Editorials

eHealth: The Foundation for Health System Transformation

Lawrence P. Hanrahan, PhD, MS

The information age has finally arrived for the health enterprise. For many years, health care has lagged behind other sectors, such as banking, manufacturing, and retail, in the use of networked information systems to support business practices. To be sure, much work still needs to be done to achieve a comparable level of familiarity, widespread use, acceptance, and integration. But as a nation1,2 and state3-6 we now realize the increasing role information systems must play if we are to greatly improve the quality and safety of health care, increase the pace of innovation and adoption of evidence-based practices, and improve the health of individuals and our communities. eHealth provides the foundation for this transformation.



Author Affiliations: Bureau of Health Information and Policy, Wisconsin Division of Public Health, Department of Health and Family Services; Department of Population Health Sciences at the University of Wisconsin-Madison School of Medicine and Public Health

Corresponding Author: Lawrence P. Hanrahan, Wisconsin Division of Public Health, 1 W Wilson St, Rm 372, Madison, WI 53701; phone 608.267.7173; fax 608.264.9881; e-mail hanralp@dhfs.state.wi.us.

Commentaries

SPHERE: Tracking Public Health Improvement with Electronic Records

Matthew J. Landis, MS; Susan Kratz; Linda Spaans-Esten; Lawrence P. Hanrahan, PhD, MS

Increasingly, public health relies on information science to assist decision-making and assess health from the individual to the statewide level. Modern public health practice requires access to advanced, networked, computer-assisted technology in order to effectively monitor disease, analyze and detect risks, provide decision support, alert and communicate, educate and train, manage public health response, and measure effectiveness.1 Accordingly, “integrated electronic data and information systems” is a Wisconsin 2010 Health Plan infrastructure priority.2



Author Affiliations: Bureau of Community Health Promotion, Wisconsin Division of Public Health, Department of Health and Family Services (Kratz, Spaans-Esten); Bureau of Health Information and Policy, Wisconsin Division of Public Health, Department of Health and Family Servic

Corresponding Author: Matthew J. Landis, Wisconsin Division of Public Health, 1 W Wilson St, Rm 372, Madison, WI 53701; phone 608.261.9308; fax 608.264.3881; e-mail landimj@dhfs.state.wi.us.

Original Research

Inventory of Electronic Health Information Exchange in Wisconsin, 2006

Seth Foldy, MD, MPH, FAAFP

Context: The Governor’s Board for eHealth Care Quality and Patient Safety plans for universal adoption of electronic health records and information exchange. Objectives: The inventory sought to describe characteristics, challenges, and policy recommendations of health information exchange (HIE) projects and create a directory and baseline for periodic reassessment. Design, Setting, Subjects: A cross-sectional Internet survey of any project where electronic patient information was transmitted by multiple organizations in Wisconsin in 2006. Main Outcome Measures: A description of operational and planned HIE projects, including stage of development, information users, organizational home, funding, governance, geographic scope, data standardization, drivers, internal and external challenges, and recommendations for statewide action. Results: Twenty-one organizations sponsor 16 operational and 11 planned HIE projects. Most are surveillance programs, but a growing proportion serves clinicians and patients. Under half use data standards for interoperability. Leading internal challenges relate to funding, organizational and staff issues, governance, and technology. Leading external challenges are marketing, enlisting participants, regulatory issues, and sustainability. Conclusion: Wisconsin enjoys rich experience with HIE, but data remains largely in separate silos. Statewide collaboration, coordination and resource sharing can enhance the future of exchange efforts.

Author Affiliations: Medical College of Wisconsin, Milwaukee, Wis.

Corresponding Author: Seth Foldy, 3061 N Marietta Ave, Milwaukee, WI 53211; phone 414.339.3865; fax 414.906.9667; e-mail sfoldy@sbcglobal.net.

Hypertensive Heart Disease Mortality in Wisconsin, 1979-2004

Lynda Knobeloch, PhD; Pamela Imm, MS

Hypertensive heart disease (HHD) is a late complication of chronic high blood pressure. Each year HHD claims the lives of more than 20,000 people in the United States. Between 1979 and 2003, 8735 Wisconsin residents died as a direct result of the condition. While annual death rates were relatively stable over this time period, racial and regional variations were observed. Wisconsin’s African American community had an age-adjusted death rate of 26.1 per 100,000 for HHD. In comparison, rates among whites and other races were 6.5 and 4.3 per 100,000, respectively. Regional rates were highest among residents of Milwaukee County. While additional research is needed to determine the cause of these disparities, our findings suggest that hereditary and environmental factors are important determinants of risk and demonstrate the importance of early screening and aggressive treatment of hypertension among high-risk populations.



Author Affiliations: Wisconsin Department of Health and Family (Knobeloch); Molecular and Environmental Toxicology Center, University of Wisconsin-Madison (Knobeloch); Bureau of Environmental and Occupational Health (Imm).

Corresponding Author: Lynda Knobeloch, PhD, Wisconsin Division of Public Health, 1 W Wilson, Rm 150, Madison, WI 53703; phone 608.266.0923; fax 608.267.4853; e-mail knobelm@dhfs.state.wi.us

Possible Factors Illuminating Increased Disparities in Neonatal Mortality in Wisconsin from 1991-2005

Wen-Jan Tuan, MS; Peggy Hatfield, PhD, MS; Abhik Bhattacharya, PhD; Gloria E. Sarto, MD, PhD; Pamela J. Kling, MD

Background: Neonatal mortality has been perceived as one of the critical and sensitive measures that reflect not only the heath status of infants and their mothers, but also the general well-being of a society. However, our knowledge of racial disparities in neonatal mortality associated with low birth weight and short gestation is relatively limited. As part of continuing statewide efforts to achieve better birth outcomes, this study intends to develop a better understanding of potential mechanisms contributing to the discrepancy in neonatal mortality rates (NMR) to help public health practitioners formulate more effective interventions to prevent unnecessary infant deaths. Objectives: To assess racial/ethnic disparities in neonatal morality risks by infant birth weight and gestational age in Wisconsin from 1991 through 2005, and to provide more information for programs emphasizing the development of policies and environmental changes to reduce and prevent infant mortality in minority populations. Methods: Linked birth/infant death data were obtained from the Wisconsin Interactive Statistics on Health (WISH) query system by birthweight, prematurity, race/ethnicity for the periods, 1991-1995, 1996-2000, and 2001-2006. The probability of neonatal mortality was analyzed through log-linear Poisson regression models to test for the pattern of variation of neonatal mortality risks in relation to infant’s race/ethnicity, birth weight, prematurity, and their interactions. Results: The proportion of the neonatal deaths to the infant deaths has gradually increased over time, and accounted for more than two-thirds of Wisconsin infant deaths. Despite a large decrease in white NMRs, neonatal mortality risks for blacks and Hispanics did not significantly change. This discord led to a widened racial/ethnic gap in NMRs. Substantial variations on neonatal mortality risks by birth weight and preterm birth were found among whites, blacks, and Hispanics infants. Notably, among low birth weight and preterm infants, blacks and Hispanics appeared to have more favorable NMRs than whites. White infants had the lowest NMRs only delivered at full-term and about 2500 g. Conclusion: Wisconsin infant mortality rates are largely driven by neonatal deaths. This shows an urgent need to develop effective public health interventions to prevent early neonatal deaths. To reduce racial/ethnic disparities in NMRs, the design of the interventions should also take into account the variation of the effects of birth weight and gestation age on neonatal mortality among racial/ethnic groups. It is hoped the result of this study will provide a critical understanding: when it comes to racial/ethnic disparities, there is far more to low birth weight or short gestational age than simply not having enough weight or days.



Author Affiliations: University of Wisconsin Health Innovation Program, University of Wisconsin School of Medicine and Public Health (Tuan); Center for the Study of Cultural Diversity in Healthcare, University of Wisconsin School of Medicine and Public Health (Hatfield, Sarto

Corresponding Author: Wen-Jan Tuan, 546 Warf Office Building, 610 Walnut St, Madison, WI 53726; phone 608.262.7385; e-mail tuan@wisc.edu.

Clinical Decision Support Systems Use in Wisconsin

Marc-Oliver Wright, MT(ASCP), MS; Mary Jo Knobloch, MPH; Carrie A. Pecher; George C. Mejicano, MD, MS; Matthew C. Hall, MD

Context: Clinical decision support systems (CDSS) are becoming increasingly common in medical practice. Objective: To assess utilization, level of interest, and potential barriers to implementation of CDSS among physicians providing inpatient care in Wisconsin. Design and Participants: A Web-based survey consisting of 20 questions e-mailed to 5783 members of the Wisconsin Medical Society. Results: Of those contacted, 496 (9%) responded and 356 (72%) were eligible for the survey. According to 38% of respondents, CDSS were in place in their facility; less than a third were computer-based. Few existing users of CDSS reported being dissatisfied (2%) although 38% of the respondents were unfamiliar with CDSS or their use in medical practice. Most (79%) described themselves as receptive to new decision support tools, though the most commonly anticipated barrier to implementation was physician acceptance. Conclusions: CDSS are used in limited capacity in Wisconsin and existing systems are not likely to be computer-based. Despite physicians expressing a generally favorable interest in CDSS, a knowledge gap persists.

Author Affiliations: Evanston Northwestern Healthcare, Evanston, Ill (Wright); Marshfield Clinic, Marshfield, Wis, Department of Medical Education (Knobloch); Marshfield Clinic, Marshfield, Wis, Center for Community Outreach (Pecher); Marshfield Clinic, Marshfield, Wis, Depar

Corresponding Author: Matthew C. Hall, MD, 1000 N Oak Ave, 2F4, Marshfield, WI 54449; phone 715.387.5193; fax 715.389.5499; e-mail hall.matthew@marshfieldclinic.org.

Review Articles

Preimplantation Genetic Diagnosis: Technology and Clinical Applications

Amy Swanson, MS, CGC; Estil Strawn, MD; Eduardo Lau, PhD; David Bick, MD

Preimplantation genetic diagnosis (PGD) is a method by which embryos formed through in vitro fertilization (IVF) can be tested for single-gene disorders or chromosome abnormalities prior to embryo transfer. This enables couples to significantly improve their chances of having a healthy child. PGD is an important addition to conventional prenatal diagnosis for genetic disorders. PGD is a complex combination of various technologies that requires close collaboration of a team of specialists for optimal patient care. This review article will cover patient management, assisted reproductive technologies including IVF and PGD as well as indications for PGD. Clinical vignettes from The Froedtert Hospital and Medical College of Wisconsin Reproductive Medicine Clinic PGD Program will be presented, including the first single-gene disorder PGD performed in Wisconsin. These vignettes highlight the importance of a detailed family history, use of PGD for cases of recurrent miscarriage, and the use of PGD for spinal muscular atrophy.



Author Affiliations: Department of Obstetrics and Gynecology, Medical College of Wisconsin (Swanson, Strawn, Bick); Department of Pediatrics and Human & Molecular Genetics Center, Medical College of Wisconsin (Lau)

Corresponding Author: Amy Swanson, MS, CGC, Medical College of Wisconsin/Froedtert Hospital, 9200 W Wisconsin Ave, Milwaukee, WI 53226; phone 414.805.9018; fax 414.805.9000; e-mail aswanson@mcw.edu.

Case Reports

Vertebral Osteomyelitis in a Healthy Young Adult

Nitin Jain, MD; Dhaval Patel, MD; Kurt J. Pfeifer, MD

A 39-year-old African American man with no significant past medical history presented to our hospital with right hand weakness and pain in both arms. He had no fever, neck pain, headache, dizziness, vision changes, or weakness in his lower extremities. Magnetic resonance imaging of the cervical spine showed extensive abnormal enhancement of the C7-T1 vertebral bodies as well as the prevertebral and epidural spaces. Open biopsy of the lesion showed inflammatory changes consistent with osteomyelitis. Culture of the biopsy specimen grew Group B Streptococcus (GBS). HIV ELISA and blood cultures were negative. The patient was treated with intravenous vancomycin for 6 weeks with complete resolution of symptoms. GBS classically affects newborns and pregnant females. However, the incidence of infection from this pathogen in nonpregnant adults is increasing. Vertebral osteomyelitis due to GBS in nonpregnant adults is exceedingly rare. To our knowledge, this is the first reported case of GBS cervical vertebral osteomyelitis in an adult without risk factors for invasive GBS infection. This case illustrates that GBS should be included in the differential diagnosis of pyogenic vertebral osteomyelitis, irrespective of immune status and predisposing factors.


Author Affiliations: Department of Medicine, Medical College of Wisconsin, Milwaukee, Wis (Jain, Patel, Pfeifer).



Corresponding Author: Nitin Jain, MD, Department of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226; phone 414.456.6791; fax 414.456.6213; e-mail njain@mcw.edu

Your Practice

Covenants non-compete agreement: What good are they, anyhow?

Thomas Godar, JD

Bob, a successful orthopedic specialist with a small clinic, has just had a very lucrative offer to join a new multi-specialty practice in a suburban location next to the newest hospital in the metro area. The new job would be about 16 miles from the current clinic. But Bob signed a non-compete when he started work 7 years ago. He really wants this new job, which he believes offers greater opportunity and compensation, and which is closer to home. Should he take the job in spite of the non-compete agreement? If you are the manager/owner of the multi-specialist clinic that wants to hire Bob, is this a reasonable risk to take, in spite of knowing he has a non-compete with another clinic?



Author Affiliations: Whyte Hirschboeck Dudek S.C.

Corresponding Author: Thomas P. Godar, JD, Whyte Hirschboeck Dudek S.C., 1 E Main St, Ste 300, Madison, WI 53703-3300; phone 608.234.6064; fax 608.258.7138; e-mail tgodar@whdlaw.com.

Implementing electronic health records in physician offices: Lessons learned

Jay A. Gold, MD, JD, MPH; Jesi Wang, CPHIT, CPEHR

A recent survey by the National Ambulatory Medical Care Survey (NAMCS) found that a quarter of office-based physicians reported using an electronic health record (EHR) in 2005.1 While this is a 31% increase from its 2001 survey results, it is a far cry from the rate of adoption that experts think is needed for optimal information access and documentation. With the national push to adopt electronic health records (EHRs) and benefits such as increased efficiency, patient safety, security, and quality of care, adoption rates are sure to increase in the coming years.



Author Affiliations: Doctor Gold is senior vice president and principal clinical coordinator for MetaStar, Inc. Ms Wang is Manager of the Doctor’s Office Quality – Information Technology (DOQ-IT) initiative at MetaStar. This material was prepared by MetaStar, Inc.

Corresponding Author: Jay A. Gold, MD, JD, MPH

Women: Don’t shortchange your retirement

Maureen E. Hansen, CLU

Nine out of every 10 women will be solely responsible for their financial well-being at some point in their lives, according to the US Census Bureau. Women are more likely to leave the workforce or reduce hours to care for family, tend to earn less than men in similar professions, and have a longer life expectancy. All these factors add up to an important truth: women—including physicians—are more likely than men to retire with inadequate resources.



Author Affiliations: Maureen E. Hansen, CLU, is a fee-only financial consultant with SVA Wealth Management, Inc., an SVA Company and Registered Investment Adviser.

Corresponding Author: For more information, contact Wisconsin Medical Society Insurance and Financial Services, Inc., at 866.442.3810.

Your Profession

Benefits of electronic medical records outweigh every challenge

Michael J. Dunn, MD Dean and Executive Vice President, Medical College of Wisconsin

From the wearing of white coats to the reciting of the Hippocratic Oath, tradition is important in medicine. But when it comes to medical information, traditional is just another word for outdated. In both business and leisure activities, our society demands lightening-quick, fingertip access to information. This philosophy has had a slower translation to medicine.


Author Affiliations: Medical College of WIsconsin

Corresponding Author: Michael J. Dunn, MD

Your Society

2007 House of Delegates Action on Resolutions and Board Reports

Wisconsin Medical Society

Editor’s Note: To read the complete text of resolutions and amendments, visit the members-only section of our Web site: http://www.wisconsinmedicalsociety.org.


Author Affiliations: Wisconsin Medical Society

Corresponding Author: WMJ

Other

Additional risk factors for open angle glaucoma

Erik Schoff, MD, Fond du Lac, Wis

I read with interest the article on primary open angle glaucoma and myopia (WMJ. 2007;106[2]:89). I believe 2 important comments should be made regarding the Conclusions paragraph.


Author Affiliations: Erik Schoff, MD, Fond du Lac, Wis

Corresponding Author: Erik Schoff, MD, Fond du Lac, Wis