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Financial help for physicians who are willing to implement, test, and help optimize health IT systems.  

If economics is the dismal science, Health economics is its most dismal branch. Hardly anything in medicine is priced rationally, inefficiencies abound, and cost-effective solutions are rare. Consider health IT, the sales pitch for which sounds irresistible: it promises to slash prescription costs, reduce errors, and streamline the entire healthcare system. Even better, recent studies have shown that some of those claims are actually true. How can doctors continue to reject such a compelling business argument? Easily. The costs of health IT systems fall almost entirely on physicians and hospitals, but most of the benefits flow to insurers, patients, and the public. Worse, health IT is still in its infancy, so early adopters must invest considerable time and money just to figure out which systems work best. Doctors simply can’t afford to do the right thing. An economist would diagnose this as a “positive consumption externality,” and prescribe a government subsidy to treat it. 

In 2004, Congress earmarked money to do just that, through the 

Agency for Healthcare Research and Quality

 (AHRQ). “What they realized was there are a number of activities or research areas that sort of cut across the standard organizational structure of the agency, centers, and offices, and health IT is certainly one of those,” says Bob Mayes, senior advisor to AHRQ’s Center for Primary Care, Prevention and Clinical Partnerships. 

As a research organization, AHRQ focuses on funding studies to test and optimize health IT systems, but it can also help clinics and hospitals make the initial purchase. Indeed, the first round of grants was aimed at getting the technology into small, rural hospitals. “There had been some successful examples of electronic medical records and other uses of health IT to improve safety and quality, but historically they had been really confined to larger institutions, big academic medical centers, or other large integrated delivery systems, such as the VA or Kaiser,” says Mayes. “The question really was ‘Why hasn’t it trickled down into smaller facilities?’” 

Although money is certainly part of the problem, AHRQ’s research has revealed more insidious difficulties as well. For example, newcomers to e-prescribing often view it as a simple series of data transactions; the reality is far more complex. A physician must write the correct prescription, and a pharmacy with an entirely different system must fill it, raising numerous compatibility and implementation problems. After those hurdles, the e-prescription faces an even tougher challenge. “The most important piece of the whole thing is did the patient actually take the medication?” says Mayes, adding that “We’ll continue to look at e-prescribing, but we also are looking more at how we move into the whole area of adherence.” 

To address such multifaceted problems, AHRQ funds a wide range of health IT grants, from $100,000 to $1.2 million, enabling everything from small-scale, proof-of-concept studies to large, demonstration projects. With a total annual budget around $45 million, the agency must turn down many applicants, but Mayes says they take pains to make the process straightforward. 

“One of the things we’re trying to do is get involvement with a broader cross-section of the health sector,” says Mayes. “Ultimately, if we put out findings, we need to have people go on the website and look at the kinds of things that research has been done on and say ‘oh, yeah, that’s me, that’s my practice.’” 

Those efforts seem to be paying off. “The AHRQ folks were very easy to work with,” says Rick Breuer, MD, an attending physician at Community Memorial Hospital in Cloquet, MN, and the lead investigator on a recent AHRQ health IT project. “Going after a Federal grant was kind of scary for us because we weren’t sure how much of a jumble of paperwork and regulations we might have to meander through, but it was really a very good process.” 

The Minnesota team used its AHRQ grant to see whether small, rural hospitals would benefit from using a networked e-prescribing system. The project connected small facilities across the state with a 24-hour pharmacy at St. Luke’s hospital in Duluth. “That’s really what the purpose of this whole project was: to give everybody access to that 24-hour pharmacy coverage,” says Breuer. 

Once the system was set up, physicians at any of the hospitals in the network could send their prescriptions to the pharmacy in Duluth for immediate review. Having a dedicated pharmacist on call was a boon for physicians accustomed to more limited coverage, and the hospitals kept the system running after the grant expired. “Every facility has stuck with it. It is an expense that we have now that we didn’t have before, but I think we see it being worth it in the satisfaction of our staff and our own pharmacists when they come back on a Monday morning and how everyone feels about what this means for patient care,” says Breuer. 

E-prescribing can also provide more quantifiable benefits, as another AHRQ project recently demonstrated. Researchers 

 from physicians using the PocketScript system and discovered a substantial payoff : a single feature of the program saved $845,000 per 100,000 patients per year. “The device or the program actually looked up the patient and got that patient’s formulary from their own insurance company and then informed the physician of the tiers of the co-payments, so the physician knew at the point of prescribing what the tier was,” says Joel Weissman, PhD, senior health policy advisor, Massachusetts Executive Office of Health and Human Services, and study co-author. 

The feature was unobtrusive, simply listing medications in different font colors based on their formulary tiers, but it influenced prescribing practices. “Doctors want to do the right thing. If there’s a choice of drugs and if they can help out the patient to pay a lower co-payment by prescribing an equivalent drug in a lower tier, they’re going to do that,” says Weissman. 

The apparent simplicity of such changes—pharmacy coverage and colored fonts are hardly technological breakthroughs&mdash;highlights what many see as the real challenge of health IT. “It wasn’t technically overly challenging to put networked pharmacies together&mdash;it was more getting all of these people together and changing our process,” says Breuer. 

Although e-prescribing is certainly hot, AHRQ funded researchers are looking at many other aspects of health IT as well. Indeed, individual sites often host multiple projects in distinct fields, such as the three-pronged effort now underway at the University of Texas Medical School in Houston, TX. There, assistant professor of medicine Eric Thomas, MD, is testing new technologies in settings ranging from intensive care units to outpatient clinics. 

In the ICU, Thomas and his colleagues are studying the impact of remote presence systems. “There’s a severe shortage of intensivists in the United States, and so the idea is that by putting a few intensivists in an off -site location and then connecting them via telemedicine technology to numerous ICUs, you could kind of help provide more coverage and more care by intensivists to more patients,” says Thomas. The study is using the 

, but its results, which Thomas expects to have soon, should be relevant to competing products as well. 

Another study focuses on developing algorithms to detect diagnostic errors by analyzing electronic health records. “What we’re doing is looking at things like visit patterns to try and detect a diagnostic error. For example, if a patient sees their primary care physician today, and then three days from now they go to the emergency room or get admitted to the hospital, it may be an indicator that the primary care physician missed something, and then a few days later it got worse and they ended up in the hospital,” says Thomas. Of course, there could be other explanations for such a pattern, so the algorithm also incorporates additional clinical information. Ultimately, the system might function like audit flags in tax-processing software, automatically highlighting areas for a human to check more closely. 

Even so, any error-checking system could be a tough sell if it’s not implemented carefully. “There might be some resistance when it gets rolled out as a day-to-day quality tool,” says Thomas, adding that a key issue will be “whether or not it’s in a punitive environment or an environment that’s focused on learning and improvement; it depends just on the culture of the place.” 

Thomas’s colleagues are also working on a less controversial application of the technology, analyzing health records to keep cancer patients from getting lost in the healthcare system. “Let’s say a 60-year-old man presents with a new iron deficiency anemia. If a man has a new anemia, then he needs to get a colonoscopy. We can detect the anemia, we can then screen to see if the colonoscopy occurred, if it did what was the pathology, if it was cancer, has that person seen a surgeon or an oncologist, if they have, have they also begun a therapeutic regimen?” says Thomas. 

When government-funded researchers produce new algorithms and software, they often release those products under open-source licenses so other researchers can copy and modify them. In health IT, things are more complicated. “There are really two pieces when you look at an application; there is the computer programming expertise and knowledge, and then there’s the domain expertise of what does it do and is it actually doing what it is supposed to?” says Mayes. He adds that it’s no accident that the open-source movement’s biggest successes have been operating systems such as Linux and general-purpose desktop applications. “If you look at Linux for instance, the very people that created the code were also the experts in operating systems,” says Mayes. 

Making an open-source health IT application work requires a more rare form of dual expertise: medicine and computer programming. The scarcity of physician-programmers means that any health IT application requires a diverse team, and commercial software development may be the most practical way to achieve that. 

The price difference—open source software is free, whereas commercial applications cost money&mdash;may not matter in health IT. “We’ve actually run focus groups with physicians and you often hear ‘what would you pay for an e-prescribing system?’ and a lot of them say ‘Well, free is not good enough,’” says Weissman. He adds that “It really does cost them time and hassle.” 

That makes the economic prognosis sound dismal, but help is on the way: true to its mission, AHRQ is now gearing up to fund a new round of studies on health IT implementation.

Can AHRQ really make a difference in HIT implementation?

Alan Dove is a freelance healthcare and science writer. 

Articles

Financial help for physicians who are willing to implement, test,
and help optimize health IT systems.

We're From the Government and We're Here to Help

, discusses the findings of his new report, Oncology Roadmap: Brand Spending Benchmarks and Market Forecast to 2013, which examines nearly 140 drugs and reports on the state of the oncology drug market.  

1) Where do you see oncology pharma and biotech R&D heading in the next five years? 

I think oncology drug research is headed pretty heavily in the direction of the tyrosine kinase inhibitors and monoclonal antibodies. Both drug classes have fewer side effects, and certainly in the oncology market, any drug with fewer side effects is welcome, because other than side effects being very painful, you can stack them onto other treatments without hitting a critical mass of side effects that make it totally unmanageable. The advantage for pharmaceuticals is that the patent on these drugs, particularly monoclonal antibodies, currently does not run out in the United States. The disadvantages from a perspective both of the oncologist and the pharma companies is that they are highly targeted, so you can’t just release one kind of drug and expect it to work on all kinds of cancer. 

Another interesting thing is that we have a top 10 drugs list at the beginning of this report for drugs that have just been released or are getting ready to be released, and two of the drugs on this list are drugs aimed at bone health. This is an issue for anyone who is on a hormone inhibitor for prostate cancer or breast cancer. But these drugs are going up against biophosphates, which are not only a standard of care right now, but they’re generically available. One of the drugs on our list is projected to be a $3 billion drug by 2012 while going up against a drug that’s already generic. You have to wonder what the drug has in its profile that makes it look so good in terms of sales. I think in order to have those kinds of sales figures, it will need to have much lower rates of osteonecrosis of the jaw, which is a prominent side effect of the biophosphates, or be even more effective. In the last set of trials, there were low rates of osteonecrosis, but I do think oncologists and doctors in general are still hesitant, and they are looking at that very carefully in the last set of trials. 

2) What does this mean in terms of the cost of these blockbuster drugs? 

Biologics are going to be even more expensive than the biophosphates were. Some of the biologic prices are $50,000— $100,000 for a year of treatment. This is the downside for these biologic treatments that are so targeted, because the patents may expire, but there’s no approval process for a generic in the US currently, so these drugs will essentially never face generic competition. That may be something the new administration will look at and try to remedy, but frankly these drugs are so expensive to create. Some of the cost studies have indicated that even if some of these generics face competition, it would only lower the price by 20% or 30%. So, with the targeted cancer drugs that are monoclonal antibodies, I think costs will continue to be a significant concern. As some of the small molecule chemotherapeutics continue to go off patent, people will have more and more options for cheaper and cheaper oncology drugs. 

3) Have you recently seen any major change in research focus? 

I think biologics in the past few years have been the most recent change. There’s also been an increase in focus at the FDA of making sure they don’t release drugs that have an anticipated side effect profile. I don’t know how much this will affect oncology going forward, but in a lot of areas where drugs are treating non-fatal diseases, drugs that would have previously been approved in the last couple years have been sent back for additional testing or received complete response letters from the FDA. I think cancer researchers are going to be even more vigilant of their endpoints. They may do more trials, see more people in those trials, and they’re probably going to more specifically aim their end points than they have in times past. 

4) Has there been a change in the number of drugs that are released every year? 

That’s actually decreased significantly in the last two years. The decrease in approvals is actually the entire reason that companies are more focused on hitting their endpoints, and making sure their drugs are safer. That’s certainly not a guarantee after Vioxx, and some of the other problems that have been seen as the FDA’s fault, whether or not that was the case. It’s not guaranteed anymore that a drug that looks fairly safe—but has questions remaining&mdash;is actually going to hit the market. The decrease in the number of drugs approved may actually translate into higher costs for patients, since drugs will face less competition and companies will want to be able to recoup more of money that they spent on research.

Jeremy Spivey discusses the findings of his new report, which examines nearly 140 drugs and reports on the state of the oncology drug market.

4 Questions ...with Jeremy Spivey

When selecting an EHR for your practice, using an EHR consultant can save you time, money, and headaches, but only if you select a consultant who knows what he or she is doing and who is a good fit for the needs of your practice. Selecting the wrong consultant can turn an already arduous process into a disaster: some are in the pockets of EHR vendors; others are only interested in locking you into a long-term services contract. So, how can you tell whether a consultant is right for you?  

There are many bad EHR consultants who have given the industry a black eye. After hearing all the horror stories about practices being railroaded into selecting unsuitable EHR systems, consultants whose advice seems only to lead to additional billable services, and consultants who leave the job half-finished and in disarray (requiring the practice to engage the services of another consultant to help get things back on track), it makes you wonder why physicians continue to use consultants at all. The unfortunate reality is that most doctors and clinics do not have the time to appropriately research the EHR selection and implementation processes, meaning that the services of EHR consultants will continue to be widely used. Although there will always be an element of risk involved with the complicated process of selecting consultants and vendors and implementing an EHR system, practices can remove a great deal of uncertainty by gaining a better understanding of the types of EHR consultants, the pros and cons of each type, and how to select a qualified EHR consultant who best fits the needs of the practice. 

In order to effectively deal with them, it is essential for physicians to understand several things about EHR consultants, including the fact that many of them are not really consultants at all. The title “EHR consultant” is self-appointed; there is no EHR consultant regulating body or credentialing organization. Therefore, physicians and their staff must exercise caution and good judgment when evaluating the capabilities and claims of prospective EHR consultants. For simplicity’s sake, EHR consultants fall into one of three types: selection, implementation, and cleanup. 

By far, the majority of bad experiences with EHR consultants have been with consultants hired to assist with the selection of an EHR. The problem is that most of the so-called EHR selection consultants are not really consultants at all. Instead, they are EHR salesmen disguised as EHR consultants. They are the “realtors” of medical IT, focused only on selling EHR software from vendors that pay them a large finder’s fee. One look at their list of clients will reveal a limited list of EHR vendors. These wolves in sheep’s clothing should be avoided at all costs. 

A qualified EHR selection consultant is someone who knows and has contacts with dozens of EHR software vendors; a look at their list of clients should show a broad spectrum of EHR vendors. Their focus is on understanding each individual medical practice and selecting the EHR software that best matches the practice’s needs. 

The difference between these two types of consultants is best described as the difference between a bounty hunter and a hired gun. The bounty hunter is only interested in collecting the referral fee (bounty) from the EHR vendor. The hired gun is interested in protecting the interests of the medical practice. 

There are two types of EHR consultants available to help with an EHR implementation. The true EHR consultant has immediate, short-term goals: get the practice on the right track, build momentum, create an implementation plan, and transfer knowledge. The other form of EHR implementation consultant could more aptly be described as a contractor; essentially, they stick around to provide extra manpower to assist with the myriad of implementation tasks and details. Sometimes, a little extra help is all that is needed, but do not confuse them with a true EHR consultant. Most medical practices choose not to use an implementation consultant, which often leads to the need for a “cleanup” consultant. 

Unfortunately, many medical practices end up having to bring in a consultant to “clean up” an EHR implementation gone awry. The cleanup may involve fixing the mistakes made by a previous EHR consultant, saving a failed EHR implementation, or even improving an already fairly effective EHR implementation. These cleanup EHR consultants are usually quite effective because they are brought in to solve specific, identifiable problems. The most effective consultant will be deeply biased to the specific EHR software and vendor your practice uses, with extensive experience with and understanding of that EHR in a medical practice. 

The reality is that every EHR consultant is biased. This can actually be a good thing when using a consultant for implementation and cleanup. However, it can pose major challenges when using an EHR consultant to select a vendor. It creates an even larger conflict of interest when you use the same EHR consultant for EHR selection and implementation. A consultant’s desire to assist with your EHR implementation may influence which EHR they push you to select.  

Now that you know what to look for (and look out for) when selecting a consultant, it’s important to establish why it is worth your time to find one who is truly qualified. 

Large practices have a fair amount of negotiating room when it comes time to purchase an EHR system. Vendors realize that physicians have a growing number of options when selecting software, and are thus often willing to be flexible when setting the terms of a contract. A well-trained EHR consultant should be well versed in EHR contracts and be able to assist with negotiation, point out problem areas, and suggest missing details. EHR consultants can even help small clinics negotiate things like long-term pricing arrangements, concessions for time spent hosting site visits for vendor prospects, and upfront costs. 

A consultant can provide a perspective that is not influenced by organizational norms. Fresh eyes are often able to see problems that daily users of a system have learned to overlook. Manage expectations Experienced implementation consultants can cut through the sales talk and provide a realistic understanding of how an EHR will affect a medical practice. Plus, they can help create realistic timelines. 

When selecting an EHR, this could be a problem. However, once an EHR is implemented, an EHR consultant’s relationship with a vendor could be the key in obtaining needed changes or fixes to the software. 

Most EHR systems require extensive configuration. Bad configuration decisions can have a long-lasting impact on the end users. Experienced EHR consultants know what has worked before in similar settings for a particular EHR and what hasn’t and can assist you in determining which configuration options best meet your clinical needs. 

Not many doctors are experts when it comes to fax servers, voice recognition software, microphones, biometric authentication, scanners, card readers, digital cameras, printers, tablets, desktops, wireless, shared drives, OCR, IM, etc. An EHR consultant should understand the capabilities and limitations of these technologies and be able to advise which are suitable for your practice. 

A number of options exist for handling old paper charts. Selecting the option that fits the needs of your practice is best done by someone who has experienced the transition firsthand. 

Consultants with a proven track record of successful EHR implementations instill more end-user confidence. They can also share firsthand experience related to the benefits of an EHR implementation. 

EHR vendor training is usually generic training that covers every feature of their EHR software. This training can be confusing, overwhelming, and a waste of time because no clinic uses every feature of an EHR. A good consultant can train end users on only the features likely to be used by the practice. 

It is unrealistic to expect that every EHR consultant provides these benefits. In fact, it is unlikely that any EHR consultant can provide all of the benefits listed. Instead, physicians should study this list and decide which are most important for their practice, and then use those criteria when researching and vetting EHR consultant candidates. 

The first step in selecting an EHR consultant is determining whether you want a consultant to assist with selection, implementation, or cleanup of your EHR. This decision will drastically influence the type of consultant you want to use. 

The best way to find capable and reliable EHR consultants is to ask colleagues who have had good experiences. Local colleagues are even better, since they can recommend consultants who know the local labs, payers, and pharmacies with whom your EHR will interface. Request to speak to and meet with a consultant’s previous clients, and do not be distracted by glossy marketing material or special pricing. Instead, ask for actual examples with measurable results. 

Remember that every EHR has its limitations, and be wary of a consultant who hypes an EHR as the perfect solution. Instead, select a consultant who is aware of the challenges associated with EHR implementation and who will openly discuss those challenges and real world solutions for overcoming them. Fit is very important. If you do not feel comfortable around that consultant, then keep looking for one who does make you feel at ease. 

Practices interested in an EHR selection consultant need to first identify his or her biases. Consultants who tell you they do not have any biases should be dismissed out of hand. Next, request from the consultant a list of clients that reveals the size of the practice and EHR selected. Look for trends that indicate a bias in favor of a particular vendor or vendors. For example, all large practices selected the same EHR. These trends may not prevent you from using this EHR consultant, but should be used to more thoroughly assess their decision-making process and the quality of their advice. 

Practices interested in finding a good EHR implementation and cleanup consultant should start by asking their EHR vendor. Vendors are often aware of consultants who are familiar with their software. EHR-related blogs (eg, 

http://nnlm.gov/pnr/advocacy/ehr-forum.html

) are also a great place to learn about specific consultants or to find EHR consultant referrals. However, do not just read the blogs and forums; participate in the conversation. 

Physicians considering engaging the services of an EHR consultant should evaluate which type of consultant is needed and what benefits that consultant will bring to their practice. Not all EHR consultants are EHR salesmen posing as consultants. Many are genuinely interested in a practice’s long-term success. Finding a qualified EHR consultant isn’t easy, but can save you large amounts of time, headaches, and money when done right. 

John Lynn is the creator and author of the website 

, which covers EMR, EHR, HIPAA, and healthcare IT.

When selecting an EHR for your practice, using an EHR consultant can save you time, money, and headaches.

Does Your EHR Consultant Have Your Best Interests in Mind?

A teenager finishes what she and her family hope will be the last in a series of chemotherapy treatments, and a celebratory trip to Disney World is underway. The teen feels a wave of nausea coming on while enjoying the festivities. She takes out her cell phone, text messages her nurse back home, and asks, “Is this a side effect of the chemo or the result of a ride on Space Mountain?” Scenarios like this are becoming more common for pediatric patients at 

Dana-Farber Cancer Institute’s Jimmy Fund Clinic

. Whereas having a serious disease like cancer once tethered patients and their families close to home, now cell phones, personal digital assistants (PDAs), and other handheld digital devices are making it possible for patients and their families to take vacations far from home and enjoy other pleasures that were once denied by cancer.

E-mail communication between children with cancer and their caregivers, particularly nurses, is nothing new at the Jimmy Fund Clinic. Communication by cell phone has simply been the next step.

Even seemingly little things, like a pager for a parent dealing with an anxious, restless child in a waiting room, can improve the clinic experience for both patient and provider. “There’s often quite a bit of wait time to see a doctor or nurse when you get to the hospital,” says Dr. Marsha Fonteyn, a nurse scientist at the Dana-Farber Cancer Institute and member of the 

. “Parents of young patients or teenagers themselves are given a beeper, much like you’d get at a restaurant, and paged when it’s their turn. It works throughout the whole hospital, so they don’t have to stay in the waiting room.”

Between visits, cell phones have quickly become an integral—and popular&mdash;component of pediatric cancer care at the Jimmy Fund Cancer Clinic. “Patients typically call their nurses about symptom management and management of their side effects from chemotherapy,” Fonteyn says. “For example, if an older child was prescribed antibiotics and becomes immunocompromised, he or she can call the hospital and give details about what’s going on. We can then tell the patient whether he or she needs to come in or if a symptom is nothing to worry about. Or a parent of a child who suddenly starts exhibiting gastrointestinal symptoms like vomiting, diarrhea, or poor appetite can call and ask if it’s normal. You want them to be able to get in touch with you so they don’t run the risk of a possible complication that may cause their status to deteriorate.”

The success of the cell phone program at the Jimmy Fund Clinic was outlined by Annie Beauchemin, RN, BSN, CPON, and Robin O’Connell, RN, BSN, CPON, during a poster session at the 2005 National Conference of the 

Association of Pediatric Hematology/Oncology Nurses

 in Portland, OR. “For patients and families, the use of cell phones creates instant access to nurses, and preliminary feedback from patients and families indicates high levels of satisfaction with this method of communication,” they said. “For staff , using cell phones saves time and increases opportunities for direct interaction with patients and families.”

Cell phones also provide the immediacy of symptom reporting, which is often vital to clinical trials; about 95% of patients at the Jimmy Fund, according to Fonteyn, are enrolled in trials. “You want them to follow their regimen very closely. Instant reporting of side effects can impact the results of a clinical trial.”

Perhaps one of the most obvious and immediate uses of cell phones in cancer patient care is as a pocket medication reminder. Proper adherence to medication dosage and schedule has a direct impact on the quality and efficacy of cancer care. Medication reminders not only help the patient, but also his or her home caregivers, who suddenly find themselves responsible for helping a loved one get through the challenge of cancer.

“The cell phone is ubiquitous today,” says John Maschenic, associate director for healthcare and head of sales and marketing for Verizon’s Pill Phone. “There’s one on every hip.” 

 is actually an application that can be downloaded to most cell phones, whether Verizon or another brand, for about $4 per month. It stores, updates, and provides photographs and generic conversions for roughly 1,800 prescription and OTC medications. It also offers a medication reminder feature, which allows users to schedule automatic reminders to take the right medicine at the right time. But as Maschenic discovered, caregivers are finding the feature to be extremely helpful as well.

One thing cell phones cannot yet do, however, is make sure someone actually took their medicine. “The healthcare industry knows medication compliance is based on the honor system,” says Maschenic. “Say I’m the caregiver for an elderly parent. I receive an automatic text message on my phone saying which medication grandpa took and when grandpa enters it into his cell phone. But if grandpa gets sick, and there’s a record of him saying he took his medication, we know we have to take a closer look as to whether he’s really taking his medication or his medication is no longer working.”

The success of the Pill Phone means it is now being considered for expansion beyond the patient and caregivers. “Now that we’re out in the field, we’ve been engaging healthcare providers, like pharmacists, to use the phone records to see if a medication is being filled on time,” Maschenic says. “If a medication that is supposed to last 30 days hasn’t been filled in 47 days and the patient ends up in the emergency room, it is critical for the physician to have this information. They’re looking at the Pill Phone as another tool to help avoid acute emergencies.”

The integration of the cell phone into patient care and patient—provider communication is not without irony. Not so long ago, large signs in most hospitals warned people to shut their cell phones off for fear of interfering with medical equipment. Now, thanks to advances in cell phone design, doctors and patients are rarely seen in hospital hallways without a phone in their hand.

“In a couple of years, I see the cell phone as being a tool with many functions and options that will make a big difference in patient care,” says Peter Waegemann, CEO of the 

Center for Cell Phone Applications in Healthcare

 (C-PAHC). “Next to the stethoscope, it will be the most prized individual item a provider could have.”

In many ways, according to Waegemann, the US is playing catch-up with the rest of the world when it comes to using cell phones as a tool in patient care and management. In many developing countries, a small remote village may be more likely to have a wireless community cell phone instead of a computer requiring a DSL line. In one particularly dramatic case, Waegemann tells of a nurse in Africa who performed a life-saving amputation guided by 15 instant messages sent by a colleague in London.

European countries are also ahead of the United States when it comes to integrating cell phones into oncology care. The 

 in London has started using a cell phone-based 

Advanced Symptom Management System for Young People

 (ASyMS©-YG) with positive results. Young people age 13-18 years with cancer receive their own PDAs and report by questionnaire how they’re feeling after a chemotherapy treatment, complete with a body diagram to show where they were feeling pain. Results are sent to a central database at the clinic, where nurses can view and track their symptoms. Based on the responses, patients automatically receive a text message telling them what to do, or if severe, receive a call from the nurse. Recently, a function enabling patients to receive advice about managing common symptoms like constipation and diarrhea was added. If severe, a nurse is paged to call the patient to offer personal advice and support.

News of these successes have prompted US oncologists, according to Waegemann, to embrace the cell phone and become eager to combine it with computers and other electronic communication devices to promote meaningful interaction with patients. “By the end of 2009, I predict people with cancer will be able to call their doctor, send insurance information, and tell their oncologist what other doctors they saw, all on their cell phone,” he says. “The cell phone will be used from the very beginning to remind patients to take their medication. Whereas oncology patients were once on their own dealing with side effects, they are now sharing information with hundreds of thousands of patients and oncology groups everyday. They’ll be able to communicate with their oncologists more but see them less, which is what many patients seem to want.” Waegemann says C-PAHC expects to announce more potential uses of the cell phone in cancer care of specific interest for oncology nurses.

Do you use your cell phone to call or text patients as part of their treatment? How would you handle a patient who constantly calls?

Knowing their nurse is just a text message away may be a big comfort to people with cancer, but it poses a new challenge to their nurses. Even while hailing the success of the Jimmy Fund Clinic model, Beauchemin and O’Connell say nurses must utilize creative time management strategies, since the pager and cell phone can be going off at the same time that they are accessing a port, comforting a family with a dying child, or checking chemotherapy with a co-worker. Responding to messages from a blinking cell phone or a chirping BlackBerry, the nurses note, “requires focused time and effort.”

Cell phone medicine, Fonteyn acknowledges, does require some juggling, but she ultimately feels that it is worth the adjustment. “Actually, in the long run, it may make your practice run a little smoother when you find you are not having to deal with as many acute crises because you will have been able to ward them off ,” she says. Her advice? “Try starting with a group of patients you are most concerned about—perhaps by first encouraging them to contact you by e-mail. See if it makes a difference in the number of unexpected visits you receive.” Many doctors, she says, are becoming more willing to incorporate changes like these into their practices if they are convinced of their value. There are those oncology practices that regard the idea of integrating cell phones into patient management with wariness, but as more patients become aware of these services, they may have little choice.

“Patients are even willing to pay an extra $10 to $20 a month, even $50 a month in cities like New York, to have access to their nurse oncologists by e-mail or IM,” Waegemann says. Doctors who collaborate by cell phone with patient support groups, he adds, have the potential to generate even more income by providing their patients with a handheld portal that enables “hundreds and thousands of cancer patients to become part of a community,” giving them access to even more support. “It is a very different practice model,” Waegemann says when comparing traditional doctor—nurse–patient communication with the era of the cell phone. “Some don’t like it, and some do. But the bottom line is that you can’t stop it—it will happen.”

Diane West is a freelance healthcare journalist. “

,” her article on communicating with patients about pain, appeared in the January 2009 issue of 

The Changing Dynamics of Cancer Care and Support in the Cell Phone Age

Putting it on the Line

Prostate cancer is second only to lung cancer as the leading cause of cancer death for men, with the American Cancer Society 

 that 28,660 men died from prostate cancer in 2008. However, many experts agree that prostate cancer is treatable and highly curable if the disease is detected early. 

A common treatment option for prostate cancer is radiation therapy, which is as effective in treating the disease as surgical removal of the prostate. Although men who opt for treatment with radiation instead of surgery can experience side effects—including fatigue and urinary and bowel frequency and urgency&mdash;they do not have to worry about urinary incontinence, bleeding, and other risks associated with surgery. Also, radiation treatments do not require hospitalization. In fact, most men are able to enjoy their normal daily activities during treatment. 

One of the biggest challenges doctors face in delivering high doses of radiation to the prostate is controlling for natural internal organ motion. Clinical studies have documented that prostate organ motion is both unpredictable and variable, based on breathing and bladder and bowel filling. Each day, the prostate can shift more than 1cm in some directions. During treatment, it may shift several millimeters as the patient breathes or coughs. Conventional methods to localize the prostate, including daily external ultrasound and CT imaging, do not allow for continuous real-time monitoring of the tumor’s position and cannot predict organ motion. 

Organ movement is a natural and commonly occurring bodily function. However, if the target (the prostate) can be effectively tracked during treatment, the radiation can be delivered more effectively. Knowing the exact location of the target, in real time, maximizes treatment benefits and minimizes potential damage to nearby tissues or organs, which limits side effects. Tracking the target allows the physician to confidently treat a smaller volume with higher doses of radiation. 

Several leading hospitals throughout the country, including Fox Chase Cancer Center in Philadelphia, have adopted a revolutionary technology called GPS for the Body. Also known as the 

, GPS for the Body specifically tracks the prostate motion in prostate cancer patients, enabling physicians to detect the slightest organ movement in real time, as well as the direction of the radiation if the prostate moves more than expected. The prostate motion is tracked based on the signals from three electromagnetic Beacon transponders, each the size of a grain of rice, which are permanently implanted within the patient’s prostate gland. The transponders send benign radio waves that allow physicians to precisely pinpoint the location of the prostate, even as it moves during treatment. If necessary, the physician can pause treatment and re-adjust the patient, thereby minimizing or avoiding potential damage to the nearby rectum and bladder. 

Current methods for aligning treatment involve imaging the tumor—using implanted gold markers and X-ray images or ultrasound scans&mdash;before each radiation session. The Calypso system provides continuous, real-time positioning, akin to having a video versus having a snapshot of the tumor. 

Patients who have undergone radiation using the Calypso System, and their physicians, find comfort in knowing that the chances of eradicating early-stage prostate cancer is potentially increased when radiation is delivered with extra precision. Patients are relieved that side effects may be minimized and quality-of-life factors, such as bladder control and sexual function, may be preserved, enabling a faster recovery. 

Dr. Horwitz is the Acting Chairman of Radiation Oncology at 

A common treatment option for prostate cancer is radiation therapy, which is as effective in treating the disease as surgical removal of the prostate.

GPS for the Body: Treating a Moving Target

As anyone who has lugged a notebook computer through an airport can attest, even today’s sleekest machines feel heavy after a few hours. Add in chargers, backup batteries, a peripheral or two, and a carrying case, and you could be hauling around an extra 10 or 15 pounds.  

But do you really need all this gear if you only want to do a few basic things, like check and respond to e-mails and surf the Internet, but want a better user experience than smartphones provide? A few years ago, a small company called Asus pioneered the so-called “netbook” category with its line of Eee PCs. Sometimes called an ultra-portable notebook, this new device category falls somewhere between a smartphone or PDA and a laptop computer. 

Many industry pundits now say that netbooks are the next big thing in small computers. In fact, analyst firm IDC predicts netbook sales will grow 300% in 2009 compared to 2008. Although I have not yet purchased a netbook, I believe there is some merit to the basic premise behind these products: people want simple, fast, and highly portable computers. At the same time, there are some drawbacks that you should consider before purchasing one. 

First, let’s consider what these pint-sized devices do well. If you use a desktop computer at home or the office, and carry a simple cell phone instead of a smartphone with Internet connectivity, a netbook makes a lot of sense. You can easily slip it into your jacket pocket, bring it anywhere, and connect to the Internet via built-in WiFi wireless networking. 

According to a quick survey of product reviews in PC periodicals, netbooks boast fast boot-up and connection times. Some of them are capable of connecting to the Internet in as little as 45 seconds from power on. For anyone who has waited the seemingly interminable five minutes or more it can take a Windows Vista computer to boot up and connect to the Internet, that kind of speediness sounds like a minor miracle. Part of the reason for the fast boot up and connect times may be due to the fact that some of these machines run the Linux OS and open source applications, which are a good deal less “bloated” than the code coming out of Redmond, WA these days. 

Needless to say, these machines are lightweight. For example, the Sony VAIO P Series, introduced at this year’s Consumer Electronics Show, weighs just 1.3 pounds. Low cost is another attractive feature, as most netbooks sell for under $600. Basic models of the well-reviewed Acer Aspire One start at around $350, making it an ideal solution for students, the budget-minded, or professionals who already have a primary laptop or desktop but want something more portable. 

So, what are the downsides? Let’s start with screen size. If you are accustomed to the large, high-resolution screen of your Dell laptop or Apple MacBook, your eyeballs will be underwhelmed with the seven to 10-inch screen on most netbook models. Nearly all of the netbooks have screens with resolutions smaller than 1024x768, which renders some sites and applications unusable, including many EHRs and other practice management applications. 

Cramped keyboards are another issue with netbooks. While having a full keyboard is a distinct advantage over using your thumbs to type into a PDA or smartphone, the truth is that a keyboard can be made too small for practical use. Some netbooks do have small, poorly designed keyboards, so I would test drive a netbook before buying one. 

Netbooks are definitely not for everyone, but they fill a useful niche in the marketplace. Is there a netbook in your future? I suggest you take a trip down to your local electronics store to see for yourself. 

Would you use one of these devices in your practice? Or does the small screen size and potential difficulty interfacing with EHRs make a netbook less than ideal for a practicing physician? 

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.  

Would you use one of these devices in your practice? Or does the small screen size and potential difficulty interfacing with EHRs make a netbook less than ideal for a practicing physician?

As anyone who has lugged a notebook computer through an airport can attest, even today’s sleekest machines feel heavy after a few hours.

The Incredible Shrinking Notebook

I work in the Washington, DC area in a private, two-physician, primary care practice. I am a believer in the intelligent application of healthcare information technology; the EMR system that I designed and have been modifying for the past 18 years works very well within my practice setting. However, I have noticed increased pressure on physicians to adopt CCHIT-certified EMR systems, e-prescribing, and other forms of health IT. The federal government, insurance companies, and vendors have been pushing ill-advised health IT policies that if implemented would be disastrous for physicians, especially those who practice in solo or small group settings. 

) provided several examples of the kind of dangerous thinking that is driving the debate over health IT. It presented many of the familiar top-level rationales supporting e-prescribing favored by many non-physicians, who don’t understand the complexities of patient care. Unfortunately, many politicians have been convinced that expensive EMR systems, with their ability to electronically prescribe, will save money and lives, and will generally be a good thing for healthcare in the United States. This apparently includes President Obama, who has sought advice on health IT from Allscripts CEO Glen Tullman; if Tullman’s views become policy, it would 

 in more unfunded and unproven health IT mandates. 

 article described Allscripts software as “being offered free to doctors.” Allscripts is not really free, because it does not integrate with the vast majority of EHR systems. If a physician does not buy the Allscripts EHR, then he or she will be forced into an unworkable double-entry situation, which will intrinsically increase the chances of making a prescription error. Providing free software is simply an Allscripts marketing ploy to get physicians accustomed to using its software. 

 article also noted that Allscripts software “displays a green smiley face next to generic and on-formulary drugs, and a red frowning face next to more expensive nonformulary drugs.” The implication being that this is an essential feature for promoting cost savings. Yet there are already several software programs (many of which, such as Epocrates, are available for free) that can be installed on almost any platform, including smartphones and PDAs, and that provide formulary data and drug-drug interaction alerts. Yet, despite the widespread availability of these applications, physician uptake has been slow. 

Physicians on the front lines must be aware of news and information about health IT that appears in newspapers and other media likely to be read and seen by patients and policy makers. Typically, these articles and news reports treat health IT as an absolute good and report on proposals to promote widespread implementation as if the big questions have already been settled and all that remains is to work out the details. As we all know, however, these accounts only provide a partial picture. They rarely acknowledge that most doctors do not want to buy or use CCHIT-certified EHRs or e-prescribing because they are expensive workflow killers that will make their lives more difficult. 

E-prescribing requirements have been pushed on providers by non-tech-savvy politicians and by EMR vendors who are trying to make a fast buck on the backs of physicians. They were 

 despite the lack of good prospective studies demonstrating that e-prescribing actually saves money and avoids errors in the ambulatory setting. In fact, the US Pharmacopeia 

 showed that data input errors far exceed handwriting errors (13% vs. 2.9%, respectively). We need more studies performed by neutral researchers before we can decide whether a forced and costly e-prescribing implementation mandate is really a prudent idea. 

We shouldn’t completely scrap the idea of full-scale e-prescribing, but we should push for a truly free, open-source product that can be used by virtually any EHR and is funded and provided by Medicare. But this cannot be an all-or-nothing proposition. CMS must still accept typed prescriptions that are printed out by basic EMR systems. Fax machines should also be reinstated as an e-prescribing option. 

We need to move forward with all health information technology, including e-prescribing, in small steps with continuous revisions and quality improvement along the way. 

Alberto Borges, MD, is in private practice and is an assistant clinical professor of medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC. Check out his website at 

An article published January 21 in the Wall Street Journal (WSJ) provided several examples of the kind of dangerous thinking that is driving the debate over health IT.