What differentiates an electronic medical record (EMR) from a computer based patient record (CPR)? Those distinctions, coupled with some clinicians’ reluctance to forsake their tried and true ways for technologies that lack a proven track record, make it hard for this particular technology to gain wide-scale acceptance among physicians.

For some in the industry, the terms EMR and CPR are used interchangeably, says Peter Waegemann, CEO of the Boston-based Medical Records Institute. “There is no consensus as to what an EMR or CPR is,” he notes.

But not for all. “We just use the term EMR,” says William F. Jessee, M.D., president and CEO of the Denver-based Medical Group Management Association (MGMA), the largest group practice association in America
Larry Dolin, president and CEO of Mayfield Heights, OH-based Noteworthy Medical Systems Inc., says there is also confusion surrounding what constitutes an EMR, let alone a CPR. Dolin, whose company has developed a total system for medical data management, views an EMR as a total computer-based medical record that does not rely on paper charts, transcription or dictation, yet includes all doctors’ notes and prescription orders. He believes a true EMR requires physicians to do their own clinical documentation by entering data as they examine patients. Waegemann agrees, saying that you really don’t have an EMR unless the physician is using a computer in the examining room.

Three simple decision-making charts can help teachers assess when intervention is appropriate and legally required.

Did you ever suspect that a student in your classroom had been the victim of child abuse or neglect? When that happened, did you know what to do about it? Did you decide just to “let it go” because you were not sure whether you had a real case? Did you decide to “wait and see” because you were afraid of a lawsuit from the parents? If you reported the case to your school administrator, was the administrator hesitant to take action? In these days of lawsuits falling on school districts like snowflakes, we all hesitate. We fear the consequences of making a false accusation.

If the abuse of a child were at the hands of a schoolyard bully or lurking pedophile, parents most likely would applaud intervention. However, precisely because most cases involve an abusive parent, intervention is almost automatically deemed a dicey proposition. The law, however, now requires teachers to report cases of suspected child abuse or neglect. Failure to report raises issues of criminal and civil liability.

An estimated 896,000 children across the country were victims of abuse or neglect in 2002 (U.S. Department of Health and Human Services 2004). That is almost 1 in every 100 Americans, with an obviously higher classroom incidence when reduced to the K-12 age group. The math implies that you already have several abused students in your school, and maybe they were, are, or will be in your classroom. You or a coworker should know when and how to intervene. This article offers three simple decision graphics that clarify when a teacher’s intervention is appropriate and necessary.

Dimensions of the Problem

Research shows that the child abuse and neglect problem in this country not only has physical, emotional, and psychological dimensions, but also serious educational impacts. Some of the research findings are enlightening:

* Cases of child abuse and neglect have been increasing nationwide (Howe 2005; Pass 1986).

* The trauma of abuse or neglect of a child often lingers with that victim into adulthood and even can influence the raising of that victim’s own children (Anda et al. 2005).

* Abused children can become child abusers themselves (Anda et al. 2005).

* Chronic malnutrition and abusive child behavior adversely affect the child’s social and emotional functioning in school, starting in preschool (Barrett, Radke-Yarrow, and Kline 1982; Anda et al. 2005).

* Most often, the abuser or neglector is someone known by the child (i.e., a relative or neighbor), and the problem usually happens in the child’s home or child-care center (Administration for Children and Families 2004).

* To prevent child abuse from happening, many suggest that the first line of defense should be the school teacher (Haeseler 2006).

* Unfortunately, because of the reluctance of educators (Pass 1986) to report possible cases, deaths have been increasing at an alarming rate (Child Welfare Information Gateway 2004).

* In 2003, the total costs of child abuse and neglect were estimated at more than $94 million. These costs included demands on the health care, mental health care, law enforcement, child welfare, and judicial systems. Additionally, indirect costs included special education, juvenile delinquency programs, and adult criminality (Goldman et al. 2003).

Knowing these facts, schools are concerned with creating protocols to enable educators to address issues of abuse and neglect more efficiently (Crosson-Tower 2002).

Educators on the Front Line

In 1974, Congress passed the Child Abuse Prevention and Treatment Act (CAPTA), which sets some minimum standards pertinent to the reporting of child abuse and neglect. CAPTA was amended and reauthorized several times, most recently in 2003. To qualify for funding under the Act, all 50 states enacted laws to promote the prevention of child abuse. Under many of these laws, the failure of a teacher to report a suspected incident could lead to the teacher’s dismissal and revocation of his or her teaching license. Generally, however, the laws protect teachers and administrators when they report in good faith (Smith 2006).

While overwhelming similarity exists in the statutes from state to state, there are still many differences. Some of these are small, but substantial; others are more nuanced, but potentially significant (Crosson-Tower 2002). For example:

* One state may require “school officials” to report, but not specify teachers, as might be the case in the law of another state. A number of states identify no particular person or category of persons as a “mandated reporter,” but require “any person” to report.

* “Some statutes call for reporting upon a mere ‘reasonable cause to believe’ or a ‘reasonable suspicion.’ Other statutes require the reporter to ‘know or suspect,’ which is a higher degree of knowledge” (Smith 2006, 1).

* Liability may be civil, criminal, or both, depending on the state.

Most healthcare attorneys will advise a client that “it is far better, in theory, to be faced with defending a civil action for reporting suspected abuse rather than the bleak alternative of defending a civil action . . . if a child is injured or killed as a result of failing to make a report of suspected child abuse” (Cox and Osowiecki 1998). To prevent unnecessary reporting of child abuse, social service, medical, and educational agencies provide teachers and administrators with information about identifying and reporting abuse. Reports and guidelines to help teachers, however, often are written in narrative form and are not easily accessible to busy educators.

 The U.S. Department of Health and Human Services (HHS) has initiated two new steps in building an electronic health care system that will allow patients and their physicians to access their complete medical records as needed, leading to reduced medical errors, improved patient care, and reduced health care costs.

HHS Secretary Tommy Thompson said HHS has signed an agreement with the College of American Pathologists (CAP) to license the college’s standardized medical vocabulary system and make it available without charge throughout the country.

He said this action opens the door to establishing a common medical language as a key element in building a unified electronic medical records system.

HHS also has commissioned the Institute of Medicine to design a standardized model of an electronic health record. The health care standards development organization, known as HL7, has been asked to evaluate the model once it has been designed.

HHS will share the standardized model record at no cost with all components of the U.S. health care system and expects to have a model record ready in 2004. It estimates that the free system will reduce medical errors and reduce health care costs by about $100 billion per year. However, many health care institutions will need to invest in computers and train staff.

With terms for more than 340,000 medical concepts, CAP’s standardized system has been recognized as the world’s most comprehensive clinical terminology database available, the agency said.

The licensing agreement with CAP will make it possible for health care providers, hospitals, insurance companies, public health departments, medical research facilities, and others to incorporate this uniform terminology system into their information systems.

The National Library of Medicine (NLM) at the National Institutes of Health will administer the CAP agreement under a five-year, $32.4 million contract to the organization for a permanent license for their terminology, known as SNOMED (Systematized Nomenclature of Medicine) Clinical Terms.

The contract includes a one-time payment shared by the Departments of Veterans Affairs, Defense, and several HHS agencies–with annual update fees paid by the NLM.

To obtain CME credits, complete the test below, following these guidelines:

1. Read each article carefully.

2. Choose the most appropriate response to each of the following questions and record these on the registration form. Unanswered questions are considered incorrect.

3. Send the completed registration form and your payment (check, money order, VISA, MasterCard, American Express) to the Center for Continuing Education, University of Nebraska Medical Center (UNMC).

4. After your test has been graded, you will receive a receipt, a copy of the correct answers, and a credit statement certifying completion from the UNMC. Questions about the test should be addressed to UNMC Center for Continuing Education (402-559-4152).

Credit: The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Nebraska Medical Center, Center for Continuing Education designates this educational activity for a maximum of 3 hours in category 1 credit towards the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

This CME activity was planned and produced in accordance with the ACCME Essentials.

1. Schweinfurth, in this month’s Laryngoscopic Clinic, cites a source that reports as much as what percentage of patients in whom stenosis occurs after they have been subjected to more than 10 days of endotracheal intubation?

a. 1.4%

b. 4.1%

c. 14%

d. 41%

2. What should be monitored in patients who are on long-term minocycline therapy, according to Pantanowitz and Tahan’s recommendation in this month’s Pathology Clinic?

a. thyroid function

b. liver function

c. kidney function

d. blood pressure

3. According to Ruenes and Palacios in this month’s Imaging Clinic, approximately 20% of extramedullary plasmacytomas occur in the head and neck.

True or False?

4. With which of the following statements regarding juvenile xanthogranuloma would Sahhar and colleagues disagree?

a. It is benign.

b. It is the least common form of non-Langerhans’ cell histiocytosis.

c. It usually appears as a localized cutaneous lesion.

d. When lesions occur cutaneously, they can be either solitary or multiple.

5. Of the following, which is the most common extracutaneous site of juvenile xanthogranulorna, according to Sahhar et al?

a. larynx

b. spleen

c. kidney

d. eye

6. According to Cinar et al, which of the following terms is/are synonymous with oncocytic carcinoma?

a. oncocytic adenocarcinoma

b. malignant oncocytoma

c. malignant oxyphilic adenoma

d. all of the above

7. Cinar et al state that radiation does not appear to favorably alter the biologic behavior of oncocytic carcinoma.

True or False?

8. According to a source cited by Purcell and her colleagues, prominent ears occur in approximately what percentage of the population?

a. 3%

b. 5%

c. 7%

d. 9%

9. According to the article by Church et al, which of the following statements regarding pigmented villonodular synovitis is false?

a. It is a malignant disease.

b. It usually involves a major joint.

c. It arises from the synovial membranes of the joints, bursae, and tendon sheaths.

d. It is usually monarthric.

10. At which of the following sites does pigmented villonodular synovitis occur most frequently?

a. hip

b. ankle

c. knee

d. shoulder

As we move forward in the 21st century, healthcare issues dominate. We are seeing medical advances that were unheard of in the early 1900s. Organ transplants, for one, have become almost commonplace. Meanwhile, Financing health care has become a political hot potato. Federal and state governments are struggling to provide health care in the face of budget shortfalls and rising costs. With dwindling resources, the question becomes how can those resources be best used to serve the greatest numbers of American people? Who is entitled to what?

One of the greatest opportunities for American public policy to improve the nation’s health is to differentiate between the macroallocation and the microallocation of resources. Those who distribute commonly collected resources, such as tax monies and health premiums, among a group of people macroallocate. Healthcare providers microallocate when their decisions focus on specific patients. We must better think through these two roles.

The individual focus of biomedical ethics is too Narrow to be useful in the macroallocation by payers. Macroallocation involves trade-offs and setting priorities. Distributing commonly collected resources among a group of patients involves very different dynamics than a provider caring for individual patients. Those distributing commonly collected funds do not have the luxury of individualized care. Government must provide multiple services to its citizens, and health insurers must provide service to multiple beneficiaries. Both have comprehensive duties to a wide group of beneficiaries. The scope of the differences between macroallocation and microallocation is considerable.

No nation, state, or health plan in the macroallocation of its funds can assume that its healthcare distributions can meet the cumulative medical need of all its individual members. This is clearer in other nations where the government more directly funds health care.

We must better reconcile individual need with the common resources that fund most of that individual need. Providers theoretically can meet all the medical needs of their patients; states can never meet all the health needs of their citizens. Providers can focus on an individual, but a government must meet many needs of all its citizens in a world of trade-offs and priorities. Providers ration when they fail to provide a medical service to a patient. A state or nation, however, rations both when it denies a needed medical benefit and when it fails to provide universal coverage. All governments ration medicine.

Once we slop avoiding the responsibility of rationing health care, we will recognize the occasional conflict between the goals and ethics of paying for (macroallocating) health care with commonly collected funds and the goals and ethics of delivering (microallocating) health care. To recognize and admit this conflict exists will be politically difficult but socially inevitable. Doing so will require a change in the cultural values of citizens and healthcare providers, but the rewards are gargantuan. America can deliver more health to its citizens for less money once it adopts a broader moral vision of health care.

Medical practice and ethics have been developed without consideration of trade-offs with other public goods, even though taxpayers pay almost half of the healthcare dollar. Government now funds about 45 percent of U.S. health care, and employers fund another 33 percent, bringing the total government and employer share of healthcare funding to almost 80 percent. (a) We lack a means of setting priorities in the macroallocation of health care and the tools for comparing health needs with other needed social goods. We have just begun to analyze the moral framework applicable to the macroallocation of resources.

Public policy has allowed providers to be the definers of the nation’s health and the chief architects of the nation’s healthcare system. We have been assuming, inappropriately, that a nation’s best route to health was to fund medical care one patient at a time, thereby allowing healthcare providers to impose their doctor-patient relationship on taxpayer monies without accountability or oversight. The total need of the group was the sum total of individual need. Public policy has not adequately asked the larger question, “How do you keep a society healthy?” How do we reconcile macroallocation with microallocation? Those who fund health care from collective funds must look beyond the individual to the entire group. When pooling money, we have to ask, “What maximizes the health of those who make up the pool?”

PROBLEM. Adverse childhood experiences have been found to be a strong predictor of emotional and physical problems in adulthood. However, the long-term sequelae for children who have suffered critical illness and exposure to invasive medical procedures are less well documented.

METHODS. This is a case study of an adult client who sought treatment for depression and attention deficit disorder. The psychotherapy treatment is discussed and the use of eye movement desensitization and reprocessing (EMDR) is described targeting a memory of a medical trauma resulting from a tonsillectomy when the client was 8 years old.

CONCLUSIONS. Significant healing outcomes were attained as a result of the therapy, i.e., decreased depression, less hypervigilance, and increased ability to concentrate, which resulted in the discontinuation of medication for depression and ADHD as well as significant improvement in overall functioning.

Search terms: Childhood trauma, EMDR, psychodynamic psychotherapy

Adverse childhood experiences have been found to be a strong predictor of emotional and physical problems in adulthood (Felitti et al., 1998). In a study of almost 10,000 participants in a medical setting, those with histories of being abused as a child were found to be at 1.6-2.9 times greater risk for cancer, chronic lung disease, skeletal fractures, hepatitis, diabetes, stroke, liver disease, and ischemie cardiac disease. In addition to these findings, the incidence of alcoholism, depression, drug abuse, and suicide was 4-12 times greater than for those without a history of abuse. Risk factors such as smoking, obesity, and promiscuity also increased significantly for adults who have suffered trauma as children.
Perry (2002) says that long-term consequences of childhood trauma include: attachment problems, eating disorders, depression, suicidal behavior, anxiety, alcoholism, violent behavior, mood disorders, and posttraumatic stress disorder. When left untreated, childhood trauma contributes to a multitude of physical and mental health problems throughout the life span. Researchers have found that trauma causes lasting neuronal and hormonal changes which shape brain structures and functioning, which then can have profound effects on all dimensions of development, social, cognitive, biological, and emotional (van der KoIk, 2003).

However, the long-term sequelae for children who have suffered critical illness and exposure to invasive medical procedures are less well documented. Shortterm behavioral responses have been documented during hospitalization. It is thought that the severity of the illness and the developmental level of the child most likely influence the subsequent responses to such events. The younger the child, the more seriously ill and invasive the procedures, the more likely the child is to have ongoing adverse affects and posttraumatic stress disorder (Rennick, Johnston, Dougherty, Platt, & Ritchie, 2002). One study of 43 children from ages 5-12 found that children undergoing cardiac surgery are at risk for developing PTSD, especially if the ICU stay is prolonged (Connolly, McClowry, Hayman, Mahony, & Artman, 2004). Postoperatively, PTSD symptoms increased in 23% of the children, with 12% meeting the criteria for a diagnosis of PTSD. No child had PTSD preoperatively. Wintgrens, Boileau, and Robacy (1997) believe that emergency interventions after accidents and painful, repeated medical procedures are traumas that could lead to posttraumatic stress reactions, but this has not been tested.

In addition to the effects of the trauma on the child, the parents are also affected, which in turn affects the child. Parental uncertainty related to survival of their child has been found to have a profound impact upon the child after a life-threatening childhood illness (Santacroce, 2003). A parent, who has had to face the loss of a child, suffers from an emotional trauma that may interfere with the ability to connect and nurture and the parent may unknowingly distance, which affects caretaking ability. This paper presents a case study of a client who suffered a significant medical trauma when he was 8 years old and his treatment as an adult in psychoanalytic psychotherapy using eye movement desensitization and reprocessing (EMDR) to target that trauma.

This year’s rally in the dollar is having an adverse impact on locally based medical device makers because they are becoming more expensive for overseas buyers.

The recent gains come after a sharp downturn in the dollar over the past two years. The dollar fell 50 percent from 2002 through 2004 as the trade deficit widened and foreign debt piled up. But with the U.S. dollar strengthening against other foreign currencies, products made here and sold elsewhere become less appealing to those foreign buyers.

“While foreign exchange has benefited many (medical technology companies) over the last several years, it is poised to do a U-turn, dampening revenue growth and–depending on the company’s hedging program–potentially dulling earnings per share growth,” said Joanne Wuensch, a medical device analyst with New York investment bank Harris Nesbitt & Co.

The dollar’s 2005 rise led Wuensch to reduce quarterly revenue estimates for several device companies she covers, including Bausch & Lomb, a rival to Santa Ana-based Advanced Medical Optics Inc. and Lake Forest-based Cooper Cos.; Biomet Inc., which purchased Interpore Cross International, a bone device maker that was based in Irvine; and Boston Scientific Corp., which has invested in several Southern California startups.

Wuensch didn’t change her revenue or earnings estimates for either Advanced Medical or Cooper. That’s because both companies earlier lowered their earnings guidance based on the strengthening dollar.

The dollar fluctuations are becoming an important issue for companies like Advanced Medical, a maker of eye surgery devices.

“With the recent softness in the euro, there is a concern that all of the benefit that corporate America has been receiving in terms of revenue growth and increased demand could create somewhat slowing revenue growth,” said Randy Meier, chief financial officer of Advanced Medical, which does about 70 percent of its business overseas.

In early June, Advanced Medical said it expects to post 2005 sales of $920 million to $930 million, down from an earlier forecast of $955 million.

That guidance “did incorporate some of our thinking about where currencies were going. But we also said that we did not expect that currencies would have a major impact in the second half of this year,” Meier said.

Hedging factor

Meier said Advanced Medical has benefited from several acquisitions that gave it manufacturing operations in foreign countries. The benefit: so-called “natural hedging” versus a dollar gain.

In the past few years, Advanced Medical has bought a cataract surgery device unit of Pfizer Inc., laser device maker Visx Inc. and a plant in Spain. The buys allow the company to make devices in Europe for sale there or export to other countries.

“A global company with operations and expenses that are in that local currency, whether it’s the euro or the yen, are somewhat naturally hedged against the fluctuations of currency,” Meier said.

Companies also use currency hedging to offset risk. They can buy contracts to convert a certain amount of foreign currency at a set U.S. dollar rate in the future. The downside is that the contracts can be expensive. The upside is that the effects of currency moves are limited.

Since Advanced Medical hedges its pretax income, a certain amount of its cash flow is converted to U.S. dollars, depending on currency trends.

Edwards Lifesciences Corp., the Irvine-based cardiovascular device maker, counts a majority of its sales from overseas buyers.

Edwards reported U.S. sales of $119 million and international sales of $139 million in the second quarter. About 47 percent of its international sales came from Europe with 34 percent from Japan.

Edwards took foreign currency issues into account when it issued its 2005 sales and earnings forecasts, said Corinne Lyle, its chief financial officer.

Lyle said the heart device maker’s sales are two-thirds hedged with foreign currency contracts, and that it’s also protected against foreign exchange issues because it makes products outside the U.S. in local currencies.

LIMITED HEALTH-CARE RESOURCES obligate physicians, employers, and third-party payors to periodically evaluate the cost-effectiveness of any medical assessment process. Evaluation is especially necessary when the process has become routine, as is the case with preemployment medical assessments. White-collar employees experience low risk at work. Office workers may perform multiple tasks, including answering the telephone, interacting with the public, handling money, receiving and delivering mail, typing and transcribing, operating office machinery, filing, and lifting supplies or parcels. Individuals may also perform professional duties (e.g., writing, editing, accounting, research, interviewing). Examples of white-collar occupations are government employees, telephone operators, clerks, and office equipment operators (e.g., computer programmers/technicians, financial workers). (1) All of these occupations are nonhazardous positions, and there is a lack of guidelines for preemployment health assessment of such workers.

In recent years, the physician-patient relationship has transformed from one of paternalism into an egalitarian and participatory partnership in which patients and physicians work together to make healthcare decisions (Committee on Bioethics, 1995). Today there is general societal acceptance that “patients have a right to know about their health, to know about available diagnostic and treatment options and then” risks and probable benefits, and to choose among the alternatives” (Committee on Bioethics, 1995, p. 315). Informed consent is an essential part of the communication process between physicians and patients. The information provided by physicians about illness and treatment options is vital to patients’ decision-making and influences their psychological well-being (Rushforth, 1999).

Although adults receive considerable encouragement to become active participants in healthcare decisions, children and adolescents often have little voice in decisions about their medical treatment (Kunin, 1997; Lidz et al., 1984). As minors, adolescents often are unable legally to provide informed consent and are granted limited access to confidential medical care. Confusion and mixed messages abound about the abilities and rights of adolescents. The present review examines the developmental literature on children and adolescents’ capacities to make medical decisions that are informed, voluntary, and rational.

In its simplest form, informed consent is the treatment authorization given by a patient to a physician. Legally, it is an intentional authorization in that it must be given knowingly, rationally, with volition, and without coercion (Grisso & Vierling, 1978; King & Cross, 1989; Scott, 1992). By informed, it is meant that the decision must be based on knowledge of the situation and potential consequences. Consent must be voluntary; it must be volitional and not reflect mere acquiescence. Consent also must be rational, implying that it is rendered by an intellectually competent and mature individual.

Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV)–collectively known as “test characteristics”–are important ways to express the usefulness of diagnostic tests. The 2 x 2 tables from which these terms are derived are familiar to some physicians (Table).

Sensitivity is the “true positive rate,” equivalent to a/a+c. Specificity is the “true negative rate,” equivalent to d/b+d. PPV is the proportion of people with a positive test result who actually have the disease (a/a+b); NPV is the proportion of those with a negative result who do not have the disease (d/c+d).

Sensitivity and specificity are fixed for a particular type of test. PPV and NPV for a particular type of test depend upon the prevalence of a disease in a population. For example, though current screening tests for HIV have high sensitivity and specificity, the low prevalence of HIV in the general population cannot justify universal screening since the majority of positive tests would be falsely positive (ie, low PPV).

* HOW TO REMEMBER THESE TERMS

Begin by assuming that you have 4 patients. For the first 2 you know only their disease status; for the last 2 patients you know only their test result.

You know your patient’s disease status:

1. Sensitivity: “I know my patient has the disease. What is the chance that the test will show that my patient has it?”

2. Specificity: “I know my patient doesn’t have the disease. What is the chance that the test will show that my patient doesn’t have it?”

You have just gotten a test result and do not know your patient’s disease status:

3. PPV: “I just got a positive test result back on my patient. What is the chance that my patient actually has the disease?”

4. For NPV: “I just got a negative test result back on my patient. What is the chance that my patient actually doesn’t have the disease?”