American College of Physicians: Internal Medicine — Doctors for Adults ®

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Letters

From the December ACP Observer, copyright 2006 by the American College of Physicians.

Promoting Dialysis Alternative

I am encouraged that the renal community is finally interested in early kidney failure ("New Kidney Disease Strategy Aimed at Earlier Intervention," ACP Observer, October 2006). Four years ago, ours was the first (and so far only) group to publish that early diabetic and hypertensive kidney disease, which causes 90% of dialysis, can actually be reversed ("Moskowitz DW. From pharmacogenomics to improved patient outcomes: angiotensin I-converting enzyme as an example." Diabetes Technol Ther. 2002; 4(4):519-32.) Reversal of nephropathy requires a higher than conventional dose of a suitably hydrophobic ACE inhibitor.

Although the director of the U.S. Renal Data System declared our data "beautiful" in a conference call arranged by the president of the National Medical Association in early 2003, none of the medical societies, government agencies, nonprofit organizations or international ministries of health that we contacted ever helped publicize our work. Without a credible second source, the media never reported our work, and it remains unknown. As a result, another generation (at least) of patients has gone on dialysis unnecessarily.

I am no longer shocked that eliminating 90% of a huge industry might be opposed. The CMS alone spends $25 billion on dialysis and transplantation. The National Institute of Diabetes and Digestive and Kidney Disease's budget for kidney disease is in the hundreds of millions of dollars. We should know from Franz Kafka that no bureaucracy is serious about eliminating its raison d'etre. And, in my experience so far, no nephrologist has wanted to jeopardize 90% of his or her income, despite having taken an oath to help their patients.

Dave Moskowitz, FACP
St. Louis, Mo.

EMR Endorsement Poses Steep Costs

It costs about $37,000 for an IT vendor to get an electronic medical record (EMR) certified by the Certification Commission for Healthcare Information Technology (CCHIT). It costs about $200,000 to pass the certification. The certification is version-specific, so software updates are not certified automatically.

According to news reports, CCHIT aims to be self-sustaining by 2008. That means to say that the fee will remain the same or may go up. Initially the vendors pay this. Ultimately, they will pass this on to customers.

In these days of diminishing office reimbursements, where the EMR is supposed to make it easier to document and serve patients, CCHIT is an unwelcome intrusion between IT vendors and doctors. It does nothing to serve patients. If this is widely adopted, the following will happen:

  • doctors already using EMRs will be forced to buy expensive systems,
  • adoption will be slowed as doctors wait until the uncertainty settles,
  • doctors who paid for software and training costs will feel they are stuck with it, and
  • insurers will allow only CCHIT-certified products to participate in pay-for-performance and incentives.

We have been running a paperless office successfully for more than two years using a small vendor, as do many others. CCHIT has created an unnecessary burden in the successful implementation of a paperless office—a goal of many doctors who toil day-in and day-out to take care of patients and of EMR vendors who aim to keep costs down.

I request that the ACP strongly consider withdrawing its endorsement of CCHIT because it is detrimental to members already using EMRs successfully and threatens to increase the overhead expenditures of ACP members.

BP Rajesh, ACP Member
St. Johns, Mich.

Editor's Note: The College recognizes that the decision to purchase an EHR is a significant and expensive one for small practices, yet it is becoming a necessary investment in an era of enforced quality and performance measurement. While the certification process may initially impose greater costs on physicians, College leaders believe that it will save money in the long run by helping physicians to select reliable products and to avoid costly mistakes that can derail the EHR implementation process. Certification is intended to help physicians make informed choices and to ensure that the products they purchase have met nationally approved standards of functionality and security. Initially, vendors may pass increased costs associated with certification onto physicians. However, over time, greater competition among vendors is likely to drive down costs, helping physicians in small medical offices to purchase reliable, certified EHRs at an affordable price.

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