Correspondence
towards the value of prevention alongside mandates that restrict analyses to a 10-year window have also lead to suboptimal investments by the Centers for Disease Control and Prevention and other government agencies. The underdevelopment of academic, political, and corporate leaders, and low media interest in prevention can also be attributed to this funding issue. Second, the classic government-led (infectious) disease-control paradigm that Harold Jaffe recommends4 needs substantial adaptation to tackle the complexity of NCD prevention. The recently completed Report on Investing in Prevention3 highlights the importance of collaborating with industry, investors, and government to make markets work for progress. Corporate interest in NCD prevention from sectors ranging from IT, retail, sports and leisure to healthy food should be harnessed as prevention partners.3 They would counterbalance the dominant voices of treatment and care that have distorted US health-care priorities for decades. Third, workplaces must be utilised more effectively for key prevention for the 155 million working-age adults. This change starts with Chief Executives leadership supported by health being reported as a key indicator alongside financial metrics in annual reports. In their report,5 the commissioners further mention the value of better public sector prevention programmes for employers but neglect to highlight the opposite need: workplace programmes that reach into communities for business and community benefit.5 I am Executive Director at Vitality Institute.
Derek Yach [email protected] See World Report page 943
The Vitality Institute, New York, NY 10019, USA 1
2
954
Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet 2014; 384: 45–52. The Lancet. Life, liberty, and the pursuit of healthiness. Lancet 2014; 384: 1.
3
4
5
Vitality Institute Commissioners. Investing in Prevention: A National Imperative. The Vitality Institute, 2014. http://thevitalityinstitute.org/ site/wp-content/uploads/2014/06/Vitality_ Recommendations2014.pdf (accessed Aug 22, 2014). Jaffe HW, Frieden TR. Improving health in the USA: progress and challenges. Lancet 2014; 384: 3–5. HERO Employer-Community Collaboration Committee. Environmental Scan: The Role of Corporate America in Community Health and Wellness. HERO, 2014. http://the-hero.org/ Research/HERO_EnvScanFinaltoIOMa.pdf (accessed Aug 22, 2014).
Electronic health records in the UK and USA Aziz Sheikh and colleagues’ Comment (July 5, p 8)1 entitled “Adoption of electronic health records in UK hospitals: lessons from the USA” emphasises the greater success in adoption in the USA and stresses the top-down decision-making processes in the UK as the key issue. The article makes a number of important points, but does not fully acknowledge the major achievement of the UK in getting almost 100% coverage of electronic health records (EHR) in primary care2 at a time when the US rate of adoption was 10–30%.3 These general practice systems maintain longitudinal, lifelong EHR and are therefore arguably more significant than episodic EHRs within individual hospitals. Hospital EHRs cover a much shorter, albeit more intense portion, of a patient’s care. The primary-care achievement also runs counter to the claim that the key factor in the UK failure was that it “pursued a top-down implementation strategy, in which central Government signed substantial contracts with a handful of EHR vendors” since it was a top-down government policy and funding that was associated with the successful primary care rollout. Jha and colleagues important study4 likely shows the true problem. A decade ago British officials leading the Connecting for Health project believed that the so-called hospital EHR problem had been solved and that they just needed to buy US EHR
systems. But in a survey4 of US hospitals half a decade later, Jha and colleagues showed that less than 10% had a basic EHR and 2·9% had a comprehensive EHR system in all departments. Half of those comprehensive systems were in Veterans Administration hospitals running the open-source VistA system and others were large so-called one-off EHR systems in academic medical centres. The commercial systems covered perhaps 1%, and had been developed to match the US insurance-based health-care processes. Now major UK primary care EHR vendors (such as TPP SystmOne and EMIS) are expanding to integrate hospital, community, and long-term care systems offering British solutions that bridge primary and secondary care. One lesson from the UK should surely be that implementation of EHRs can only happen when appropriate, well tested EHR systems actually exist. OAJ is a director of the health informatics software company X-Lab. HSFF is a cofounder and leader of OpenMRS an open source, non-profit EHR project. The other authors declare no competing interests.
Owen A Johnson, Hamish S F Fraser, Jeremy C Wyatt, *John D Walley [email protected] Leeds Institute for Health Sciences, University of Leeds, Leeds LS2 9PL, UK 1
2
3
4
Sheikh A, Jha A, Cresswell K, Greaves F, Bates DW. Adoption of electronic health records in UK hospitals: lessons from the USA. Lancet 2014; 384: 8–9. Payne TH, Detmer DE, Wyatt JC, Buchan IE. National-scale clinical information exchange in the United Kingdom: lessons for the United States. J Am Med Inform Assoc 2011; 18: 91–98. Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int J Med Inform 2008; 77: 848–54. Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med 2009; 360: 1628–38.
Violence against doctors in Iraq While violence against healthcare workers, as reported by Roxanne Nelson (April 19, p 1373),1 is a global problem, health-care workers in war zones are even more prone to these violent acts with bigger www.thelancet.com Vol 384 September 13, 2014
Correspondence
I declare no competing interests.
Sadeer Al-Kindi [email protected] Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH 44106, USA 1 2
3
4
Nelson R. Tackling violence against health-care workers. Lancet 2014; 383: 1373–74. O’Hanlon ME, Campbell JH. Iraq Index, Oct 1, 2007. The Brookings Institution. http:// www.brookings.edu/fp/saban/iraq/index.pdf (accessed April 1, 2014). Burnham GM, Lafta R, Doocy S. Doctors leaving 12 tertiary hospitals in Iraq, 2004–2007. Soc Sci Med 2009; 69: 172–77. Donaldson RI, Shanovich P, Shetty P, et al. A survey of national physicians working in an active conflict zone: the challenges of emergency medical care in Iraq. Prehosp Disaster Med 2012; 27: 153–61.
www.thelancet.com Vol 384 September 13, 2014
5
6
Lafta M, Pandya A. Verbal and physical aggression against resident physicians in two general hospitals in Baghdad. J Musl Ment Hlth 2006; 1: 137–44. Doocy S, Malik S, Burnham G. Experiences of Iraqi doctors in Jordan during conflict and factors associated with migration. Am J Disaster Med 2010; 5: 41–47.
Tackling violence against health-care workers in Spain I read with interest Roxanne Nelson’s World Report (April 19, p 1373).1 In Spain, April 20 is National Day Against Aggression in Health-Care Facilities. This national day was created in reaction to the murder of a resident family doctor by a patient in 2009.2 Spanish health-care providers demanded the Ministry of Public Health to give special attention to this event.3 Since that event, things have changed in Spain, thanks to the actions taken by the Spanish General Medical Council and the establishment of this National Day, violence against health-care professionals has achieved awareness in the society Moreover, the government issued a law to penalise attacks against doctors as a criminal offense of undermining on the authority of a government agent. Several offenders have already been sentenced for up to 2 years in prison. These progresses should be credited to the Observatory for aggression of the Spanish General Council of Medical Colleges. This Observatory for aggression is responsible for collecting all data about attacks on doctors, characteristics of the attacks, and the final outcome of the legal processes, with the aim of generating legal strategies on the basis of judgments that have produced dissuasive effects. Such efforts may have influenced the 16% decrease in the number of assaults since 2012. The National Day Against Aggression in Health-Care facilities promotes social awareness, encourages professionals to fight against this scourge, and attempts
to get the attention of the general population through social media with initiatives like the creation of the “#stopagresiones” Twitter hashtag. We encourage all our colleagues to raise awareness against this scourge by promoting a cultural change in professional, social, and political circles, to eradicate this problem that affects not only our quality of life as health-care providers, but also the quality of care provided to populations. This year’s motto was “Against health workers aggression: zero tolerance”. We hope that next year the slogan will be “Attacks on health workers in Spain are over”.
Getty Images
consequences. 11 years have passed since the 2003 war in Iraq and the dreams to have a better life never came true. Iraqi doctors are getting assaulted, violated, and humiliated, and as a result, more physicians are leaving the country. More than 2000 doctors have been killed since 2003.2 According to Gilbert Burnham and colleagues’ study,3 a 22% decrease has occured in the number of medical specialists in the capital Baghdad between 2004 and 2007 due in part to violent deaths (1·65%), threats (3%), and kidnappings (0·67%). In a 2008 survey 4 of emergency department physicians in Iraq, 80% reported an assault by a patient or a family member, 38% of which involved a gun threat. Resident physicians were no exception, 87% reported assault and 86% reported that it is emotionally painful to talk about their experience.5 These violent assaults were a trigger for many physicians to leave the country.6 In war-torn Iraq, these assaults might result from bereavement, lack of security, internal political corruption, and inadequate repartition of physicians. If this phenomenon continues, more doctors will be forced to leave the country and the health of the population will continue to deteriorate. Here, I call for immediate action from the Iraqi Government and WHO to protect the remaining health-care workforce from humiliation and violence.
I declare no competing interests.
Manuel María Ortega Marlasca [email protected] Primary Care Medicine, Medical College of Cadiz, Jerez de la Frontera 11406, Spain 1 2
3
Nelson R. Tackling violence against health-care workers. Lancet 2014; 383: 1373–74. Anon. Fallece la doctora tiroteada por un paciente esta madrugada en Moratalla. March 11, 2009. http://www.murcia.com/ moratalla/noticias/2009/03-11-fallece-doctoratiroteada-paciente.asp (accessed May 4, 2014). Anon. Concedida la Medalla de Oro al Mérito del Trabajo a la doctora asesinada en Moratalla. http://www.laverdad.es/murcia/20101203/ local/region/murcia-consejo-ministrosconcede-201012031739.html (accessed May 4, 2014).
Violence against doctors in India I read with interest the Editorial1 about the deterioration of the doctor–patient relationship in China. I believe the situation in India is worse than it is in China. Studying in private medical colleges has become very expensive. Admission is based on entrance examination, not on vocation, aptitude, or attitude of the student. How can one expect ethics and humanity in the medical profession? Moreover, to settle in big cities, where life is expensive, doctors might unwillingly practise unethically, such as advising expensive unnecessary radiology, endoscopic, or laboratory investigations. 2 In government
For more on the Observatory for aggression see https://www. cgcom.es/documentacion_ agresiones
955
towards the value of prevention alongside mandates that restrict analyses to a 10-year window have also lead to suboptimal investments by the Centers for Disease Control and Prevention and other government agencies. The underdevelopment of academic, political, and corporate leaders, and low media interest in prevention can also be attributed to this funding issue. Second, the classic government-led (infectious) disease-control paradigm that Harold Jaffe recommends4 needs substantial adaptation to tackle the complexity of NCD prevention. The recently completed Report on Investing in Prevention3 highlights the importance of collaborating with industry, investors, and government to make markets work for progress. Corporate interest in NCD prevention from sectors ranging from IT, retail, sports and leisure to healthy food should be harnessed as prevention partners.3 They would counterbalance the dominant voices of treatment and care that have distorted US health-care priorities for decades. Third, workplaces must be utilised more effectively for key prevention for the 155 million working-age adults. This change starts with Chief Executives leadership supported by health being reported as a key indicator alongside financial metrics in annual reports. In their report,5 the commissioners further mention the value of better public sector prevention programmes for employers but neglect to highlight the opposite need: workplace programmes that reach into communities for business and community benefit.5 I am Executive Director at Vitality Institute.
Derek Yach [email protected] See World Report page 943
The Vitality Institute, New York, NY 10019, USA 1
2
954
Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet 2014; 384: 45–52. The Lancet. Life, liberty, and the pursuit of healthiness. Lancet 2014; 384: 1.
3
4
5
Vitality Institute Commissioners. Investing in Prevention: A National Imperative. The Vitality Institute, 2014. http://thevitalityinstitute.org/ site/wp-content/uploads/2014/06/Vitality_ Recommendations2014.pdf (accessed Aug 22, 2014). Jaffe HW, Frieden TR. Improving health in the USA: progress and challenges. Lancet 2014; 384: 3–5. HERO Employer-Community Collaboration Committee. Environmental Scan: The Role of Corporate America in Community Health and Wellness. HERO, 2014. http://the-hero.org/ Research/HERO_EnvScanFinaltoIOMa.pdf (accessed Aug 22, 2014).
Electronic health records in the UK and USA Aziz Sheikh and colleagues’ Comment (July 5, p 8)1 entitled “Adoption of electronic health records in UK hospitals: lessons from the USA” emphasises the greater success in adoption in the USA and stresses the top-down decision-making processes in the UK as the key issue. The article makes a number of important points, but does not fully acknowledge the major achievement of the UK in getting almost 100% coverage of electronic health records (EHR) in primary care2 at a time when the US rate of adoption was 10–30%.3 These general practice systems maintain longitudinal, lifelong EHR and are therefore arguably more significant than episodic EHRs within individual hospitals. Hospital EHRs cover a much shorter, albeit more intense portion, of a patient’s care. The primary-care achievement also runs counter to the claim that the key factor in the UK failure was that it “pursued a top-down implementation strategy, in which central Government signed substantial contracts with a handful of EHR vendors” since it was a top-down government policy and funding that was associated with the successful primary care rollout. Jha and colleagues important study4 likely shows the true problem. A decade ago British officials leading the Connecting for Health project believed that the so-called hospital EHR problem had been solved and that they just needed to buy US EHR
systems. But in a survey4 of US hospitals half a decade later, Jha and colleagues showed that less than 10% had a basic EHR and 2·9% had a comprehensive EHR system in all departments. Half of those comprehensive systems were in Veterans Administration hospitals running the open-source VistA system and others were large so-called one-off EHR systems in academic medical centres. The commercial systems covered perhaps 1%, and had been developed to match the US insurance-based health-care processes. Now major UK primary care EHR vendors (such as TPP SystmOne and EMIS) are expanding to integrate hospital, community, and long-term care systems offering British solutions that bridge primary and secondary care. One lesson from the UK should surely be that implementation of EHRs can only happen when appropriate, well tested EHR systems actually exist. OAJ is a director of the health informatics software company X-Lab. HSFF is a cofounder and leader of OpenMRS an open source, non-profit EHR project. The other authors declare no competing interests.
Owen A Johnson, Hamish S F Fraser, Jeremy C Wyatt, *John D Walley [email protected] Leeds Institute for Health Sciences, University of Leeds, Leeds LS2 9PL, UK 1
2
3
4
Sheikh A, Jha A, Cresswell K, Greaves F, Bates DW. Adoption of electronic health records in UK hospitals: lessons from the USA. Lancet 2014; 384: 8–9. Payne TH, Detmer DE, Wyatt JC, Buchan IE. National-scale clinical information exchange in the United Kingdom: lessons for the United States. J Am Med Inform Assoc 2011; 18: 91–98. Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int J Med Inform 2008; 77: 848–54. Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med 2009; 360: 1628–38.
Violence against doctors in Iraq While violence against healthcare workers, as reported by Roxanne Nelson (April 19, p 1373),1 is a global problem, health-care workers in war zones are even more prone to these violent acts with bigger www.thelancet.com Vol 384 September 13, 2014
Correspondence
I declare no competing interests.
Sadeer Al-Kindi [email protected] Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH 44106, USA 1 2
3
4
Nelson R. Tackling violence against health-care workers. Lancet 2014; 383: 1373–74. O’Hanlon ME, Campbell JH. Iraq Index, Oct 1, 2007. The Brookings Institution. http:// www.brookings.edu/fp/saban/iraq/index.pdf (accessed April 1, 2014). Burnham GM, Lafta R, Doocy S. Doctors leaving 12 tertiary hospitals in Iraq, 2004–2007. Soc Sci Med 2009; 69: 172–77. Donaldson RI, Shanovich P, Shetty P, et al. A survey of national physicians working in an active conflict zone: the challenges of emergency medical care in Iraq. Prehosp Disaster Med 2012; 27: 153–61.
www.thelancet.com Vol 384 September 13, 2014
5
6
Lafta M, Pandya A. Verbal and physical aggression against resident physicians in two general hospitals in Baghdad. J Musl Ment Hlth 2006; 1: 137–44. Doocy S, Malik S, Burnham G. Experiences of Iraqi doctors in Jordan during conflict and factors associated with migration. Am J Disaster Med 2010; 5: 41–47.
Tackling violence against health-care workers in Spain I read with interest Roxanne Nelson’s World Report (April 19, p 1373).1 In Spain, April 20 is National Day Against Aggression in Health-Care Facilities. This national day was created in reaction to the murder of a resident family doctor by a patient in 2009.2 Spanish health-care providers demanded the Ministry of Public Health to give special attention to this event.3 Since that event, things have changed in Spain, thanks to the actions taken by the Spanish General Medical Council and the establishment of this National Day, violence against health-care professionals has achieved awareness in the society Moreover, the government issued a law to penalise attacks against doctors as a criminal offense of undermining on the authority of a government agent. Several offenders have already been sentenced for up to 2 years in prison. These progresses should be credited to the Observatory for aggression of the Spanish General Council of Medical Colleges. This Observatory for aggression is responsible for collecting all data about attacks on doctors, characteristics of the attacks, and the final outcome of the legal processes, with the aim of generating legal strategies on the basis of judgments that have produced dissuasive effects. Such efforts may have influenced the 16% decrease in the number of assaults since 2012. The National Day Against Aggression in Health-Care facilities promotes social awareness, encourages professionals to fight against this scourge, and attempts
to get the attention of the general population through social media with initiatives like the creation of the “#stopagresiones” Twitter hashtag. We encourage all our colleagues to raise awareness against this scourge by promoting a cultural change in professional, social, and political circles, to eradicate this problem that affects not only our quality of life as health-care providers, but also the quality of care provided to populations. This year’s motto was “Against health workers aggression: zero tolerance”. We hope that next year the slogan will be “Attacks on health workers in Spain are over”.
Getty Images
consequences. 11 years have passed since the 2003 war in Iraq and the dreams to have a better life never came true. Iraqi doctors are getting assaulted, violated, and humiliated, and as a result, more physicians are leaving the country. More than 2000 doctors have been killed since 2003.2 According to Gilbert Burnham and colleagues’ study,3 a 22% decrease has occured in the number of medical specialists in the capital Baghdad between 2004 and 2007 due in part to violent deaths (1·65%), threats (3%), and kidnappings (0·67%). In a 2008 survey 4 of emergency department physicians in Iraq, 80% reported an assault by a patient or a family member, 38% of which involved a gun threat. Resident physicians were no exception, 87% reported assault and 86% reported that it is emotionally painful to talk about their experience.5 These violent assaults were a trigger for many physicians to leave the country.6 In war-torn Iraq, these assaults might result from bereavement, lack of security, internal political corruption, and inadequate repartition of physicians. If this phenomenon continues, more doctors will be forced to leave the country and the health of the population will continue to deteriorate. Here, I call for immediate action from the Iraqi Government and WHO to protect the remaining health-care workforce from humiliation and violence.
I declare no competing interests.
Manuel María Ortega Marlasca [email protected] Primary Care Medicine, Medical College of Cadiz, Jerez de la Frontera 11406, Spain 1 2
3
Nelson R. Tackling violence against health-care workers. Lancet 2014; 383: 1373–74. Anon. Fallece la doctora tiroteada por un paciente esta madrugada en Moratalla. March 11, 2009. http://www.murcia.com/ moratalla/noticias/2009/03-11-fallece-doctoratiroteada-paciente.asp (accessed May 4, 2014). Anon. Concedida la Medalla de Oro al Mérito del Trabajo a la doctora asesinada en Moratalla. http://www.laverdad.es/murcia/20101203/ local/region/murcia-consejo-ministrosconcede-201012031739.html (accessed May 4, 2014).
Violence against doctors in India I read with interest the Editorial1 about the deterioration of the doctor–patient relationship in China. I believe the situation in India is worse than it is in China. Studying in private medical colleges has become very expensive. Admission is based on entrance examination, not on vocation, aptitude, or attitude of the student. How can one expect ethics and humanity in the medical profession? Moreover, to settle in big cities, where life is expensive, doctors might unwillingly practise unethically, such as advising expensive unnecessary radiology, endoscopic, or laboratory investigations. 2 In government
For more on the Observatory for aggression see https://www. cgcom.es/documentacion_ agresiones
955
