Chronic, nonmalignant pain is a substantial public health problem in the United States. Research over the past 2 decades has defined chronic pain by using a "biopsychosocial model" that considers a patient's biology and psychological makeup in the context of his or her social and cultural milieu. Whereas this model addresses the pathology of chronic pain, it also places many demands on the physician, who is expected to assess and manage chronic pain safely and successfully. There is a growing body of evidence suggesting that opioids can be effective in the management of chronic pain, but there has also been a rise in opioid-related overdoses and deaths.Clinicians should be aware of assessment tools that may be used to evaluate the risk of opioid abuse. A basic understanding of chronic pain pathophysiology and a uniform approach to patient care can satisfy the needs of both patients and physicians. pain is of short duration and quickly forgotten. Unfortunately, for some the pain does not pass but becomes a continuous burden, an unrelenting suffering, and the "perfect misery" described in Paradise Lost.1 With these patients, however, the physician faces one of the greatest challenges: the relief of chronic pain.In a 2011 report, authors at the Institute of Medicine 2 underscored that "effective pain management is a moral imperative, a professional responsibility, and a duty of people in the healing profession." Nonetheless, few physicians are formally trained in effectively managing pain, and achieving this goal remains problematic.In the current review we examine chronic pain, discuss theories regarding its cause, evaluate nonpharmacologic and pharmacologic therapy, address the unique aspects of prescribing opioids, and provide a list of take-home points regarding the problem of chronic pain (Figure 1). Chronic pain is defined as pain that persists for longer than 3 to 6 months, or the "normal healing" time of an injury. 2 A physician may be frustrated by the lack of objective findings in a patient with chronic pain, because the extent of an injury does not always correlate with the severity of the patient's discomfort.The "biopsychosocial model" is currently accepted as the optimal conceptual approach, 5 one that envisions chronic pain in terms of the biological parameters in conjunction with the psychological, social, and cultural contexts of the patient. processing. Melzack 6 developed the "neuromatrix theory," which suggests that pain is "produced by the output of a widely distributed neural network that is genetically determined and modified by sensory experience." Accordingly, chronic pain is affected by neural output and not only by sensory input from tissue injury.

Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005–12. The most common contributing factors noted in the reports included coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of short-term follow-up. Other contributing factors were team-level decision making problems resulting from miscommunication of urgency between providers and providers' lack of awareness of or knowledge about a patient's situation; and communication failures among providers, patients, and other health care team members. Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination.

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A computerized CDSS performed relatively accurately compared to clinicians for assessment of asthma control but was inaccurate for treatment. Pediatric pulmonologists failed to follow guideline-based care in a small proportion of patients.

Purpose To investigate use of a new guideline-based, computerized clinical decision support (CCDS) system for asthma in a pediatric pulmonology clinic of a large academic medical center. Methods We conducted a qualitative evaluation including review of electronic data, direct observation, and interviews with all nine pediatric pulmonologists in the clinic. Outcome measures included patterns of computer use in relation to patient care, and themes surrounding the relationship between asthma care and computer use. Results The pediatric pulmonologists entered enough data to trigger the decision support system in 397/445 (89.2%) of all asthma visits from January 2009 to May 2009. However, interviews and direct observations revealed use of the decision support system was limited to documentation activities after clinic sessions ended. Reasons for delayed use reflected barriers common to general medical care and barriers specific to subspecialty care. Subspecialist-specific barriers included the perceived high complexity of patients, the impact of subject matter expertise on the types of decision support needed, and unique workflow concerns such as the need to create letters to referring physicians. Conclusions Pediatric pulmonologists demonstrated low use of a computerized decision support system for asthma care because of a combination of general and subspecialist-specific factors. Subspecialist-specific factors should not be underestimated when designing guideline-based, computerized decision support systems for the subspecialty setting.