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This study uses Department of Health and Human Services data to analyze surveillance of electronic health records for patient safety issues to identify those with a potential for patient harm, and the frequency of these issues.

Importance Success on the internal medicine (IM) examination is a central requirement of the American Board of Internal Medicine’s (ABIM’s) Maintenance of Certification program (MOC). Therefore, it is important to understand the degree to which this examination reflects conditions seen in practice, one dimension of content validity, which focuses on the match between content in the discipline and the topics on the examination questions. Objective To assess whether the frequency of questions on IM-MOC examinations were concordant with the frequency of conditions seen in practice. Design, Setting, and Participants The 2010-2013 IM-MOC examinations were used to calculate the percentage of questions for 186 medical condition categories from the examination blueprint, which balances examination content by considering importance and frequency of conditions seen in practice. Nationally representative estimates of conditions seen in practice by general internists were estimated from the primary diagnosis for 13 832 office visits (2010-2013 National Ambulatory Medical Care Surveys) and 108 472 hospital stays (2010 National Hospital Discharge Survey). Exposures Prevalence of conditions included on the IM-MOC examination questions. Main Outcomes and Measures The outcome measure was the concordance between the percentages of IM-MOC examination questions and the percentages of conditions seen in practice during either office visits or hospital stays for each of 186 condition categories (eg, diabetes mellitus, ischemic heart disease, liver disease). The concordance thresholds were 0.5 SD of the weighted mean percentages of the applicable 186 conditions seen in practice (0.74% for office visits; 0.51% for hospital stays). If the absolute differences between the percentages of examination questions and the percentages of office visit conditions or hospital stay conditions seen were less than the applicable concordance threshold, then the condition category was judged to be concordant. Results During the 2010-2013 IM-MOC examination periods, 3600 questions (180 questions per examination form) were administered and 3461 questions (96.1%) were mapped into the 186 study conditions (mean, 18.6 questions per condition). Comparison of the percentages of 186 categories of medical conditions seen in 13 832 office visits and 108 472 hospital stays with the percentages of 3461 questions on IM-MOC examinations revealed that 2389 examination questions (69.0%; 95% CI, 67.5%-70.6% involving 158 conditions) were categorized as concordant. For concordance between questions and office visits only, 2010 questions (58.08%; 95% CI, 56.43%-59.72% of all examination questions) involving 145 conditions were categorized as concordant. For concordance between questions and hospital stays only, 1456 questions (42.07%; 95% CI, 40.42%-43.71% of all examination questions) involving 122 conditions were categorized as concordant. Conclusions and Relevance Among questions on IM-MOC examinations from 2010-2013, 69% were concordant with conditions seen in general internal medicine practices, although some areas of discordance were identified.

This Viewpoint discusses issues related to the use of “provider” to describe primary care health professionals with varying levels of training and certification and the effects of these issues on quality of care.

When should a physician retire? This question is being asked more frequently as the number of physicians in the United States older than 60 years continues to increase. In 2012, it was estimated that 26% or nearly 241 000 of all actively licensed physicians in the United States were older than 60 years.1 Patient safety advocates, consumer groups, and policy makers have questioned whether older physicians maintain the necessary cognitive and motor skills to continue to provide safe and competent care. In response, the American Medical Association has announced plans to identify organizations that should participate in the development of guidelines for the testing of competency of aging and late-career physicians that may include periodic evaluation of physical and mental health, neurocognitive testing, and review of clinical care.

Narrowing of the scope of practice of US family physicians has been well documented. Proposed reasons include changing practice patterns as physicians age, employer restrictions, or generational choices. Determining components of care that remain integral to the practice of family medicine may be informed by assessing gaps between the intended scope of practice of residents and actual scope of practice of family physicians.To compare intended scope of practice for American Board of Family Medicine (ABFM) initial certifiers at residency completion with self-reported actual scope of practice of recertifying family physicians.Cross-sectional data were collected from a practice demographic questionnaire completed by all individuals applying to take the ABFM Maintenance of Certification for Family Physicians examination. Initial certifiers reported intentions and recertifiers reported actual provision of specific clinical activities. All physicians who registered for the 2014 ABFM Maintenance of Certification for Family Physicians examination were included: 3038 initial certifiers and 10,846 recertifiers.Initially certifying physicians vs recertifying physicians.The Scope of Practice for Primary Care score (scope score), a psychometric scale, was calculated for each physician and ranged from 0 to 30, with higher numbers equating to broader scope of practice. Recertifiers were categorized by decades in practice.The final sample included 13,884 family physicians and, because the questionnaire was a required component of the examination application, there was a 100% response rate. Mean scope score was significantly higher for initial certifier intended practice compared with recertifying physicians' reported actual practices (17.7 vs 15.5; difference, 2.2 [95% CI, 2.1-2.3]; P .001). Compared with recertifiers, initial certifiers were more likely to report intending to provide all clinical services asked except pain management; this included obstetric care (23.7% vs 7.7%; difference, 16.0% [95% CI, 14.4%-17.6%]; P .001), inpatient care (54.9% vs 33.5%; difference, 21.4% [95% CI, 19.4%-23.4%]; P .001), and prenatal care (50.2% vs 9.9%; difference, 40.3 [95% CI, 38.5%-42.2%]; P .001). Similar differences from initial certifiers were present when comparisons were limited to recertifiers in practice for only 1 to 10 years.In this study of family physicians taking ABFM examinations, graduating family medicine residents reported an intention to provide a broader scope of practice than that reported by current practitioners. This pattern suggests that these differences are not generational, but whether they are due to limited practice support, employer constraints, or other causes remains to be determined.

Importance Administrative costs in the US health care system are an important component of total health care spending, and a substantial proportion of these costs are attributable to billing and insurance-related activities. Objective To examine and estimate the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system. Design, Setting, and Participants This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system’s total cost of processing an insurance claim. Exposures Estimated time required to perform billing and insurance-related activities, based on interviews with management personnel and physicians. Main Outcomes and Measures Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures. Results Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of professional revenue, professional billing costs were estimated to represent 14.5% for primary care visits, 25.2% for emergency department visits, 8.0% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures, and 3.1% for inpatient surgical procedures. Conclusions and Relevance In a time-driven activity-based costing study in a large academic health care system with a certified electronic health record system, the estimated costs of billing and insurance-related activities ranged from $20 for a primary care visit to $215 for an inpatient surgical procedure. Knowledge of how specific billing and insurance-related activities contribute to administrative costs may help inform policy solutions to reduce these expenses.

Specialty board certification is a longstanding component of the US medical profession’s system of collective self-regulation. Although processes for board certification have changed over the years to match advancing medical practice and expanding public expectations of accountability, board certification has demonstrated to the public, the profession, colleagues, and the individual physician that certified specialists meet high specialtyspecific standards of education, expertise, and character.ThisViewpointdescribestheroleofboardcertification in collective professional self-regulation, current challenges and future directions.

A revolution in medicine is occurring and is directly related to several major factors, including substantial changes in the health care system, largely due to the Affordable Care Act; remarkable scientific advances and an accelerated pace of discovery in biomedical science 1 ; increasing recognition of the need to practice restraint with respect to both diagnostic testing and therapeutic interventions; the promise of personalized medicine; more physicians being employed by large medical organizations; the increasing trend of consolidation and corporatization of health care delivery; and heightened public demands and expectations for transparency and accountability in health care. 2 At the same time, fundamental aspects affecting physician education and certification have come under intense scrutiny, with expansion of the number of medical schools, critical examination of government funding for residency training, and recent contentious debates regarding maintenance of board certification. 3 Considering these fundamental, dynamic, and rapid

Importance In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. Objective To measure associations between the original ABIM MOC requirement and outcomes of care. Design, Setting, and Participants Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. Main Outcomes and Measures Quality measures were ambulatory care–sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). Results Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, −1.7 to 1.9];P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of −$167 (95% CI, −$270.5 to −$63.5;P = .002; 2.5% of overall mean cost). Conclusion and Relevance Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

This study investigates fees charged to physicians for certification examinations and finances of the American Board of Medical Specialties member boards.

The US health care delivery system and the field of medicine have experienced tremendous change over the last decade. At the system level, narrowing of insurance networks, employed physicians, and financial pressures have resulted in greater expectations regarding productivity, increased workload, and reduced physician autonomy. Physicians also have to navigate a rapidly expanding medical knowledge base, more onerous maintenance of certification requirements, increased clerical burden associated with the introduction of electronic health records (EHRs) and patient portals, new regulatory requirements (meaningful use, e-prescribing, medication reconciliation), and an unprecedented level of scrutiny (quality metrics, patient satisfaction scores, measures of cost).

The Affordable Care Act (ACA) strives to encourage health care value by simultaneously improving quality of care and slowing the rate of increase of health care costs. Some of the law’s provisions, such as the Physician Value-Based Modifier (PVBM), will include financial incentives that directly affect individual clinicians, thus providing an external force for engaging physicians in efforts to improve health care value.1,2 Despite this looming mandate—PVBM will go in effect in 2015 for large physician groups and in 2017 for all physicians—some physicians may lack the tools and motivation necessary to improve the value of their individual care delivery. Notably, the current system does not compel high-value care. Not only is mitigating waste and judiciously ordering tests and referrals disincentivized in the fee-for-service system, doing so is more cognitively taxing and there is a perceived increased risk of legal repercussions.

Importance US internal medicine residency programs are now required to rate residents using milestones. Evidence of validity of milestone ratings is needed. Objective To compare ratings of internal medicine residents using the pre-2015 resident annual evaluation summary (RAES), a nondevelopmental rating scale, with developmental milestone ratings. Design, Setting, and Participants Cross-sectional study of US internal medicine residency programs in the 2013-2014 academic year, including 21 284 internal medicine residents (7048 postgraduate-year 1 [PGY-1], 7233 PGY-2, and 7003 PGY-3). Exposures Program director ratings on the RAES and milestone ratings. Main Outcomes and Measures Correlations of RAES and milestone ratings by training year; correlations of medical knowledge ratings with American Board of Internal Medicine (ABIM) certification examination scores; rating of unprofessional behavior using the 2 systems. Results Corresponding RAES ratings and milestone ratings showed progressively higher correlations across training years, ranging among competencies from 0.31 (95% CI, 0.29 to 0.33) to 0.35 (95% CI, 0.33 to 0.37) for PGY-1 residents to 0.43 (95% CI, 0.41 to 0.45) to 0.52 (95% CI, 0.50 to 0.54) for PGY-3 residents (all P values P values P P P P Conclusions and Relevance Among US internal medicine residents in the 2013-2014 academic year, milestone-based ratings correlated with RAES ratings but with a greater difference across training years. Both rating systems for medical knowledge correlated with ABIM certification examination scores. Milestone ratings may better detect problems with professionalism. These preliminary findings may inform establishment of the validity of milestone-based assessment.

About 18% of the US gross domestic product is consumed by health care�more than that of any other industrialized country�and that number is expected to increase to 20% by 2020. Physicians are principal gatekeepers who decide when, how, and what health care services are delivered, with some estimates that at least 60% of health care costs are determined or influenced by physicians.

STROKE IS A LEADING CAUSE OF MORBIDITY AND MORtality in the United States and worldwide and is associated with enormous health care expenditures. Approximately 800 000 new or recurrent strokes occur annually in the United States, and of these, about 87% are ischemic cerebral infarctions. Since 1996, when the use of intravenous tissue plasminogen activator was approved by the US Food and Drug Administration (FDA) for the treatment of patients with acute ischemic stroke within 3 hours of symptom onset, there has been a sea change in the approach to identification and management of stroke patients to improve their outcomes. Parallel to these advances, there has been an equally important move toward a systems-based approach to stroke care. The very short time window needed for acute therapies to reverse brain injury has inspired several national and statewide initiatives to improve hospital care of the stroke patient. The Brain Attack Coalition criteria for primary stroke centers, first recommended in 2000 and revised in 2011, have formed the basis for Joint Commission certification for stroke center status. Additional certification for comprehensive stroke centers begins in July 2012. These efforts are rooted in a developing evidence base demonstrating that organized, systems-based care, informed by guidelines and quality assurance efforts, can improve outcomes. There is evidence, for example, that patients with acute stroke are more likely to survive, return home, and regain independence if treated in hospital units specializing in the care of patients with stroke. The restructuring of health insurance in the United States, with the focus on increasing efficiency, improving outcomes, and providing value to the public, has stimulated efforts to provide valid measures of health care quality. One such measure includes assessment and ranking of hospital performance in the care of commonly encountered and significant illnesses, of which stroke is a good example. Approaches to the measurement of such outcomes, however, are potentially fraught with biases and other complexities. Although the implications of such measures are substantial, both for the individual hospital and the health care system as a whole, targeted research about health care–related outcomes is a relatively new field and optimal analytic approaches are still being developed. In this issue of JAMA, Fonarow and colleagues evaluate the influence of including or excluding stroke severity in prognostic stroke outcome models in a large Medicare insurance database. The authors used data from almost 128 000 patients with ischemic stroke from 782 Get With The Guidelines–Stroke participating hospitals. For all patients included in the analysis, information on the severity of the stroke was available in the form of the National Institutes of Health Stroke Scale (NIHSS) score. The primary outcome was 30-day mortality, and prognostic models were evaluated for their overall model discrimination as well as for differences in rankings of the hospital performance when including or excluding information on stroke severity. The main prognostic model included information on age, sex, prior stroke or transient ischemic attack, and a large number of comorbid conditions and was compared with a model that additionally included information on stroke severity. All statistical measures of model performance showed that the model including stroke severity was superior, indicating that stroke severity substantially improved the prediction of 30-day mortality above and beyond other clinical predictors. Considered at the level of the individual patient, this result does not seem surprising: a patient who has a relatively more severe stroke is at increased risk of death. Moreover, when the prediction models were used to classify and rank hospitals based on 30-day mortality, the model including stroke severity demonstrated substantially more accurate classification and substantially changed hospital rankings. Of the 782 participating hospitals, the absolute change of the median hospital rank position was 79 places. More than half (58%) of hospitals first classified as having higher than expected mortality were reclassified to having the expected mortality rate after incorporating severity into

PROFESSIONS DEVELOP AROUND THE DELIVERY OF SPECIALizedservices.Lawyersgive legaladvice,electricians install wiring, and teachers provide education. At some point in the evolution of a field, licensure or certification defines its area of expertise. Licensure is a legal entity allowing only certain people to perform a task. Certification is a non−legallybindingdesignationthatinformsconsumersofqualifications.Frequently, licensingandcertificationareperformed byprofessionalorganizations thatoverseeeducation, training/ apprenticing, and evaluation through examination. Specialization in medicine depends on 3 principal factors: advances in medical science and technology, professional preferences, and economic considerations. A new diagnostic tool or procedure may create a need for physicians with special training in its use. Some innovations, like lithotripsy, generate their own demand for specialists, whereas other innovations, like new angioplasty technologies, are endogenous, generated by the experience and needs of specialists. Some physicians are drawn to specialization because it offers defined responsibility, more control over their practice, prestige, and potential remuneration. Economic considerations play a major role in the development of specialties. Adam Smith begins The Wealth of Nations by stressing the importance of specialization and the division of labor. He notes that its extent is limited by the size of the market. As markets for medical care have expanded through increases in population and income, urbanization, and improvements in transportation and communication, specialization within medicine has increased. Payment differentials between specialists and primary care physicians, which vary across countries, also influence physician choice. Today, most individual physicians and surgeons are trained and qualified to provide only some kinds of care. Thus, the physician workforce has differentiated into a heterogeneous group of professionals. In 1960, there were only 18 specialty boards and a handful of subspecialties in the United States, but by 2011 there were 158 specialties and subspecialties. Canada has 67 specialties and subspecialties; France, 52; and England, 97. In addition to variation in the number of specialties, the distribution of physicians who are specialists (as opposed to generalists) varies between countries. Recent data from the Organisation for Economic Cooperation and Development show that 12% of physicians in the United States are generalists (including family physicians), compared with 47% in Canada. However, most of this difference is explained by nomenclature, because general internists and general pediatricians, many of whom deliver primary care in the United States, are considered specialists in this report. When these 2 groups of physicians are included, the US proportion of generalists is 36%. These differences raise the question of how much medical specialization is good for society. The answer depends on the effect of specialization on health outcomes, such as length of life and quality of life, and costs. Circumstantially, it appears that the United States has developed more specialization and higher costs without offsetting gains in health outcomes. The criteria for certifying a new subspecialty appear to have been largely technology driven. There has been no requirement for empirical evidence that creating a specialty will do more good than harm. This Viewpoint addresses the issues involved in answering the question: How much specialization in medicine is appropriate? Because the United States is about to implement the Affordable Care Act mandating expansion of physician services at a time when the financial credibility of federal and state governments is at stake, the economic effects of specialization are especially important now.

Expanded abstract Citation Prasad M, Holmboe ES, Lipner RS, Hess BJ, Christie JD, Bellamy SL, Rubenfeld GD, Kahn JM. Clinical Protocols and Trainee Knowledge About Mechanical Ventilation. JAMA. 2011; 306(9):935-941. PubMed PMID: 21900133 This is available on http://www.pubmed.gov Background Clinical protocols are associated with improved patient outcomes; however, they may negatively affect medical education by removing trainees from clinical decision making. Methods Objective: To study the relationship between critical care training with mechanical ventilation protocols and subsequent knowledge about ventilator management. Design: A retrospective cohort equivalence study linking a national survey of mechanical ventilation protocol availability with knowledge about mechanical ventilation. Exposure to protocols was defined as high intensity if an intensive care unit had 2 or more protocols for at least 3 years and as low intensity if 0 or 1 protocol. Setting: Accredited US pulmonary and critical care fellowship programs. Subjects: First-time examinees of the American Board of Internal Medicine (ABIM) Critical Care Medicine Certification Examination in 2008 and 2009. Intervention: N/A Outcomes: Knowledge, measured by performance on examination questions specific to mechanical ventilation management, calculated as a mechanical ventilation score using item response theory. The score is standardized to a mean (SD) of 500 (100), and a clinically important difference is defined as 25. Variables included in adjusted analyses were birth country, residency training country, and overall first-attempt score on the ABIM Internal Medicine Certification Examination. Results The 90 of 129 programs (70%) responded to the survey. Seventy seven programs (86%) had protocols for ventilation liberation, 66 (73%) for sedation management, and 54 (60%) for lung-protective ventilation at the time of the survey. Eighty eight (98%) of these programs had trainees who completed the ABIM Critical Care Medicine Certification Examination, totaling 553 examinees. Of these 88 programs, 27 (31%) had 0 protocols, 19 (22%) had 1 protocol, 24 (27%) had 2 protocols, and 18 (20%) had 3 protocols for at least 3 years. 42 programs (48%) were classified as high intensity and 46 (52%) as low intensity, with 304 trainees (55%) and 249 trainees (45%), respectively. In bi-variable analysis, no difference in mean scores was observed in high-intensity (497; 95% CI, 486-507) vs low-intensity programs (497; 95% CI, 485-509). Mean difference was 0 (95% CI, -16 to 16), with a positive value indicating a higher score in the high-intensity group. In multivariable analyses, no association of training was observed in a high-intensity program with mechanical ventilation score (adjusted mean difference, -5.36; 95% CI, -20.7 to 10.0). Conclusions Among first-time ABIM Critical Care Medicine Certification Examination examinees, training in a high-intensity ventilator protocol environment compared with a low-intensity environment was not associated with worse performance on examination questions about mechanical ventilation management.

Context Certification by an American Board of Medical Specialties (ABMS) member board is emerging as a measure of physician quality. Objective To identify demographic and educational factors associated with ABMS member board certification of US medical school graduates. Design, Setting, and Participants Retrospective study of a national cohort of 1997-2000 US medical school graduates, grouped by specialty choice at graduation and followed up through March 2, 2009. In separate multivariable logistic regression models for each specialty category, factors associated with ABMS member board certification were identified. Main Outcome Measure ABMS member board certification. Results Of 42 440 graduates in the study sample, 37 054 (87.3%) were board certified. Graduates in all specialty categories with first-attempt passing scores in the highest tertile (vs first-attempt failing scores) on US Medical Licensing Examination Step 2 Clinical Knowledge were more likely to be board certified; adjusted odds ratios (AORs) varied by specialty category, with the lowest odds for emergency medicine (87.4% vs 73.6%; AOR, 1.82; 95% CI, 1.03-3.20) and highest odds for radiology (98.1% vs 74.9%; AOR, 13.19; 95% CI, 5.55-31.32). In each specialty category except family medicine, graduates self-identified as underrepresented racial/ethnic minorities (vs white) were less likely to be board certified, ranging from 83.5% vs 95.6% in the pediatrics category (AOR, 0.44; 95% CI, 0.33-0.58) to 71.5% vs 83.7% in the other nongeneralist specialties category (AOR, 0.79; 95% CI, 0.64-0.96). With each $50 000 unit increase in debt (vs no debt), graduates choosing obstetrics/gynecology were less likely to be board certified (AOR, 0.89; 95% CI, 0.83-0.96), and graduates choosing family medicine were more likely to be board certified (AOR, 1.13; 95% CI, 1.01-1.26). Conclusion Demographic and educational factors were associated with board certification among US medical school graduates in every specialty category examined; findings varied among specialty categories.

SINCE PUBLICATION OF TO ERR IS HUMAN, ELECTRONIC health records (EHRs) and related health information technologies have been promoted as means to improve patient safety. This promise remains largely unfulfilled. For instance, whereas EHRs with clinical decision support (CDS) interventions integrated into computerized physician order entry (CPOE) have measurably improved clinicians’ performance on process metrics, their effect on patient outcomes remains unconfirmed. Recently, the US Department of Health and Human Services (DHHS) launched “Partnership for Patients: Better Care, Lower Costs” by committing $1 billion to improve safety. Meanwhile, EHR vendors and health care organizations have focused considerable effort on meeting standards for “meaningful use” of EHRs as required by the DHHS for incentive payments. Each year, the Joint Commission issues a concise National Patient Safety Goal (NPSG) advisory identifying the highest-priority topics for quality care. Ideally, addressing the NPSGs should be incorporated into the EHR certification process, requiring each vendor to specifically engineer targeted solutions and each organization to carefully implement and use these systems to improve safety. For 2011, the NPSG priorities for hospital quality improvement initiatives are patient identification, staff communication, medication labeling, infection control practices, medication reconciliation and interactions, and mitigation of suicide risks. Electronic health records, along with CPOE, CDS, and bar code medication administration (BCMA), if designed, developed, implemented, and used correctly, potentially play critical roles in addressing these safety goals. In this Commentary, we provide an overview of these goals, current EHR solutions and shortcomings, and potential for improvement.

Recent passage of the American Reinvestment and Recovery Act (ARRA) increases pressure on healthcare practitioners and organizations to implement currently available electronic health records (EHRs). Research and experience gained to date shows that such implementation efforts are difficult, costly, time-consuming, and fraught with many unintended consequences1. Evaluation of these systems after implementation suggests that they do not routinely meet safety standards of other safety-critical industries2. The aggressive timeline proposed in the ARRA bill means that a large number of practitioners and organizations will soon be attempting a monumental feat without the time or ability to customize these systems to their local workflows3. In a previous article, we proposed 8 dimensions or “rights” of EHR safety that addressed the complex social, technical, and personal issues associated with EHR use4. The goal of this article is to describe an approach for a comprehensive EHR monitoring and evaluation framework (i.e., the 8th dimension of EHR safety). Without such a comprehensive framework, safe and effective EHR use cannot be assured. This proposed framework has five essential components: 1) ability for practitioners and organizations to report patient safety events or potential hazards related to EHR use 5,6; 2) enhanced EHR certification that includes specific assurances that good software development procedures7 have been followed along with evidence that previously reported adverse events and hazards have been addressed; 3) self-assessment, attestation, testing, and reporting by both clinicians and healthcare organizations that all eight dimensions of safe EHR use have been addressed; 4) Local, state, and national oversight in the form of an on-site, in-person accreditation of EHRs as implemented and used by clinicians in the healthcare setting; 5) A national EHR-related adverse event investigation board that reviews incident reports and has the authority to investigate.

In the United States, Canada, and the United Kingdom, the medical profession is accountable to the public for the delivery and quality of care provided to patients. Traditionally, this accountability has been achieved through the development and maintenance of professional standards established by the profession itself—self-regulation. Medical self-regulation is being re-examined by regulators, government, and the profession in response to a range of drivers including payers seeking ways to hold physicians accountable for cost-effective care; patients seeking more information about their physician's qualifications; and the emergence of a number of high-profile cases of unacceptable medical practice. This article outlines the current state of medical regulation in the United States, Canada, and the United Kingdom and highlights the increasing external pressure on the self-regulatory framework that is leading to a shift toward shared regulation between the profession and other stakeholders.

OR A QUARTER CENTURY, AN ONGOING DIALOGUE HAS focused on the integrity of the surgical residency training curriculum. The complexities of resident training,theacquisitionofcognitiveknowledgeand technical skills, the quantification of experience, and intricacies of the certification process have been scrutinized and discussed. As a vital constituent in the health care systems of the rural and urban United States, surgeons have benefitedfromthisdialogue,whichhascontributedtothestandards of the profession. In addition, the varied implications of the economic, technological, and workforce challenges that have confronted every academic and community-basedsurgeonhavelikewiseresultedinreformsand substantial changes in the evolution of surgical education. 1 Despite such a deliberate focus on the training and accreditation of surgeons, there now emerge novel challenges related to national health care reform that undoubtedly will affect the current practice of surgery. With a looming projected deficit in the surgical workforce 2 and with possible further reductions from the current 80-hour resident work week, the challenges that presently confront surgical practice are immense. For instance, thegreatestrewardinthepracticeofsurgeryhascomefrom seeing patients improve with operative care. To accomplish this requires a multifactorial process that is based on the intensity, duration, and experiences of training that requires programmed, continual lifetime learning. However, contemporary discussions concerning rationing, regionalization, and limiting surgical care have suddenly emerged and are not confined to issues related to individual surgeon competency but rather to concerns about the innate andfundamentalabilitytoprovideappropriatesurgicalcare when it is needed. Aging of the US population and the anticipated shortage of surgeons in multiple specialty categories will have inevitable and imminent effects on future surgical intervention. 3 Strategiestoenhancethegeneralsurgeryworkforce— including national efforts to promote recruitment and to ensureequalityofsurgicalfundingcommensuratewiththat being allocated for primary care; prospective evaluation of resident work hours and operative experience; expansion of surgical training sites and enlargement of medical school classes; and structured recruitment of international medical graduate students 4 —all appear well founded and relatively straightforward, but their influence on the surgical workforce will not be realized for years to come. The appropriateness of surgical care, however, is a more fundamental yet complex problem that reflects, according toLeeandKo, 5 thebalanceoftoomanypatientshavingsurgery they do not need and too many not being offered or not undergoing operations they do need. Questioning and ensuring the appropriateness of surgery are necessary to realize the full benefits of surgery for the public’s health and will be needed to attempt to formulate policies tied to the rationing of surgical care that have not been addressed over the last 25 years. Addressing racial, ethnic, and socioeconomic variation in surgery, analyzing geographic practice variations in surgery running counter to prevailing professional norms about when surgery is indicated, and eliminating competitive pressures of when and where to operate are issues of primary importance. 5,6

When David Ross, MD, a family medicine physician who works in an Affiliated Community Medical Centers clinic in Litchfield, Minnesota, as well as a part-time emergency department physician in a local hospital, treats a patient who is from out of town, he wishes that he were able to quickly and easily look at that patient’s electronic health record (EHR). Often, he said, a patient who arrives at the emergency department may be unconscious or incoherent, and without access to the patient’s record, he doesn’t know anything about that patient’s medical history. When he cares for local patients at the clinic, he can view their hospital EHR if he has admitting privileges there, but because hospitals use different EHR systems than the clinics, he can only read the hospital’s EHR; he cannot integrate that information into the clinic’s EHR. “This results in a delay of information [in] transit and most often the faxing and the scanning of paper documents into our respective EMRs [electronic medical records],” said Ross in an email. Although people often take for granted their ability to withdraw money from an ATM hundreds of miles from home or call someone in another cellphone network, many organizational, financial, and technical barriers still need to be surmounted before that same sort of universal operability is achieved for the electronic exchange of patient information. Yet if the vision of the Office of the National Coordinator for Health Information Technology (ONC)—the federal entity charged with coordinating health care technology initiatives—is achieved, electronic exchange of health information among clinicians, health facilities, and patients should be widely available within 10 years. The ONC was legislatively mandated as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, a program that is part of the American Recovery and Reinvestment Act of 2009. Earlier this year, the ONC unveiled a draft of a 10-year interoperability road map (http://bit.ly/1EltEAx) in which the ONC outlines steps needed to be taken in governance, technical standards, certification and testing, business and regulatory climate, and privacy and security to ensure the secure and seamless flow of health care data among providers and consumers. The ability of clinicians to share data electronically has become especially important because the Centers for Medicare & Medicaid Services’ newest draft regulations for stage 3 “meaningful use” of EHRs stipulate that clinicians must be able to exchange health care information through EHRs (http://1.usa.gov /1csPsna). Medical News & Perspectives.......p1213