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.

The dramatic change in healthcare delivery from private practitioner-based to managed care created a vacuum of responsibility for self care that the patient has needed to fill. In response to this, the lay cancer community has created a sophisticated model for offering and disseminating updated information for the Web-savvy information seeker. Its success has accelerated a fundamental change in the patient—doctor relationship which could not have been anticipated even 10 years ago.  

Patients begin to assume new roles and responsibilities 

The way in which patients acquired health and medical information traditionally followed a doctor-centric “You come, I listen, and I speak” model. However, after World War II, more collaborative models began to evolve. To bolster their own information base, patients used traditional sources: the library, newspapers, magazines, books, and friends. Childcare books from Dr. Benjamin Spock and others spoke to generations of parents on what to do, and what not do, about common health and developmental problems in children. 

In the 1980s, people became more interested and proactive in their health as the tobacco law suits linking cancer and smoking became publicized and the early results of heart disease studies became better known. This information suggested that diet, exercise, and avoidance of smoking were the responsibility of the patient, not the healthcare system. Better educated people started to ask their physicians more questions. 

The American Cancer Society (ACS) continued to be the public face of the American cancer community, but still was quite doctor-centric in its outlook. It challenged quacks but not its own physicians’ inability to communicate with the public. Its information models stayed “inside the box.” But Yankee ingenuity and resourcefulness soon filled an unmet and unrecognized need in the brain tumor world. Foundations were created by people personally affected by brain tumors: The National Brain Tumor Foundation (NBTF), The American Brain Tumor Association (ABTA), The Brain Tumor Society (TBTS), the Florida Brain Tumor Association (FBTA), and many others began to fund research in this area and provide help to the afflicted. People who had “been there” developed a database with pamphlets and networks of useful professionals to help others through the trauma of a brain tumor diagnosis. These foundations targeted brain tumor research that had been overlooked by traditional ACS and National Cancer Institute (NCI) funding. These heroes’ ideas were soon copied in other countries, and patient-centered brain tumor foundations sprung up in Australia, England, France, and elsewhere in the 1990s. 

The healthcare “system” in the USA as we knew it started to unravel in the 1990s. Healthcare became more of a free-market business that placed greater responsibility on patients, beginning their long transformation into “healthcare consumers.” 

 that played a part in this included an explosion in the alternative health market, with vitamin and supplement makers making all sorts of claims about the health benefits of their products (up to and including that they can cure cancer); a lift on the ban prohibiting direct-to-consumer advertising promoting prescription drugs; the rise of Health Maintenance Organizations (HMOs), followed by limitation of treatments by HMOs and insurance companies based on cost; and the purposeful delaying of payment by insurance companies to physicians and hospitals. These and other events left patients with more questions than answers, questions that could hardly be accommodated during a 10-minute, HMO- or third-party-reimbursed visit. The result, predictably, frustrated doctors and patients. 

Within the last 10—15 years, people with brain tumors had an alternative: they could use the Internet to find information about their condition, research treatment options, and seek other providers. Now, patients had online access to exactly the same data as practicing physicians. They could do their own MEDLINE or PubMed search. Brain tumor centers not only advertised in Time magazine to attract patients, but they had one-button connections on favorite websites as well. In a space of 10 years, a world library of all the available brain tumor data along with analysis, commentary, and personal anecdotes has filled cyberspace. The only thing lacking in this equation was context. Whose responsibility was it to put into the proper context the hundreds of pages of downloaded information patients started bringing with them to office visits? 

Online health information and the evolving patient—doctor relationship 

Why the Internet for health? Well, it worked for movies, hotels, and rent-a-cars. It is accessible and private; and it provides information that, at least until recently, was not offered by the healthcare systems (many HMOs and other payers now provide cost-effectiveness information on their websites). According to 

, more than 80% of US Internet users have searched for healthcare information online, and 35% of them make medical decisions based on information learned online. When polled, 79% of these Internet users wanted to interact with their physicians via Internet. However, only 21% of physicians wanted to interact via Internet. Thus, 

 between provider preferences and healthcare consumer needs. 

The Internet has changed the professional relationship in additional, unanticipated ways. With the democratization of knowledge, a shift has occurred in the balance of power. Patients can now know nearly as much about their condition as their doctor. Challenges to the doctors’ knowledge and treatment decisions based on patients’ own research have become more common. The roles of knowledgeable physicians have changed from pronouncement and data recitation to provision of contextual information. Negotiation rather than a physician edict has become the rule on whether to continue chemotherapy or delay radiation in a child. This has become an inhospitable landscape for physicians who do not want to collaborate with their patients. 

But patients are not physicians. Though they can become experts in their own disease, they often do not understand the context of information they have gathered. There is a practical resolution. In a 30-minute clinic visit, I, and many of my colleagues, leaf through dozens of pages of downloads, sorting misinformation from in vitro or mouse studies, and anecdotes, to a shorter pile with bona fide useful information. “The Internet is a real-time democracy, but it is also unfiltered. Beware!” I tell my patients. Google searches for “brain tumor treatment” return links to dubious “natural” treatments along with legitimate information from major brain tumor centers. It is imperative that patients consult with their providers before acting on any information they find online, even if it is from a reliable and reputable source. 

How do you teach patients to be successful information gatherers? 

How can we as physicians help our patients keep their heads above water when searching for information following a diagnosis? First, you and your office staff have to buy into the role of mentoring your patients to be successful. Successful patients are organized. Tell them to get two file folders; in the first, they should store all financial information—hospital bills, insurance forms, replies, denials, letters of appeal, etc. In the second folder, they can file (in separate sections) business cards (yours, their other doctors’, consultants’, etc); blood tests and other lab reports; pathology reports; MRI scans (film and CD-ROMs if they have them) and dictated MRI reports; a list of questions to ask during office visits, answers they have received to previous questions, and notes on the visit; and second (and even third) opinions, including questions for the expert, the answers, and a copy of the dictated consultation. Even better would be to compile and store all this information electronically in a personal health record. 

For some physicians, this may seem a natural extension of the patient—physician relationship. Others may be uncomfortable ceding this much territory and responsibility to their patients. In my experience, doing this will earn your patient’s respect, gratitude, and confidence. 

Challenging authority: A lesson from art history 

In the story of Adam and Eve, Eve desired to taste of the fruit of the Tree of Knowledge of Good and Evil. She was challenging the higher authority and wanted to be equal in knowledge. What was the lesson? Challenge a higher source and you get expelled from the Garden. But is this punishment, or the act of becoming conscious? Our view of the banishment from Eden as punishment is best illustrated in Michelangelo’s 16th-century ceiling painting in the Sistine Chapel depicting Eve and Adam leaving the Garden in disgrace. Seventy-five years earlier, however, a young painter named Masaccio decorated the walls of the Brancacci Chapel in Florence with an entirely different Expulsion scene. This one portrayed Adam and Eve being led by an Angel with upturned sword in the right hand (a friendly gesture) into adulthood (consciousness of their mortality) and with rays of light (knowledge) radiating over Adam’s right shoulder. The logic of these contrasts is that the acts of becoming conscious, leaving the fantasy of Eden, and confronting authority and acknowledging one’s mortality are painful and difficult, but normal, transitions from childhood to adulthood. 

This sequence parallels in some ways the process patients undergo following a cancer diagnosis. One leaves Eden (the time before knowing about the tumor), suffers with the disease or treatment, and needs to confront the fact of eventual mortality. Many oncologists tell me that it is common for patients to initially think of their brain tumor as a punishment. Yet, we have a paradigm with a basis in 15th century art that suggests that knowledge and questioning can lead to empowerment. Patients nowadays, in part thanks to access to previously unavailable knowledge and information, feel empowered to challenge the physician as the ultimate authority on their disease. 

Although patients are smarter and betterinformed than ever, and are to be encouraged to take a more active role in their treatment, they should not discount the value of their oncologist’s expertise, authority, and experience, which can be a major factor in determining their treatment outcome. For example, we have known since at least 1984 that children with leukemia have better survival if placed on 

, in which they typically receive state-of-theart care. Another example of the importance of individual physician expertise can be seen in the effect of neurosurgeons’ resection of medulloblastoma. Our 

 from the Children’s Oncology Group clearly showed that if the neurosurgeon left less than 1.5cc of tumor, the survival was 75%; yet, if more than that remained, survival dropped to 50%. This is 

 for supratentorial PNETs and ependymomas. 

The Internet has made this information available to the public as well. Recently, I was asked by a patient for referral to a “two-log reducer” neurosurgeon! Data from a 

 demonstrated that highvolume cancer centers have better survival rates and fewer surgery-related deaths. 

The data is clear. The public’s access to online information is producing a class of empowered “medical shoppers” who are comfortable seeking the highest quality product, challenging authority, and demanding an equal voice in making treatment decisions. 

Paul M. Zeltzer, MD, is Clinical Professor in Neurosurgery at the David Geffen School of Medicine, Los Angeles, CA.

Articles

The dramatic change in healthcare delivery from private practitioner-based to managed care created a vacuum of responsibility for self care that the patient has needed to fill.

From Pronouncement to Partnership: Understanding New Modes of Communication in a Changing Healthcare System

2008 was a busy year in the field of breast cancer medicine, with thousands of abstracts presented at the ASCO, ASCO breast, and ESMO meetings and the San Antonio Breast Cancer Symposium in December, in addition to the many papers published over the course of the year (a PubMed search reveals that 5,252 papers published in the last year contained the words “breast cancer” in the title). Some of these developments rightly attracted considerable attention. Issues such as the potential impact of adjuvant bisphosphonates on breast cancer outcomes and the impact of the addition of bevacizumab to chemotherapy for metastatic disease garnered extensive coverage in both the oncology and the mainstream media. Yet, some stories, for one reason or another, passed under the radar and failed to get the attention they deserved. Perhaps they concerned the less glamorous topic of supportive medications rather than the “big-hitters,” the cytotoxics themselves. Perhaps they explored the schedule of treatment administration rather than novel treatment agents. Regardless, they contributed something to our knowledge of this disease. We have selected five of these developments that we think merit a closer look. Our criteria are simple: any story that potentially impacts our day-to-day practice, but which failed to make the news. 

The first story concerns the use of gonadotrophin releasing hormone (GnRH) analogues in premenopausal women to preserve fertility. Motivated by promising evidence from 

 have been performed and have suggested an improvement in fertility preservation for patients undergoing cytotoxic chemotherapy who received GnRH analogues throughout their treatment course. Consequently, the use of GnRH analogues has entered clinical practice, despite a lack of randomized clinical trial data to support their use. An 

 at this year’s ASCO meeting detailed the first prospective randomized trial to examine this issue. In the study, 49 pre-menopausal women receiving (neo)adjuvant chemotherapy for breast cancer were randomized to receive goserelin versus no goserelin. Patients were stratified by age, ER status, and treatment type. Menstrual status, FSH, and Inhibin levels were monitored every six months. One of the salient points of this trial was the high rate of recovery of menstrual function in both the goserelin and the control group: 88% and 84%, respectively, at 18 months. This is in keeping with a 

 reporting an 85% recovery of menstrual function among patients age 40 years and younger who were treated with adjuvant anthracycline and taxane. No significant difference between the groups was observed in the current study. The major limitation of this trial is its small sample size. Nevertheless, it raises concerns regarding the widespread adoption of GnRH analogues as a means of preserving ovarian function in the face of chemotherapy treatment in pre-menopausal women. Several larger phase III trials are accruing or have recently completed accrual (Sidebar). The emerging data from these trials will help to clarify the role of GnRH analogues in fertility preservation for young women with breast cancer. 

It has become increasingly apparent that the estrogen receptor exerts its effect in the context of a molecular milieu, which includes crosstalk with growth factor signaling pathways. More recently, 

 that high EGFR expression can indicate resistance to tamoxifen treatment in patients with ER+ breast cancer. An 

 from ASCO 2008 examined the role of combined signaling blockade with an aromatase inhibitor (anastrozole) and an EGFR inhibitor (gefitinib) in women with ER+ metastatic breast cancer. In this multi-center, double-blind phase II trial, 94 women were randomized to receive anastrozole with gefitinib or placebo. Patients had either received no prior hormonedirected therapy for their breast cancer or had progressed during/after adjuvant tamoxifen. Unfortunately, enrollment was stopped early due to slow accrual, limiting the statistical yield of this trial. Nevertheless, intriguing results were seen, namely a marked PFS advantage for the anastrozole plus gefitinib arm: median 14.5m versus 8.2m (hazard ratio 0.55, 95% CI 0.32-0.94). There were no unexpected toxicities. In a similar 

 presented at San Antonio in December 2007, patients with metastatic breast cancer were randomized to gefitinib or placebo in addition to tamoxifen. This trial demonstrated a non-significant improvement in PFS for patients with hormone therapy-naïve disease or who had completed adjuvant tamoxifen a year or more before study entry. Taken together, these provocative results suggest a role for continued exploration of combined ER and EGFR therapies in patients with ER+ breast cancer. 

Molecular Characterization of Individual Tumors 

This method has already entered routine clinical practice with the availability of the 

 assay to aid decision making regarding adjuvant chemotherapy in women with ER+ node-negative tumors. One question that has arisen is how this technology might interact with existing decision-making tools such as 

, which estimates risk using clinicopathologic data. Does “molecular risk” trump “clinically calculated risk,” or is there a role for both? This issue was addressed by several presentations at San Antonio in December 2007. In the first 

, tumor samples from women with 0-3 positive lymph nodes receiving chemotherapy and tamoxifen on clinical trial E2197 were assigned recurrence scores by Oncotype and were also assigned to low-, intermediate-, and high-risk groups by Adjuvant!. Recurrence score and Adjuvant! calculation were found to be independently associated with recurrence. For patients in low or intermediate Adjuvant! risk groups, the risk of recurrence was significantly increased for intermediate and high recurrence scores. The low recurrence score patients had excellent five-year survival, even in the setting of positive lymph nodes, a 

result supported by the analysis of S8814

, which showed that recurrence score was prognostic in women with 1-3 positive nodes and suggested a lack of benefit for chemotherapy in women with in this group with low recurrence scores. It would seem to follow that we may soon witness a shift from the anatomic classification of breast cancer to a more biologic classification. 

An integral part of the care of patients with breast cancer is the concept of survivorship: empowering women to return to full, healthy lives after completing their adjuvant therapies. A common question posed by women entering this phase of their cancer journey is, “what can I do to reduce my risk of a recurrence?” While we consider ourselves to be datadriven on chemotherapeutic interventions, lifestyle modifications are less well studied. An updated 

 from the women’s intervention nutrition study (WINS) provides some evidence basis for advice. A previous report had indicated a significant improvement in relapse-free survival for patients with resected breast cancer who received a dietary intervention targeting fat intake reduction, associated with significant weight loss. This update reveals a non-significant decrease in mortality for the intervention group. In an exploratory analysis of 362 women with ER- and PR- disease, a significant overall survival benefit was seen for intervention group participants (7.5% vs. 18.1%, cumulative mortality, RR 0.41, P=0.003). Whether this significant subset analysis is simply due to chance is unclear; certainly the cardiovascular benefits of low-fat diets are well established. 

Trastuzumab Monotherapy in Metastatic Disease 

 that monotherapy in metastatic breast cancer is associated with a response rate of approximately 15%, it is not known if initiating therapy with trastuzumab alone and deferring chemotherapy until disease progression will have a negative impact on patient outcome. A 

 this year attempted to address this by randomizing patients to docetaxel plus weekly trastuzumab (Arm A) or trastuzumab followed by docetaxel at progression (Arm B). The response rates in the combination arm were not surprisingly higher (57% vs 34%, P=0.03). However, there was no significant difference in time to progression (9.1 months in arm A, and 9.8 months in Arm B)—although progression-free survival for the trastuzumab component was 3.9 months. This study suggests that there is a subset of women in whom a maximal response rate is not required (ie, no critical organ impairment), in whom initiation of cytotoxic therapy may be deferred with the use of trastuzumab monotherapy. A key weakness of the trial is that the trastuzumab was not continued with the chemotherapy agent. 

 presented at the same meeting revealed additional benefit for continuing trastuzumab after progression in patients commencing capecitabine. A significant improvement in time to progression was seen in patients continuing trastuzumab with their chemotherapy (8.5 vs 5.6 months), although no statistical overall survival benefit was shown. The outcome for patients who received trastuzumab monotherapy and then received trastuzumab plus chemotherapy on progression as compared to patients receiving combined therapy from the start is not known. 

Dr. Murphy is a special fellow and Dr. Seidman is a medical oncologist, Department of Breast Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 

Prevention of Chemotherapy-induced Menopause by Temporary Ovarian Suppression with Triptorelin vs. Control in Young Breast Cancer Patients (PROMISE) 

Study to Prevent Chemotherapy-induced Ovarian Failure with the GnRH-Agonist Goserelin in Young Hormone Insensitive Breast Cancer Patients Receiving Anthracycline Containing (Neo)Adjuvant Chemotherapy

Study of a Goserelin Acetate for Preservation of Ovarian Function in Patients with Primary Breast Cancer 

Ovarian Protection Trial in Premenopausal Breast Cancer Patients (OPTION) 

Trial of LHRH Analog Administration during Chemotherapy to Reduce Ovarian Failure Following Chemotherapy in Early Stage, Hormone-receptor Negative Breast Cancer 

The Year in Breast Cancer: The Top Five Under-appreciated Developments of 2008

It is the final month of what has been economically a very tough year. Oncology centers and practices continue to face declining reimbursements on all service lines, and most have had either flat or lower revenues. Financial strife is a reality in this economy. Going forward, it is unclear what changes will emerge with the new Obama administration in 2009. Clearly, healthcare is a front-burner issue, and perhaps the Medicare program will be expanded to become “Americare.” Many private payers are reporting lower profitability. In the trenches, many hospitals reported declining profits in 2008. 

Contributing further to the current gloomy outlook, the recently released 

• 94% of respondents said the time they devote to nonclinical paperwork has increased in the last three years. 

• 63% stated that non-clinical paperwork led to less time spent with patients. 

• Only 17% of physicians rated their practice’s financial position as “healthy and profitable” (62% of surveyed physicians were practice owners; 34% were solo practitioners). 

Time spent on non-clinical issues continues to increase and put pressure on time with patients. More than ever, physicians are facing enormous challenges in their quest to find ways to deliver the best possible care at the lowest possible costs. I believe that the current economic environment will drive consolidation in the oncology space to gain efficiencies of size and scale and also for potential leverage with payers. Reimbursement models are starting to change with the advent of personalized medicine and the need to secure compensation for disease management and lower utilization of services. 

One increasingly clear answer to many of the questions and challenges confronting modern practice can be found in the careful adoption of IT tools. Technology tools can help ease workflow pains while enhancing care and quality. IT is the major enabler of both doing more with less and being more effective. To derive maximum benefit, practices must ensure their IT tools do one (or more) of the following: enhance revenue cycle management, support disease management to help contract with payers, or help provide care with fewer staff. 

Revenue cycle management has to be optimal in a business like ours with thinning margins. There is no room for major errors. This level of performance requires comprehensive, carefully implemented systems that support care delivery. There are many new tools from practice management systems vendors, claims clearing houses, and standalone remittance analyzers. 

Accumulating sufficient capital to invest in IT is a major issue for clinical practices (especially the small- to mid-sized practices). It is possible that the Obama administration will allocate some funding to support financing EMR adoption; during the campaign, he talked about spending $50 billion over five years to promote the adoption of EMRs and other information technology. However, given the current financial and budget outlook, whether that will happen is anyone’s guess. It will most likely be necessary for providers, payers, and other groups to come together to really build the IT infrastructure deep enough to succeed at a high level of performance in this environment. 

There is still time for your practice to make significant hardware and software investments by year end and still realize the tax benefits. This is also a time to reflect and refocus on the core value propositions for our patients and our organizations. We have an opportunity to come through these times retooled and more effective than ever before. Happy holidays, and see you in 2009! 

, a large oncology practice based in Dallas/Fort Worth, TX. He is also CEO of 

, an Internet services company that supports the patient/provider network with technology solutions. Readers can visit 

 to learn more, and can e-mail Dr. Sharma at 

It is the final month of what has been economically a very tough year. Oncology centers and practices continue to face declining reimbursements on all service lines, and most have had either flat or lower revenues.

Opportunities and Challenges: A Time to Reflect at the End of a Busy Year

The decision to move from a paper-based oncology practice to one based on an EHR system can be onerous and intimidating, in part because there are literally hundreds of vendors with products on the market, each with different cost structures, feature sets, and ability to connect and share data with other systems. When you also consider the inevitable post-implementation disruption to workflow and volume, and concomitant dip in revenue, the slow rate of EHR adoption in this country makes sense. However, new systems and technologies on the horizon may enable practices to cut through all the clutter and make the transition to a paperless environment much cheaper and smoother. 

 indicate that EHR system cost remains the biggest barrier to adoption. Because the purchase and implementation of an EHR system represents such a significant expenditure, you want to make sure that your practice derives similarly significant value from it. When deciding which EHR system to purchase for your practice, it is important that you consider not just the sticker price of the software itself, but the true cost of the product, which includes the hardware requirements for the system, ongoing IT support, training, and a host of other factors that add to the cost of creating an e-office. 

WITH EHRS, SOFTWARE IS JUST THE FIRST STEP 

Deciding upon what kind of software system (hosted versus in-house) you want to implement can be perhaps the most significant determinant of the overall cost. Some of the hundreds of EHR systems have limited functionality— chart creation only, for example. Others are so feature-filled that they overwhelm the user and get in their own way, slowing the physician down rather than helping speed the process along. To help buyers sort through all this, over the past few years, the 

 (Certification Commission for Healthcare Information Technology) has developed an exhaustive set of standard functionality, security, and interoperability criteria and certified several dozen systems. 

A practice in a particular specialty may want a specific EHR that is tailor-made for that specialty. In oncology, for example, there are several unique workflows that oncologists undertake that might best be addressed by an oncology-specific EHR, rather than by adapting a general-purpose system. 

Traditionally, EHR systems have been developed as client-server enterprise software, meaning that you purchase the software from the vendor, install it on your own machines, and upgrade it as new versions are released. With this approach, there is an up-front cost (typically in the $8,000-$16,000 per-physician range for a CCHIT-certified system), and an ongoing update/service cost in the 18%-of-original- cost-per-year range. 

Some systems are hosted (meaning you don’t have to install them on your own servers) and are priced as a “lease”—several hundred dollars per physician per month, possibly with an initial set-up fee. These software-as-a-service (SaaS) systems are emerging as a more favored approach for several reasons, including lower up-front software costs, minimal local hardware needs, and more potential for clinical data sharing between subscribing physicians. 

HOSTING AND SUPPORT IS AN ONGOING COMMITMENT 

If you decide to implement a traditional enterprise system, then you will also need to consider what kind of hardware is required to run your EHR. You will need a server and a local area network (LAN). You will need data backup (onsite and offsite) for your locally hosted data. Depending on the way the software is written, you might not be able to access your system from outside your LAN, which means you will need to enable special security portals (virtual private network, or VPN, connections) in order to access your EHR from outside your office, which adds an additional element of cost. 

If you have decided on a SaaS-based system, your hardware needs are much reduced. All you will need is a collection of Internet-connected computers in your office. Performance, of course, will be a function of your Internet connection speed; however, broadband connectivity is pretty much ubiquitous these days. Nevertheless, broadband Internet connectivity is a cost element that must be factored into the overall IT budget. 

Implementing a full-fledged LAN with data backups, ongoing security patches, and upgrades is something most medical offices do not have the skill set to carry out. Large group practices or staff-model or hospital-supported systems might be able to hire an IT professional; smaller practices must generally hire outside IT vendors to act as consultants. In either case, one must rely on IT vendors/professionals for network support, as well as vendors for EHR software support. These may or may not be the same vendors. 

THE NEXT STEP: TRANSITION COSTS AND STRATEGIES 

Once a decision has been made to deploy an EHR, actually transitioning the workflows from paper to e-tools is daunting, confusing, and disruptive. Apart from costs, the second-most- important barrier to EHR adoption is exactly this: disruption in core workflows, and therefore a transient drop in revenue stream as productivity dips during the learning curve of the transition. 

EHR design plays a big part here. If the system chosen is cumbersome or the interfaces are overly cluttered and “stiff,” the effect will be to slow one down. Oncologists should be spending their time primarily interacting with patients, not interacting with the EHR system. If the EHR system is designed in a way that matches the workflows an oncologist experiences in the office or hospital, then the learning curve is quick; if the system expects the oncologist to change his/her workflows to conform to the software-flow, then the software is “in the way” and a net-negative. 

Good EHR design should allow stepwise adoption of the e-tools. There are multiple workflows encountered in an ambulatory practice: scheduling and check-in; billing; charting, including generating de-novo prescriptions; management of refill requests for patients not being seen today; immunization management; review and management of lab test results; review and management of outside correspondence and documents (usually paper); and internal messaging within the practice, including handling phone calls to/from patients. These are the day-to-day tasks, not counting population-management reporting, review of disease registries, scheduling patients needing disease-management or wellness interventions who have been lost to follow-up, etc. A good EHR system should allow a practice to transition to the e-workflows in whatever sequence makes sense to the individual practice, so the overall transition is less disruptive. 

Because of the costs and burdens of e-transition, adoption of EHRs by practicing physicians in any specialty has remained low, to the frustration of many. Not surprisingly, EHR adoption has largely taken place in group practices, staff-model clinics, and hospital-supported organizations; small and solo practices, which is where more than 50% of physicians are deployed in the US today, have had very low rates of EHR adoption (see more on this on page X). 

Numerous strategies have emerged to address these concerns. Government encouragement, largely based on the presumptions that EHRs are Enterprise (and not SaaS) solutions, is ongoing. Local networks and IPAs (independent physicians associations) have tried banding together to underwrite some of the costs involved in EHR purchase and implementation (hardware, software, and support), which has been met with variable success. Hospitals have invested in and hosted ambulatory systems, with local connections to favored local physicians, a top-down approach, again with variable success. The fact that multiple types of assistance efforts have taken place would suggest that there is no one-size-fits-all solution, especially when implementing traditional enterprise-type systems. Oncologists should therefore look at the “lay of the land” in their local communities to see what local opportunities might be available. 

One can think of the traditional enterprise-type EHR systems as “EHR 1.0” and the newer generation of systems that are more SaaS-based as “EHR 2.0.” Not only are the newer generation of EHR systems less costly to implement (no need for local LAN system, no servers, no data backups, etc), they are less costly to maintain—local IT consultants may not even be needed if the system doesn’t require a full- fledged LAN with servers that require constant maintenance. 

EHR 2.0 systems also have the significant structural advantage of hosted data, which means that oncologists can share relevant clinical information much more easily with other practitioners who are also taking care of a given patient. One of the most challenging issues, even with high-end, costly, CCHIT-certified “EHR 1.0” systems is sharing clinical data with colleagues; each practice has its own local database (the e-equivalent of each practice having its own paper chart rack), and transmitting clinical information between consultants remains challenging. With hosted systems, the concept of “one patient, one chart” becomes possible. 

The final intrinsic strength of EHR 2.0 systems that are just now emerging is the potential for novel business models. Some of the SaaS systems have a very low monthly service fee. Practice Fusion, for example, is a hosted EHR that is actually free of charge to physician end-users (it is supported by advertising in the product). 

 that only about 11% of the benefits in cost savings to the system resulting from EHR use is reaped by the physicians themselves—the rest is reaped by insurers and others who avoid unnecessary or duplicated procedures and tests, not to mention improved patient safety due to legibility and better adoption of evidence-based guidelines and standards. However, it is the physician who has typically borne the burden of the costs. With EHR 2.0, there are emerging, novel ways to move the costs of adoption away from the end-user physician and more into the hands of those who ultimately benefit from it. 

The decision of what kind of EHR system to adopt is influenced by local factors, types of support, and long-term view. With the emergence of SaaS-based EHR systems, it is possible to foresee a significant paradigm change in the EHR world, and much more widespread adoption (especially by smaller practices) can finally be achieved. 

Robert Rowley, MD, is chief medical officer of Practice Fusion, Inc.

The decision to move from a paper-based oncology practice to one based on an EHR system can be onerous and intimidating.

The Right System for the Right Price: To Avoid EHR Sticker Shock, You Have to See the Big Picture

The ICD-9 medical coding system we’ve all relied on for decades will soon change—and it’s not going to be an easy or cost-free transition for most of us. The new system, ICD-10, is a radical departure from ICD-9, under which the number of diagnosis and procedure codes will increase from approximately 16,000 to more than 155,000. For many of us who use the same hundred or so codes all the time, the reasons behind why the code set will expand tenfold are difficult to comprehend and feel like more of the same bureaucracy that has brought us HIPAA and CCHIT. 

Because there aren’t thousands of new disease states, most of the new codes are sub-sub divisions of existing codes designed to capture more detail. For example, consider a patient who comes in with a sore throat. In ICD-9, the physician would likely code a 462 as the diagnosis (Acute pharyngitis, which includes most common iterations, such as suppurative, infective, and not otherwise specified [NOS] and excludes about a dozen others, such as abscess, chronic, Mono, flu, and Strep). Coding the same patient under ICD-10 would require the physician to choose from among four codes that differentiate between an acute sore throat, Strep, other causes, and NOS, each of which has inclusions and exclusions as well, leading to a decision tree containing dozens of sub-choices. Another example is coding an ankle sprain. With ICD-9, there are five detailed codes essentially locating which ligament is involved (845.xx). In the ICD-10 code set, however, you end up with 45 codes. The additional codes allow the provider to describe, among other things, the location of injury on the ankle joint, the degree of injury, whether it is a first-time injury, and cause of injury. 

Considering there will be increases in coding categories across the board, documenting and coding simple diagnoses will require much more physician decision making. Proponents of the new system argue that it will improve the quality of patient care, help track outcomes and other vital information used for research and distribution of prevention resources, and provide a more rational approach to payment systems. Sounds great, but who is going to pay me for this extra time and work, or for the EHR that can figure this out behind the scenes? For physicians like me with small medical practices, ICD-10 represents the frightening prospect of a steep learning curve, more coding and billing errors, and figuring out how to capture and record more clinical information during the course of an already too-short patient visit. 

What’s the answer? One option is to not play the game at all and refuse to accept third-party payments, though most of us likely don’t have the stomach for this level of dissent (But can you imagine a world in which patients paid you directly and then had access to affordable catastrophic insurance for additional needs?). But that’s a discussion for a future article… 

More likely, we’ll need to adopt complex EHR software that can help us do the coding. Based on how most of us use ICD-9, I suspect we’ll just end up with a tenfold increase in incorrect codes that don’t really describe the true nature of the diagnosis. Even worse, this further degrades the doctor—patient relationship as the patient becomes more of a traceable and codified commodity, whose numeric summary further moves them away from what most patients (and their providers) really want: an honest, straightforward relationship with a well-educated physician who can provide logical guidance in dealing not only with sore throats and ankle sprains, but also childbirth and rearing, anxieties and depression, and, perhaps most importantly, end-of-life issues. Isn’t that why most of us went into this field in the first place? 

Dr. Bertman is Physician Editor-in-Chief of MDNG: Primary Care/ Cardiology Edition. 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. 

The ICD-9 medical coding system we’ve all relied on for decades will soon change.

Code Overload

In the past 12 months, we have seen the rise of social networking sites for physicians, growing enthusiasm for the concept of patient-centered medical homes, the roll-out of PHRs by major players like Google and Microsoft, a shift from medical search engines to general search engines, and the first wave of retail DNA tests. One thing we didn’t see in 2008 was major progress in physicians’ adoption of HIT. We tackle these topics and more in this review of some of the top health IT stories from 2008.   

Despite a number of efforts to promote HIT adoption, including studies showing the cost-savings that could accompany widespread HIT adoption; local efforts, such as 

Michael Bloomberg’s charitable foundation

 that provided $27 million for EHR adoption; continuous 

 to increase transparency and adoption; and financial incentives offered by Medicare for e-prescribing, the fact is that IT adoption in healthcare is proceeding at a snail’s pace. Let’s review some lowlights from 2008: 

 from the California HealthCare Foundation said efforts to create a Nationwide Health Information Network are “impractical and cannot be implemented,” and added that “none of the [health IT] leaders interviewed for this report could point to substantial, real advances in the adoption and utilization of [health IT] since the president launched his initiative.” 

 reported using a “functional EHR;” only 14% used a “minimally functional EHR.” Adoption rates were 35% in practices of 10 or more and 6% for solo practices. 

 that 90% of US physicians and more than two-thirds of hospitals still use paper records, putting healthcare in the country “at least a generation behind the rest of society in terms of technology,” according to David Merritt, project director at the Center for Health Transformation. 

 found that it will take more than 30 years at the current HIT adoption rate to expand clinical support tools to all US physicians. 

 found that although 68% of US hospitals have implemented some type of EHR, most are only used in parts of the facility. 

: According to a Healthcare Information and Management Systems Society 

, roughly 30% of physician group practice administrators said they have functional components of an EHR in place in their organization, up just 4% from 2006. 

 presented at the American Health Information Community meeting showed that between 2% and 12% of US hospitals use EHRs, depending on how the term is defined. 

It is becoming increasingly difficult to stump medical students on clinical rounds nowadays; they always seem to come up with the correct diagnosis, in part because they are particularly adept at finding the right information as quickly as possible using the Internet. 

Search engines are extremely useful, because they can take a query, find the words that match, and put them together into an outcome that makes sense. Unlike medical search engines that rely on keywords, from the author and the researcher, the Internet looks at all of the words entered and makes no judgments as to their value. Your words are just as important as the authors’, though there is some contextual awareness. 

Google makes no judgments unless you misspell a word, and it will then suggest a correction. It allows you to search the way you think, not how the author was thinking. Occasionally, you will type in a query, find the article, and get blocked because the publisher wants you to pay to view the content. To solve this problem, simply take the article citation and search through secondary sources at a university, hospital, or office library to do the PubMed or Ovid search. 

I am preparing to take my recertification in geriatrics, and during the individual self-evaluation medical knowledge modules, Google and Google Scholar were my best friends. When there was a question I needed help with, these search engines gave me the easiest way to find the right answer. If a keyword is obvious, and you search Ovid, PubMed, or Up-To- Date, you might narrow your query but still might be unable to find the quote. With Google, you type in the quote, and the article pops right up. 

—By MDNG editorial board member Eric G. Tangalos, MD 

The patient-centered medical home concept continues to gain steam as more and more physicians and organizations— including the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, and American Osteopathic Association&mdash;endorse the idea. In fact, these organizations have collaborated to produce the 

Joint Principles of the Patient Centered Medical Home

. Other organizations are now emerging to do their part to encourage the evolution of the medical home, including Bridges to Excellence, a not-for-profit organization that rewards healthcare providers who “demonstrate that they have implemented comprehensive solutions,” which has developed different levels of medical home designations. Physicians who are able to attain these designations can receive an annual bonus payment of $125 for each patient covered by a participating employer, with a suggested maximum yearly incentive of $100,000. To read more about the program, visit [

]. As support grows for this patient-centered approach to providing comprehensive primary care, the big question becomes, “What role will healthcare IT play?” Technology systems are already in place to help healthcare providers maintain records, electronically prescribe medications, and exchange all types of medical information. In order for the medical home concept to thrive, physicians will have to use information technology for care management and quality improvement, as well as to provide an adequate payment method and to communicate with patients. As is the case with many ideas intended to improve healthcare delivery, the technology is there, but the major stakeholders need to iron out interoperability issues, manage costs, and continue to produce standards that will truly make the medical home revolutionary.  

“In spite of continued talk about expanding health information technology, I am not aware of much tangible delivery.” —G. Stephen Nace, MD, MDNG editorial board member, and Associate Professor of Clinical Medicine, University of Illinois College of Medicine at Peoria  

Creating a single network for processing almost all US electronic prescriptions promises many benefits, including lower costs for providers and patients and an expedited and simplified medication ordering and dispensing process.  

Uncle Sam Wants You… to Get Paid for E-prescribing! 

 “a new initiative for physicians to trade in their prescription pads and improve efficiency and safety when ordering drugs for patients with Medicare.” The final step in a years-long legislative and policy effort, this announcement finally put into place a concrete (albeit modest) financial incentive for physicians who treat Medicare patients to take the leap into the brave new world of electronic prescribing. In addition to the well-known potential benefits for patients from e-prescribing (virtual elimination of drug errors due to illegible or misread handwritten prescriptions, reduced out-of- pocket costs, etc), now physicians, too, can derive tangible benefits. Physicians who adopt e-prescribing technology in 2009 and 2010 will get a 2% bonus in their Medicare payments. In 2011 and 2012, they will get a 1% bonus. Docs who wait until 2013 will get only a 0.5% bonus. However, starting in 2012, 

 will also assess a 1% penalty on physicians who refuse to adopt e-prescribing; the payment cuts will escalate to 1.5% in 2013 and 2% in 2014 (). 

If the combination of fewer medication errors and a little bump in reimbursement is appealing, but you are still unsure of how exactly you should go about trading in your trusty prescription pad, download 

The Clinician’s Guide to Electronic Prescribing

. Issued by The eHealth Initiative in collaboration with the AMA, the AAFP, the ACP, the MGMA, and the Center for Improving Medication Management, the guide was created to be a “how-to” guide to “help clinicians make informed decisions about how and when to transition from paper to electronic prescribing systems.” For more on the various caveats, adjustments, and concerns some practitioners have raised, read Dr. Robert Jasmer’s detailed 

“In the single most significant advance to the accuracy, efficiency and quality of information associated with the four billion prescriptions written annually in the United States, the nation’s retail pharmacies and leading pharmacy benefit managers (PBMs) today announced an unprecedented collaboration to unite the country’s two leading health information networks.” Thus was the merger of SureScripts and RxHub announced with typical understated corporate PR-speak. Seriously, though, this was a major development. Creating a single network for processing almost all US electronic prescriptions promises many benefits, including lower costs for providers and patients and an expedited and simplified medication ordering and dispensing process. Plus, the combined network’s sheer size and ubiquity enable it to set standards for the whole industry, which has its good and bad points (good in that it simplifies things for technology vendors, while also requiring them to create products with valuable features like medication histories and eligibility checks; bad in that there are always concerns whenever one player in an industry is in a position to wield so much infl uence; privacy advocates have also expressed worries about having so much patient data in the hands of one company). Go read more about the company and the details of the 

 Magazine Just Spittin’ in the Wind When it Comes to Personal Genomic Testing? 

magazine was spot on when it named Apple’s iPhone as the invention of the year. However, they may have blown it this year by bestowing the title on 23andMe’s retail DNA test. The test predicts disease risk and ancestral history by relying on a technology developed last century that has been applied to research this century. If direct-to-consumer genetic testing continues, physicians could have patients who have had a single-nucleotide polymorphism (SNP) scan. With the cost of sequencing genomes decreasing rapidly (now $30,000), what does this mean for you? 

Every cell in the human body carries an individual’s genetic information, and microarrays—which probe hundreds of thousands of gene markers simultaneously&mdash;can measure whether certain genes are “faulty.” Affymetrix, the first company to offer high-density arrays (>500,000 markers), combined its efforts with results from the Human Genome Project/HapMap to enable whole genome investigation. Pacific Biosciences developed rapid genome scanning, which could allow for the $100 genome within two years. Its technology relies on Mother Nature’s ability to rapidly copy a genome and merely eavesdrops on it to produce a clearer picture than a microarray scan. The real trick lies in interpreting this information and deriving clinical utility from it. The Genome Wide Association Scan was one of the first to utilize this technology and was recently used to identify novel molecular pathways in a cadre of diseases. This approach has the advantage of being an unbiased, comprehensive search across the genome for susceptibility alleles and has been successfully applied for many single-gene disorders. 

For common complex diseases, the message is not so clear. Even with positive links, using SNP for common disease testing may not be useful for clinical application. An 

 recently reported on the lack of significant benefit in diabetes risk prediction using chips similar to the one 23andMe off ers. Using microarray analysis may be interesting, but it has not been validated as a way to obtain risk estimates for disease. Despite this lake of granularity, Time has decided to name 23andMe—a company which sells this technology with little, if any, clinical validity directly to the public&mdash;as the invention of the year. Hopefully, they don’t end up with spit on their face. 

—By Steven A. R. Murphy, MD, founder/ president of 

The Case for Aggregating Health Data around Patients 

In 2004, President Bush promoted the idea of an electronic health record for most Americans by 2014. This set in motion a wide variety of initiatives and projects. The Office of the National Coordinator for Health Information Technology was established. A certification process was set up for ambulatory and hospital EMR vendors to ensure a certain level of interoperability between systems. There was a lot of talk about developing a National Health Information Network (NHIN) through the funding of Regional Health Information Organizations (RHIOs). Although a few RHIOs have become operational, many have failed, and the long-term business model for those that remain is illusive. 

As I’ve traveled the world, I’ve yet to see a fully developed digital health information exchange in any country I’ve visited, yet alone one that could scale to the kind of system we would need for all Americans. I’ve come to believe that developing a digital network providing for the free, bidirectional fl ow of health information between every physician, hospital, clinic, pharmacy, laboratory, imaging center, insurance plan, and everything else in the ecosystem just isn’t feasible at scale. Even if the technology existed to do this, the money certainly does not, and furthermore, there’s no business model to support the exchange of information between competing physicians, hospitals, and clinics. 

Fortunately, there is an answer to this dilemma, and I believe most pundits are coming to the same conclusion. Why not put patients at the center and aggregate a copy of their health data around them? Even among organizations that compete, few have a problem with sharing most, if not, all of the patient’s health record with the patient. Global technology companies have come forward with solutions like Microsoft HealthVault, Google Health, and medical record banking initiatives that make it possible for patients to securely store a copy of their personal heath information electronically on the Internet and to receive electronic copies of heath information from their providers. In the case of HealthVault, patients have complete control over who they share this information with (family member, care provider, or anyone else who needs to know), and when. It is also possible to connect a myriad of devices—like blood pressure cuff s, glucometers, weight scales, spirometers, and heart rate monitors&mdash; that collect health data and store this information where others who need to know can see it. Imagine a day when each of us has a PHR and an EHR in the “cloud” that is always available, whenever and wherever we might be. RHIOs and other health information exchanges could then focus on an achievable goal&mdash;unifying critical patient information for care providers in a region. 

I do believe that local and regional information exchanges make sense. First and foremost, we’ll never get where we need to be so long as health information exists on paper or is locked up electronically in silos. But I also believe that aggregating health data around the person to whom it belongs is not only a solution that scales, but is perhaps the only way we can attain the vision of a truly transportable, always available EHR for most, if not all, Americans. 

—By MDNG Healthcare It Advisory Board member Bill Crounse, MD, senior director of Worldwide Health for Microsoft Corporation

The healthcare world has embraced the principles of Web 2.0, even taking the liberty to rename it in its own image, Health 2.0. The idea is catching on, and conferences such as 

 are enjoying a record number of attendees. At one time, people argued that these 2.0 technologies were not sustainable for lack of a viable business model and source of financial revenue. Setting those fears aside, it looks like these user-generated platforms are here to stay with Health 3.0, and even some rumblings of Health 4.0 in the distance. What do all these fancy names mean? 

3. Health 3.0 = content + community + consumer-centric commerce 

4. Health 4.0 = content + community + working commerce models + coherence (connectors) 

The Health 3.0 concept, which incorporates a source of financial benefit into its models, is stepping out of the theoretical imagination and into the real world. 

 incorporates text messaging and AIM into its physician practice model. 

 provides qualified health professionals who answer online submitted questions for fees ranging from $9-15. 

 offers live chat with health professionals, charging by the minute. Other Health 3.0 approaches include 

Social Networking Is Just What the Doctor Ordered 

Would it bother you to know that your physician smokes cigars? That your gynecologist was a member of a group called “I Hate Medical School”? Should physicians share this kind of personal information on social networking sites like Facebook and MySpace, where patients could potentially see it? Many doctors are turning to physician-only networks to get away from the prying eyes of patients. After all, we are all human and need to relax, socialize, and talk about our children, work, frustrations, and hopes without being paranoid it is going to come back and haunt us. Three of my favorites are: 

iMedExchange is only open to practicing physicians. Chief Executive Tobin Arthur says that the company hopes to create a virtual version of the doctor’s lounge at a hospital. iMedExchange may not have the catchiest name, but it is one of my favorite sites. iMedExchange verified my identity with a phone call, checking that I was a physician and that I registered. They were the only site to do this. They also have a very impressive live chat with customer service. In development for more than a year, iMedExchange studied how sites such as LinkedIn, Facebook, and Craigslist could be applied to physicians, and it shows! 

The Student Doctor Network is an independent community of students, advisors, educators, and practicing doctors. The membership extends from college students to practicing doctors in every healthcare specialty. It is a wonderful resource for college students from hoping to get into medical school on through residency. 

On Sermo, physicians come together to talk about observations from their daily practice. Physicians can tap into the collective knowledge to achieve better outcomes for their patients. Physicians can benefit, too; I’ve seen burned out physicians get invaluable support on Sermo, which is now partnered with the American Medical Association. A visitor must verify that he or she is a physician before participating in the discussions. 

—By MDNG editorial board member Nancy Tice, MD 

Mobile Phones Will Revolutionize Your Practice 

Smartphones and other mobile technologies will become major tools for physicians for improving quality of care and communicating better with patients and colleagues. Indeed, mobile phones are rapidly morphing from forbidden gadgets in healthcare to the most prized clinical assistants, facilitating improved communication and mobile computing in medicine. 

Mobile phone-based solutions can be helpful to physicians and patients alike. For example, appointment management software allows physicians to automatically contact patients, reminding them of their appointments in advance and requiring them to confirm that they are on their way. This software has the potential to decrease “no shows” and excessive wait times. 

The ability to use a cell phone to access relevant patient data when in the exam room or during hospital rounds can dramatically increase efficiency. Using this technology, physicians can have inexpensive and effective mobile e-prescribing systems; access to key data, such as previous medications and possible interactions, which can reduce medical errors; and immediate access to important guidelines and protocols that can enhance care and reduce costs. Also supported are real-time charge capture systems and point-of-care documentation. 

Today, we see the beginning of a new range of disease management modules based on mobile phone communication. Successful programs have been demonstrated for diabetes, asthma, smoking cessation, and other conditions, with increased two-way communication greatly influencing results. Vitals and other data can be readily and automatically collected and transmitted for quick collection and processing. 

Patients want better communication than is possible in the few minutes available during a typical visit. In the near future, many patients will carry a copy of their personal health information on their mobile phone. Expect that patients will send their eligibility and health history data to your office before they arrive. There will be no cumbersome on-site collection of insurance information, demographic data, etc. Even more importantly, patients will start sending their “agenda”—the list of symptoms and problems they want you to address during the visit&mdash;in advance. This will change the workflow of your encounter. A patient may tell you about specific information she found on the Web, and your mobile phone will help you to check that data on the spot and respond accordingly in a timelier manner. Today’s software systems also allow any practice to set up preferred patient groups who, for an extra fee, are reminded to take their medications and have the option of dialing their doctor’s office directly with a simple code. This is just the tip of the iceberg. 

, which sponsors the annual TEPR+ conference (

) and recently established the Center for Cell Phone Applications in Healthcare (C-PAHC).  Mobile phones are rapidly morphing from forbidden gadgets in healthcare to the most prized clinical assistants, facilitating improved communication and mobile computing in medicine.

Some of the Top Health IT Stories from 2008 are discussed.

One Last Look back: The 10 Biggest Health IT Stories of 2008

My heart broke a bit when my normally attentive OB/GYN walked into the exam room with a tablet PC and barely looked up from the screen during my visit. Studies have shown that exam room computers have positive impacts on physician—patient interactions without significant negative effects on other areas, such as time available for 

. Integration of computers into the delivery of care improves patient satisfaction. However, even skilled physicians commonly display troubling behaviors, such as spending too much time looking at the computer monitor, typing while patients are talking about intimate concerns, reading silently from the monitor, using templates to lead interviewing rather than listening to patient narratives, and turning their backs to patients in spite of mobile computer monitors.

Electronic medical records are a wonderful asset and can help prevent drug interactions and allergic reactions by automatically checking patient history. Many malpractice carriers offer physicians a discount for using one. Plus, physician users always have access to their patients’ records, a crucial factor when a patient is taken to an emergency room and cannot give a verbal history, or when a patient is traveling and enters a hospital or visits a different physician. There is also no need to worry about illegible notes and scrawled—and sometimes misread&mdash;prescriptions. Electronic medical records have the potential to bring a new level of care to patients while making physicians’ lives easier. So, how can you make the most of what technology has to off er and not compromise your patients?

This is an obvious recommendation, but it is an important one. Until voice recognition improves dramatically, cost concerns will demand that physicians type their notes or enter them through templates. Your typing speed and accuracy will improve with time, and you’ll be grateful not to deal with your hand-scrawled notes.

Integrate typing around your patients’ needs. 

Regardless of your note-taking style—whether you type during the visit, immediately afterward in the exam room, or later in your office&mdash;it is important to know when to push the computer screen away. Using an EMR may require a heightened recognition of sensitive psychosocial concerns. Patients need to have eye contact and feel connected to their physician.

Templates are an excellent way to structure notes but can be disastrous when used to structure interviews with patients. Their closed-ended, question-and-answer format allows little room for patients’ narratives to evolve, a key task in patient-centered care. Don’t change your interviewing style to fit a template.

Unless a physician reviews notes at the beginning of the day or in the hall before entering the exam room, there may be little chance to focus attention on the presenting patient until after entering the exam room. Try to listen to patient concerns before opening up the EMR to review the last visit’s notes.

Keep your patients informed about what you are doing - as you’re doing it. 

If you sit silently looking for information on the computer—opening and closing windows or scrolling though text&mdash;you risk alienating your patients. Instead, try to keep talking as you go about the work of both searching for and entering data into the EMR. Let the patient know you are just making a notation or looking something up for them.

Many patients like seeing their lab results and the charts and graphs that EMRs provide. However, even computer-savvy patients may find that their emotions override their ability to quickly grasp where to look. Use a finger, pen, or cursor to guide the patient’s gaze when discussing data viewed on the monitor. This is a great time for showing, for instance, a trend between rise in body weight and cholesterol to illustrate cause and effect. Patients will sometimes get the message more clearly when shown charts.

We’ve all seen the movies with the doctor scribbling in silence. Instead, try saying things like “Would you mind if I typed while we speak?” or “May I show you what I’m doing?” when using an EMR to promote, rather than hinder, the physician— patient relationship.

The reality is that even with the availability of mobile screens, many experienced clinicians still stare at the computer monitor. Remember that you are speaking to and caring for the patient, not the EMR. The EMR is an inanimate tool to aid patient care and it is the patients who deserve our primary attention. EMRs in the examination room are quickly becoming a reality. Paying attention to how we integrate our clinical styles with the use of this technology will ensure that they are used in ways that best fit the social, emotional, and medical needs of our patients.

If you don’t mind a Web-based solution, 

 is an excellent, and free, EMR. The online system allows users to log on from anywhere at any time without installing special hardware or software. Providers can also easily manage patients, their schedules, and all of the communication between staff with Practice Fusion’s Practice Management service. The EMR was designed by physicians and allows users to build charts “your own way” with templates that cover more than 30 specialties, typing, drag-and-drop features, and dictation. Users also have the ability to write prescriptions and refills. Support staff will conduct training sessions over the phone as needed, and training videos are available online. Although the software is intuitive enough that not much training is needed, watching the videos will show features that may be missed otherwise. As a free service, PracticeFusion’s site comes with advertising, but it is unobtrusive and medically oriented. Those who find the presence of advertisements too intrusive can opt for the fee-based service without ads.

An oncologist colleague of mine uses the 

, a suite of healthcare IT software solutions from GE Healthcare that includes software for independent physician practices, academic medical centers, hospitals, and large integrated delivery networks. The various modules perform practice management, revenue management, medical imaging, and other functions. Because my colleague is a poor typist, he delays his note taking until after the patient leaves the office. He does share flow sheets and graphs with his patients, as he states they love seeing the information presented this way.

iPhone users can take advantage of numerous native applications in a variety of categories, including games, business, news, sports, health, reference, medical texts, travel, and now EMRs. Thanks to 

, users can now carry their office in a pocket with the $149 iChart program, the first complete handheld EMR system for the iPhone. iChart was designed to act as an electronic “personal medical assistant” and focuses on streamlining the daily “chart, bill and fill” routine of any healthcare provider. The convenience of having all your patient data in your pocket cannot be overstated. The program has an intuitive interface and is a pleasure to use.

Track patients within hospital, clinic, or home-care settings.

Write prescriptions with a built-in drug reference and drug interaction checking.

Track labs and studies with built-in lab menus.

Write SOAP and procedure notes with built-in smart menus.

Sync data to an online data center for further editing and printing.

Technology and medicine are a wonderful combination, but not if the doctor hides behind it, a real concern in a world of EMRs and handheld medical devices.