OncologyLive® is the flagship publication of OncLive®. Each issue delivers expert insights and clinical oncology news and updates, which impact the day-to-day clinical practice of oncology professionals who work tirelessly to help improve patient outcomes.

Does it seem like everyone in the world has suddenly created a profile on Facebook and wants to become your “friend?” If you already use social networking sites like Facebook, MySpace, Friendster, and Twitter, then read no further. But if you think a Twitter produces the high notes in your stereo speakers and a Facebook is your old high school yearbook, this column is for you.    

For most of our lives, “socializing” meant attending a function or event in person, meeting people, and making small talk. “Networking” meant meeting someone through a common bond with a third person. Today, thanks to the Internet, social networking has an entirely different meaning. In place of face-to-face meetings, social networking now occurs online, mediated through a “profile” or some other form of Web page that represents you to the rest of the world. People frequently use these pages to express themselves, share their interests, and post updates about their personal and professional lives. People become “friends” or “colleagues” by linking their pages together. 

The 800-pound gorilla of the social networking space right now is 

. Started by a college student who wanted to create the online equivalent of the “facebook” typically given to freshman at college orientation, Facebook today has tens of millions of members. When you join Facebook, you select a user name and password and then create a profile page. You can add pictures, videos, and as much information about yourself as you want. If you enter your school and work affiliations, Facebook will automatically seek out and find people you may know based on those associations. 

Something strange will happen not long after you set up a Facebook page: old friends and colleagues you haven’t heard from or thought about in years will invite you to become their “friends.” Unless you accept their invitations, these people cannot see your page or any of your personal information. Once you do accept, you can view the other person’s page and be added to their network and vice-versa. Facebook pages can also be created for companies, organizations, and groups. So, your Facebook page might have connections with your college alumni page, medical school alumni page, and a Grateful Dead fan page. 

If you’re part of the Gen-X or baby boomer generations, this decade’s earlier social networking phenomenon, MySpace, almost certainly passed by you unnoticed. MySpace seemed to be tailor-made for hormone-crazed pre-teens, teenagers, and adults obsessed with acting youthful. MySpace offers much less privacy than Facebook; anyone can see your MySpace page (Check out my attempt at 

Twitter deserves special mention, not only because it is currently all the rage, but also because I believe it represents one of the worst aspects of social networking—the narcissistic need some people have to update everyone in their network on exactly what they are doing at that very moment. In all seriousness, people use Twitter to broadcast things like: “I just ate an apple” or “I’m stuck in traffic.” To be fair, I have seen it used for slightly more productive purposes, including providing live, near-instant updates from meetings and conferences. 

There are also several professional social networking sites for physicians and other healthcare providers. Probably the most popular of these is Sermo.com, but others include DoctorsHangout.com, DoctorNetworking.com, and PhysicianOnline.com. I don’t use these sites, but they offer a highly focused forum for professional and social exchange between medical practitioners. 

Whether you want to locate an old boyfriend or girlfriend from college, or just network with other pediatricians practicing in Chicago, there is probably a social networking site for you. Don’t be afraid to try social networking, but don’t be foolhardy in how you approach it. Try to minimize the amount of financial or personal identity information you give out online, and don’t download software or files from anyone you don’t trust. And remember: the information you post is now public information that will be online forever, so don’t brag about anything that could derail your chances to become the next Surgeon General. 

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.   

Articles

Does it seem like everyone in the world has suddenly created a profile on Facebook and wants to become your "friend?" If you already use social networking sites like Facebook, MySpace, Friendster, and Twitter, then read no further.

Social Networking Comes of Age

Physicians who see Medicare patients are practicing in very difficult times. The Obama administration wants to continue to not only cover the elderly who pay for an insignificant portion of their healthcare but to also add on an extra 40 million people who currently are uninsured. President Obama wants to 

 primarily through taxing the rich and Medicare cutbacks. 

The administration wants to set limits on payment growth for medications, hospitals, and physicians by implementing a nationwide certified EHR (c-EHR) system, which can be used to control physician independence, to further strain the physician—patient relationship, and to facilitate 

 by government bureaucrats of the way that healthcare is administered. 

On February 13, Congress passed the $787 billion economic stimulus bill, which, among other things, calls for up to an eventual 5% penalty for non-participation in new HIT mandates if 

 75% of physicians are “meaningful c-EHR users.” Through the bill, Congress wants physicians to pay for a c-EHR system that is costly in terms of software, hardware, and training. The Department of Health and Human Services (HHS) has yet to define what constitutes “meaningful use” of a c-EHR, but pundits say it will include e-prescribing, decision support, and quality data reporting, functionality that will require increased computer time for physicians and less face-to-face patient time. Adopting these technologies may well hamper a physician’s ability to see enough patients in order to maintain the financial viability of his or her practice. This administration wants to 

 who perform according to the stringent usage and reporting parameters up to a paltry $44,000 over five years, if they do manage to get paid at all. 

PC_HR.1_0409.JPGThose physicians who are not planning to comply with these new Medicare mandates have options that can actually stabilize, and possibly increase, their gross office incomes: 

1) Change your Medicare participation status from a participating provider to a non-participating provider, which allows you to legitimately increase reimbursement by charging the “limiting fees,” which represent the maximum allowable reimbursement (15% over Medicare’s approved amount). To learn more about the plusses and minuses of becoming a mid-level participant, check out 

www.acponline.org/pmc/ medicare_options08.pdf

2) “Opt out” and quit your Medicare participation altogether. Generally, you need to sign an opt-out affidavit that, among other things, states that you cannot re-apply for Medicare participation status for two years. The good thing is that you can then contract any fair payment arrangement directly with patients. 

3) Add an extra patient a day (say, $75 x 200 days) for an off set of $15,000 a year, or an increased income of $75,000 over five years. 

4) Start a cash-only ambulatory acute care clinic, which is associated with-on-the-spot payments and no third-party intermediaries. 

5) Start a “concierge clinic,” charging patients a yearly amount that covers issues such as availability and expediency. 

6) If you’re in a solo practice and it becomes untenable, but you still wish to provide patient care, then join a group, begin visiting nursing homes, become a hospitalist, or become a full-time clinical professor at your local medical school. There will be no overhead costs, and you’ll receive a stable paycheck. 

7) Change careers—become an author, a researcher, or a professor. 

These are all difficult choices, but the practice landscape is changing quickly, requiring all of us to make important, well-informed decisions regarding our futures. 

Whatever alternative choice you make will send a message to Congress that the bailout bill HIT provisions are driving out physicians from the Medicare program. 

Alberto Borges, MD, is in private practice and is an associate clinical professor of medicine at the George Washington University in Washington, DC. Check out his website at 

The opinions expressed in this column do not necessarily reflect those of 

Physicians who see Medicare patients are practicing in very difficult times.

Congress Passed the Stimulus Bill; What Should You Do Now?

Viruses and other malicious software can quickly and easily ruin a computer’s program and files. What should you know about malware, what can you do to protect your computer, and what should you do if your computer becomes infected?    

Healthcare providers spend their professional lives fighting attacks on the human body. Do they need to worry about attacks on the computers they use in day-to-day practice? Unfortunately, the answer is yes. The dangers to computers today are greater than ever. 

The good news is that protective technologies provide ever-better methods for safeguarding computer systems. Those tools are complex, and applying them appropriately as part of an overall security strategy requires some technical expertise. Although large groups and institutions have professional IT staffs to worry about all this, physicians in small groups or solo practice have to be more self-reliant.  

The malware problem really is worse than ever 

The threat from malicious software continues to grow at an explosive rate. The number of new viruses, worms, and other types of “malware” detected in 2007 was double that for 2006; new variations detected in 2008 were triple the 2007 numbers. Indeed, there were more 

 discovered in 2008 than in all the previous years for which records are available combined. 

Do lots of variations translate into lots of actual threats? Indeed, yes, and the threat is nearer than you probably think. You may have heard that countries like Russia and China were What Is Malware and Viruses and other malicious software can quickly and the sources of most of the Internet’s plagues. Those may be among the more popular points of origin, but more malware is actually hosted on American websites, and more spam is relayed from American computers, than in 

This doesn’t mean the US is full of Internet criminals. It means it’s full of computers that have been infected and hijacked by Internet criminals to do their nefarious work. It’s 

 that 10-15% of all computers worldwide are infected.

What is malware, and how do infections occur? 

Malware is an umbrella term for destructive entities, such as viruses, worms, Trojan horses, and spyware. The common factor is that these digital invaders alter the way a computer operates, without the permission or knowledge of the user. 

In a simpler time, the primary way a computer got infected with malware was by physical contact—sharing files on portable storage media like floppy disks. Today, malware more commonly arrives in e-mail messages, either in an infected file attached to the e-mail or via an enticing Web link within the message. 

Malware can also be embedded in a downloaded file (eg, an image or music file from a peer-to-peer service). Or it can enter through an open network connection, without any inadvertent abetting action by a human user, if a computer does not have appropriate security protections. 

Some malware inflicts damage directly on the computer that has become its host, by altering data files or programs. Particularly vicious malware can destroy the contents of a computer’s hard disk entirely, or other wise render the system unusable. 

Other varieties commandeer the infected system to use for reproduction. Destructive possibilities include using the compromised system as a “bot”— also sometimes called a “zombie host”&mdash;with the collection of such infected systems forming a massive “botnet” of infected computers. The infected bot systems can be used for launches of denial-of-service attacks (flooding a target website with requests) or for mass export of questionable materials (such as pornography or spam).  

In addition to wreaking obvious havoc with files and programs, malware may announce its presence by displaying text, graphics, or audio (some creators like to brag). Alternatively, malware may operate entirely in silence unless/until discovered or an internal “sunset” clock shuts it down. Lack of obvious symptoms is no guarantee of a clean bill of health. 

www.f-secure.com/en_EMEA/security/security-lab/latest-threats/security-threat-summaries/2008-4.html

Can protective software prevent malware infection? 

The traditional method of defense is to rely on detecting the “signature” of malicious software—that is, the unique bit pattern of the computer code that constitutes the malware. Protective software should be set to check all incoming e-mail and e-mail attachments, all files downloaded from websites, and all files transferred from removable media (floppies, CDs/DVDs, flash drives). It should also be set to scan a system’s entire hard drive regularly, to detect malware that has made it past the initial scans. 

Most anti-malware software now also looks for the suspicious network communications and traffic patterns typical of malware—sometimes called “behavioral” detection. New malware variations disperse through the Internet so fast that it is not possible to rely on signatures alone, even if those signatures are continually updated. Hence, the reliance on behavioral tools as well. 

Other forms of protection, like “intrusion detection/prevention systems” and “firewalls,” rely on varying combinations of signature and communications pattern approaches. Here, as in so many other areas of information security, it’s usually necessary to have more than one form of defensive strategy, so that all is not lost if one barrier is compromised. 

In a large corporate network, antimalware software (and hardware) is deployed in multiple layers: on the network routing devices, on the server computers providing shared services, and on each individual personal computer connecting to the network. In a small office, you need to worry mainly about the personal devices. “Firewall” software (or hardware) to detect intrusions over network connections is also highly recommended for small office networks and at-home systems. 

As noted at the outset, putting these pieces together appropriately requires some technical skill. It’s recommended that you consider contracting out for this, unless you are confident in your own skills. Security is one area of computing life in which it does not pay to pinch pennies. 

When appropriately deployed, the combinations of automated defenses are quite robust. But human behavior is still the key. By clicking on a link in an e-mail or on a website, you can instantly infect your computer—and very quickly possibly infect other computers in the same part of the network&mdash; before the pattern and signature defenses have had time to react and isolate the infection. 

Fortunately, the human behaviors to prevent this are relatively easy to list: don’t click on a link unless you have complete confidence in the e-mail or website containing that link. Make a habit of checking where a link is actually going; the address will typically display when you hover your cursor over the link. And never provide your user ID and password to a website unless you are sure it is a site authorized to ask for those credentials. 

What do I do if my computer gets infected? 

Anti-malware software will intercept and isolate any problems it detects and attempt to un-do any associated damage to critical system files. But not all infections can be reversed, and some data files may not be recoverable. In extreme cases, you may be required to re-install your computer’s operating system, which will erase all your data files. You will need to re-install other software as well. 

For this reason—as well as the ever present risk of hard drive failure&mdash;I strongly recommend that you have secure backup copies of your files. If the files relate to something critical, like your clinical operations, you can’t have too many backups. The countervailing constraint is the expense of storing those backups in a secure place. It is fine to keep some of the backups close by, but some should also be transferred to a physically distant location safe from both human and environmental threats. The latter are particularly important to consider; fire and water hazards show up much more in the insurance claim statistics than you might imagine. 

Most people, in my experience, plan to make adequate regular backups— the reason to do so is obvious, after all&mdash;but nearly nobody does. Your best bet is to install software that automates the process.  

#1 Be cautious about e-mail attachments. Unless you are sure the e-mail is from a reliable source, don’t open the attachment. Scanning with anti-malware software is a good safety step, but the newest viruses may still get through. Be conservative about your own use of attachments. Cut and paste plain text into e-mails whenever possible. 

#2 Be cautious about file downloads. Even files from seemingly reliable places can contain malware. Downloads from malware havens like peer-to- peer networks are practically guaranteed to produce an infection sooner or later. 

#3 Be cautious about links in e-mails and online. Links can trigger file downloads or start up executable files. 

#4 Use appropriate security settings. Your computer’s operating system, browser, and e-mail software can be set to protect you against the most common forms of attack (eg, by disabling macros and scripting languages). 

#5 Keep your anti-malware software up to date. Protective software must be regularly updated with new “signatures” in order to be effective at detecting the newest infestations. Fortunately, most products can be set to install updates automatically. 

#6 Keep up with upgrades for your computer’s operating system, Internet browser, and e-mail software. Malware designers target software vulnerabilities, particularly those for which “patches” have recently been issued. Use whatever automatic update features are available for these, too. 

It is common to refer to all malware as “viruses”—and protective software is still sometimes called “anti-virus”&mdash;but there are also worms, Trojan horses, spyware, and other virtual life forms with which to contend. Today’s malware writers build increasingly complex hybrid beasts that blur the traditional categories. The formal differences are these: 

 require a host for survival and reproduction, just like their biological namesakes. Viruses must insert their code into an application like Word or Excel, or a data file for such programs, particularly ones that have macros or a scripting language capability. Worms, by contrast, are self-replicating programs that do not need a separate software host. 

 are generally “network-aware” creatures that can propagate by seeking out other connected computers within adequate defenses. 

 are programs or data files that appear benign but carry a malicious payload, like a virus. The term owes its origin to the famous wooden horse from Homer’s Iliad, doing to the host computer what the Greeks did to Troy. 

 is any software that aims primarily to extract information, either by harvesting data stored on computers or by monitoring a user’s computer activities. Companies that promulgate the less-invasive forms of spyware—designed primarily to track your behavior for marketing purposes&mdash;prefer the term “adware.” However, since spyware is generally installed without users’ knowledge, and does things that most users do not desire, it probably deserves to be labeled as malicious, too. Spyware once required different protective software, but most “anti-virus” software can detect it now. 

Do you maintain up-to-date anti-virus protection and other safeguards for your office computer systems? Has your system ever been infected with a virus or other form of malware? Have you ever hired an outside IT consultant for your practice?

Dr. Cushman is the director of operations and user support in the Medical Information Technology department of the University of Miami Health System and School of Medicine. 

What should you know about malware, what can you do to protect your computer, and what should you do if your computer becomes infected?

What Is Malware and Why Should I Worry About It?

Carmel Pharma introduces PhaSeal’s new Injector Luer Lock N35, an intuitive component of the market’s only clinically proven closedsystem drug transfer device for the safe handling of hazardous drugs. Designed around the same dependable Injector that helped make PhaSeal the “Gold Standard in Safe Handling,” as distinguished by clinical thought leaders, the N35 features simple turnkey motion, a built-in locking mechanism, a secure grip, and an easy access connection, enabling quick and efficient use, from preparation and administration to waste disposal. For more information, visit 

Imagine how much more effective venipunctures would be if you could locate the patient’s veins beneath the skin. Now you can! The AccuVein AV300 is a revolutionary, portable, noncontact vein illumination device that can help make IV starts and blood draws more successful. For more information, visit 

SenoRx’s new SenoSonix model, like its predecessor, integrates a breast biopsy system with ultrasound imaging; however, this new version incorporates microminiaturization ultrasound technology, offering personal computing power, flexibility, and portability. The modular design and sophisticated imaging architecture are available in a reduced footprint, allowing it to be used in both an office setting and the hospital surgery suite. For more information, visit 

Here are three new products that oncology professionals might be interested in learning more about.

Product Spotlight

Navigating the EHR marketplace can be dizzying, with numerous products available to choose from, including locally installed client/server systems that require server hardware, local networks, data backup, and IT support, as well as hosted, Web-based systems. Although most platforms are built on the presumption that physicians will pay for the EHR, some follow other business models, resulting in low-cost or even free opportunities. With a myriad of options available, you may wonder how to determine which system is right for your oncology practice. Should you pick a general-purpose EHR that has oncology modules added on or an EHR that is designed specifically for oncology practices? Regardless of which of these you choose, there are several key general and oncology-specific features you should be looking for. Let’s examine these features to make your experience shopping for an EHR less daunting. 

Physicians have many workflow patterns in common, regardless of specialty. The following general features are essential to keep any practice running smoothly, so be sure any EHR you consider offers them:  

• Ability to create chart notes easily using specialty-specific templates, preventing you from being slowed down by cumbersome data entry tasks. Ideally, the system should enable dictation/transcription and free-text typing and provide templates that can minimize typing. 

• Capability to integrate billing, either as an in-the- product billing application or the electronic equivalent of generating a superbill as a message transmitted to a biller. 

• Availability of electronic prescribing, which is becoming increasingly important now that CMS is placing a bonus on services rendered by practices using electronic prescribing. 

• Capacity to create and maintain diagnosis lists, medications lists, and refill histories, whether by electronic prescribing, written prescriptions, samples given, or parenteral medications administered. 

• Ability to access records remotely.  

If all of the EHRs you are entertaining provide these features, another distinguishing general feature you can look for is the ability to write reports to referring physicians or others involved in the care of complex patients. This feature may be especially useful to oncology practices, where patients often require multidisciplinary care.  

Some of the workflows oncologists experience are unique to this specialty. The following oncology-specific features can help meet some of the specific needs encountered in an oncology practice: 

When a cancer diagnosis is made, there are several “auxiliary” elements that need to be associated with it, including tissue type (the ICD9 number), TNM classification and staging, and, in some cases, tumor grade. Ideally, an EHR should have a tumor-specific algorithm that allows quick specification of T, N, and M, and suggests a stage based on the results. There should also be a variable or free-text way of including additional descriptors, such as genetic markers, which will vary from cancer to cancer. Once this is specified, links should be generated that point to the most current treatment options available. 

Decision support at the point of care is one of the most important functions that a good EHR can provide, as evidence-based algorithms for the treatment of cancers are evolving rapidly. An EHR needs to be able to point you to the most current data, rather than trying to include them in the product itself, which would render them obsolete from day one. The EHR should also be able to automatically point to a list of resources based on tumor type and stage, TNM classification, and grade, and the generated resource links should be automatically assembled so that “chasing down” links through a succession of clicks is minimized. Ideally, these links would also include the most current data on any available genetic-marker testing, including any evidence showing some or no impact on outcome, both of which may be relevant to decision making. 

The array of treatment protocols appropriate for a given cancer and stage, along with any other appropriate markers, should be displayed via a link to trusted reference sources. Such access to the ever-evolving data is essential for optimizing patient care, reducing treatment variability across the oncology landscape, and minimizing liability. 

Chemotherapeutic agents must be monitored much more aggressively than medications commonly prescribed in the ambulatory, go-to- the-pharmacy setting. A good EHR will offer more than drug—drug interaction warnings; it will also provide you with dosing, duration, and frequency of medications and infusions, which are heavily influenced by laboratory findings. Ideally, the EHR would prompt you on a patient’s lab findings and automatically adjust the regimen accordingly. At the very least, links to resources should be provided. 

Because chemotherapy treatment is generally administered through in-office infusions, a good flowchart for documenting infusion sessions should be available in the EHR. This capability would allow both nursing staff and physicians to document these encounters in a coordinated manner. 

Unlike other specialties, where laboratory work is largely outsourced, much of the lab testing in oncology practices is performed in-house, especially those related to chemotherapy. While most of the decision making will be determined by in-house lab test results, the ability to link with an outside reference lab is still an important feature, especially with genetic-marker testing becoming increasingly important. Nevertheless, since in-house lab testing is the norm in oncology, an interface should be provided to allow entry of these lab values into the system, either manually or via an interface within-house lab equipment. 

An oncology patient has complex needs for an episode of care, especially during the initial phase of chemotherapy. During this time, multiple visits and lab tests need to be scheduled and care with other specialties needs to be coordinated, including surgery, radiation oncology, and primary care. The ability to schedule all of these appointments in one place is beneficial to patients and to everyone involved in administrating care. Because scheduling is so complex in the oncology setting, a system that allows spreadsheet-like appointment grids is particularly useful. 

Some EHRs offer a patient interface, allowing patients to access certain routine items, such as scheduled visits, lab test results, medication and allergy information, and perhaps some wellness-prompting items, such as mammography screening and vaccination reminders. Few diagnoses, however, evoke as much fear and attention in patients as cancer. These patients have urgent questions and desperately seek as much information as possible about their disease. Unfortunately, the Web is filled with “information” that is not evidence-based or that simply panders to patients’ fears. An EHR that provides a patient interface that also offers a Web portal to good, reliable, patient-oriented links about the patient’s specific cancer type, prognosis, and treatment, including anticipated outcomes and anticipated treatment experience, provides a great service and is well worth considering. 

Although all EHRs are intended to help physicians document patient encounters and facilitate the workflows carried out in day-today practice, not all EHRs are created equally. While oncologists have a number of workflow elements in common with other specialties, including the need for chart note creation and the ability to review outside lab results and imaging studies, general-purpose EHRs won’t be able to address the unique workflows encountered in an oncology practice. To choose the EHR tool that will best meet the needs of your oncology practice, look for one that incorporates as many of the aforementioned oncology-specific features as possible. 

Will your practice be implementing an EHR system in 2009? If so, do you think you will be inclined to use it? If you have already gone paperless in your practice, are you happy with your EHR? Are there any features that are lacking?

Robert Rowley, MD, is chief medical officer of 

Navigating the EHR marketplace can be dizzying, with numerous products available to choose from, including locally installed client/server systems that require server hardware, local networks, data backup, and IT support, as well as hosted, Web-based systems.

Navigating the EHR Marketplace How to Choose the Right EHR for Your Oncology Practice

Even if you did not support the American Recovery and Reinvestment Act, commonly known as the stimulus package, you should be aware that one of its provisions—the HITECH Act&mdash;could help or hinder your future income. The law authorizes approximately $20 billion to encourage widespread adoption of health-information technology (HIT), described as EHRs, PHRs, health information exchange, CPOE, clinical decision support systems, and e-prescribing. 

The HITECH Act allocates the bulk of the $20 billion for incentive payments to physicians who treat Medicare/Medicaid enrollees, a boon for practices eager to go electronic. Medicare/Medicaid will pay generous bonuses to physicians who demonstrate “meaningful use” of a health IT system, as defined by the HHS. Physicians using an approved HIT system by 2011 or 2012 qualify for annual bonuses over 5 years totaling as much as $44,000 (see sidebar on page 28). Waiting until 2013 to adopt a system nets you a maximum of $39,000 over 4 years, and procrastinating until 2014 cuts the total to a cumulative $24,000 over 3 years. Physicians serving in a “provider shortage area” are eligible for a 10% increase to their incentive payments. If you collect the Medicare HIT bonus, you will no longer be able to receive the current incentive payments for e-prescribing. 

Medicaid has a separate bonus schedule from Medicare. If at least 30% of your patients (20% for pediatricians) are covered under Medicaid, you are eligible to collect up to $64,000 over 5 years, provided you have not received Medicare bonus payments. Nurse practitioners and nurse midwives can also apply for the Medicaid incentives. 

Did you know that if your practice treats Medicare patients but does not transition to a paperless system by 2015, money will come out of your pocket instead of going in? Starting in 2015, physicians not using an HHS-approved HIT system will see cuts in their Medicare reimbursement fees of 1%. The penalty increases to 3% by 2017 and persists, unless the practitioner receives a hardship exemption. If 85% of the nation’s physicians and hospitals have not gone electronic by 2018, HSS can cut fees for noncompliance another 2%. 

Further, if you fail to adopt an EHR system that uses e-prescribing, you will be penalized twice: once under the HITECH Act and once under the Medicare Improvements for Patients and Providers Act, at least until 2014 when Medicare phases out e-prescribing penalties. Medicaid does not penalize physicians for noncompliance with the HITECH Act. 

Simply setting up an HIT system is not enough. Physicians must be able to show HHS that they are using the system “in a meaningful way.” HHS has until the end of 2009 to issue specific guidelines on what “meaningful” means, but current law specifies the following: 

• An EHR with e-prescribing capability per current HHS standards; 

• Connectivity to other providers to improve access to a patient’s entire health history; 

• Ability to report on use of the technology to HHS.  

Some physicians may have already shelled out a small fortune on a system that will not meet HHS specifications. If they cannot upgrade the system to meet the guidelines, they might have to start from scratch with a new vendor. 

In May 2008, the Congressional Budget Office (CBO) estimated that adopting a standard health IT system would cost the average physician $25,000 to $45,000, with annual outlays of $3,000 to $9,000 to maintain the system. In an effort to reduce the financial burden of implementing an HIT system, Congress designated some of the stimulus money to institute a national HIT coordinator at HHS. The IT coordinator is tasked with securing a government-sponsored EHR system that physicians and other healthcare providers can purchase for a nominal fee, which has yet to be determined. 

Physicians will still have the option of buying an HHS-approved system from a private vendor, but they run the risk of having an obsolete system on their hands if the vendor should go bust. A number of startup companies are likely to emerge in the next few years to take advantage of the demand for HIT, making this is a very real danger for physicians. 

In an analysis of the HITECH Act, CBO projected that, by 2019, 70% of hospitals and 90% of physicians will have an EHR system in place. CBO also predicted “its adoption on a nationwide basis would reduce total spending on health care” in several ways: reducing inappropriate tests and procedures, decreasing medical errors, cutting the administrative overhead, and improving diagnosing and care. CBO concluded the HITECH Act would reduce federal spending on Medicare, Medicaid, and the Federal Employee Health Benefits programs by $12 billion from 2011 to 2019. CBO said that because the measure would lower healthcare costs overall, private insurers, employers who provide health insurance, and people without insurance, would also benefit. 

Many physicians and patients have qualms about instituting the technology, citing patient privacy as a major concern. Other physicians welcome the measure, particularly those who have grown up in a digital age. At this point, whether you support it or not, the ship has left the dock and physicians who fail to get on board could pay a hefty price in the coming years. 

Christin Melton is the managing editor of 

Even if you did not support the American Recovery and Reinvestment Act, commonly known as the stimulus package, you should be aware that one of its provisions—the HITECH Act—could help or hinder your future income.

Go Paperless, or Pay the Price

Twitter started with the desire of a young software engineer named Jack Dorsey to know what his friends were doing in real time. Wondering if a platform could be built around the concept of a simple status update, Jack decided to present the idea to his colleagues at 

. Shortly thereafter, the company decided to build a prototype. Following a successful launch in August 2006, the service quickly grew, resulting in the founding of Twitter Incorporated in May 2007. 

Twitter is considered a microblogging site, so unlike other social networking sites, which have complex interfaces that allow customization and a multitude of other functionalities and applications, Twitter really only wants to know one thing: “What are you doing?” You can answer this question as often or as little as desired once you set up your account (see “Signing up” on page 20), which is free, but your response each time can be no more than 140 characters. In the Twitter world, where short and sweet is the motto, these microblogs are referred to as “tweets.” 

As with other networking sites, you can search for friends, relatives, colleagues, groups, and organizations. Many mainstream news outlets and reputable societies have a presence on Twitter (see “Conference coverage” and “News” on pages 18 and 20, respectively), so it is not just for those who wish to know what some of their favorite celebrities are up to at the moment. Once you find individuals or entities you wish to receive updates from, you simply click a button to start following them; unlike with other sites, they will not need to approve you first, but they will be notified that you have started following them, just as you will be notified when someone starts following you. If you feel uncomfortable with someone receiving your updates, you can block them. You can also keep your updates and profile private, but this information will be public until you adjust your settings, so as with any public site, it is prudent not to post something you would prefer to keep private or may later regret posting. 

While the idea of following numerous individuals and/or organizations in real time may seem like a time-consuming and daunting endeavor, how much attention you devote is entirely up to you. There are also scheduling settings that you can employ to control when you receive updates on your phone, instant messenger, or Twitter home page. So, if you do not want to receive updates while you are working, you can set your account accordingly.  

5 ways oncologists can benefit from twittering 

While Twitter has been criticized by many for the multitude of useless and banal updates that its members post, there are actually many ways you can make intelligent use of this service. You can use it to obtain job leads, receive the latest conference coverage, connect with other physicians and industry leaders, and as another source for oncology news. You can also establish an account for your practice and use it to provide your patients with important general information. Let’s examine each of these 5 uses in detail. 

Several job sites have a presence on Twitter. Two of the most applicable to physicians are 

. Both of these entities also have an RSS feed that you can subscribe to, as is the case with many organizations on Twitter. 

Additional job postings can be found by doing a general search, such as by entering “oncology jobs” or “physician jobs” into the general search field (not the “Find People” field, which often requires specific names before it will yield results); you can access this general search field by clicking “Search” at the very bottom of any Twitter page. A general search may bring up relevant postings from specific institutions looking to fill a position or other relevant news, such as a tweet about programs being implemented to help fill vacant positions at a particular institution. While certain tweets may not provide a direct job opportunity, they may serve as an indirect job lead if you do some additional investigating. 

Once you have other individuals following you, another way to find a lead is through your own tweets; you can simply ask if anyone knows of any opportunities. However, unless your information is made private, it will be available for all to see. If you do not want to risk your employer or anyone else catching wind of your job hunt, you may be better off contacting relevant individuals privately. 

With the economy still in a slump, many institutions are sending fewer physicians to key conferences, and even physicians who own their own practices may opt not to attend in order to scale back expenses. If you find yourself in either of these situations, consider using Twitter to receive the latest conference news. You can do this by following entities that have a high likelihood of having one or more representatives in attendance, such as various medical associations and publications. Some of the organizations you can consider following include the American Cancer Society (“AmericanCancer”), American Society of Clinical Oncology (“ASCO” or “MJ Gillman”), ACOR Cancer News ( “ACOR,” “cancer news,” or “ACOR cancer news”), and, of course, 

; the names/terms that appear in parenthesis are the search terms that will bring up these organizations in Twitter’s “Find People” field. 

If you are following numerous physicians and other industry key opinion leaders, chances are at least one of these individuals will also be in attendance and providing meaningful tweets. By receiving information from such a diverse pool of resources, you are ensuring that the coverage you receive is well-rounded and reliable. 

Unlike other networking sites, Twitter allows you to pretty much follow anyone, which enables you to quickly build a nice resource for yourself. Of course, the quality of the tweets you receive will ultimately depend on the organizations and individuals you decide to follow. So, if a colleague of yours is on Twitter but tends to be a negative Ned or Nancy on the job, perhaps this individual would not be the best choice to follow. If you decide to follow him or her anyway but soon regret it, you can always remove that person from your list. One way to do this is to click on his or her thumbnail, and when the page opens, simply click the “Following” button at the top of the screen, which will generate a “Remove” button below it; once you click “Remove,” that person will be omitted from your list. This ease of omitting entities paired with the ease of adding new ones is a great quality-control measure. 

While you ultimately can’t control what others will tweet about, you have full control over your own tweets, so you should never post something that could get you into hot water. Even a seemingly innocuous post like “bored at work” can have serious repercussions, as a young Briton found out when she was fired shortly after posting this as her Facebook status update: 

. Try to make the most of your tweets. For instance, use them to market yourself or an event that is important to you; for example, if you are publishing a paper, spearheading a clinical trial, or presenting at a conference, you may want to let your followers know. You can also use your tweets to get opinions or answers to practice-related dilemmas; however, you should never disclose any patient or other sensitive information in the process. By keeping your posts meaningful and professional, you will make a positive impression on those who are following you and will likely gain more followers, all of which can lead to good things.  

If you start following organizations such as those suggested in the Conference Coverage section, you will receive general oncology news, but you can also use Twitter to find news on specific tumor types. For instance, by typing “Breast Cancer” in the “Find People” or general search field, you will find Breast Cancer News (“BrstCancerNews”) as well as a host of other related groups and organizations. The same will be true for most other common cancers, but you will sometimes have to be creative in how you conduct your search. For instance, at the time I am writing this, searching on “Lung Cancer” yields no results when entered into the “Find People” field (though “Breast Cancer” will), but simply searching “Lung” in this field pulls up a considerable list of resources, including the American Lung Association (“American Lung Assoc”). When it comes to rarer tumors, such as leiomyosarcomas, little or no information may be available, but this too may change as Twitter catches on with more organizations. So, if searches on a particular tumor type or other topic yields disappointing results after you use both the “Find People” and general search field, consider rechecking the site in a few weeks. 

You may also want to receive updates from various governmental organizations, such as the FDA and the CDC, both of which have a presence on Twitter. You can subscribe to receive FDA recall alerts by entering “FDArecalls” in the “Find People” field and clicking “Follow” when the listing pops up. If you are interested in food recalls, you can do the same by following “foodrecalls.” The CDC also has numerous streams that you can subscribe to, including CDC Emergency (“CDCemergency”), which provides CDC emergency and preparedness information; CDC e_Health Marketing (“CDC_ eHealth”), which provides science-based health and safety information in a more interactive forum (eg, video links); and CDC Flu (“CDCFlu”), which will notify you of any updates posted to the CDC Flu Website. If you are seeking more mainstream news coverage, most major news outlets are tweeting, often having an abundance of news streams that you can follow. For instance, CNN has CNN Breaking News (“cnnbrk”), CNN Political Ticker (“politicalticker”), standard CNN (“cnn”), CNN Top Stories (“CNN_top”), and a myriad of others. You will no doubt find several interesting streams to follow.  Practice accounts Once you become comfortable using Twitter, you may consider setting up one for your practice or institution as another means of reaching patients. While you would never want to post any patient-specific information, you could use Twitter to keep your patients informed about important news regarding the practice itself, such as an important change in staff or a new program. You can also use it to make them aware of any new oncology news that is particularly relevant, a new clinical trial that is being conducted, or an FDA recall that could have a considerable impact on them. Patients with cancer are constantly looking for new information about their disease. Unfortunately, there is a lot of misinformation in the cancer community. By providing them with another reliable source of information, you are taking a step toward protecting them from some of the potentially harmful information that they may encounter on their quest for knowledge. Signing up Setting up a Twitter account takes less than a minute. Go to 

 and click the big green “Get Started—Join!” button in the center of the screen. Next, complete the five required fields on the “Join the Conversation” page and click “Create My Account.” Now you can start tweeting and searching for entities (also known as twitterers) to follow; of course, we’d love for you to start following 

Twitter really only wants to know one thing: "What are you doing?"