Combine vaccine with testing
I am writing in response to the article, "HPV vaccine raises questions and debate," in the March issue of ACP Observer. As an internist and champion for patient empowerment, I wanted to thank you and Dr. Diane Harper for emphasizing the importance of ongoing cervical cancer screening despite the availability of the vaccine. However, there is another piece to the screening regimen that was not discussed—HPV testing. While the Pap test is the most appropriate test for women under the age of 30, the HPV test is FDA-approved for use in combination with the Pap test in women 30 and older (those most at risk for cervical cancer).
Your readers can protect their younger patients with the HPV vaccine, and can protect themselves with the most accurate tests. The Pap alone is not foolproof. One-third of cervical cancers occur in women whose Pap tests appeared normal. Therefore, by routinely screening women age 30 and older for HPV, along with their Pap, we can eliminate any margin of error from the Pap and increase screening accuracy to virtually 100 percent. Those women identified as having high-risk HPV can then be monitored closer by their doctors, to catch abnormal cell changes that may be missed by a Pap test, well before they develop into cervical cancer.
Many women I speak to do not know about the HPV test, therefore it is important that we educate them so they can in turn, educate their children and generations to come.
Marie Savard, MD
More study on language barrier
The April 24 edition of ACP Observer Weekly reported a press briefing presenting the results of a survey by Ginsberg et al. of internists practicing in the U.S. The article stated that "roughly half of survey respondents said they spend an extra five to 15 minutes with (limited English proficiency) LEP patients versus those who are proficient in English; another quarter reported spending an extra 16 to 30 minutes; while 15% said they spent no additional time with LEP patients," (ACP White Paper, 2007).
The extra time spent was attributed to patients with limited English proficiency having more difficulty understanding basic health information, and the need to spend more time in physician-patient communication. We applaud ACP's efforts to systematically study communication challenges and opportunities for improvement in LEP persons.
In 1996 we conducted a time-motion study comparing English-speaking with non-English speaking patients to determine whether the physician perceptions that they spent more time with non-English speaking patients were accurate (J Gen Intern Med. 1999:14:303-9). In our survey of the physicians studied, 85.7% felt that they spent more time during a visit with non-English speaking patients, and 90.4% felt they needed more time to address important issues during a visit. However, after adjusting for demographic and comorbidity variables, visits with non-English speaking and English speaking patients did not differ on any time-motion variables, including physician time spent on the visit. The similarity of time spent was an unexpected finding to us as, like the internists surveyed in the ACP study, we expected there would be more time spent with LEP patients.
There were limitations to our study. It was conducted at a single center, with a well established and extensive interpreter system. We studied patients representing 22 different languages, so no one group predominated. We also did not study the content of the physician-patient communication, and it is possible that important elements of the visit were shortened or omitted. It may be that because physicians are forced to abbreviate their visits with LEP patients, they cover fewer topics and feel frustrated, which results in the perception that the visits take longer.
Thus, we would like to raise caution about interpreting the survey by Ginsberg et al. As we demonstrated in our study, physician perceptions about time spent with non-English speaking patients can be inaccurate, and these perceptions should not be presented as fact. We do agree with the ACP's advocacy for better funding for LEP patient encounters, given the rapidly growing LEP population in the US, and the limited resources that many physicians have for high quality interpreter services. What is really needed is further study of the content of communication between physicians and LEP patients. This research could provide a basis for determining how much time during a visit is needed to provide LEP patients with the same content and quality of care that English speaking patients receive (West J Med. 1998;6:504-511).
Thomas M. Tocher, ACP Member
Eric B. Larson, MACP
EHRs: informing the debate
The Institute of Medicine has identified health information technology (IT) as a key factor in improving the quality and efficiency of health care. Health IT and electronic health records (EHRs) in particular, can help reduce (or can prevent) medical errors not only by centralizing health information for patients within a given institution or organization but also by supporting cross-institutional data sharing, thus shifting the focus from single-care encounters to episodes of care.
Several successful implementations of EHRs have been documented to date. These illustrate how EHRs can improve quality of care as well as achieve efficiency. For example, Miller et al. found that across 14 different sites, many practices experience efficiencies in billing and greater efficiency from an increased use of coding and overall decrease in personnel costs. (Health Affairs, September/October 2005,24(5):1127–37). In another case, 1 year after the Western Colorado Physician Group's EHR implementation, practitioners found a 21 percent increase in cardiovascular risk reduction performance. They also benefited from administrative and operational efficiencies such as reduction in the use of medical record transcription staff. (www.cmwf.org/tools/tools_show.htm?doc_id=305354)
The Agency for Healthcare Research and Quality (AHRQ) is committed to promoting informed consideration of EHRs and other health IT applications in the health care environment. We have made a substantial investment in this area, with a research portfolio totaling over $166 million and supporting over 125 projects across the country. We recognize that if our nation is to realize the full potential of EHRs and other tools in health IT, all of us—especially practitioners—need more information as soon as it can be made available.
As more physicians recognize the value of EHRs, it is essential that they be given the information needed to guide their health IT decisions. AHRQ's National Resource Center on Health IT is an extensive, valuable source of information that physicians can consult as they make decisions about EHRs and other health IT investments. The Resource Center makes the latest tools, most current research findings, and best practices being implemented available on a single Web site. The site includes a Knowledge Library with more than 7,000 information sources and an Evaluation Toolkit for those planning to implement health IT projects.
We salute ACP's ongoing commitment to fostering informed discussions about EHRs and health IT issues. As you debate the merits of EHRs, I encourage you to consider not just the costs of adopting this technology, but also the consequences of not adopting it in terms of preventable medical errors, inefficiency, cost savings lost, and miscommunication.
Carolyn M. Clancy, MACP
Director, Agency for Healthcare Research and Quality
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