Lab Soft News

Moving LISs Toward Greater Support for Preventive and Predictive Medicine

I have posted a number of previous notes about predictive and preventive medicine (see: Preventive and Predictive Medicine as Components of the Healthcare Continuum, The Relationship Between Predictive and Preventive Medicine). Lab medicine professionals can play a leadership role in predicting disease and monitoring how lifestyle changes can prevent the onset of more serious disease. Think genomic testing, biomarkers, and lipid profiles. John Moore who blogs over at Chilmark Research returned rather depressed from the recent HIMSS conference in Chicago (see: HIMSS’09 & Depression). Here's what he had to say about the event:

 [I]t is clear that the mindset of [the HIT] industry and many of its self-promoting pundits, needs to hit the reset button....We are not, as an industry, focusing on the right things.  Rather than focusing on how to keep people out of the healthcare system, keep them from becoming patients, everything I have seen and heard here at HIMSS is about keeping people tied into the system....I am convinced that the only way we are going to move the needle in a positive direction is to begin handing over the reins to the consumer.  For far too long this industry has kept the consumer in the dark and has not helped that consumer in directly managing their health.  It has taken a paternalistic view that must end immediately.  Nowhere at HIMSS did I see or hear people discuss the consumer (well, there was the occasional marketing education session on how to reach the consumer, but that is just marketing and doesn’t count).  The only perspective on display at HIMSS is that of consumer as patient.  Problem is, that view goes under the assumption that the only purpose of healthcare is to treat people that are already sick.

I am in basic agreement with John about the need for a greater focus on wellness and not disease in our healthcare system. An interesting facet of this discussion is the role of HIT in the promotion of wellness. Unfortunately, I don't believe that most physicians, hospital C-suite executives, or HIT professionals are going to "see the light" any time soon and begin thinking about how to keep consumers healthy. In fact, I can't recall any physicians around me discussing consumers at all. The reason is that the physicians are not selling what many consumers may increasingly want to buy, which will be the means and methods to stay healthy.

If I am correct that the clinical lab industry has a role to play in predictive/preventive medicine, then surely the major HIT instrument of lab professionals, the laboratory information system (LIS) or some extension of it, has a role to play in this enterprise. I presented a "booth lecture" at HIMSS on this topic (see: How Predictive/Preventive Medicine Will Change Healthcare Medicine Will Change Healthcare Delivery and the IT That Drives It) and I am now in the process of discussing with executives of a major LIS vendor the nature of the support that the LIS can provide for wellness.

I suspect that the it would impractical to designate some part of the LIS, in its current form, as a "wellness domain" because many physicians and nurses have little interest in this topic. In the mini-lecture linked to above, I come to the conclusion that the tethered personal health record (PHR) can and should be the repository for copies of lab test results relating to wellness because these records are being developed and maintained by and for the healthcare consumers themselves. Given that PHRs will be web-based, it will also be feasible within them to provide links to wellness resources on the web about how consumers can improve their health and prevent illness using lab test results as guides.

Impact of the Hospitalist Movement on Residency Training Programs

I have posted a number of previous notes about hospitalists, by which I mean any physician who works full-time in a hospital as a hospital employee. Physicians in training programs are not included. The larger category of hospitalists can be subdivided into subgroups based on work function and now includes at least the following types: intensivists, surgicalists, proceduralist, and laborists. As this growing list would suggest, hospitalists are on the rise but a recent blog note by KevinMD puts some numbers on this phenomenon for me (see: Hospitalists assimilate inpatient medicine, is resistance futile?). Below is an excerpt from it with boldface emphasis mine:

MedPage Today reports on a NEJM study, not surprisingly concluding that "hospitalists now account for nearly 40% of inpatient Medicare claims for general internist services, up from less than 10% in 1995."...How will it affect primary care doctors, who increasingly are confined to the office? Well, it's not a positive as you'd think. "The well-intentioned efforts of many primary care physicians to make themselves more available to their outpatients and provide their inpatients with the benefit of doctors with expertise in hospital medicine may have reduced their own value in the eyes of their patients and, in some instances, decreased their job satisfaction," writes the accompanying editorial.... Bob Wachter, the man who coined the term "hospitalist," gives his take, and basically says, "I told you so."..."These data portend a future in which hospitalists...will be involved in the care of virtually every sick patient – medical and surgical – in the building, something I’ve predicted for years. This has major implications for training. Future hospitalists need to be as comfortable helping to manage hip fracture or subarachnoid bleed patients as they are COPD patients. The old residency model of doing a couple of weeks on “med consult” ... is increasingly out of sync with modern practice." With the hospitalist movement, we're seeing traditional internal medicine turned upside-down before our eyes.

We have all read about the shortage of primary care physicians and internists in favor of super-specialists such as cardiologists. This is commonly attributed to the debt-load of physicians from medical school who seek higher paying positions. This is a surely a factor but we must also consider the fact that the medical and surgical subspecialties may have more appeal on a scientific and technical basis to medical students choosing their future careers.

However, we also need to ask who is going to train the office-based primary care physicians of the future? Putting aside family practice training programs which I am sure will continue in this mode, the internal medicine programs in teaching hospitals will undoubtedly train more hospitalists. This is the only mode of practice that the faculty members know and there will also be an eager market for this type of practitioner in hospitals. For me, this is added impetus for the idea that the first tier of office medical practice should be delivered primarily by nurse clinicians and physician assistants (see: Disruptive Innovation and Reform of Our Healthcare System). However, this latter term may soon be outdated.

Browsing My Morning (Electronic) Newspaper over Coffee

I have posted a number of previous posts about newspapers and their decline in the face of new media (see: Mainstream Media Begin to Adopt Link Journalism, A Strategy for Saving Our Hometown Newspapers). My hometown newspaper, the Ann Arbor News, will soon cease publishing and its decline has been sad for the town residents to watch. In my view, the key error that was made by the publisher of the newspaper was forgetting that the company was in the news business rather than in the newspaper business. 

I love newspapers and I have also loved reading them over my morning cup of coffee or after dinner. But stick with me as I explore some of the facets of these rituals. I confess that I bought the idea that a critical component of the ritual was connected to the tangible feel of the newspaper in my hands. For me, at least, this turns out not to be true. I discovered this when I recently bought a Dell Inspiron Mini 9, a small netbook weighing abut 2.5 pounds. It connects automatically to my home wireless network for Internet access.

So I now keep my little netbook close to the breakfast table and fire it up as I brew my coffee. I have the New York Times, the Wall Street Journal, and Google News tabbed on my Mozilla browser so I can easily scan the news from multiple sources using my netbook. I can also view the news on a horizontal timeline with Google News Timeline which was just released by Google Labs. I can also point my browser to Mlive.com which provides a web version of the soon-to-be-defunct Ann Arbor News. By the way, Google Timeline intersperses video clips with textual news, providing a whole new slant on news content. Any time that I want to dig deeper into a news story, Google search is only a tab away. It's not your father's newspaper.

I am not happy to see the local newspaper exit and there will be an unfilled void remaining, part of which will be filled by new media. However, let me also reaffirm that our print newspapers have fulfilled in the past the key function of investigative journalism for which there is no current web equivalent (yet). Nevertheless, I have come to view my access to the electronic news in the morning as superior in many ways to the former hardcopy newspaper product.

Corporate Support for Continuing Medical Education Conferences

It's time for some brief comments about the topic of corporate support for CME conferences. A recent blog note (see: If the pharmaceutical industry won't pay for CME, who will?) provides a glimpse of some of the issue that are being raised with regard to this topic:

The purging of drug companies from continuing medical education courses continues....CME is a big money industry, and ...Pfizer contributed some $12.3 million to the University of Wisconsin's courses. So, if medical schools were to ban the drug industry from funding their CME, who will pay for them? Cash-strapped medical schools? Likely not. It's probably going to fall on individual physicians who, in many states, need CME credits to maintain their licenses. I suspect that CME will become significantly more expensive to attend in the near future.

First of all, let's take a look at the proposed Massachusetts law entitled Pharmaceutical and Medical Device Manufacturer Conduct that is considered by some to be draconian. One of its requirements is that pharmaceutical and medical device manufacturing companies supporting conferences being held in the state must have a code of conduct in place by July 1, 2009. For me, the key element in this law is that drug and medical devices companies are prohibited from tampering with the educational content of medical conferences. In my opinion, this goes without saying and is both long overdue and warranted given the history of Big Pharma putting a spin on educational content directed to physicians. This document also speaks to the financial sponsorship of conferences in 970.007:4 from which I quote below, with boldface emphasis mine:

4. Nothing in 105 CMR 970.000 shall prohibit:

a. compensation or reimbursement made to a health care practitioner serving as a speaker or providing actual and substantive services as a faculty organizer or academic program consultant for a CME event, third-party scientific or educational conference, or professional meeting, provided that the payment: 1. is reasonable; 2. is based on fair market value; and 3. complies with the standards for commercial support as established by the relevant accreditation entity.
b. sponsorship or payment for any portion of a third-party scientific or educational conference, charitable conference or meeting, or professional meeting, where the payment is made directly to the conference or meeting organizers.
c. the use of hotel facilities, convention center facilities or other special event venues for CME or other third-party scientific, educational or professional meetings or conferences.

Industry trade associations have scurried to update their codes of conduct in response to this Massachusetts legislation as well as similar actions in other states. One such association, the Advanced Medial Technology Association (AdvaMed), has posted its new ethical code, adopted last December, on the web (see: CODE OF ETHICS ON INTERACTIONS WITH HEALTH CARE PROFESSIONALS). I quote below from Part IV of the document labeled Supporting Third-Party Educational Conferences:

Advertisements and Demonstration. Companies may purchase advertisements and lease booth space for Company displays at conferences.

Unless I am missing some of the fine points and please correct me if this is the case, I am having trouble perceiving how or why any of this regulation is harmful to the planning of CME conferences or the registration for them. Here are my reasons:

• The conference organizers control the lecture content and lease tables or booth space to vendors who then interact with conference registrants in the vendor area. There needs to be a fire-wall between the vendor space and the lecture hall.
• These rental fees from vendors will offset a large proportion of the cost of the conference in the same way that advertising revenue offsets the cost of the publication of magazines and newspapers. I cannot envision why the registration fees for such conferences would rise unless there is gross mismanagement and waste.
• It would seem, however, that unrestricted corporate educational grants to the CME units of medical schools and professional societies will now be verboten. Such grants have probably been the source of much of the influence of pharmaceutical and medical device companies in the past. Perhaps this is what all the crying has been about. I personally believe that vendor funds should be tied to individual educational events and obtained in exchange for leasing tables or booths.
  

Younger Web Users as Both Consumers and Conduits of Information

One of the interesting features of the web is its echoic or multiplier effect. This is based on the fact that bloggers will frequently pick up a story that interests them and then republish it, frequently analyzing it or giving it a new twist. This effect is a key element in web marketing.  In Twitter, the process of republishing a tweet from one person so that it can then be presented to one's own followers is called retweeting.

In addition to blogs, this web multiplier effect is also illustrated by the habit of younger users to pass on to their friends items of interest that they discover on the web. This phenomenon was described in a recent article (see: Finding Political News Online, the Young Pass It On). Below is an excerpt from it with boldface emphasis mine. It makes the key point that the web multiplier effect is a more modern and powerful version of word-of-mouth.

According to interviews and recent surveys, younger voters tend to be not just consumers of news and current events but conduits as well — sending out e-mailed links and videos to friends and their social networks. And in turn, they rely on friends and online connections for news to come to them. In essence, they are replacing the professional filter — reading The Washington Post, clicking on CNN.com — with a social one....In one sense, this social filter is simply a technological version of the oldest tool in politics: word of mouth. Jane Buckingham, the founder of the Intelligence Group, a market research company, said the “social media generation” was comfortable being in constant communication with others, so recommendations from friends or text messages from a campaign — information that is shared, but not sought — were perceived as natural.

Continuing in this same train of thought, I have posted previous notes about how the cell phone has become the most common small computer in use and also a valuable means for distributing public health information (see: Making e-Health Information Accessible with Smart Phones); The Mobile Web and the Future of eHealth). Recall that many cells phones have browsers and access to the web. There is even a term used to refer to health programs and applications deployed on smart phones -- m-Health, which stands for mobile health. So, all of the elements are in place to mount youth-oriented public health campaigns focusing on issues such as obesity, exercise, alcohol abuse, and STDs. There is only one major problem with this idea -- many of the public health officials in charge of such programs do not understand the power of the medium or how to craft messages that will resonate with the young users of the technology so that they will pass it on to their friends.

I know that this sounds odd, but what we need is some sort of captivating video about, say, the risk of chlamydia infection (see: Chlamydia Infection Common but Controversy Arises About Screening Programs) such that viewers will want to pass it on to their friends.

Optimal Training and Background for a Hospital CIO

Many of the hospital CIOs I have interacted with over the years have been ineffective leaders and avid supporters of the purchase of commercial healthcare applications. Mr. HIStalk helps to explain the problem in the following recent passage on his blog:

One camp [concerning hospital CIO training] says hospital CIOs should be doctors and nurses, another says they should be the same kind of person you’d want for COO or even CFO, while the old-schoolers says the CIO should know the bits and bytes. I’ve yet to see a convincing correlation between CIO effectiveness and their background since so much depends on leadership style and the organization they work for. I do believe that hospital CIOs are too cozy with the idea that everything revolves around vendor software, often because that’s all they know. Look at how chummy CIOs are with vendors with HIMSS and CHIME – is that an admirable win-win position or is it an incestuous relationship? Either way, that’s why it’s an uphill battle for open source applications, internal development, or simply optimizing the use of what’s already been bought. Those less-sexy efforts rarely get you on the A-list of advisory boards, speaking engagements, and rah-rah magazines. Plus, lemming hospital executives are swayed by vendorspeak, too (“vision centers” are for non-IT execs looking through a gauzy and deceiving lens, for the most part, not CIOs) and not encouraging their CIOs to blaze any trails.

I concur with Mr. HIStalk that the natural instincts and training of the majority of hospital CIOs today is to select new systems, particularly EMRs, from a short list of the products available in the market. The majority, continuing in this same vein and quoting from him, are unready or unprepared to manage open source software, develop some software internally, or more fully integrate their myriad legacy systems. For the most part, this "buy over make" strategy will be solidly endorsed by their hospital executive colleagues, including CEOs. The latter know little if anything about IT and themselves have a limited bag of tricks -- managing reimbursement from payors, purchasing other hospitals, and managing new building projects. Or, in today's, challenging financial environment, shutting such projects down.

I explained the failure of hospital CEOs and CIOs to purchase adequate systems, or enhance their current systems, in a previous note  (see: EMR Failures and a Recipe for Their Avoidance in the Future)

For their part, EMR vendors continue to pursue their short-term strategy of selling inadequate and poorly designed systems that that are difficult to install, don't scale up, or perform inadequately. CIOs and CMIOs keep buying inadequate EMRs, despite the long  history of failure of these systems, because they are paid to deploy "modern" systems and there are few if any in the market that respond to their wish lists.

Given this background, it's easy to understand why the channeling of more federal money to hospitals to "enhance IT" is a recipe for a disaster. Here's a quote on this same topic from a previous note (see: Possible Adverse Consequences of Increased Federal Investment in HIT):

HIMSS execs will certainly be staking a claim on the newly available federal money on behalf of their favorite EMR companies. Hopefully, the hospital CEOs and CIOs will be able to withstand these efforts to purchase and install proprietary "pre-Internet era software" and hold out for the next generation of what hopefully will be superior products.

Where I come down on this issue of hospital CIO preparation and training is that the technical component is more important than the managerial one, both are required in some measure, and that people of this caliber are simply unavailable in most areas.

A Key Link Between Predictive and Preventive Medicine

I recently listened to a podcast by Mari Baker, previously CEO of Navigenics, in which she touched on personalized, predictive, and preventive medicine (see: Building an Organization, Building a Team). These are likely topics of interest for a former executive in the genomics testing business. She made two interesting points. The first was that Navigenics, in its early days, was in competition with 23andme which had developed a business model oriented toward consumer genomics, which is to say, personal DNA analysis. The executives of Navigenics did not initially believe that physicians would be as receptive to DNA testing as they turned out to me. In response to an increasing level of physician interest in genomics, the company shifted its focus more toward a more standard model of care, as opposed to a consumer customer base. and began marketing to physicians. The second point she made in relationship to predictive and preventive medicine was that patients whose genetic testing suggested a predisposition to a disease such as cancer would be ideal candidates for subsequent follow-up screening.

I have posted a number of notes lately about predictive/preventive medicine and particularly the role of the clinical labs in these disciplines (see: The Relationship Between Predictive and Preventive Medicine, Preventive and Predictive Medicine as Components of the Healthcare Continuum). In another recent note (see: Chlamydia Infection Common but Controversy Arises About Screening Programs), I presented the difference between screening and screening programs:

Any benefits of screening in a population will only be achieved if screening is implemented as a program. This means regular repeated screening of all those in the target population. Opportunistic screening as usually practiced does not ensure that people who have been screened once are invited for subsequent screening tests

Carry this idea about screening vs. screening programs from an infectious disease like chlamydia to cancer, assuming that early detection will be more effective and less costly than late detection. This is a central tenet of the early health model. Rather than screening the general population for a particular cancer(s), one should develop screening programs focusing on patients who are genetically predisposed to the cancer as, for example, those with a strong family history. Those who test positively will be the subsequent target for biomarker or IVDMIA screening for the development of the actual neoplasm as evidenced by the circulation of abnormal proteins or abnormal amounts of normal proteins. Of course, such reliable biomarkers/IVDMIAs may not exist at the present time for a wide variety of neoplasms but they surely will be developed in short-order. Of course and in the case of BRCA1 and BRCA2, the neoplasms may be so aggressive and fast-growing that some patients may elect for prophylactic resection of those organs predisposed to the development of the cancer.

UpToDate: Access by Consumers to One of the Best Sources of Medical Knowledge

I have posted notes in the past about the topic of converging access to medical knowledge by which I mean that physicians, healthcare consumers, and patients are often acquiring medical information from the same source (see: All Media is One: Convergence and Accessibility of Medical Knowledge). In this note and as evidence for my conclusion, I cited the long-standing access of consumers and patients to PubMed which is an archive of medical journal articles. I just recently learned that healthcare consumers and patients can now pay a modest fee for the same access to UpToDate that physicians enjoy. Here is how this web-based service describes itself on its home page:

The UpToDate community includes our faculty of more than 4,000 leading physicians, peer reviewers, and editors  and over 360,000 users. Our faculty writes topic reviews that include a synthesis of the literature, the latest evidence, and specific recommendations for patient care. Our users provide feedback to the editorial group. This community's combined efforts result in the most trusted, unbiased medical information available. Patient/consumer subscription options for UpToDate include the following two choices: One-month (30 day) subscription ($44.95) and one-week (7 day) subscription for $19.95.

As noted in the company's self-description, it provides an integrated synthesis of the medical literature by topic accompanied by specific recommendations for care. Its assertion that it provides the most trusted, unbiased medical information available is not marketing hype -- it's an outstanding resource. In fact, it is so authoritative and the prose so dense that I suspect that even some physicians may have difficulty wading through some of the entries. So we now arrive at the moment of truth. Patients and consumers, for a modest fee, have identical access to the same information about diagnosis and treatment available to physicians. How, in fact, should they leverage this access to increase their chances for optimal treatment in our healthcare environment?

If I were a healthcare consumer with a diagnosed serious disease, or in the early stages of the diagnosis of one, here's what I would do:

• Subscribe to UpToDate for one month (or more as necessary).
• Work my social network to find the best physicians I could find who would be willing to sit down with me in front of the computer and review the relevant entries in UpToDate regarding the diagnosis and treatment of the disease.
• Such physicians should be as neutral as possible regarding my diagnosis and treatment, which is to say that they would have no stake in the outcome of the discussion other than as a friend.
• I would develop an understanding of the optimal diagnosis and treatment plan for patients such as myself, taking into consideration factors such as age, financial status, and tolerance for risk.
• I keep these facts in mind, and refer to my notes, as I discussed the various options presented to me by my physicians.

For some patients, a preliminary first step, rather than paid access to the physician side of UpToDate, could be its free patient portal that comes equipped with its own search engine. This service provides access to medical information tuned for a consumer audience. If this material proves to be insufficient, there is a link on the patient portal page to subscribe to "physician-level" information for a fee.

Upcoming AACC Audioconference on Autoverification of Lab Test Results

The autoverification of lab test results has an interesting history. This is a process by which algorithms installed within an LIS verify that selected results are correct and can be released to the test-ordering physician. If the LIS is doing its job properly and the algorithm is designed properly, autoverification is a task best performed by a computer rather than a human operator. You can read more about autoverification in a brochure entitled Autoverification of Clinical Laboratory Test Results; Approved Guideline that was published by the Clinical and Laboratory Standards Institute, formerly NCCLS. The lead author of this publication is Dr. William Neeley.

The AACC is presenting an audioconference entitled Leveraging Autoverification for Greater Lab Efficiency on Wednesday, April 22, 2009, at 2:00-3:30 pm Eastern time.

Major points to be covered in this presentation include the following:

• Add new layers to your autoverification program, learning from real-world examples of the rules and delta checks experts use
• Create time-saving and useful multi-component algorithms
• Optimize the capabilities of systems with and without middleware
• Manage QC frequency using autovalidation
• Verify autoverification ranges for CAP and other accrediting organizations
• Test and maintain your autoverification rules

Faculty include the following experts on the topic:

• Jay B. Jones, PhD, (Moderator), Director of Chemistry & Regional Labs, Geisinger Health System, Danville, PA
• William Neeley, MD, Medical Director of Laboratories, Detroit Medical Center, Detroit, MI
• Susan Dawson, MS, Clinical Lab Manager, Swedish Covenant Hospital, Chicago, IL

Earlier in my career, there was certain suspicion about autoverification caused, in part, by lab inspection guidelines that required human (i.e, medical technologist) verification of test results prior to release. My frustration about this regulation, subsequently changed, was that I believed that humans were inferior to computers in performing this task and it caused degradation of quality. In my opinion, some of the opposition to autoverification at that time was also the result of a concern for protecting FTEs. These days and with the well-documented shortage of medical technologists (see: A New Resource for Information about the Medical Technologist Shortage), there is no good excuse for not using autoverification in any lab.

Chlamydia Infection Common but Controversy Arises About Screening Programs

Chlamydia may not be as well known as gonorrhea or syphilis but it is the most common bacterial sexually transmitted disease (STD) in the United States with more than 2.8 million new cases estimated to occur each year according to the CDC. I have posted previous notes about this problem (see: Chlamydia Reports to CDC Hit All Time High, Direct Access Testing for STDs). Now comes the news that screening for chlamydia in the U.S. is inadequate (see: Fewer than half of U.S. women screened for chlamydia). Below is the story with boldface emphasis mine:

Fewer than half of vulnerable U.S. women are being screened for chlamydia, a common sexually transmitted disease that often causes few symptoms but can lead to infertility....Screening rates have spiked up from 25 percent in 2000 to nearly 42 percent in 2007, but that is still far too few women being screened, the team at the U.S. Centers for Disease Control and Prevention reported...."Chlamydia trachomatis infection is the most common bacterial sexually transmitted disease (STD) in the United States, with more than 2.8 million new cases estimated to occur each year," [according to CDC researchers]. "During 2007, approximately 1.1 million cases of chlamydia were reported to CDC; more than half of these were in females aged 15 to 25 years." It often causes few or no symptoms and if not treated with antibiotics can cause pelvic inflammatory disease, infertility, chronic pain and ectopic pregnancy, which is a pregnancy outside the uterus -- something that can kill the mother or the baby. Men and women alike can be infected with chlamydia and can re-infect one another if only one sexual partner is treated. It can make men sterile, too, but only rarely. Chlamydia can be passed to a newborn and can cause pneumonia and conjunctivitis, or pink eye. The CDC recommends yearly chlamydia testing of all sexually active women 25 or younger, older women who have a new sex partner or multiple sex partners, and all pregnant women.

It turns out that there is controversy in public health circles about what constitutes an optimal chlamydia screening program. Population-wide screening programs for chlamydia may not actually work, according to Dr. Nicola Low, an epidemiologist at the University of Bern. According to her, this opinion is particularly relevant for so-called "opportunistic" programs whereby patients are routinely tested for chlamydia whenever they seek medical care (see: Chlamydia Screening Programs Don't Work: Expert). Here's how she distinguishes between screening and a screening program:

"There is a difference between 'screening' and a 'screening program,' " Low said. "Any benefits of screening in a population will only be achieved if screening is implemented as a program. This means regular repeated screening of all those in the target population. Opportunistic screening as usually practiced does not ensure that people who have been screened once are invited for subsequent screening tests."The bottom line, according to the Swiss expert: "Low overall coverage and infrequent screening will not control the spread of an asymptomatic, infectious disease."

I am certainly no expert in this area but it strikes me as unusual that there is no unanimity of opinion among public health experts about a topic as basic as the optimal way to screen populations for an STD.

:: Update on 6/30/2009 @ 3:20 p.m.

See: Chlamydia, the Silent STD That Can Cause Infertility