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A cohort study with a 25-month follow-up showed that there was no difference in stature or growth of children aged 3 to 4 years at baseline across quintiles (27 to 38 percent) of total fat intake (Shea et al discount clomid line women's health quotations. The Special Turku Coronary Risk Factor Intervention Project showed no difference in growth of children 7 months to 5 years of age when they consumed 21 to 38 percent fat (Lagström et al order clomid with amex women's health clinic sf. Niinikoski and coworkers (1997a) reported that 1-year-old children who consistently con- sumed low fat diets (less than 28 percent) grew as well as children with higher fat intakes clomid 100 mg with visa breast cancer deaths per year. A cohort study showed that children aged 2 years in the lower tertile of fat intake (less than 30 percent) had a height and weight similar to that of the higher fat intake groups (Boulton and Magarey 100mg clomid sale menstruation pain relief, 1995). A few studies have observed impaired growth among hypercholsterolemic children who were advised to consume 30 percent or less of energy from fat. However, the energy intake was also reduced (Lifshitz and Moses, 1989) or not reported (Hansen et al. In a group of Canadian children 3 to 6 years of age, a fat intake of less than 30 percent of energy was associated with an odds ratio of 2. The dietary determinants that best explained low birth weight were energy, protein, and animal fat, suggesting that high-quality animal protein and associated nutrients are important for growth and development. Because the diets of young children are less diversified than that of adults, the risk of inadequate micronutrient intake is increased in these children. A cohort of 500 children aged 3 to 6 years showed that those who consumed less than 30 percent of energy from fat consumed less vitamin A, vitamin D, and vitamin E com- pared with those who consumed higher intakes of fat (30 to 40 percent) (Vobecky et al. Calcium intakes decreased by more than 100 mg/d for 4- and 6-year-old children who consumed less than 30 percent of energy from fat (Boulton and Magarey, 1995). Lagström and coworkers (1997, 1999), however, did not observe reduced intakes of micronutrients in chil- dren with low fat intakes (26 percent). Tonstad and Sivertsen (1997) observed no reduced intake of micronutrients with diets providing 25 percent of energy as fat. Nicklas and coworkers (1992) reported reduced intakes of certain micronutrients by 10-year-old children who consumed less than 30 per- cent of energy as fat; however, this level of fat intake was associated with marked increased intakes of candy. It has been suggested that children who consume a low fat diet can meet their micronutrient recommendation by appropriate selection of certain low fat foods (Peterson and Sigman- Grant, 1997). This is especially true for older children whose diets are typically more diverse. The tables in Appendix K show the intakes of nutrients at various intake levels of carbohydrate. With increasing intakes of carbohydrate, and therefore decreasing intakes of fat, the intake levels of calcium and zinc markedly decreased in children 1 to 18 years of age (Appendix Tables K-1 through K-3). Several surveys have evaluated the impact of added sugars intake on micronutrient intakes in children (Table 11-5). In a study of British adolescents, reduced intakes of calcium, phosphorus, iron, vitamin A, vitamin D, and folic acid were associated with increased sugars intakes (mean added sugars intake for the high sugars consumers was 122 g/d for boys and 119 g/d for girls) (Rugg-Gunn et al. In a smaller survey (n = 143), added sugars intakes at levels as high as 27 per- cent of energy did not have a significant impact on micronutrient intakes (Nelson, 1991). This reduction in micronutrient intake was most significant when added sugars intake levels exceeded 25 percent of energy. Bever- ages, particularly soft drinks, were important contributors to the increased carbohydrate consumption. During this period, micronutrient intakes (except for iron) did not increase and calcium intakes decreased. This was attributed to the fact that increased energy was largely obtained from soft drinks, which do not add nutrients and displace milk in children’s diets, with negative consequences for total diet quality (Morton and Guthrie, 1998). Children who were high consumers of nondiet soft drinks had lower intakes of riboflavin, folate, vitamin A, vitamin C, calcium, and phosphorus in comparison with children who were nonconsumers of soft drinks (Harnack et al. Juice (100 percent fruit or vegetable juice) consumption was posi- tively associated with achieving vitamin C and folate recommended intakes in all age groups, as well as magnesium intake among children aged 6 years and older. Soft drink intake was negatively associated with achieving rec- ommended vitamin A intake in all age groups, calcium in children younger than 12 years of age, and magnesium in children 6 years of age and older. Others have shown that children who consumed milk at the noon meal had the highest daily intakes of vitamin A, vitamin E, calcium, and zinc, whereas the opposite was true for children who consumed soft drinks and tea (Johnson et al. Hence, beverages that are major contributors of the naturally occurring sugars, such as lactose and fructose, in the diet (e. The findings from three surveys on the relationship between total sugars intake and micronutrient intake in children are mixed (Table 11-6). Gibson (1993) did not observe reduced micronutrient intakes when total sugars intake exceeded 25 percent of energy. A linear reduction in several micronutrients was observed with increasing total sugars intake (Farris et al. High Fat, Low Carbohydrate Diets of Children Risk of Obesity In the United States and Canada, there is evidence that children are becoming progressively overweight (Flegal, 1999; Gortmaker et al. Furthermore, Serdula and coworkers (1993) reviewed a number of longitudinal studies with vary- ing cut-off levels for obesity and concluded that 26 to 41 percent of obese preschool children and 42 to 63 percent of obese school-age children became obese adults. Clinical evidence of disease associated with excess body weight, reduced physical activity, or high dietary fat intakes, however, are generally absent. The evidence for a role of dietary fat intakes in pro- moting higher energy intakes and thus promoting obesity in young chil- dren is conflicting. A positive trend in energy intake was associated with an increased percent of energy from fat for children up to 8 years of age (Boulton and Magarey, 1995). A positive correlation between fat intake and fat mass has been reported for boys 4 to 7 years of age (Nguyen et al. However, several studies showed a positive correlation between dietary fat intake and body fatness in children 8 to 12 years of age (Maffeis et al. The average fat intake of nonobese children was measured to be 31 to 34 percent for children 9 to 11 years old, whereas the average fat intake of obese children was 39 percent of energy (Gazzaniga and Burns, 1993). A positive association between fat intake and several adiposity indices were observed, but only for up to 35 percent of energy (Maillard et al. Furthermore, a significant positive association between fat intake and total cholesterol con- centration was observed in only two of five countries (Knuiman et al. The prevalence of aortic fatty streaks differs only slightly among children and adolescents of all populations studied, regardless of the fre- quency of atherosclerosis and coronary artery disease in adults of the respective population (Holman et al. The absence of a relation between aortic fatty streaks and the clinically relevant lesions of atherosclerosis in epidemiological and histological studies has thus raised questions on the clinical significance of fatty streaks in the aorta of young children (Newman et al. The Pathobiological Deter- minants of Atherosclerosis in Youth Study, however, has provided evidence that an unfavorable lipoprotein pattern (i. These findings are consistent with the hypothesis of the progression of fatty streaks to fibrous plaques under the influence of the prevailing risk factors for coronary artery disease (McGill et al. In addition, there are still pivotal issues that must be examined further, including the relationship between fatty streaks found in the arteries of young children and the later appearance of raised lesions associated with coronary vascular disease, the effects of dietary total fat modification on predictive risk factors in children, the safety of the diet with respect to total energy and micronutrients for the general population, and the long- term health benefit of establishing healthy dietary patterns early in childhood. It can been seen from these tables that as the level of carbohydrate intake decreases, and therefore the level of fat increases, certain nutrients such as folate and vitamin C markedly decrease. Furthermore, with increasing levels of fat intake, the intake of saturated fat relative to linoleic acid intake markedly increases. Dietary fat provides energy, which may be important for younger children with reduced food intakes, particularly during the transition from a diet high in milk to a mixed diet.

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Effect of ramipril vs amlodipine on renal outcomes in hypertensive nephrosclerosis: a randomized controlled trial purchase clomid online from canada pregnancy 0-0-1-0. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy discount 50mg clomid amex menstrual cramps 6 weeks pregnant. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes purchase 100mg clomid mastercard menstrual psychosis. Effects of calcium- channel blockade in older patients with diabetes and systolic hypertension 50mg clomid mastercard womens health robinwood. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. A thorough understanding of a systematic approach to hyperbilirubinemia/jaundice is by far preferable to random knowledge of highly specific etiologies. The liver responds pathologically to injury in characteristic ways and knowledge of these patterns can also be very useful in differential diagnosis. Several etiologies of liver disease such as acute/chronic viral hepatitis and alcohol-induced liver disease are sufficiently common as to require specific attention. In addition, many liver diseases can result in cirrhosis and its complications and, therefore, understanding this end-stage development is important. The biochemical/physiologic/mechanistic approach to hyperbilirubinemia, including: • Increased production. The biochemistry and common causes of unconjugated and conjugated hyperbilirubinemia. The common pathologic patterns of liver disease and their common causes, including: • Steatosis (fatty liver). The epidemiology, symptoms, signs, typical clinical course, and prevention of viral hepatitis. The common causes and clinical significance of hepatic steatosis and steatohepatis. The epidemiology, symptoms, signs, and typical clinical course of autoimmune liver diseases such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis. The pathophysiologic manifestations, symptoms, signs, and complications of alcohol-induced liver disease. The pathophysiologic manifestations, symptoms, and signs of spontaneous bacterial peritonitis. The basic pathophysiology, symptoms, signs, typical clinical course, and precipitants of hepatic encephalopathy. The basic pathophysiology, symptoms, signs, and typical clinical course of the hepatorenal syndrome. The analysis of ascitic fluid and its use in the diagnostic evaluation of liver disease. The epidemiology, pathophysiology, symptoms, signs, and typical clinical course of cholelithiasis and cholecystitis. The clinical syndrome of “ascending cholangitis” including its common causes and typical clinical course. The indications for and utility of hepatobiliary imaging studies, including: • Ultrasound. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease, including: • Jaundice, discolored urine, pruritis, light-colored stool, unintentional weight loss, fever, nausea, emesis, diarrhea, altered mental status, abdominal pain, increased abdominal girth, edema, rectal bleeding, hematemesis. Physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: • Jaundice. Differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology of liver disease. Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Communication skills: Students should be able to: • Communicate the diagnosis, treatment plan, and subsequent follow-up to the patient and his or her family. Basic and advanced procedural skills: Students should be able to: • Assist in performing a paracentesis after explaining the procedure to the patient. Management skills: Students should able to develop an appropriate evaluation and treatment plan for patients that includes: • The diagnostic evaluation of asymptomatic, isolated elevation of the transaminases and/or Alk Phos. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection of diagnostic and therapeutic interventions for liver disease. Recognize the importance of patient needs and preferences when selecting among diagnostic and therapeutic options for liver disease. Respond appropriately to patients who are nonadherent to treatment for liver disease. Appreciate the impact liver disease has on a patient’s quality of life, well- being, ability to work, and the family. Recognize the importance of and demonstrate a commitment to the utilization of other healthcare professionals in the diagnosis and treatment of liver disease. Discuss the public health role physicians play in the prevention of viral hepatitis. Most often the primary care provider is the first health care professional to see a depressed patient. Frequently, the initial presentation is associated with somatic complaints that bring the patient to the physician. Major depression is also a relatively common accompaniment to serious medical conditions. There is significant evidence that primary care physicians commonly fail to diagnose major depression. With relatively recent improvements in available treatment, it is even more important for internists to screen for major depression and to know the common presenting symptoms. The internist should also be familiar with available therapeutic options and be prepared to treat selected patients, including those who decline consultation with a mental health professional. The epidemiology of major depression in the general population and the impact of major illness on the prevalence of major depression (e. Common somatic complaints that accompany depressive disorders and the potential for the occurrence of these symptoms without obvious psychological symptoms (e. The distinguishing features of major depression with psychotic features, bipolar disorder, dementia, and delirium. The differential diagnosis of major depression, including: • Other psychiatric disorders. Indications and efficacy of the basic therapeutic options for major depression, including: • Psychotherapy (cognitive behavioral therapy or interpersonal psychotherapy). The side effects of the major classes of antidepressants and common interaction with other medications. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including: • Eliciting the symptoms of major depression. Physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: • A complete neurologic examination. Differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology for major depression (psychiatric and nonpsychiatric). Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences.

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Chapter 4: Disorders of the abdominal wall 155 toneum dragged down into the testes during the embryonic descent of the testes from the posterior Skin abdominal wall clomid 25 mg with amex menstrual kits for girls. It is usually obliterated leaving the tunica vaginalis as a covering of the testes buy genuine clomid on-line womens health 50 secret. Femoral hernias are particularly prone to incarceration or strangulation order 50mg clomid overnight delivery womens health group enfield ct, Figure 4 order clomid pregnancy 42 weeks. Females have femoral hernias more often than Aetiology/pathophysiology males, but inguinal hernias are still the most common Congenital hernias exploit natural openings and weak- hernia in females (by 4 to 1). They may not become obvious until later in life and may be predisposed to by coughing straining, surgical incisions and muscle splitting. Examples of her- approximately 5% of postoperative patients, risk fac- nias include inguinal (direct and indirect), femoral, tors include infection, poor wound healing, coughing paraumbilical, umbilical and ventral hernias (see and surgical techniques. Of groin hernias, 60% are indirect inguinal, 25% are direct inguinal and 15% are femoral. Clinical features r Indirect inguinal hernias are a result of failure of oblit- Hernias may be completely asymptomatic, or present eration of the processus vaginalis, a tube of peri- with a painless swelling, sudden pain at the moment of herniation and thereafter a dragging discomfort made worse by coughing, lifting, straining and defecation (which increase intra-abdominal pressure). Persistent or severe pain may be a sign of one of the complications of hernias, i. Umbilical r Indirect hernias once reduced can be controlled by pressure applied to the internal ring. This distin- Inguinal guishes indirect from direct hernias, which cannot be controlled, and where on reduction the edges of the Incisional defect may be palpable. Femoral r An inguinal hernia passes above and medial to the pubic tubercle whereas a femoral hernia passes below Figure 4. Irreducibility cessive alcohol ingestion, cigarette smoking, coffee, red (incarceration) is more likely if the neck of the sac wine, anticholinergic drug, oesophageal dysmotility and is narrow (e. Obstruction of the intestinemayoccurcausingabdominalpain,vomiting Pathophysiology and distension. The lower oesophageal sphincter is formed of the distal r Strangulation denotes compromise of the blood sup- few centimeters of the oesophageal smooth muscle. Nor- ply of the contents and significantly increases mor- mally after the passage of a food bolus the muscle rapidly bidity and mortality. Sphincter tone can increase obstructs first, the resultant back pressure results in in response to a rise in intra-abdominal or intra-gastric arterial insufficiency, ischaemia and ultimately infarc- pressure. Investigations The normal squamous epithelium of the oesophagus These are rarely necessary to make the diagnosis, al- issensitivetotheeffectsofacidandthusacuteinflamma- though imaging such as ultrasound is sometimes used. Contin- uing inflammation may manifest as ulceration, scaring, Management fibrosis and stricture formation. Surgical treatment is usually advised electively to reduce Continuing inflammation may result in glandular ep- the risk of complications. However, longstanding, large ithelial metaplasia (a change from the normal squamous herniaswhicharerelativelyasymptomaticmaybetreated epitheliumtoglandularepithelium)termedBarrett’soe- conservatively, as they have a low risk of incarceration sophagus, which predisposes to neoplasia. Direct hernias are reduced and the defect Clinical features closed by suture or synthetic mesh. Indirect hernias are Patients complain of symptoms of dyspepsia (see ear- repaired by surgical removal of the herniation sac from lier in this chapter) particularly heartburn, a retroster- the spermatic cord. If the internal ring is enlarged it is nal burning pain aggravated by bending or lying down. For other hernias, the principle is to Effortless regurgitation of food and acid (waterbrash) excise the sac and obliterate the opening either by sutur- into the mouth may occur. Gastrooesophageal reflux disease Management Definition Patients are managed as for dyspepsia, i. Chapter 4: Disorders of the oesophagus 157 Older patients and those with suspicious features should diameter of 10–15 mm. It may be axial/sliding, r Patients should be advised to lose weight if obese, and paraesophageal/rolling or mixed. Prevalence r The most effective relief is provided by proton pump Increases with age, very common in elderly patients (up inhibitors; however, many patients have adequate to 70%). This can eventually shorten the oesoph- terprevious upper gastrointestinal tract surgery. Symptoms may result from pressure on the heart latation to stretch the stricture to achieve a luminal orlungs. Oesophagus Gastro-oesophageal Herniated Diaphragm junction stomach Stomach Sliding (axial) hernia 90% Para-Oesophageal (rolling) hernia 10% Disrupts normal anti-reflux mechanisms Anti-reflux mechanisms intact Figure 4. Patients with a slid- Patients may present with a lump in the throat and dys- ing hernia may present with symptoms of dyspepsia due phagiawithregurgitationofundigestedfoodsomehours to gastro-oesophageal reflux. Endoscopic techniques may be used in elderly Investigations patients, with a large dependent pouch, who are unfit Chest X-ray may reveal a gas bubble above the di- for surgery. Endoscopycanestablishtheextent Plummer–Vinson syndrome and severity of inflammation and exclude oesophageal Definition carcinoma. Plummer–Vinson syndrome or Paterson–Brown–Kelly syndrome is an unusual combination of iron deficiency Management anaemia and dysphagia. In fundoplication (open or laparo- the upper oesophagus with the formation of a post- scopic) the gastric fundus is mobilised and wrapped cricoid web. Thereisahighriskofupper patients) to reduce the risk of strangulation and other oesophageal or pharyngeal malignancy. Surgery consists of ex- cisionoftheperitonealsac,reductionoftheherniaand closure of the defect. Webs are dilated endoscopically to relieve obstruction, iron deficiency anaemia is treated. Pharyngeal pouch Definition Achalasia A false diverticulum arising at the junction of the oe- sophagus and the pharynx. Definition Achalasia is a disordered contraction of the oesophagus Aetiology/pathophysiology of neuromuscular origin. In co-ordinationbetweenthecontractionofthepharynx andrelaxationoftheupperoesophagealsphinctercauses Aetiology the pharyngeal mucosa to herniate posteriorly between Degeneration is seen in the vagus nerve associated with the upper and lower fibres of the inferior constrictor adecrease in ganglionic cells in the Auerbach’s nerve muscle (Killian’s dehiscence). Chagas’ disease in Chapter 4: Disorders of the oesophagus 159 South America is very similar where infection by Try- oesophageal sphincter. Surgical intervention is indicated panosoma cruzi causes destruction of the myenteric in those who fail to respond; a 10–12 cm incision is made plexus. Gastro-oesophageal reflux is a The neuromuscular damage causes disordered motility complication with both procedures. On manom- etry there is aperistalsis and incomplete relaxation of Diffuse oesophageal spasm the lower oesophageal sphincter in response to swallow- ing. The gastrooesophageal sphincter classically remains Definition tightly closed and there is dilation of the oesophagus. Aetiology/pathophysiology Clinical features There is a generalised abnormality of the oesopha- Patients present with progressive dysphagia, regurgita- gus with resultant hypermotility leading to painful oe- tionandnocturnalaspiration. Clinical features Complications Painisretrosternalandrangesfrommildtoseverecolicky Patients may aspirate and develop respiratory symp- spasms that occur spontaneously or on swallowing.

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Having specified a minimal clinical information infrastructure for a safer health system order line clomid breast cancer 45 year old woman, federal law should provide a malpractice “safe harbor” for institutions and practitioners who use these tools buy cheap clomid 50mg menstruation 6 days after ovulation, including clinical outcome guidelines order discount clomid line women's health issues contraception. There is precedent here best buy for clomid womens health 9 positions, in the decision by malpractice insurers to rate those anesthesiologists who used pulse oximetry to monitor patient conditions in surgery as safer and eligible for lower rates. More than 85 percent of all Medicare claims are presently filed in electronic form, but much of this is in tape format, which is not fully interactive. The ability to verify coverage and obtain payment quickly, as well as to resolve Medicare billing problems in real time, rather than through paper and telephone interactions, will save the federal government and providers a small fortune in reduced clerical expenses. The lack of standardization of health plans’ data requirements is a major lingering source of unnecessary administrative expense for healthcare providers. Thousands of small hospitals and practitioners will not have the cash, credit, or technical staff to make the transition from paper to electronic charts and billing systems. They will need federal assistance, perhaps in the form of a Hill-Burton-type program. Wealthy institutions should perhaps receive some token federal assistance to underscore the timeliness of needed information sys- tem renovations. But it is not sensible to substitute tax dollars for private dollars that would voluntarily have been spent digitizing hospitals’ clinical and operating systems. Other Challenges and Considerations Earlier, it was argued that hospitals and physicians ought not to maintain the present balkanized medical information structure, with separate and nonlinkable medical records in the hospital and the physician’s office. Even where the climate of collaboration be- tween hospitals and physicians would permit a common record system to emerge, present federal laws raise barriers. Hospitals that provided connection by physicians to a clinical record system could be construed as violating federal fraud and abuse regulations, which forbid hospitals from offering services or payment to physicians for using their facilities (the modern variant of an ancient and ethically indefensible practice known as “fee splitting”). Moreover, for the 85 percent of all hospitals that are presently not-for-profit, federal and state tax laws forbid them from providing physicians anything of value. If inurement provisions did not exist, many not-for-profit institutions would function as mere front or- ganizations for profit-making enterprises, funneling tax-free dollars into individuals’ and businesses’ pockets. However, changes in federal law could work to minimize these risks in the public benefit. If clinical information systems by differ- ent vendors all used common formats, medical vocabularies, and coding schemes, no provider could achieve market leverage by “lock- ing in” physicians to using their proprietary medical records system, and the fraud and abuse risk could be alleviated. On the not-for- 164 Digital Medicine profit issue, one could reasonably argue for exempting clinical in- formation systems from inurement provisions on the grounds of markedly improved patient safety resulting from the free flow of clinical information among all the diverse actors in medicine. Moreover, an ethos of personal responsibility for health and health costs is vital to containing future health cost increases. However, the present policy climate in clinical information, on both the ven- dor and provider sides, approaches anarchy. Tens of thousand of lives are needlessly lost every year because of inadequate or poorly coordinated care. Creating the infrastructure and decision support to improve standards of care is a legitimate job for government. Current Medicare and private pay- ment policy contains inappropriate incentives, not only to maximize provider income by doing more, perhaps, than patients may need to care for them, but, by implication, to wait until a disease progresses far enough to justify more lucrative, high-technology intervention. Maintenance of health, disease management, advice and coun- seling—these are not the focus of the current healthcare payment schemes. Furthermore, as we enter an era of increasingly precise genetic prediction, the economy is already laboring to take care of the 5 percent of the population who are sick; how can it possibly finance care for everyone who has some genetic risk of illness? Ideally, physicians would be paid a monthly or annual subscription fee for each consumer who signed up to be cared for by the physician. Some of the emerging and controversial concepts in physician practice, like so-called “boutique medicine,” where consumers pay a fee to enter a physician’s practice, anticipate this subscription model. The key to the subscription is establishing electronic connectiv- ity between the consumer and the physician he or she has chosen. After electronic connectivity has been established between con- sumers and providers, maintaining electronic contact with con- sumers should be far less costly than under a visit-and-telephone- consultation system. Many interactions that required patient visits under the old system could be handled “asynchronously” under the electronic system, with software assistance supported by the physician’s office staff. Many functions, like prescription renewals, transmittal of vi- tal signs, scheduling, and billing, that were handled in person or through telephone interactions could be automated through Inter- net applications and managed by the physician’s or hospital’s staff. In addition, someone other than the physician may handle many requests for information. Subscription fees would cover maintenance of the 24/7 connec- tions, as well as the cost of most services the consumer would use in a year. The fees would be paid to the principal physician by the health plan or federal government, which would be functioning not as a fiscally interested intermediary, but rather as a sponsor of the relationship. The costs of periodic screening both for genetic and cellular abnormalities would be included in the subscription amount. Hospitalizations and other relatively rare medical interventions would probably be paid separately from the subscription amount. These costs, as well as those of specialists and consultants, would 166 Digital Medicine Figure 7. These per-episode payments would be larger for older consumers or those with complex health problems. Physicians should have broad discretion in determining what type of services are provided, but should have an incentive to economize where possible. As with surgical procedures, hospi- talizations would carry a substantial consumer cost share, based on ability to pay. The method of payment should be neutral on the cost of im- munizations and immune therapy. The custom fabrication of im- munizations or other forms of therapy based on the consumer’s genotype would be treated as an “episode of care” like a surgical procedure, but to encourage these preventive measures, the cost should be borne separately by the health plan and be shared mod- estly with the patient or the physician to encourage them to be used. Health Policy Issues Raised by Information Technology 167 Substantial consumer cost sharing, graded to income, would be essential to exert a braking influence on procedure costs. Thus, consumers and physicians would have the same incentive to avoid unnecessary care, or care that could be made unnecessary by suc- cessful management of identified health risks. The “intelligent” clinical information system discussed earlier could provide the information base not only to analyze patterns of healthcare spending, but also to determine the most effective methods of care. Analysis of this information across large groups of patients could give to providers at risk for the cost of care the tools and information needed to make intelligent decisions about how to maximize the health of their subscribers. This information was missing in nearly all of the examples where physicians groups attempted to manage “capitated” payment during the 1990s (and went broke doing it). The principal way that physicians would increase their income is by enrolling more consumers and by minimizing the amount of cu- rative medicine their patients need. They would grow their practices by earning higher consumer satisfaction evaluations and garnering referrals from satisfied customers. These satisfaction scores would be posted on consumer web sites and be available to help guide consumers’ choice of physicians. Physicians who do an especially skillful job of organizing their connectivity and support for con- sumers, particularly responding to consumer questions and manag- ing disease-management protocols, could handle a larger panel of consumers than physicians today. The more effective physicians are in helping consumers identify and manage their medical risks, the more they earn.