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Stop Pain: Complex Regional Pain Syndrome (CRPS)

	This site covers all the bases for patients who need to know about complex regional pain syndrome. Visitors can read up on who gets the syndrome, symptoms, and treatment options. Under the “What Is Happening in My Body to Cause CRPS?” section, readers can learn about sympathetically maintained pain and the role it may play in CRPS. Or, they can simply open up the pop-up interactive flash module, sit back, and listen to the program, which covers all of these topics.

Reflex Sympathetic Dystrophy Syndrome Association

	Direct your patients here to receive reliable information from one of the oldest associations dedicated to complex regional pain syndrome. Patients can read about how CRPS is diagnosed, as well as common symptoms. The site maintains updated collections of recent news, medical articles, research, and events for those who wish to become a part of the association or participate in an event. The website is “designed to give patients, family members, and healthcare professionals the most up-to-date information on treatment, legislation, support groups, research, fundraising, and patient stories.”

	Complex Regional Pain Syndrome: Treatment Guidelines

	Take a look at the guidelines for complex regional pain syndrome featured at the Reflex Sympathetic Dystrophy Syndrome Association’s website. The new edition of the guideline was edited by R. Norman Harden, MD, director, Center for Pain Studies, Addison Chair, Rehabilitation Institute of Chicago. The site features the full-text guideline, from the table of contents to interventional therapies. The appendices on treatment algorithm, pharmacotherapy guide, and psychological intervention are

	also included. A gallery of 16 photos accompanies the guideline as well.

	Module 5: Complex Regional Pain Syndromes

	This activity is the fifth module in a series of CME activities under the palliative care umbrella. At the conclusion of this module, “participants should be able to understand the symptoms of Complex Regional Pain Syndromes (CRPS); distinguish CRPS1 from CRPS2; and discuss the treatment algorithm for CRPS.”

	Validation of Proposed Diagnostic Criteria (the “Budapest Criteria”) for Complex Regional Pain Syndrome

 “This validation study compared current IASP diagnostic criteria for CRPS to proposed new diagnostic criteria (the “Budapest Criteria”) regarding diagnostic accuracy.”

 “Discriminating between diagnostic groups based on presence of signs or symptoms meeting IASP criteria showed high diagnostic sensitivity (1.00), but poor specificity (0.41), replicating prior work. In comparison, the Budapest clinical criteria

	retained the exceptional sensitivity of the IASP criteria (0.99), but greatly improved upon the specificity (0.68).” The “inclusion of four distinct CRPS components in the Budapest Criteria contributed to enhanced specificity.”

Familial Occurrence of Complex Regional Pain Syndrome

Canadian Journal of Neurological Sciences

 To further study the etiology of complex regional pain syndrome (CRPS) and evaluate the idea that “different environmental and genetic factors” may contribute

 The team “reviewed the clinical data from a cohort of 69 patients with CRPS.” According to the data, “CRPS can be familial” and “may have a genetic basis in some

	families.” The researchers concluded that “larger studies will be needed to ascertain clearer patterns of inheritance.”

Wherever Is My Arm? Impaired Upper Limb Position Accuracy in Complex Regional Pain Syndrome

 Researchers sought to “determine the degree to which experimental data supported the reported difficulty in limb position sense” for patients with complex regional pain syndrome.

 Results demonstrated evidence “of bilateral arm positioning impairments in unilateral arm CRPS,” which “suggests that central mechanisms are involved.” The team suggested cortical reorganization “in regions associated with the body” as one explanation.

	Safety and Efficacy Study of Ethosuximide for the Treatment of Complex Regional

 Researchers are looking to “evaluate the efficacy and safety of ethosuximide in search of much-needed adjunctive therapy to relieve the pain and suffering associated with CRPS.”

Pregabalin vs Placebo as an Add-on for Complex Regional Pain Syndrome of the Upper Limb Managed by Stellate Ganglion Block

 “The purpose of this study is to assess the efficacy of pregabalin

	in patients with complex regional pain syndrome Type I and to determine

	whether it provides clinically significant pain relief and whether it improves

Articles

Cover Story

A collection of links and resources from across the web focused on one specific condition. These resource range from useful websites to clinical trials. 

Net Guide: Complex Regional Pain Syndrome

	Direct your patients to this site to read about trigeminal neuralgia. Here, patients can learn how the disorder is defined, where the trigeminal nerve is located and its biological role, what causes the disorder, and the symptoms one can expect, as well as diagnosis and treatment options. Under the “Symptoms” header, patients can learn about triggers that can cause pain. For example, the site explains that “The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind.” In the “How Is it Treated?” section, the site covers the many different treatment options, including surgical interventions like rhizotomy. The site goes onto explain what is to be expected when undergoing a rhizotomy—including the likelihood that the procedure “causes some degree of permanent sensory loss and facial numbness”&mdash;and goes over the many different types of rhizotomy, including balloon compression and glycerol injection.

	This site provides a detailed review of trigeminal neuralgia, noting that the condition “is sometimes described as the most excruciating pain known to humanity.” Here, patients can learn what causes the “intense, stabbing, electric shock-like pain” and what treatment options are currently available. The site describes, in detail, the three branches that the trigeminal nerve divides into after leaving the brain and traveling into the skull. It explains that the first controls “sensation in your eye, upper eyelid, and forehead;” the second controls “sensation in your lower eyelid, cheek, nostril, upper lip, and upper gum;” and the third controls “sensations in your jaw, lower lip, lower gum,” and some muscles involved in chewing.

About Neuropathic Facial Pain and TN (Trigeminal Neuralgia)

	Featured here is a detailed illustration and diagram of the nerves involved in trigeminal neuralgia. The site, provided by The Facial Pain Association, offers articles describing TN, neuropathic facial pain, and dental issues. The “Neuropathic Face Pain and Trigeminal Neuralgia Tip Sheet” features tips from patients. The site is careful to mention that the tips are intended for informational purposes and not to replace the advice of qualified professionals. The “Diagnostic Questionnaire,” provided by the Oregon Health & Science University, provides yes-or-no questions that can be scored to determine if a patient is most likely suffering from TN. Among the questions: “Do you have any constant background facial pain (eg, aching, burning, throbbing, stinging)?” and “Did your pain start after a facial injury?”

	This video explains trigeminal neuralgia, who it affects, the prevalence of the disorder, and the symptoms. It offers key points of information, including the fact that the “syndrome usually develops in individuals over 50 years old and occurs in approximately 4/100,000 individuals.” Additionally, the video explains that “painful attacks may occur spontaneously, but are more often associated with a specific stimulus in a ‘trigger area.’” The site is “written and edited by board-certified physicians from a variety of different specialties.”

	Physicians looking to refresh their memories on the basics of trigeminal neuralgia should check out this article, featured on the American Academy of Family Physician’s website. The overview, written by Rudolph M. Krafft, MD, discusses the pathophysiology, diagnosis, and treatment of the syndrome. A number of features accompany the text, including a drawing of the trigeminal nerve; tables, including “Key Recommendations for Practice;” and diagrams, including a “Diagnosis and Treatment of Trigeminal Neuralgia” flow chart.

Cardiovascular Response during Trigeminal Ganglion Compression for Trigeminal Neuralgia According to the Use of Local Anesthetics

: Tibano A, de Siqueira S, da Nóbrega J, Teixeira M

 To “investigate cardiovascular parameters (blood pressure and heart rate [HR])  of patients that underwent trigeminal balloon compression with local anesthetics compared to a control group (placebo).”

 The “means of systolic and diastolic blood pressures (SBP and DBP, respectively) were higher in the control group when compared to the study group” at the evaluation during puncture with catheter and balloon compression. The researchers concluded that the “use of local anesthetics during the trigeminal balloon compression for TN can have a preventive role for the risk of cardiovascular events.”

Severe Psychosocial Compromise in Idiopathic Trigeminal Neuralgia: Case Report

 To study the psychosocial compromise of idiopathic trigeminal neuralgia, based on the findings of a case report.

 The team focused on a case report involving a “60-year-old man with 17 years of idiopathic trigeminal neuralgia (ITN) which affected tooth brushing for six years, causing severe dental complications and psychosocial problems.” The patient underwent neurosurgery following diagnosis, “but after three months, pain recurred and was accompanied by dysesthesia and periodontal disease.” He then received dental treatment and “had complete alleviation of pain and no further need of medication over the following three years.” Researchers concluded that the patient’s “intense suffering” represents the importance of a multidisciplinary evaluation for pain-caused secondary complications. Additionally, “Appropriately trained health professionals are necessary to evaluate and treat these patients.”

Is it Effective to Raise The Irradiation Dose from 80 to 85 Gy in Gamma Knife Radiosurgery for Trigeminal Neuralgia?

 Researchers sought to “assess the effect of raising gamma knife radiosurgery (GKS) doses from 80 to 85 Gy for the treatment of trigeminal neuralgia (TN).

“The authors retrospectively collected follow-up data of 104 GKS procedures conducted for TN. Doses of 80 and 85 Gy were prescribed for 60 and 44 patients, respectively.” Researchers found that “85 Gy brought more rapid clinical improvement

	without causing more complications,” and seemed to be “preferable to 80 Gy, but prospective randomized trials are mandatory to get a more definite conclusion on the optimal dose for GKS of TN.”

Effect of Various Surgical Modalities in Recurrent or Persistent Trigeminal Neuralgia

The researchers sought to assess the effectiveness of various surgical modalities in recurrent or persistent trigeminal neuralgia.

The team concluded that “percutaneous rhizotomy is recommended for most patients with recurrent pain after microvascular decompression, and MVD can be effective in patients with a history of failed percutaneous procedures. Radiosurgery can be utilized to treat those that have not responded to other surgical modalities.”

Injection of Botulinum Toxin Type A (BOTOX) into Trigger Zone of Trigeminal Neuralgia as a Means to Control Pain

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics

 To evaluate whether botulinum toxin type A may be used to effectively treat the pain associated with trigeminal neuralgia.

The article focuses on a case involving a “65-year-old female who did not respond to pharmacotherapy.” The patient suffered from a “persistent pain over the right

	external nasal area and right mental region,” which was “relieved for several hours after daily injections of bupivacaine.” She was given a “trial of a single dose of 100 units of botulinum toxin type A (BOTOX) diluted in 2.5 mL saline,” which was “injected into the external nasal trigger zone (60 units) and to the mental nerve region (40 units).” The

	patient was pain-free in the “external nasal region for five months,” but then the pain returned. The patient was again “injected with 100 units of botulinum toxin type A.”

Evaluation of the Pathophysiology of Classical Trigeminal Neuralgia by Blink Reflex Study and Current Perception Threshold Testing

 The researchers sought to evaluate the pathophysiology of Classical trigeminal neuralgia by blink reflex study and current perception threshold testing.

The team recruited “49 patients with classical trigeminal neuralgia” and “divided them into an acute and chronic group.” They “used blink reflex study and current perception threshold (CPT) testing to evaluate the painful facial areas and contralateral non-painful areas of patients with classical TN.” According to the results, the team found that “classical TN is not a simple largemyelinated nerve fiber dysfunction but a more complex process with a main dysfunction of unmyelinated nerve fibers.”

//Clinical Trials Transcranial Magnetic Stimulation (TMS) Effects on Pain Perception

 “The purpose of this study is to investigate the effects of transcranial magnetic stimulation on pain perception.”

	Medical Management of Trigeminal Neuropathic Pains

 To cover trigeminal neuralgia and other neuralgic conditions in the face region, guidelines associated with the conditions, and “drug therapy for these relatively rare facial pains.”

 “Trigeminal neuralgia continues to be best managed using anticonvulsant drugs, the primary ones being carbamazepine and oxcarbazepine; baclofen may be helpful and, of the newly emerging drugs, pregabalin has potential.”

Efficacy and Tolerability of Carbamazepine CR in Diabetic Neuropathy Pain

“The trial is designed to evaluate the efficacy and tolerability of carbamazepine in neuropathic pain in diabetic patients.”

Net Guide: Trigeminal Neuralgia

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American Chronic Pain Association: Communication Tools

	Patients can download useful pain-management tools at this site, which they can bring with them to the hospital, a doctor’s appointment, or use at home to keep track of their pain or treatment program. For example, the follow-up visit card allows a patient to keep track of tests that need to be administered before the next visit, treatments that need to be adhered to, and activities that should be done or avoided. Similarly, a quality of life scale can be downloaded through the site with which patients can rate their quality of life based on a number of factors. The site also contains a list of diseases associated with chronic pain, ranging from temporomandibular joint and muscle disorders to fibromyalgia. Visitors will also find a number of videos, including a “Consumer Guide to Pain Medication and Treatment;” and a collection of surveys on chronic pain.

	Caregivers can often feel overwhelmed from the process of providing support. Because a patient can benefit from the attitude and support of their caregivers, send your patient and their caregiver to this site to learn healthy techniques that will aid them both in managing chronic pain. “Families and Chronic Pain” covers the all-too-common communication issues, financial issues, and depression associated with managing chronic pain.

	Updated regularly with news on the latest treatments, research, patient stories, and more, this site, provided by Saint Jude Medical Center, offers chronic pain sufferers the tools to take charge of their pain and try to better manage their symptoms. The site covers neurostimulation in detail as a mode of treating chronic pain and also offers videos and background information on different kinds of chronic pain, chronic pain solutions, pain treatment levels, and other topics. For those patients considering different treatment options, the site offers information on its ambassador program, which connects patients with “ambassadors”— chronic pain patients who can provide first-hand information about specific treatments.

	Physicians looking to refresh their memory on chronic pain guidelines or read up on the latest updates should visit this site from the University of Michigan Health System. In the “Managing Patients with Chronic Non-Terminal Pain” section, visitors can access a pain guideline, which reviews diagnosis, treatment, guidelines for initial patient visits, items to look for when examining patients, and the common medications used to treat the condition. The section also offers tools for physicians, including downloadable documents that discuss the methods for and reasons behind altering opioid dosages.

	This blog features a number of videos presented by Dr. Peter Mackenzie, Consultant in Anesthesia and Pain Management, and Dr. David Craig, Consultant Clinical Psychologist at the New Victoria Hospital, Glasgow. Four of these videos provide tips and advice on how physicians can successfully communicate with their patients. The videos also provide answers to questions such as: “What is the impact of chronic pain on the individual and society?” and “What are the effects of chronic pain on absence from work?”

	Pain Report #12 — Optimizing Chronic Pain Management in Elderly Persons: Integrating Pharmacokinetics & Pharmacodynamics

	This activity “reviews physiological changes in the older adult” and “common relevant age-related changes” and describes the pharmacologic agents that are commonly used to treat these conditions. Pain medications are compared and contrasted as well.

Strategies for Opioid Rotation: Decision Support in Chronic Pain Management

	This activity reviews evidence for “effective opioid rotation strategies in patients with chronic pain” who are appropriate candidates for this treatment but have demonstrated “unacceptable adverse effects or ineffective analgesic responses.” The 2009 guidelines

	developed by the American Pain Society and the American Academy of Pain Medicine are also analyzed.

Drug Treatment of Chronicintermittent Abdominal Cramping and Pain: A Multi-national Survey on Usage and Attitudes

 Mueller-Lissner S, Quigley E, Helfrich I, Schaefer E

 The authors sought to examine data on the treatment of abdominal cramping and pain across countries to form comparisons.

 A multi-national survey was conducted in the USA, Mexico, Brazil, Argentina, Germany, Belgium, Italy, and the UK. There were 1,717 participants who were “interviewed on various aspects of drug treatment of their complaints.” Results demonstrated that those “from the Americas used more medication (about 90%) than those from Europe (about 70%).” Mostly, over-the-counter remedies were used rather than prescription drugs (except in Mexico). Further results showed, “The majority of people afflicted by abdominal cramping and pain use medication and take them on demand. Consequently, rapid onset of action is mentioned as most important. Antispasmodics are the class most frequently used with considerable variation from country to country.”

Methadone: Does Stigma Play a Role as a Barrier to Treatment of Chronic Pain?

To explore the benefits of “methadone as an analgesic in the relief of chronic neuropathic pain.”

 The team surveyed 124 pain physicians from “private practice, university settings, and community hospitals” to determine their methadone prescribing practices. Results showed that “The majority of survey responders (90%) prescribed methadone in their pain practice, but on a very limited basis; 59% state <20% of their patients are on methadone.” The authors found the fact that “many clinicians do not prescribe methadone as a primary analgesic” to be of interest. They concluded that one reason this may be so “is due to the social stigma of its use in treatment of heroin addicts.” “The role of stigma

	as a barrier to adequate treatment of chronic pain among pain physicians prescribing practices is a fundamental, yet unexplored issue.”

A Telephone Feedback System for Prevention of Chronic Pain Relapse

National Institute of Arthritis and Musculoskeletal and Skin Diseases

The study is designed to determine if a “telephone-based self-monitoring

	and skills review program with personalized therapist feedback following group CST for chronic pain can reduce and prevent relapse of the pain, physical disability, and psychological distress experienced by patients with chronic pain of the muscles and bone.”

	Direct your patients to this site to review the risks and benefits of taking Celebrex, as well as safety tips and vital information, such as what to do if he or she misses a dose and what might indicate that he or she may have taken too much of the medication. In the frequently asked questions section, patients will find answers to commonly asked questions like, “Do all NSAIDs have the same warnings for serious stomach and intestine side effects?” The “Working with Your Doctor” section provides patients with tips on questions they should ask their doctors and how to manage their pain symptoms.

The Effects of Celecoxib or Naproxen on Blood Pressure in Pediatric Subjects

 Interventional Age/Gender requirement: 2-18 years (male/female)

 This multicenter, active-controlled trial will “evaluate the effects of celecoxib (Celebrex) or Naproxen on blood pressure in pediatric subjects with juvenile idiopathic arthritis.”

Celecoxib as a Post-tonsillectomy Pain Medication

 This study will test the hypothesis “that celecoxib effectively reduces pain after a tonsillectomy and reduces post-operative narcotic use.” Patients will receive either celecoxib or placebo, and all participants will “receive the standard post-operative pain medications.”

Net Guide: Chronic Pain

	Just how well do you know your patients? Every day physicians across the country treat patients from all different walks of life—some they’ve known for years, others they see once or twice a year, and some are new patients whom they know little about other than what they’ve read off initial forms.

	The role of the physician is to evaluate, diagnose, and offer treatment to individuals needing medical attention; but increasingly, that role now seems to require an additional component: to grill patients about their medication history. Doing so provides an added measure of safety— not only for the patient, but for the physician as well. The reason for this shift is because more and more, patients are turning to a variety of sources to obtain medications, such as multiple doctors and pill farms, and are even crossing borders to obtain prescription drugs.

	One example is Leslie Cooper, a patient who became addicted to painkillers “after a particularly tough surgery,” as reported in USA Today. The addiction continued for a decade. Cooper, 34, visited several doctors and pain clinics in southern Ohio until overdosing after traveling two hours to fill a prescription (http://hcp.lv/9Mbqqb).

	According to a report issued by the CDC on June 18, “Emergency department visits for nonmedical use of opioid analgesics increased 111% during 2004-2008”  (http://hcp.lv/cwndxz). That is why organizations like the National Alliance for Model State Drug Laws (NAMSDL; www.namsdl.org) and doctors across the country are pushing for prescription drug monitoring programs (PDMPs) to be the standard in every state.

State Prescription Drug Monitoring Programs

	PDMPs are statewide electronic databases that collect data on dispensed narcotic substances and distribute it to individuals authorized under state law to receive it for purposes of their profession (http://hcp.lv/aXhnka). PDMPs, which are usually overseen by a statewide regulatory, administrative, or law enforcement agency, gather information on the prescription drug habits of patients and the prescribing patterns of physicians, tracking data such as how often a patient receives prescriptions, for which conditions they receive prescriptions, and from how many doctors they receive prescriptions.

	According to the NAMSDL, the five main benefits of PDMPs are their ability to:

	• Support access to legitimate medical use of controlled substances

	• Identify and deter, or prevent, drug abuse and diversion

	• Facilitate and encourage the identification, intervention with, and treatment of persons

	• Inform public health initiatives through outlining of use and abuse trends

	• Educate individuals about abuse and diversion of and addiction to prescription drugs (http://hcp.lv/ aK9q1Y)

	Many supporters generally believe that tracking this  kind of information can help prevent the misuse  of prescription drugs and curb abuse. According to Dr. John F. Dombrowski, a board member of the American Society of Interventional Pain Physicians

	(ASIPP; www.asipp.org), not only could this be a crucial step in controlling the availability of illegal prescription drugs on the street, but by its very nature it can help curb healthcare costs.

	“With respect to these medications, obviously they have a lot of risks in terms of addiction, abuse, perhaps even death, but they also cost money,” Dombrowski says. “So, if we can then limit all those  drugs that are out there then we can also limit the cost of all those drugs being out there. And once that system gets up and running, you can have costcontainment.”

	Currently, there are 33 operational state PDMPS across the county. These PDMPs actively collect prescription data and release it upon request to the appropriate parties. Overall, 42 states have currently enacted laws to create and utilize PDMPs as of June 1, according to research from the NAMSDL (http://hcp.lv/ceDD9z).

	However, not all state PDMPs are created equally. For example, some programs may only include schedule II drugs, while others may only include schedule IV-V drugs. The groups that have access to the databases can also vary, as can the methods of access. States typically fall into two categories: those with proactive PDMPs and those with reactive PDMPs. Proactive PDMPs “identify and investigate cases, generating unsolicited reports whenever suspicious behavior is detected,” and also “tend to be law-enforcement oriented.” On the other hand, reactive PDMPs “generate specific reports only in response to a specific inquiry” (http://hcp.lv/bJHZiT). In 2004, the NAMSDL developed criteria for building strong and effective PDMPs, recommending that programs:

	• Include drugs that demonstrate a potential for abuse, especially as indicated by law officials and addiction treatment professionals

	• Proactively provide information to law enforcement, occupational licensing officials, and other appropriate individuals.

	• Allow dispenser and prescribers, law enforcement officials, and occupational licensing officials to request specific information from the databases

	• Attempt to address interstate misuse and abuse of prescription drugs

	The NAMSDL, in a 2006 follow-up evaluation of PDMPs nationwide, found that proactive programs “may be more effective” than reactive programs “in reducing the per capita supply of prescription pain relievers and stimulants.” (http://hcp.lv/bJHZiT)

	Among the states frequently mentioned as having effective programs in place are Nevada, Kentucky, Ohio, Maine, and Vermont, according to Sherry Green, chief executive officer, NAMSDL. “There are now over 20 states that are allowed to provide some type of unsolicited report,” Green says. “Some states are allowed to send pertinent information to professional licensing or occupancy boards or law enforcement if, in reviewing the PMP [prescription monitor program] data, there is reason to believe that a violation of law or a breach of an occupational standard has occurred. Some states are allowed to send information to prescribers if there is reason to believe there has been misuse or abuse of prescription medications.”

	Getting information into the hands of knowledgeable health professionals who are able to most effectively address the issue is the ongoing focus, she says. “This suggests to me that PMP officials are striving to use their programs for early intervention and early identification of potential problems as much as possible.”

	Today, many of the recommendations made by the NAMSDL for establishing effective programs are still valid and are being utilized across the country, says Green. “Our components were based on those successful elements common to most programs at the time we developed the document. I’m glad to say that as more and more states have established PMP programs, they have generally incorporated the same successful elements.” The burgeoning nationwide initiative to establish PDMPs is clearly having an effect; next up is getting users familiar and comfortable with the programs. Since 2006, PMP officials have been intent on identifying ways to improve the effectiveness of the programs as information tools for professionals, Green says. “To this end, states have been creating 24/7 access through secure Web portals for prescribers to access the PMP data at the times most useful to them in terms of assessing treatment plans for their patients.”

	Protecting data is also of concern, and attention is also being placed on “upgrading various technical security measures,” she adds. “Additionally, over the last several years, we’ve seen a strong effort among PMPs to educate authorized users of the data on how to use the PMP system, the value of the PMP data to their professional responsibilities, and the appropriate uses of the data.”

	While establishing PDMPs at the state level may be useful, the problem of doctor-shopping and pharmacy-hopping across state lines has some supporters—including members of ASIPP&mdash;calling for a national prescription monitoring program. A strong PDMP supporter, ASIPP has helped lobby Congress to offer aid to individual states to create their own databases through the signing of the National All Schedules Prescription Electronic Reporting Act in 2005 (www.nasper.org). Behind the creation of the bill is another initiative headed by the ASIPP to eventually establish a national database that is accessible by physicians across the country (http://hcp.lv/cq1dPB).

	Opening up database information to neighboring states, or even creating a national database accessible to all physicians, is believed by many to be an even better way to achieve the goals that are associated with state prescription monitoring program databases (http://hcp.lv/casJs9).

	While the NAMSDL does not have an official statement on the concept of a national PMP, Green says she is aware of “several interstate sharing initiatives” that the group is tracking. For example, Green mentions that the IJIS Institute is currently working with states such as Kentucky and Ohio, along with several PMP officials, on the “development of a technological infrastructure which would allow multiple state PMPs to securely transmit PMP data to other state PMPs.” Similarly, Green says that the Council of State Governments’ National Center on Interstate Compacts is drafting “an interstate compact on PMP data sharing” that “would be considered by all state legislatures,” and if adopted, “would allow that state’s PMP to share PMP data with other PMPs in states that have also adopted the compact.”

Just how well do you know your patients? Every day physicians across the country treat patients from all different walks of life-some they've known for years, others they see once or twice a year, and some are new patients whom they know little about other than what they've read off initial forms.

Keeping Patients Safe by Keeping Track of Drugs

One of the topics addressed at this year’s HIMSS conference was “the power of no,” a term coined by The New York Times that refers to the concept of limiting a patient’s right to treatment if those in power decide that the care is too expensive, the patient is too old, or the treatment is not likely to deliver enough value. At the heart of this debate is electronic health record (EHR) technology and the impact it may have on patient care (http://hcp.lv/aAHWgo; http://hcp.lv/93ysjw).

The problem that I have with all of this is that putting the concept of “best practices” to work can hinder or even eliminate the nuances involved in the art of treating patients that are learned through many years of medical training.

There are situations that unfortunately cannot be programmed into a computerized medical chart. You cannot supplant the learned experience of a physician with a computer system and subsequently call it “quality.” You cannot deny care to patients using a computer algorithm and call it “decreasing costs.” You cannot replace the mistakes that can occur with paper records with new mistakes using the EHR, and call it “reduction in errors.” This is not progress; in fact, some believe this increased bureaucracy is a form of “digital socialism.”

I agree with the points that David Blumenthal, MD, made during his speech at HIMSS, where he said the EHR can be a very powerful instrument that can help the physician see patients in a more organized manner, and can be a tool by which the physician can provide better care. Where I disagree with Dr. Blumenthal is that I believe the physician should have the freedom to choose the EHR that is most compatible with his style of documentation and is more in line with what he can afford. We should not have the government forcing physicians into choosing expensive, complicated EHR systems that can be used to track patient behavior—or worse yet, to mine patient data for the purpose of limiting care. In his speech, Dr. Blumenthal proudly stated that he was a friend of HIMSS. I feel that it is inappropriate for a powerful bureaucrat, a direct representative of the President of the United States, to align himself with one of the most powerful political lobbying organizations in the country, and to take part in crafting legislation that will benefit HIMSS members&mdash;possibly at the expense of physicians. Can we ensure that improving patient care is the top priority if there is a conflict of interest like the one Dr. Blumenthal appears to have (http://hcp.lv/bT35W7)?

President Obama and many in Congress want to take the failed concept of “managed care” and resurrect it with the use of expensive, powerful EHR systems and turn the US healthcare system into a European-style socialized medical system. Those in favor of this are ignoring the fact that 93% of physicians are not currently in the position to achieve “meaningful use” as outlined in the ARRA-HITECH legislation (http://hcp.lv/a7nt9a; http://hcp.lv/affsGB).

They are ignoring the will of the people, 55% of whom say they are against the new healthcare bill (http://hcp.lv/9tYeq3). They are ignoring the fact that in Massachusetts, the cost of healthcare centered around the use of powerful HIT systems has cost 15% more than the national average, and the fact that although 97% of the population has universal coverage, it does not mean universal access to a doctor, because of critical shortages of primary care physicians who since 2006 have opted to either leave the state or retire (http://hcp.lv/cWare4).

They are also ignoring the situation in Arizona, where in 2005, then-Governor Janet Napolitano passed a mandate that all physicians adopt HIT systems; four years later, EHRs were being uninstalled at a rate of more than 20% (http://hcp.lv/bL4LLN). They are hiding the fact that more than 50% of HER implementations failed in 2007, according to the Office of the National Coordinator for Health IT (http://hcp.lv/cYfbKs).

Worldwide, numerous countries that have pushed for high EHR adoption are experiencing difficulties, such as in the UK, where Cerner, a major subcontractor on parts of the National Health Service project, has faced a great deal of criticism suggesting that its systems are too difficult to use and implement. In Sweden, a country hailed for its progress with electronic records, a government panel issued a report in May 2009 linking computer malfunctions to “severe incidents” and even deaths (http://hcp.lv/b9xQ8g). Even Canada’s EHR initiative has stalled (http://hcp.lv/cGw20Z).

The history of EHR and its associated problems cannot be ignored. Statements attributed to the EHR such as “increased  quality, decreased errors, and decreased costs” should not be taken at face value, but instead proven in large, scientific prospective trials. Big government and the insurance industry need to let physicians do what they do best—provide care for patients in an unfettered, less bureaucratic environment.

Alberto Borges, MD, is in private practice and is an associate clinical professor of medicine at the George Washington University in Washington, DC. Check out his website at http://msofficeemrproject.com.

The opinions expressed in this column do not necessarily reflect those of MDNG.

Columns

One of the topics addressed at this year's HIMSS conference was "the power of no," a term coined by The New York Times that refers to the concept of limiting a patient's right to treatment if those in power decide that the care is too expensive, the patient is too old, or the treatment is not likely to deliver enough value.

The HIT Realist: Digital Socialism and the Power of No

Before I launch into this month’s topic, I would be remiss if I failed to acknowledge the technological phenomenon sweeping the nation this spring. I am speaking, of course, about the “magical and revolutionary” iPad, which hit stores April 3 and almost immediately altered the course of history as we know it. Or so the hype would have us believe.

Don’t get me wrong: the iPad is a cool new device, but its applications to this point don’t seem as absolutely essential as its proponents would have us believe. So, while the rest of the world focuses on the iPad, I’m actually more interested in another recent development that might end up having just as great an impact on all our lives: flexible screen  technology. I know, it’s not nearly as sexy as whatever the latest iThingy is, but trust me, if you haven’t heard about flexible screen technology yet, you will soon.

That’s because the latest research indicates that flexible and even “rollable” displays, a space-age concept touted for years in movies like Minority Report and the Harry Potter series, are actually just around the corner. Imagine computers that can be folded up and put in your pocket, televisions that can be bent to view, and of course, cool new tools for your practice.

About two years ago, a company called Polymer Vision introduced e-Readius, an e-reader with a five-inch diagonal flexible screen, sporting a 320x240 resolution in 16 shades of gray. I haven’t used one myself, but the company claims its proprietary active-matrix electrophoretic display is as thin and light as paper, cannot be torn or broken, and can be rolled or folded into something as small as a finger.

Unlike the iPad, this product has not yet grabbed the public’s attention, which is interesting since it would be a boon to those who now get their daily news fix by scanning the headlines on an e-reader but miss the way they could roll up their old newspaper to swat a fly or smack their dog. Looking further out into the future, Organic LED (OLED) may be the ultimate winner of this race. OLED is a light-emitting diode (LED) whose electroluminescent layer is composed of a film of organic compounds. The LED backlighting required by conventional liquid crystal displays (LCDs) is rigid, expensive, and complex to manufacture. On the other hand, OLED displays are easier to manufacture, more flexible and, as an added bonus, consume less energy.

That’s why industry giants like Sony, Samsung, and Kodak are all devoting significant time and money to the development of flexible OLED display screens. In October 2008, Samsung showcased the world’s thinnest OLED display, which was also the first to be bendable. It measured just 0.05 mm (thinner than a sheet of paper) and triggered a rumor that Apple would be using this OLED technology for their iPad.

The reality is that glitches, such as size and resolution limitations, and the difficulty of structuring the organic compounds so they won’t distort when bent, have kept designs from actually coming to market. But with the recent strides made with rollable displays (which, unlike the OLEDs, are enabled by plastic electronics rather than glass), we could be closer than ever to using these technologies in our everyday lives.

Practically speaking, the benefits of these flexible screens are boundless. Imagine, for instance, an HER device as thin as paper, which can be as large as necessary, then completely rolled up or folded away when not in use.

By closely mimicking paper, an EHR on this type of device might be more natural for many physicians to use during a patient encounter than a conventional PC or laptop. This may finally render obsolete the traditional paper chart, with its illegible writing, limited dynamic information, and all-round general unwieldiness.

I, for one, cannot wait for the day when I no longer have to lug my laptop around. And that is why I’m more excited about this developing story than the iPad which, frankly, is simply regurgitating existing technology (the iPhone) in a clever looking new package.

(Disclosure: I don’t have enough Apple stock.)

Dr. Bertman is Physician Editor-in-Chief of MDNG: Primary Care/Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Before I launch into this month's topic, I would be remiss if I failed to acknowledge the technological phenomenon sweeping the nation this spring. I am speaking, of course, about the "magical and revolutionary" iPad, which hit stores April 3 and almost immediately altered the course of history as we know it. Or so the hype would have us believe.

June 2010

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