judged by the "sum of its parts" and concern management of the drug da¬ "some of those parts" are in need of tabase. Processing of various data repair. I cannot stand by without com¬ about drugs may be obtained, eg, add¬ To the Editor.\p=m-\Asan otolaryngologist ment while the minority among us ing a new drug, deleting an old one, in my third year of medical practice, shoot themselves in the foot, then the retrieving the information about a I am stunned by what I see going on impact ricochets and hits the rest of us drug, and, finally, modifying any data around me. My sense of profession- squarely between the eyes. on any drug. A drug can be accessed LINDSAY I. GOLDEN, MD alism is offended by some of the billby its code number or name. Addi¬ Silver Spring, Md ing and coding procedures that are tionally, a list of all drugs included may appear. Sorting is possible in ev¬ occurring in my area. The actions of a few are affecting all of us. ery field of information, but searching I can understand that the setting of is the area where this program, and fees for medical and surgical services Computerized most modern PCs, displays its real is not a simple task. On one hand, we Prescription Writing strength. To obtain versatility, the pro¬ all see the inadequacies that stem from in gram was designed to be able to search Otolaryngology
A Few Bad
Apples. . .
the Resource Based Relative Value Scale that is being used in formulating Medicare fees. Clearly, the expertise, practice and malpractice costs, and cognitive effort used in performing an endoscopic anterior ethmoidectomy is worth more than the $382 that Medicare is allowing. On the other hand, a 2-hour "sinus operation," no matter how complex, cannot be worth the $12 000 that some are requesting. This discrepancy can only serve to raise the eyebrows of third-party pay-
To the
Editor.\p=m-\Pioneeringefforts
to
computerize prescription writing have been hindered by hardware limits. Most hospitals and institutions used time-sharing systems, and the first computers were expensive, inflexible, and cumbersome. Personal computers (PCs) have developed greatly dur-
ing recent years as regards memory, speed, and computing ability, minimizing the above problems. Taking most and, ors, legislators, importantly, advantage of this progress we have our patients. designed a PC-based prescription\x=req-\ Most disturbing is the "creativity" writing program for use by otolarynthat I have seen in the entitlement and gologists. The program is currently running coding of surgical procedures. I have had the opportunity to see several pa¬ in an IBM PC with a 20-megabyte fixed tients in consultation, with the benefit of operative reports and insurance forms. Some of the practices that I have seen include billing for partial inferior turbinectomy and electrocau¬ tery of the inferior turbinâtes, descrip¬ tions (and full billing for endoscopie ethmoidectomy and antrostomy) of endoscopie visualization of the max¬ illary sinus and frontal recess without mention of uncinectomy or ethmoid dissection, and billing for intraoper¬ ative diagnostic nasal endoscopy si¬ multaneously with other endoscopie sinus surgery. I am sure most of us go to bed at night satisfied that he or she has ren¬ dered quality care at a reasonable fee and that we have represented this care fairly. Our specialty as a whole is
disk, 640 kilobytes of random access memory (RAM), and a video graphics adaptor monitor. However, the program will operate on any IBM-compatible PC, needing only 64 kilobytes
of RAM. Prescriptions are printed on continuous fanfolded narrow paper by a dot-matrix printer. The program was written using random files of BASIC, the most friendly and widespread programming language. Three files have been created: the drug database, the main program, and a small file with ready prescriptions. The drug database includes infor¬ mation about the common drugs that are
currently in use by otolaryngolo¬
according to relevant medical literature.1-2 Most functions of the main program gists,
for data with any combination of search parameters. A most interesting feature of the search option is the pos¬ sibility to type only a few characters of the desired data, making it possible for every user to establish his or her own codes for all the drug data, avoid¬ ing excessive typing, and making the program work even faster. One function of the main program concerns
prescription writing. During
this process, the screen is divided in two halves: the upper half is available for the composition of prescriptions, and the lower half contains helpful information. The name of the hospital and the clinic appear on top, and the user is asked to enter the patient's name and the date. Drugs are inserted by the code number they possess in the database. By entering the appro¬ priate number, the respective drug ap¬ pears on the screen, together with its usual formulation, dosage, and in¬ structions. Entering a new number makes the respective drug appear, and so on. Finally, the prescription is printed, if so desired. On the lower half of the screen, through a series of keys (Fl to F8), a list of the drugs with their code num¬ bers as well as various lists of formu¬ lations, doses, quantities, and com¬ mon instructions may appear. Every item from these lists may be inserted into the basic prescription by just one keystroke, helping to modify the pre¬
scription easily and thereby saving time and typing. Additionally, a list
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/03/2015
ready prescriptions for the treat¬ ment of common otolaryngologic dis¬ of
eases
is offered, but,
appropriate drugs, the
user
by choosing the
it is also easy for
to prepare his or her
own
beforehand.
prescriptions The prescription writing system has
been in use for 2 years in our ear, nose, and throat department, and it was ef¬ ficiently integrated into daily office practice, having been adopted by, and constantly used by, most doctors. It requires the use of a functioning PC with a connected printer, both of which are usually present in most modern hospitals and doctors' offices. A few efforts in computerized prescription writing have been reported.3-4 These efforts were oriented to the fields of dermatology and gastroenterology. The new program was specifically designed for otolaryngologists and, to obtain wide acceptance by physi¬ cians, the program had to present sev¬ eral advantages over hand writing pre¬ scriptions. These advantages are the
following: 1. This
system
is faster than hand¬
writing, requiring only a few key¬ strokes to write a complete prescrip¬ tion. The resulting prescription is su¬ perior in many aspects, since it is com¬ plete, accurate, legible, with clear
instructions and fewer errors. 2. The user can take advantage of the drug database, obtaining any ad¬ vice that is needed. Functions of the program, like searching and sorting, may greatly assist the physician in
patient management.
3. The program is personally ori¬ ented to the user. The user can pro¬ cess any data he or she likes, and a user-defined coding system may be established. The physician may pre¬ pare his or her own prescriptions for common diseases, a thing that, in the long run, has been proven to be a greatly appreciated feature of the pro¬ gram, since most physicians like to use certain drugs they trust, affording a specific treatment for every disease.
4. The program is simple and userfriendly, since it is menu driven. Data entry is a simple typing task, controlled by error traps in most instances. The system issues various help messages on ocurrence of errors or during crit¬
ical stages of the program. 5. Automated prescription writing, although, at present, a novel idea, un¬ doubtedly is going to be a standard situation in the future. This program may cover most future demands, since it can successfuly accommodate in¬ formation about many thousands of drugs. The only limiting factor is the amount of available space in the hard disk. With slight variations in pro¬ gramming, the system may also be useful in many other medical
specialties.
DIMITRIS G. BALATSOURAS, MD Piraeus, Greece
1. Physicians' Desk Reference. 44th ed. Oradell, NJ: Medical Economics Co Inc; 1990.
2. Gilman AG, Nies AS, Rall TW, Palmer T, eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 8th ed. New York, NY: Pergamon Press Inc; 1990. 3. Levit F, Garside DB. Computer-assisted prescription writing. Comput Biomed Res. 1977;10:
501-510. 4. Allen SI, Johannes RS, Brown CS, Kafonek DM, Plexico PS. Prescription-writing with a PC.
Comput Methods Programs Biomed. 1986;22: 127-135.
Nasal A
Polyps:
Sign of Disease
To the Editor.\p=m-\Nasalpolyps have been recognized from 1000 bc1 and are said
to be a disease of the ethmoid sinuses. Mucosal reactions at the cellular level,
the relatively poorly developed blood supply of the ethmoid sinus, and the complex anatomy of the ethmoid labyrinth are factors implicated in the pathogenesis of polyps.2 With regard to the cause, Bernouilli phenomenon,
polysaccharide changes,
vasomotor
imbalance, infection, and allergy
are
contributory factors.2 It is also known that if they are unilateral, transitional
cell papilloma or malignancy have to be ruled out.2 We have seen patients with angiofibromas, fungal infections like aspergillosis, mucormycosis, and longstanding foreign bodies on the nose, who have presented to us as having unilateral nasal polyps, and rarely bilateral, particularly in fungal infections affecting the sphenoid sinus spreading intracranially. These polyps resemble nasal polyps on macroscopic as well as microscopic examination. Histologically only eosinophilia as described2 was not prominent. It needed a deeper examination on the operat¬ ing table after polypectomy to iden¬ tify the disease process underneath that was confirmed later through fun¬ gal smear or cultures. Angiofibromas were, of course, clinically obvious on nasopharyngeal examination and the histologie nature of the polyps near the tumor were also confirmed after the surgery for angiofibromas. In view of this, it is suggested that nasal pol¬ yps be considered not as a disease in itself but a sign of a disease process underneath. Local pathologic features such as allergy or infection of the nose and sinuses or general pathologic con¬ ditions such as aspiring sensitivity and cystic fibrosis can be included in this definition of the disease process. Re¬ currence of polyps have also been ob¬ served when there is recurrence of the disease like aspergillus. The surgical treatment of polypectomy may be purely symptomatic to relieve nasal obstruction. In the absence of eosino¬ philia on histologie examination of the polyp, a disease in the deeper plane must be suspected, particularly if there is a recurrence within a short period. R. RAMAN, MS, DLO Vellore, India 1. Vancil ME. A historical survey of treatment for nasal polyposis. Laryngoscope. 1969;79:435\x=req-\
445. 2. Drake LAB. Nasal polyps. In: Kerr AG, Groves J, Mackey IS, Bull TR, eds. Otolaryngology Rhinology. 5th ed. Stoneham, Mass: Butter-
worths; 1987;4:142-144.
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/03/2015
A Few Bad
Apples. . .
the Resource Based Relative Value Scale that is being used in formulating Medicare fees. Clearly, the expertise, practice and malpractice costs, and cognitive effort used in performing an endoscopic anterior ethmoidectomy is worth more than the $382 that Medicare is allowing. On the other hand, a 2-hour "sinus operation," no matter how complex, cannot be worth the $12 000 that some are requesting. This discrepancy can only serve to raise the eyebrows of third-party pay-
To the
Editor.\p=m-\Pioneeringefforts
to
computerize prescription writing have been hindered by hardware limits. Most hospitals and institutions used time-sharing systems, and the first computers were expensive, inflexible, and cumbersome. Personal computers (PCs) have developed greatly dur-
ing recent years as regards memory, speed, and computing ability, minimizing the above problems. Taking most and, ors, legislators, importantly, advantage of this progress we have our patients. designed a PC-based prescription\x=req-\ Most disturbing is the "creativity" writing program for use by otolarynthat I have seen in the entitlement and gologists. The program is currently running coding of surgical procedures. I have had the opportunity to see several pa¬ in an IBM PC with a 20-megabyte fixed tients in consultation, with the benefit of operative reports and insurance forms. Some of the practices that I have seen include billing for partial inferior turbinectomy and electrocau¬ tery of the inferior turbinâtes, descrip¬ tions (and full billing for endoscopie ethmoidectomy and antrostomy) of endoscopie visualization of the max¬ illary sinus and frontal recess without mention of uncinectomy or ethmoid dissection, and billing for intraoper¬ ative diagnostic nasal endoscopy si¬ multaneously with other endoscopie sinus surgery. I am sure most of us go to bed at night satisfied that he or she has ren¬ dered quality care at a reasonable fee and that we have represented this care fairly. Our specialty as a whole is
disk, 640 kilobytes of random access memory (RAM), and a video graphics adaptor monitor. However, the program will operate on any IBM-compatible PC, needing only 64 kilobytes
of RAM. Prescriptions are printed on continuous fanfolded narrow paper by a dot-matrix printer. The program was written using random files of BASIC, the most friendly and widespread programming language. Three files have been created: the drug database, the main program, and a small file with ready prescriptions. The drug database includes infor¬ mation about the common drugs that are
currently in use by otolaryngolo¬
according to relevant medical literature.1-2 Most functions of the main program gists,
for data with any combination of search parameters. A most interesting feature of the search option is the pos¬ sibility to type only a few characters of the desired data, making it possible for every user to establish his or her own codes for all the drug data, avoid¬ ing excessive typing, and making the program work even faster. One function of the main program concerns
prescription writing. During
this process, the screen is divided in two halves: the upper half is available for the composition of prescriptions, and the lower half contains helpful information. The name of the hospital and the clinic appear on top, and the user is asked to enter the patient's name and the date. Drugs are inserted by the code number they possess in the database. By entering the appro¬ priate number, the respective drug ap¬ pears on the screen, together with its usual formulation, dosage, and in¬ structions. Entering a new number makes the respective drug appear, and so on. Finally, the prescription is printed, if so desired. On the lower half of the screen, through a series of keys (Fl to F8), a list of the drugs with their code num¬ bers as well as various lists of formu¬ lations, doses, quantities, and com¬ mon instructions may appear. Every item from these lists may be inserted into the basic prescription by just one keystroke, helping to modify the pre¬
scription easily and thereby saving time and typing. Additionally, a list
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/03/2015
ready prescriptions for the treat¬ ment of common otolaryngologic dis¬ of
eases
is offered, but,
appropriate drugs, the
user
by choosing the
it is also easy for
to prepare his or her
own
beforehand.
prescriptions The prescription writing system has
been in use for 2 years in our ear, nose, and throat department, and it was ef¬ ficiently integrated into daily office practice, having been adopted by, and constantly used by, most doctors. It requires the use of a functioning PC with a connected printer, both of which are usually present in most modern hospitals and doctors' offices. A few efforts in computerized prescription writing have been reported.3-4 These efforts were oriented to the fields of dermatology and gastroenterology. The new program was specifically designed for otolaryngologists and, to obtain wide acceptance by physi¬ cians, the program had to present sev¬ eral advantages over hand writing pre¬ scriptions. These advantages are the
following: 1. This
system
is faster than hand¬
writing, requiring only a few key¬ strokes to write a complete prescrip¬ tion. The resulting prescription is su¬ perior in many aspects, since it is com¬ plete, accurate, legible, with clear
instructions and fewer errors. 2. The user can take advantage of the drug database, obtaining any ad¬ vice that is needed. Functions of the program, like searching and sorting, may greatly assist the physician in
patient management.
3. The program is personally ori¬ ented to the user. The user can pro¬ cess any data he or she likes, and a user-defined coding system may be established. The physician may pre¬ pare his or her own prescriptions for common diseases, a thing that, in the long run, has been proven to be a greatly appreciated feature of the pro¬ gram, since most physicians like to use certain drugs they trust, affording a specific treatment for every disease.
4. The program is simple and userfriendly, since it is menu driven. Data entry is a simple typing task, controlled by error traps in most instances. The system issues various help messages on ocurrence of errors or during crit¬
ical stages of the program. 5. Automated prescription writing, although, at present, a novel idea, un¬ doubtedly is going to be a standard situation in the future. This program may cover most future demands, since it can successfuly accommodate in¬ formation about many thousands of drugs. The only limiting factor is the amount of available space in the hard disk. With slight variations in pro¬ gramming, the system may also be useful in many other medical
specialties.
DIMITRIS G. BALATSOURAS, MD Piraeus, Greece
1. Physicians' Desk Reference. 44th ed. Oradell, NJ: Medical Economics Co Inc; 1990.
2. Gilman AG, Nies AS, Rall TW, Palmer T, eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 8th ed. New York, NY: Pergamon Press Inc; 1990. 3. Levit F, Garside DB. Computer-assisted prescription writing. Comput Biomed Res. 1977;10:
501-510. 4. Allen SI, Johannes RS, Brown CS, Kafonek DM, Plexico PS. Prescription-writing with a PC.
Comput Methods Programs Biomed. 1986;22: 127-135.
Nasal A
Polyps:
Sign of Disease
To the Editor.\p=m-\Nasalpolyps have been recognized from 1000 bc1 and are said
to be a disease of the ethmoid sinuses. Mucosal reactions at the cellular level,
the relatively poorly developed blood supply of the ethmoid sinus, and the complex anatomy of the ethmoid labyrinth are factors implicated in the pathogenesis of polyps.2 With regard to the cause, Bernouilli phenomenon,
polysaccharide changes,
vasomotor
imbalance, infection, and allergy
are
contributory factors.2 It is also known that if they are unilateral, transitional
cell papilloma or malignancy have to be ruled out.2 We have seen patients with angiofibromas, fungal infections like aspergillosis, mucormycosis, and longstanding foreign bodies on the nose, who have presented to us as having unilateral nasal polyps, and rarely bilateral, particularly in fungal infections affecting the sphenoid sinus spreading intracranially. These polyps resemble nasal polyps on macroscopic as well as microscopic examination. Histologically only eosinophilia as described2 was not prominent. It needed a deeper examination on the operat¬ ing table after polypectomy to iden¬ tify the disease process underneath that was confirmed later through fun¬ gal smear or cultures. Angiofibromas were, of course, clinically obvious on nasopharyngeal examination and the histologie nature of the polyps near the tumor were also confirmed after the surgery for angiofibromas. In view of this, it is suggested that nasal pol¬ yps be considered not as a disease in itself but a sign of a disease process underneath. Local pathologic features such as allergy or infection of the nose and sinuses or general pathologic con¬ ditions such as aspiring sensitivity and cystic fibrosis can be included in this definition of the disease process. Re¬ currence of polyps have also been ob¬ served when there is recurrence of the disease like aspergillus. The surgical treatment of polypectomy may be purely symptomatic to relieve nasal obstruction. In the absence of eosino¬ philia on histologie examination of the polyp, a disease in the deeper plane must be suspected, particularly if there is a recurrence within a short period. R. RAMAN, MS, DLO Vellore, India 1. Vancil ME. A historical survey of treatment for nasal polyposis. Laryngoscope. 1969;79:435\x=req-\
445. 2. Drake LAB. Nasal polyps. In: Kerr AG, Groves J, Mackey IS, Bull TR, eds. Otolaryngology Rhinology. 5th ed. Stoneham, Mass: Butter-
worths; 1987;4:142-144.
Downloaded From: http://archotol.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/03/2015
