Administration, finds that while projections on the number of physicians entering practice each year is expected to be adequate to meet the “aggregate demand,” it may not be well matched to the needs of older Americans. And the report points to the need for more geriatricians, registered nurses, clinical psychologists, nursing home administrators, and other health care workers to meet the needs of the growing older population. The report also found that the demand for services by older adults is likely to be affected by health insurance reimbursement policies, emerging technology, new models of care, and changes in the profession-specific scope of practice. The full report is available online at

http://chws.albany.edu

Researching Psoriatic Arthritis

The National Psoriasis Foundation has awarded $120,000 in seed money to researchers trying to understand the mechanism of disease for psoriasis and psoriatic arthritis. The idea behind the program is to fund research that will generate preliminary data to be used in grant applications to the National Institutes of Health. The four grants—funded at $30,000 each—were awarded to researchers in Oregon, Utah, Colorado, and New York. One grant recipient at Columbia University will focus on understanding the environment of joints in psoriatic arthritis. The results of this type of research could lead to better therapeutic targets for psoriatic arthritis, according to the Psoriasis Foundation.

Decline in Charity Care

The decade-long decline in the proportion of physicians providing charity care continued in 2004–2005, according to a study by the Center for Studying Health System Change. The percentage of physicians providing any free or reduced-fee care decreased to 68% in 2004–2005, down from 72% in 2000–2001. “Declines in charity care were observed across most major specialties, practice types, practice income levels, and geographic regions,” study authors Peter J. Cunningham, Ph.D., and Jessica H. May wrote. “Increasing financial pressures and changes in practice arrangements may account in part for the continuing decrease in physician charity care.” More than 70% of physicians providing charity care reported that they typically did so in their own practice, while 14% provided it while on call in a hospital emergency department and 6% in another practice or clinic.

Vote of Low Confidence

Americans have a low level of trust and confidence in President Bush when it comes to improving the U.S. health care system, a Wall Street Journal Online/Harris Interactive poll found. Only 25% of adults are “confident or very confident” that the president can reduce the percentage of Americans without health insurance, according to the online survey of more than 2,400 adults. About half (49%) of Republicans expressed this level of confidence, compared with 7% of Democrats and 19% of Independents. Respondents expressed somewhat more trust in the Democrats (45%) and potential 2008 Democratic presidential candidate Sen. Hillary Clinton (D-N.Y.) (41%) to improve the health care system than in the Republicans (31%) and President Bush (30%).

PHILADELPHIA — Officials at the American College of Physicians are proposing major changes in the way general internists practice, get paid, and are trained.

The recommendations are outlined in three new policy papers aimed at addressing reform of the payment system, a national workforce for internal medicine, and redesign of internal medicine training programs.

The Medicare payment system is one of the principal reasons that physicians are abandoning primary care, said Robert B. Doherty, ACP senior vice president for governmental affairs and public policy.

ACP officials are recommending changes to the current payment system to improve compensation for general internists, but say that more sweeping reforms are needed. Proposed changes to the Medicare Resource-Based Relative Value Schedule (RBRVS) include increasing the work relative value units (RVUs) for evaluation and management services, reexamining the methodologies used to derive the practice expense RVUs, and establishing a process to identify potentially misvalued RVUs.

If recommendations by the RVS Update Committee—the group of physicians that recommends changes in the payment level for new and revised CPT codes—to increase payments for evaluation and management codes are accepted, the changes would take effect on Jan. 1, 2007, he said.

ACP also is seeking separate Medicare payments for services that contribute to coordinated care. For example, ACP is calling on CMS to provide a separate payment for e-mail, telephone, and related technology that can reduce the need for face-to-face visits for nonurgent care. CMS should also develop specific codes for care coordination activities, such as intensive follow-up, the use of patient registries and population-based treatment protocols, and disease management training, according to ACP.

In addition, ACP officials would like CMS to provide an add-on payment when office visits include the use of health information technology, such as electronic health records, electronic prescribing, or clinical decision support tools.

On pay for performance, ACP maintains that potential rewards should be substantial enough to allow for continuous quality improvement. Also, positive incentives should be used rather than penalties.

In the long term, Congress should replace the Sustainable Growth Rate with a formula that would provide adequate and predictable payment increases for all physicians, ACP said in its position paper. And ACP officials want to work with Medicare and other payers to design a new model for health care financing that would build on the concept of the advanced medical home.

Reforms to the education of medical students and the training of internal medicine residents also are needed. The ACP position paper, “Redesigning Training for Internal Medicine,” was published online and will appear in the June 20 print edition of Annals of Internal Medicine.

Rethinking Internist Residency Training

The ACP position paper on training for internal medicine outlines six revisions to the current model for graduate medical education:

▸ Defining the design model for residency training. ACP is calling for the creation of a 3-year model for residency education that would include 2 years of core training and 1 year of customized experiences tailored to the career goals of the trainees. For example, someone interested in becoming a hospitalist would spend more of the third year in the hospital, while others would spend more time in ambulatory care settings.

▸ Integrating educational and service needs. Such a change would move away from excessive workloads for residents, which currently meet the needs of the institutions but not of the residents or patients.

▸ Enhancing ambulatory training. When possible, residents should train in office settings that use advanced technology, such as electronic health records, and that have a team approach to care, according to ACP. In addition, the time spent in ambulatory settings should be structured so that residents do not view it as a distraction from their inpatient duties. Ambulatory training has been the “poor stepchild” of graduate medical education, Dr. Weinberger said, and usually is conducted in settings that make it difficult to practice and learn.

▸ Utilizing team-based care. Training should incorporate team-based care that includes nurses, social workers, case managers, and midlevel providers, according to ACP. In addition, residents can be paired together or with faculty so that one member can provide inpatient care while the other cares for ambulatory patients.

▸ Developing faculty models. Training programs should also consider creating a “core faculty,” a specialized group of clinician educators, who would receive sufficient time, money, and status to train and mentor residents. “We don't have the right faculty models,” Dr. Weinberger said.

▸ Stressing professionalism. The core values include patient-centered, culturally sensitive, evidence-based care.

PHILADELPHIA — Officials at the American College of Physicians are proposing major changes in the way general internists practice, get paid, and are trained.

The recommendations are outlined in three new policy papers aimed at addressing reform of the payment system, a national workforce for internal medicine, and redesign of internal medicine training programs.

The Medicare payment system is one of the principal reasons that physicians are abandoning primary care, said Robert B. Doherty, ACP senior vice president for governmental affairs and public policy.

ACP officials are recommending changes to the current payment system to improve compensation for general internists, but say that more sweeping reforms are needed. Proposed changes to the Medicare Resource-Based Relative Value Schedule (RBRVS) include increasing the work relative value units (RVUs) for evaluation and management services, reexamining the methodologies used to derive the practice expense RVUs, and establishing a process to identify potentially misvalued RVUs.

If recommendations by the RVS Update Committee—the group of physicians that recommends changes in the payment level for new and revised CPT codes—to increase payments for evaluation and management codes are accepted, the changes would take effect on Jan. 1, 2007, he said.

ACP also is seeking separate Medicare payments for services that contribute to coordinated care. For example, ACP is calling on CMS to provide a separate payment for e-mail, telephone, and related technology that can reduce the need for face-to-face visits for nonurgent care. CMS should also develop specific codes for care coordination activities, such as intensive follow-up, the use of patient registries and population-based treatment protocols, and disease management training, according to ACP.

In addition, ACP officials would like CMS to provide an add-on payment when office visits include the use of health information technology, such as electronic health records, electronic prescribing, or clinical decision support tools.

On pay for performance, ACP maintains that potential rewards should be substantial enough to allow for continuous quality improvement. Also, positive incentives should be used rather than penalties.

In the long term, Congress should replace the Sustainable Growth Rate with a formula that would provide adequate and predictable payment increases for all physicians, ACP said in its position paper. And ACP officials want to work with Medicare and other payers to design a new model for health care financing that would build on the concept of the advanced medical home.

Reforms to the education of medical students and the training of internal medicine residents also are needed. The ACP position paper, “Redesigning Training for Internal Medicine,” was published online and will appear in the June 20 print edition of Annals of Internal Medicine.

Rethinking Internist Residency Training

The ACP position paper on training for internal medicine outlines six revisions to the current model for graduate medical education:

▸ Defining the design model for residency training. ACP is calling for the creation of a 3-year model for residency education that would include 2 years of core training and 1 year of customized experiences tailored to the career goals of the trainees. For example, someone interested in becoming a hospitalist would spend more of the third year in the hospital, while others would spend more time in ambulatory care settings.

▸ Integrating educational and service needs. Such a change would move away from excessive workloads for residents, which currently meet the needs of the institutions but not of the residents or patients.

▸ Enhancing ambulatory training. When possible, residents should train in office settings that use advanced technology, such as electronic health records, and that have a team approach to care, according to ACP. In addition, the time spent in ambulatory settings should be structured so that residents do not view it as a distraction from their inpatient duties. Ambulatory training has been the “poor stepchild” of graduate medical education, Dr. Weinberger said, and usually is conducted in settings that make it difficult to practice and learn.

▸ Utilizing team-based care. Training should incorporate team-based care that includes nurses, social workers, case managers, and midlevel providers, according to ACP. In addition, residents can be paired together or with faculty so that one member can provide inpatient care while the other cares for ambulatory patients.

▸ Developing faculty models. Training programs should also consider creating a “core faculty,” a specialized group of clinician educators, who would receive sufficient time, money, and status to train and mentor residents. “We don't have the right faculty models,” Dr. Weinberger said.

▸ Stressing professionalism. The core values include patient-centered, culturally sensitive, evidence-based care.

PHILADELPHIA — Officials at the American College of Physicians are proposing major changes in the way general internists practice, get paid, and are trained.

The recommendations are outlined in three new policy papers aimed at addressing reform of the payment system, a national workforce for internal medicine, and redesign of internal medicine training programs.

The Medicare payment system is one of the principal reasons that physicians are abandoning primary care, said Robert B. Doherty, ACP senior vice president for governmental affairs and public policy.

ACP officials are recommending changes to the current payment system to improve compensation for general internists, but say that more sweeping reforms are needed. Proposed changes to the Medicare Resource-Based Relative Value Schedule (RBRVS) include increasing the work relative value units (RVUs) for evaluation and management services, reexamining the methodologies used to derive the practice expense RVUs, and establishing a process to identify potentially misvalued RVUs.

If recommendations by the RVS Update Committee—the group of physicians that recommends changes in the payment level for new and revised CPT codes—to increase payments for evaluation and management codes are accepted, the changes would take effect on Jan. 1, 2007, he said.

ACP also is seeking separate Medicare payments for services that contribute to coordinated care. For example, ACP is calling on CMS to provide a separate payment for e-mail, telephone, and related technology that can reduce the need for face-to-face visits for nonurgent care. CMS should also develop specific codes for care coordination activities, such as intensive follow-up, the use of patient registries and population-based treatment protocols, and disease management training, according to ACP.

In addition, ACP officials would like CMS to provide an add-on payment when office visits include the use of health information technology, such as electronic health records, electronic prescribing, or clinical decision support tools.

On pay for performance, ACP maintains that potential rewards should be substantial enough to allow for continuous quality improvement. Also, positive incentives should be used rather than penalties.

In the long term, Congress should replace the Sustainable Growth Rate with a formula that would provide adequate and predictable payment increases for all physicians, ACP said in its position paper. And ACP officials want to work with Medicare and other payers to design a new model for health care financing that would build on the concept of the advanced medical home.

Reforms to the education of medical students and the training of internal medicine residents also are needed. The ACP position paper, “Redesigning Training for Internal Medicine,” was published online and will appear in the June 20 print edition of Annals of Internal Medicine.

Rethinking Internist Residency Training

The ACP position paper on training for internal medicine outlines six revisions to the current model for graduate medical education:

▸ Defining the design model for residency training. ACP is calling for the creation of a 3-year model for residency education that would include 2 years of core training and 1 year of customized experiences tailored to the career goals of the trainees. For example, someone interested in becoming a hospitalist would spend more of the third year in the hospital, while others would spend more time in ambulatory care settings.

▸ Integrating educational and service needs. Such a change would move away from excessive workloads for residents, which currently meet the needs of the institutions but not of the residents or patients.

▸ Enhancing ambulatory training. When possible, residents should train in office settings that use advanced technology, such as electronic health records, and that have a team approach to care, according to ACP. In addition, the time spent in ambulatory settings should be structured so that residents do not view it as a distraction from their inpatient duties. Ambulatory training has been the “poor stepchild” of graduate medical education, Dr. Weinberger said, and usually is conducted in settings that make it difficult to practice and learn.

▸ Utilizing team-based care. Training should incorporate team-based care that includes nurses, social workers, case managers, and midlevel providers, according to ACP. In addition, residents can be paired together or with faculty so that one member can provide inpatient care while the other cares for ambulatory patients.

▸ Developing faculty models. Training programs should also consider creating a “core faculty,” a specialized group of clinician educators, who would receive sufficient time, money, and status to train and mentor residents. “We don't have the right faculty models,” Dr. Weinberger said.

▸ Stressing professionalism. The core values include patient-centered, culturally sensitive, evidence-based care.

PHILADELPHIA — Physicians purchasing an electronic health record will be able to consult a list of certified products as early as this summer, according to Dr. Mark Leavitt, chair of the Certification Commission for Healthcare Information Technology.

The certification commission planned to begin accepting applications from electronic health record (EHR) vendors in late April or early May and to publish a list of certified products and their developers in late June or early July.

The list, featuring the first batch of products with the certification commission's seal of approval, will be published on its Web site (www.cchit.org

The process of certification is voluntary and its success is dependent on acceptance in the marketplace, Dr. Leavitt said at the annual meeting of the American College of Physicians. “We're not setting the bar above everyone's heads so that no products meet it,” he said. “But it is not trivial to have a product that meets the criteria.”

The certification commission was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology. In September 2005, the group received a 3-year contract from the Department of Health and Human Services to work on certification criteria for EHRs.

The certification commission is focusing first on certifying products for the ambulatory setting. In phase II, the certification commission will work on evaluating EHR products for the inpatient setting, and in phase III it will evaluate the infrastructure or network components for EHR interoperability.

Vendors will apply for certification and pay a testing fee. To keep costs down, the testing will be done virtually through an Internet browser. A three-person panel, including at least one practicing physician, will judge the demonstration of the product during a process that could take several hours to a day, Dr. Leavitt said.

It's unclear how many products will be certified in the first round, Dr. Leavitt added.

EHR products will be evaluated based on more than 250 functional requirements. But the commission is not in the business of designing EHRs, said Dr. Sarah T. Corley, cochair of the certification commission's functionality workgroup, and there will be some variability in the market.

The standards developed by the commission will set a baseline for what every physician needs in an EHR, but some subspecialists may need to work with vendors to add more functionality, she said.

For example, oncologists may want to customize EHR products to add functionality specific to the care they provide, Dr. Leavitt said. However, the work of the certification commission should be valuable to physicians in all specialties because it will help to narrow the field.

“You still need to do your homework,” Dr. Leavitt said, but certification will allow physicians to home in on the advanced level of functionality they need.

PHILADELPHIA — Physicians purchasing an electronic health record will be able to consult a list of certified products as early as this summer, according to Dr. Mark Leavitt, chair of the Certification Commission for Healthcare Information Technology.

The certification commission planned to begin accepting applications from electronic health record (EHR) vendors in late April or early May and to publish a list of certified products and their developers in late June or early July.

The list, featuring the first batch of products with the certification commission's seal of approval, will be published on its Web site (www.cchit.org

The process of certification is voluntary and its success is dependent on acceptance in the marketplace, Dr. Leavitt said at the annual meeting of the American College of Physicians. “We're not setting the bar above everyone's heads so that no products meet it,” he said. “But it is not trivial to have a product that meets the criteria.”

The certification commission was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology. In September 2005, the group received a 3-year contract from the Department of Health and Human Services to work on certification criteria for EHRs.

The certification commission is focusing first on certifying products for the ambulatory setting. In phase II, the certification commission will work on evaluating EHR products for the inpatient setting, and in phase III it will evaluate the infrastructure or network components for EHR interoperability.

Vendors will apply for certification and pay a testing fee. To keep costs down, the testing will be done virtually through an Internet browser. A three-person panel, including at least one practicing physician, will judge the demonstration of the product during a process that could take several hours to a day, Dr. Leavitt said.

It's unclear how many products will be certified in the first round, Dr. Leavitt added.

EHR products will be evaluated based on more than 250 functional requirements. But the commission is not in the business of designing EHRs, said Dr. Sarah T. Corley, cochair of the certification commission's functionality workgroup, and there will be some variability in the market.

The standards developed by the commission will set a baseline for what every physician needs in an EHR, but some subspecialists may need to work with vendors to add more functionality, she said.

For example, oncologists may want to customize EHR products to add functionality specific to the care they provide, Dr. Leavitt said. However, the work of the certification commission should be valuable to physicians in all specialties because it will help to narrow the field.

“You still need to do your homework,” Dr. Leavitt said, but certification will allow physicians to home in on the advanced level of functionality they need.

PHILADELPHIA — Physicians purchasing an electronic health record will be able to consult a list of certified products as early as this summer, according to Dr. Mark Leavitt, chair of the Certification Commission for Healthcare Information Technology.

The certification commission planned to begin accepting applications from electronic health record (EHR) vendors in late April or early May and to publish a list of certified products and their developers in late June or early July.

The list, featuring the first batch of products with the certification commission's seal of approval, will be published on its Web site (www.cchit.org

The process of certification is voluntary and its success is dependent on acceptance in the marketplace, Dr. Leavitt said at the annual meeting of the American College of Physicians. “We're not setting the bar above everyone's heads so that no products meet it,” he said. “But it is not trivial to have a product that meets the criteria.”

The certification commission was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology. In September 2005, the group received a 3-year contract from the Department of Health and Human Services to work on certification criteria for EHRs.

The certification commission is focusing first on certifying products for the ambulatory setting. In phase II, the certification commission will work on evaluating EHR products for the inpatient setting, and in phase III it will evaluate the infrastructure or network components for EHR interoperability.

Vendors will apply for certification and pay a testing fee. To keep costs down, the testing will be done virtually through an Internet browser. A three-person panel, including at least one practicing physician, will judge the demonstration of the product during a process that could take several hours to a day, Dr. Leavitt said.

It's unclear how many products will be certified in the first round, Dr. Leavitt added.

EHR products will be evaluated based on more than 250 functional requirements. But the commission is not in the business of designing EHRs, said Dr. Sarah T. Corley, cochair of the certification commission's functionality workgroup, and there will be some variability in the market.

The standards developed by the commission will set a baseline for what every physician needs in an EHR, but some subspecialists may need to work with vendors to add more functionality, she said.

For example, oncologists may want to customize EHR products to add functionality specific to the care they provide, Dr. Leavitt said. However, the work of the certification commission should be valuable to physicians in all specialties because it will help to narrow the field.

“You still need to do your homework,” Dr. Leavitt said, but certification will allow physicians to home in on the advanced level of functionality they need.

Pharmaceutical companies should not end their patient assistance programs because of the implementation of the Medicare Part D drug program, according to a statement from the Centers for Medicare and Medicaid Services.

Companies can continue to provide free and reduced-cost drugs to Medicare beneficiaries as long as it is done outside of the Part D benefit.

For example, a pharmaceutical company can provide coverage for certain drugs that are part of the Medicare Part D benefit, but no claims for payment can be filed with the Medicare Part D drug plan for that medication and the cost of the medication will not be counted toward the beneficiary's true out-of-pocket costs, according to CMS.

The Department of Health and Human Services' Office of Inspector General (OIG) issued a special advisory bulletin last November warning that pharmaceutical companies would be at risk under the federal antikickback statute if they paid all or a portion of a Medicare beneficiary's Part D cost sharing for their company's products. But the OIG bulletin outlined alternative program designs that would allow Medicare beneficiaries to continue to receive assistance.

“The bulletin also makes clear that pharmaceutical companies may choose to provide free or reduced-price drugs to financially needy Part D beneficiaries, [as] long as the assistance program is properly structured and the free or reduced-price drugs are provided entirely outside the Part D benefit,” the CMS statement said.

Pharmaceutical companies should not end their patient assistance programs because of the implementation of the Medicare Part D drug program, according to a statement from the Centers for Medicare and Medicaid Services.

Companies can continue to provide free and reduced-cost drugs to Medicare beneficiaries as long as it is done outside of the Part D benefit.

For example, a pharmaceutical company can provide coverage for certain drugs that are part of the Medicare Part D benefit, but no claims for payment can be filed with the Medicare Part D drug plan for that medication and the cost of the medication will not be counted toward the beneficiary's true out-of-pocket costs, according to CMS.

The Department of Health and Human Services' Office of Inspector General (OIG) issued a special advisory bulletin last November warning that pharmaceutical companies would be at risk under the federal antikickback statute if they paid all or a portion of a Medicare beneficiary's Part D cost sharing for their company's products. But the OIG bulletin outlined alternative program designs that would allow Medicare beneficiaries to continue to receive assistance.

“The bulletin also makes clear that pharmaceutical companies may choose to provide free or reduced-price drugs to financially needy Part D beneficiaries, [as] long as the assistance program is properly structured and the free or reduced-price drugs are provided entirely outside the Part D benefit,” the CMS statement said.

Pharmaceutical companies should not end their patient assistance programs because of the implementation of the Medicare Part D drug program, according to a statement from the Centers for Medicare and Medicaid Services.

Companies can continue to provide free and reduced-cost drugs to Medicare beneficiaries as long as it is done outside of the Part D benefit.

For example, a pharmaceutical company can provide coverage for certain drugs that are part of the Medicare Part D benefit, but no claims for payment can be filed with the Medicare Part D drug plan for that medication and the cost of the medication will not be counted toward the beneficiary's true out-of-pocket costs, according to CMS.

The Department of Health and Human Services' Office of Inspector General (OIG) issued a special advisory bulletin last November warning that pharmaceutical companies would be at risk under the federal antikickback statute if they paid all or a portion of a Medicare beneficiary's Part D cost sharing for their company's products. But the OIG bulletin outlined alternative program designs that would allow Medicare beneficiaries to continue to receive assistance.

“The bulletin also makes clear that pharmaceutical companies may choose to provide free or reduced-price drugs to financially needy Part D beneficiaries, [as] long as the assistance program is properly structured and the free or reduced-price drugs are provided entirely outside the Part D benefit,” the CMS statement said.

Successful implementation of an electronic medical record system to improve quality requires attention and effort from physicians at the start of the process, according to experts.

The more time physicians spend up front customizing the system to fit their needs, the less they will struggle later on, said Dr. Barry Bershow, director of quality and informatics at Fairview Health Services in Minnesota.

Dr. Bershow has seen first hand how effective electronic medical record tools can improve quality. At Fairview Health Services, which includes hospital and clinics across Minnesota, there has been significant improvement in quality measures in recent years. For example, screening for chlamydia has nearly doubled from 2004 to 2005, and there have been major improvements in asthma management and obesity screening.

Electronic medical records also can improve quality within small practices, he said. Before coming to work for the Fairview system 2 years ago, Dr. Bershow spent about 28 years working in a small family medicine practice affiliated with the Fairview system. In 1999, the practice became a pilot site to test Fairview's electronic medical record. The implementation proved successful, and the practice continues to use the system today.

Implemention of the EMR system led to reduction of staff by approximately four full-time employees and to improvements in quality, particularly in coronary artery disease and diabetes care, he said.

“It wasn't just because we were really good doctors,” he said. In fact, the performance improvements they saw were in areas where the EMR included clinical decision support and other prompts.

But Dr. Bershow doesn't downplay the tough transition to the system. It took 3 months before the physicians in the practice could start to go home at the same time they did before implementation. But at 6 months, half of the physicians were going home earlier than before, he said.

In the first couple of months, physician and staff satisfaction dropped, according to satisfaction surveys. At that point the excitement was gone, and they had yet to realize the benefits. But at 4–6 months, patients started coming in for return visits, and staff began to see efficiency in the system. At 6 months, all the results had improved including patient satisfaction, Dr. Bershow said.

One common mistake that physicians make is not building in the shortcuts at the beginning, he said.

Implemention of an electronic health record is not a guarantee of improved quality. In fact, a qualitative look at one suburban family medicine practice shows that a lack of communication about the goals of the EMR has actually led to a drop in quality improvement activities.

Jesse C. Crosson, Ph.D., of the New Jersey Medical School, Newark, and his colleagues, analyzed the EMR use of a family medicine practice in an upper middle-class suburban community in 2002 with follow-up in 2003 (Ann. Fam. Med. 2005;3:307–11).

Dr. Crosson and his team found that before the implementation of the EMR, the practice had used reminder stickers on their paper charts for screening, prevention, and disease management. But when the practice switched to an electronic system, the EMR's built-in reminders were disabled because they were too cumbersome, leaving the practice without any formal reminder system.

The lack of communication was a real obstacle in this practice, Dr. Crosson said in an interview. He recommended that physicians planning to implement an EMR meet early on with a broad group of people within the practice to figure out how to maintain existing quality of care system once the electronic system is in place. This could mean using duplicate systems during the transition period, he said.

One barrier to realizing the full potential of EMR systems is that physicians are trained to take care of one person at a time, Dr. Crosson said, and many of the innovative EMR functions help in caring for groups of patients. There needs to be a shift in the mind set of physicians in order to truly take advantage of the advances in technology, he said.

When shopping for an EMR that can aid in the collection and reporting of quality improvement measures, look for a system that can export the data in an electronic format, advised Dr. David C. Kibbe, director of the American Academy of Family Physicians' Center for Health Information Technology.

Health IT Lessons

Officials at the Agency for Healthcare Research and Quality are putting out some of the lessons learned from their health information technology projects. The information is available on the ARHQ Web site—

www.healthit.ahrq.gov

The Web site includes some of the early lessons from AHRQ-funded projects in a range of settings including health plans, hospitals, and small practices. The site also features links to more than 5,000 health IT resources, an evaluation tool kit to help implement health IT projects, and funding information.

“Adoption of health IT will be too slow if providers have to reinvent the wheel one by one,” AHRQ Director Dr. Carolyn Clancy said in a statement. “This shared learning tool brings the lessons of experience together in one place, so we can help providers avoid problems and achieve greater benefits when they make their move to health IT.”

Successful implementation of an electronic medical record system to improve quality requires attention and effort from physicians at the start of the process, according to experts.

The more time physicians spend up front customizing the system to fit their needs, the less they will struggle later on, said Dr. Barry Bershow, director of quality and informatics at Fairview Health Services in Minnesota.

Dr. Bershow has seen first hand how effective electronic medical record tools can improve quality. At Fairview Health Services, which includes hospital and clinics across Minnesota, there has been significant improvement in quality measures in recent years. For example, screening for chlamydia has nearly doubled from 2004 to 2005, and there have been major improvements in asthma management and obesity screening.

Electronic medical records also can improve quality within small practices, he said. Before coming to work for the Fairview system 2 years ago, Dr. Bershow spent about 28 years working in a small family medicine practice affiliated with the Fairview system. In 1999, the practice became a pilot site to test Fairview's electronic medical record. The implementation proved successful, and the practice continues to use the system today.

Implemention of the EMR system led to reduction of staff by approximately four full-time employees and to improvements in quality, particularly in coronary artery disease and diabetes care, he said.

“It wasn't just because we were really good doctors,” he said. In fact, the performance improvements they saw were in areas where the EMR included clinical decision support and other prompts.

But Dr. Bershow doesn't downplay the tough transition to the system. It took 3 months before the physicians in the practice could start to go home at the same time they did before implementation. But at 6 months, half of the physicians were going home earlier than before, he said.

In the first couple of months, physician and staff satisfaction dropped, according to satisfaction surveys. At that point the excitement was gone, and they had yet to realize the benefits. But at 4–6 months, patients started coming in for return visits, and staff began to see efficiency in the system. At 6 months, all the results had improved including patient satisfaction, Dr. Bershow said.

One common mistake that physicians make is not building in the shortcuts at the beginning, he said.

Implemention of an electronic health record is not a guarantee of improved quality. In fact, a qualitative look at one suburban family medicine practice shows that a lack of communication about the goals of the EMR has actually led to a drop in quality improvement activities.

Jesse C. Crosson, Ph.D., of the New Jersey Medical School, Newark, and his colleagues, analyzed the EMR use of a family medicine practice in an upper middle-class suburban community in 2002 with follow-up in 2003 (Ann. Fam. Med. 2005;3:307–11).

Dr. Crosson and his team found that before the implementation of the EMR, the practice had used reminder stickers on their paper charts for screening, prevention, and disease management. But when the practice switched to an electronic system, the EMR's built-in reminders were disabled because they were too cumbersome, leaving the practice without any formal reminder system.

The lack of communication was a real obstacle in this practice, Dr. Crosson said in an interview. He recommended that physicians planning to implement an EMR meet early on with a broad group of people within the practice to figure out how to maintain existing quality of care system once the electronic system is in place. This could mean using duplicate systems during the transition period, he said.

One barrier to realizing the full potential of EMR systems is that physicians are trained to take care of one person at a time, Dr. Crosson said, and many of the innovative EMR functions help in caring for groups of patients. There needs to be a shift in the mind set of physicians in order to truly take advantage of the advances in technology, he said.

When shopping for an EMR that can aid in the collection and reporting of quality improvement measures, look for a system that can export the data in an electronic format, advised Dr. David C. Kibbe, director of the American Academy of Family Physicians' Center for Health Information Technology.

Health IT Lessons

Officials at the Agency for Healthcare Research and Quality are putting out some of the lessons learned from their health information technology projects. The information is available on the ARHQ Web site—

www.healthit.ahrq.gov

The Web site includes some of the early lessons from AHRQ-funded projects in a range of settings including health plans, hospitals, and small practices. The site also features links to more than 5,000 health IT resources, an evaluation tool kit to help implement health IT projects, and funding information.

“Adoption of health IT will be too slow if providers have to reinvent the wheel one by one,” AHRQ Director Dr. Carolyn Clancy said in a statement. “This shared learning tool brings the lessons of experience together in one place, so we can help providers avoid problems and achieve greater benefits when they make their move to health IT.”

Successful implementation of an electronic medical record system to improve quality requires attention and effort from physicians at the start of the process, according to experts.

The more time physicians spend up front customizing the system to fit their needs, the less they will struggle later on, said Dr. Barry Bershow, director of quality and informatics at Fairview Health Services in Minnesota.

Dr. Bershow has seen first hand how effective electronic medical record tools can improve quality. At Fairview Health Services, which includes hospital and clinics across Minnesota, there has been significant improvement in quality measures in recent years. For example, screening for chlamydia has nearly doubled from 2004 to 2005, and there have been major improvements in asthma management and obesity screening.

Electronic medical records also can improve quality within small practices, he said. Before coming to work for the Fairview system 2 years ago, Dr. Bershow spent about 28 years working in a small family medicine practice affiliated with the Fairview system. In 1999, the practice became a pilot site to test Fairview's electronic medical record. The implementation proved successful, and the practice continues to use the system today.

Implemention of the EMR system led to reduction of staff by approximately four full-time employees and to improvements in quality, particularly in coronary artery disease and diabetes care, he said.

“It wasn't just because we were really good doctors,” he said. In fact, the performance improvements they saw were in areas where the EMR included clinical decision support and other prompts.

But Dr. Bershow doesn't downplay the tough transition to the system. It took 3 months before the physicians in the practice could start to go home at the same time they did before implementation. But at 6 months, half of the physicians were going home earlier than before, he said.

In the first couple of months, physician and staff satisfaction dropped, according to satisfaction surveys. At that point the excitement was gone, and they had yet to realize the benefits. But at 4–6 months, patients started coming in for return visits, and staff began to see efficiency in the system. At 6 months, all the results had improved including patient satisfaction, Dr. Bershow said.

One common mistake that physicians make is not building in the shortcuts at the beginning, he said.

Implemention of an electronic health record is not a guarantee of improved quality. In fact, a qualitative look at one suburban family medicine practice shows that a lack of communication about the goals of the EMR has actually led to a drop in quality improvement activities.

Jesse C. Crosson, Ph.D., of the New Jersey Medical School, Newark, and his colleagues, analyzed the EMR use of a family medicine practice in an upper middle-class suburban community in 2002 with follow-up in 2003 (Ann. Fam. Med. 2005;3:307–11).

Dr. Crosson and his team found that before the implementation of the EMR, the practice had used reminder stickers on their paper charts for screening, prevention, and disease management. But when the practice switched to an electronic system, the EMR's built-in reminders were disabled because they were too cumbersome, leaving the practice without any formal reminder system.

The lack of communication was a real obstacle in this practice, Dr. Crosson said in an interview. He recommended that physicians planning to implement an EMR meet early on with a broad group of people within the practice to figure out how to maintain existing quality of care system once the electronic system is in place. This could mean using duplicate systems during the transition period, he said.

One barrier to realizing the full potential of EMR systems is that physicians are trained to take care of one person at a time, Dr. Crosson said, and many of the innovative EMR functions help in caring for groups of patients. There needs to be a shift in the mind set of physicians in order to truly take advantage of the advances in technology, he said.

When shopping for an EMR that can aid in the collection and reporting of quality improvement measures, look for a system that can export the data in an electronic format, advised Dr. David C. Kibbe, director of the American Academy of Family Physicians' Center for Health Information Technology.

Health IT Lessons

Officials at the Agency for Healthcare Research and Quality are putting out some of the lessons learned from their health information technology projects. The information is available on the ARHQ Web site—

www.healthit.ahrq.gov

The Web site includes some of the early lessons from AHRQ-funded projects in a range of settings including health plans, hospitals, and small practices. The site also features links to more than 5,000 health IT resources, an evaluation tool kit to help implement health IT projects, and funding information.

“Adoption of health IT will be too slow if providers have to reinvent the wheel one by one,” AHRQ Director Dr. Carolyn Clancy said in a statement. “This shared learning tool brings the lessons of experience together in one place, so we can help providers avoid problems and achieve greater benefits when they make their move to health IT.”