Friday, November 27, 2009

Electronic Medical Records: A look at the past with a view into the future

By Dr. Paul G. Yungst, DPM, DABPS

Electronic Medical Records, called EMRs, are computer-based systems used for recording, delivering and managing patients’ personal medical data. Computer-based patient records (CPRs) include any information taken at doctor visits, including medical history, physicals, Lab tests, prescriptions, referrals, and procedures performed in the office, hospital, clinics or outpatient offices. Lab information including biopsies, imaging, specimen tests, and diagnostic testing procedures are also listed in the record.

Dr. Lawrence L. Weed, known as the “father of the problem-oriented medical record (POMR),” first introduced the concept of the electronic medical record (EMR) in 1969. 28 years later in an article which appeared in the British Medical Journal in 1997 entitled “New connections between medical knowledge and patient care” Dr. Weed writes “medical practice requires tools to extend the mind's limited capacity to recall and process large numbers of relevant variables, just as medical science requires the microscope to extend our capacity to see at the microscopic level. We must abandon the arrogance of professional "expertise" that shuns such tools. Instead, we must use the new tools routinely as they are developed for more and more diagnostic and management problems.” Why has it taken doctors so long to adopt Dr. Weed’s insightful vision?

Methods of medical documentation have evolved in the past 50 years. In the early sixties the majority of doctors recorded patient care by hand writing notes in charts. With the development of the mini cassette in 1967 and the micro cassette in 1969, physicians and hospitals began adopting dictation/transcription which permitted more legible and thorough documentation of medical histories and examination findings. With the advent of digital computer technology we now enter the age of the EMR/EHR (electronic health record).

A short review of the history of the EMR should give the reader a better understanding of why medical documentation is moving in this direction. In 1968, Dr. G. Octo Barnett led a collaborative effort between the Massachusetts General Hospital Laboratory of Computer Science and the Harvard Community Health Plan to implement an automated medical record system. The Computer Stored Ambulatory Record (COSTAR) which they developed supported direct patient care, billing, and quality assurance programs like the monitored follow-up of treatment after positive throat cultures for streptococcus.

Another important and parallel step was the development of the Health Evaluation through Logical Processing (HELP) system. This integrated hospital information system, conceived in the late 1960s by a team led by Homer R. Warner, provided decision support for health professionals and demonstrated that computer systems could not only replace much of the paper record, but could also improve the process of care by enhancing the use of that record.

In 1991, the Institute of Medicine published The Computer-Based Patient Record: An Essential Technology for Health Care. This seminal document presented blueprints for the future of computer-based patient records (CPR). In the 1997 revised version, an expert committee explored the potential of CPRs to improve decisions about diagnosis and care, provided database for policymaking, and attempted to answer these questions: • Who uses patient records? • What technology is available and what further research is necessary to meet users' needs? • What should government, medical organizations, and others do to make the transition to CPRs?

In September 1999, the Quality of Health Care in America Committee of the Institute of Medicine (IOM) filed a report entitled “To Err is Human: Building a Safer Health System,” In this report the Committee described a comprehensive strategy by which government, health care providers, industry, and consumers, could reduce preventable medical errors. One of the report’s main conclusions is that errors are caused by faulty systems, processes, and conditions that not only fail to prevent mistakes, but often actually lead people to make them. In its subsequent report “Patient Safety: Achieving a New Standard of Care,” dated November 2003, the IOM encouraged hospitals and physicians to adopt electronic medical records (EMRs) as a major step toward preventing medical errors.

In 2003 the RAND Health Information Technology (HIT) Project began a study of EMRs with two objectives: 1. To better understand the role and importance of EMRs in improving health care; 2. To encourage government actions that could maximize the benefits of EMRs and increase their use.
The RAND study estimated the potential savings, costs, and health and safety benefits of EMRs if it is assumed that interconnected and interoperable EMR systems are adopted widely and used effectively. Some of the key findings of their study included:
• Health Information Technology would save money and significantly improve healthcare quality.
• The annual savings from efficiency alone could exceed $77 billion.
• Health and safety benefits could double the savings while reducing illness and prolonging life.
• Obstacles to adoption of EMRs include market disincentives because in general, those who pay for Health Information Technology do not receive the related savings.

In response to these findings, the Federal government moved to improve health care quality, efficiency, and equity, and established the goal that nearly every American should have an EMR within ten years. But despite the involvement of federal agencies such as the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and the Agency for Healthcare Research and Quality (AHRQ), electronic systems have been adopted by only a small number of physicians and hospitals. In a study reported in the New England Journal of Medicine in 2008, DesRoches looked at the adoption of electronic medical records among 2,758 primary care physicians. Only 4% reported having an extensive, fully functional, electronic records system, and 13% reported having a basic system.

Private practices have been slow to adopt EMR because of early start-up costs and uncertain financial gains, according to a 2004 study by Miller and Sim. They noted that up-front costs for EMRs ranged from $16,000 to $36,000 per physician. During the initial weeks of using a new system, many practices also see fewer patients and spend more time entering data into their EMRs, which leads them to work longer days.

Another barrier to adoption is the current lack of data exchange among different EMRs and existing practice management systems. The typical office is deterred by the cost, complexities, and maintenance required in order to share data among different systems. Ideally, an office will buy a practice management system from the same vendor as their EMR, thus eliminating the need for a computer program that allows the two different systems to share data. Such sharing enables the office staff to use scheduling and registration data plus clinical data from the EMR to generate codes and charges automatically.

Data exchange is also an issue among EMRs and laboratory or radiology systems at area hospitals or testing centers. The necessary computer programs for such exchanges are either unavailable, or are costly to maintain and upgrade, with the result that paper reports must be scanned into the system. In order to track results over time, for reporting or for pay-for-performance purposes, staff must then manually enter those results into the EMR.

Despite these barriers there are numerous advantages to adoption of EMR in private practice. Predictions based on statistical models suggest that Health Information Technology has the potential to assist in dramatically transforming the delivery of health care, making it safer, more effective, and more efficient.

This has been my own personal experience. In 1997 after fifteen years of private practice in podiatry I transitioned from a dictation/transcription system to a basic electronic medical documentation system, MD Logic, Inc., a digital, touch screen, template driven system. Within the first year after the initial capital expense I began to realize a profit on my investment due to more accurate coding, added efficiency in office workflow, and increased referrals resulting from improved communications with referring physicians. The most significant effect was an increase in quality of care to my patients. Once the completed podiatric knowledge base was in place I was able to spend more time in face to face interaction with my patients and less time documenting. In 2006 I transitioned my group practice into MD Logic Worldwide EMR, a fully functional EMR, enabling our practice to go “paperless.” All components of the patient’s medical record are now stored on a hard drive and accessible from any computer at each of our offices. The streamlining of work flow and elimination of redundant tasks resulted in major improvement in the efficiency and attitudes of fellow employees. Instant access to patient’s medical records and insurance information has proven to be an invaluable resource along with the creation of an interface permitting transfer of information from the medical record to the practice management billing software.

At this time the future direction of EMR appears to be in the hands of the government. The American Recovery and Reinvestment Act of 2009 provide significant cash incentives to physicians who implement electronic health records. However, in order to qualify for these incentives the physician must not only have the proper software but must engage in “meaningful use” of the software. The government has yet to define “meaningful use” thus making it impossible for EMR software vendors to guarantee incentive reimbursement to physicians. Additionally the Certification Commission for Health Information Technology (CCHIT), an independent non-profit organization recognized as the certification body for electronic health records, has yet to finalize the certification standards which will be required by the government.

Early adopters of EMR who have embraced Dr. Weed’s vision have reaped numerous benefits of this innovative technology while preparing for health care delivery in the 21st century. Physicians now have a tool which can dramatically improve their medical outcomes and the quality of their patient’s lives.

Dedicated to your foot health,
Dr. Paul G. Yungst, DPM, DABPS

Dr. Yungst has been the podiatry consultant for MD Logic, Inc. since 1997 and he is the author of the MD Logic Podiatry Knowledge base.

Sunday, November 22, 2009

Treatment of Fungal Toenail: Fact or Fiction

Onychomycosis is a fungal infection of the toenails or fingernails. The actual infection is of the bed of the nail and of the plate under the surface of the nail resulting in thickening and discoloration of the nail plate along with damage to the underlying nail bed. Onychomycosis is the most common of all diseases of the nails. It’s estimated that in North America, the incidence is as high as 13% and that over 25 million Americans suffer from fungal toenails. The incidence of onychomycosis is also greater in older adults, and up to 90% of the elderly may be affected. Men are more commonly infected than women.

Individuals who are especially susceptible include those with chronic diseases such as diabetes and circulatory problems and those with diseases that suppress the immune system. Other risk factors include a family history, previous trauma to the nails, warm climate, and occlusive or tight footwear.

Onychomycosis is caused by three types of fungi called dermatophytes, yeasts, and nondermatophyte molds. Fungi are simple parasitic plant organisms that do not need sunlight to grow. Toenails are especially susceptible because fungi prefer dark damp places. Swimming pools, locker rooms, and showers typically harbor fungi. Chronic diseases such as diabetes, problems with the circulatory system, or immune deficiency disease are risk factors. A history of athlete's foot and excess perspiration are also risk factors.

There are numerous conditions that mimic the appearance of fungal toenails and it is essential to confirm the diagnosis of fungus prior to initiating treatment. These other conditions include candida, contact dermatitis, lichen planus, psoriasis, subungual tumor, traumatic onychodystrophy, yellow nail syndrome, amelanotic melanoma, granuloma, and melanoma. In order to confirm the diagnosis of onychomycosis, a careful history, clinical examination and culture or microscopic examination of the involved nail should be performed.

Onychomycosis can be present for years without causing pain or disturbing symptoms. Typically, the nail becomes thicker and changes to a yellowish-brown. Foul smelling debris may collect under the nail. The infection can spread to the surrounding nails and even the skin.

Onychomycosis is very difficult and sometimes impossible to treat, and therapy is often long-term. In order for a fungus to grow it must produce a variety of enzymes, proteins which are responsible for acting as catalysts to promote reactions at the cellular level. Current therapy is directed at inhibition of the enzymes within the fungus and consists of topical treatments that are applied directly to the nails, as well as oral systemic drugs. As the fungus overtakes the nail, the nail slowly dies and thickens making it difficult for topical medications to penetrate the nail bed. Subsequent damage to the nail bed results in decreased blood supply making it difficult for oral medications to get to the infection in high enough concentration in order to destroy the fungus. Another factor which makes treatment difficult is recontamination of the nail since the fungus may thrive in the warm moist environment found inside shoes.

Topical therapy is reserved for only the mildest cases and has about a 10-15% cure rate. First and second generation oral antifungals such as griseofulvin and ketoconazole is problematic, and there are typically high relapse rates of 50-85%. In addition, treatment must be continued for a long duration (10-18 months for toenails), with monthly laboratory monitoring for several side effects, including liver toxicity. Individuals taking these medications must also abstain from alcohol consumption.

In the past few years, newer oral antifungal agents have been developed, and include itraconazole (Sporanox), terbinafine (Lamisil), and fluconazole (Diflucan). These agents, when taken orally for as little as 12 weeks, bring about better cure rates and fewer side effects than either griseofulvin or ketoconazole. The most common side effect is stomach upset. Patients taking oral antifungal therapy should have a complete blood count and liver enzyme workup every four to six weeks. Terbinafine in particular has markedly less toxicity to the liver, one of the more severe side effects of the older agents, griseofulvin and ketoconazole.

Due to the relatively low success rate, risk of side effects and high cost of the prescription antifungals, numerous over the counter topical preparations have been developed and touted to purportedly destroy the fungus and restore normal nail growth. There have been no scientific studies to support these findings, only bold claims by their manufacturers and distributors and empirical data from their patients describing their personal experience. These over the counter preparations and therapies include tea tree oil, tea tree oil mixed with lavender oil, Listerine mouthwash, diluted apple cider vinegar, oregano and olive oil mixture, alpha hydroxyl acid creams, baking soda scrub, diluted Clorox bleach and Vick’s VapoRub. In the 29 years that I have been treating onychomycosis I have encountered a number of patients who’ve related stories about a friend or relative who used one of these therapies with success, however, I have never had a patient claim that they personally had success although I have seen some positive results with Thymol and Miconazole (Fungoid tincture).

A new technology has recently been developed using a laser beam of near infrared light to destroy the fungus at the cellular level. This has shown great promise in the treatment of onychomycosis and is currently pending FDA approval for treatment of this condition. Recent clinical studies using this modality have demonstrated a 70-80% cure rate. Anesthesia is not required when performing this procedure, and medications are typically not used in combination with laser therapy, thus minimizing side effects and issues of compliance.

The best advice is to consult with your Podiatrist to confirm the diagnosis of onychomycosis prior to initiating any treatment. Once the diagnosis is confirmed, treatment should consist of medications or techniques that have been scientifically proven to inhibit the growth of the fungus. You should then be examined on a regular basis to monitor for possible side effects and to document the status of your nail condition.

Dedicated to your foot health,
Dr. Paul Yungst, DPM, DABPS

Sunday, October 18, 2009

Shock wave therapy - a new painless treatment for heel pain

Approximately 2 million Americans suffer from plantar fasciitis. Treatment using Extracorporeal shock wave therapy (ESWT) is an option in about 5 to 10 percent of those cases. Previously, surgical intervention for chronic heel pain was required when conservative treatments failed. Today, ESWT is available as an alternative, non-invasive treatment option. We have been performing ESWT at the Sarasota Foot Care Center for the past 5 years with excellent results.
ESWT uses acoustic energy (similar to lithotripsy used to treat kidney stones) from a special ESWT device focused onto the targeted tissue. The shock waves are delivered outside the body to trigger an individuals own repair mechanisms. The concept behind shock wave therapy in foot disorders is to stimulate and reactivate healing to encourage revascularization and other elements necessary to advance normal tissue healing. Additionally, shock waves help to over-stimulate pain transmitting nerve fibers which leads to reduction in sensitivity and pain.
ESWT stimulates your body's own healing and compared to traditional surgical techniques, ESWT has fewer side effects. There is shorter recovery time and risks associated with surgery and general anesthesia are eliminated. The most common patient complaint is some tenderness after treatment which may last a few days. Other side effects might include skin bruising, reddening, or swelling of the treated area. These rare occurrences usually resolve within a few days.
ESWT is not recommended for patients with pacemakers and those taking blood thinners. Also, children and pregnant women are not considered appropriate candidates for ESWT.
There are two types of shock wave units currently in use, low energy and high energy. Studies have shown similar success rates with both therapies. High energy shock wave requires administration of local anesthesia and involves one 20 minute treatment while low energy shock wave is performed without anesthesia and typically requires three treatments.

Dedicated to your foot health,
Dr. Paul G. Yungst, DPM, DABPS