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1. What major goals do you hope to achieve during your tenure, and which is the number one issue on your list?

	My goal during my tenure is to help move the health IT agenda from one phase to another. When 

 was here, he and his staff were setting up the 

Office of the National Coordinator for Health Information Technology

 and put a lot of effort into establishing a solid foundation. Now we’re shifting to the next phase, where we need to execute and begin delivering on the plans that are underway. For example, when the 

 recommended in October 2006 its first set of EHR interoperability standards to the Secretary of the Department of Health and Human Services, it was the end of the initial phase of development; we went from proposing ideas to identifying and creating the standards that are needed to support interoperability. We’ll also move forward with the EHR certification process and identify what we call “prototype use cases”—hypothetical ways in which EHRs would be used in various healthcare scenarios&mdash;and then establish the core set of use cases, based on which we will develop the certification standards for these products. As we continue to grow those standards over time, developers will move forward with products that incorporate those standards. We will also continue to make progress toward the Nationwide Health Information Network; we will complete the prototypes and demonstration projects and draw from those to create the next phase of development.

2. What are the biggest challenges facing the HIT Industry?

	I think that HIT companies have been making important advances, but since until recently not enough attention was paid to healthcare information technology, patients and providers have not received the full economic benefit of the health IT that is already in place. That’s why we’ve been moving forward with the agenda to create EHR interoperability standards, with the ultimate goal of establishing a nationwide network.

3. What role will the tech industry play in your efforts as National Coordinator?

	It will play a very active role. In order for us to succeed with our national health IT agenda, we are absolutely dependent on participation from all parts of the healthcare sector. The health IT companies need to be at the table, helping us identify and create the standards, participating in aggressive and achievable plans by which those standards can be incorporated into electronic health records, personal health records, and other products, and delivering them into production. The next few years are going to be a very interesting environment and create a growing opportunity for health IT vendors.

 certification process for EHRs played out with the industry?

	From what I can tell, it’s played out very nicely. We started with standards and certification for ambulatory care assistance, which is a subset of all of the systems. We called for two rounds of certification and now have more than 35 products that have passed certification based on the current criteria. Then, starting sometime in 2007, we’ll go into the next round, which will be expanding to inpatient EHRs and upgrading to version II of the criteria for ambulatory EHRs. In 2008, we’ll move toward a network of providers (network services) and criteria for that as well.

5. What tangible outcomes in HIT can practicing physicians expect to see in the next couple of years, and what can they do to help promote greater health IT adoption and implementation?

	Providers who are already using EHR systems can help to communicate to their colleagues the benefits that they’ve seen and the practical lessons learned in terms of what it takes to successfully implement the systems. Currently, there are a number of useful products that enable providers to do several things, including electronically prescribe and exchange some laboratory information. That will become more and more widespread as we move forward with implementing the standards for interoperability. Providers that have tools that support quality measures will be able to get feedback and see how the quality of care they provide is improving.

6. Is the hype surrounding HIT detrimental at this point because of the high expectations it creates?

	I think that the interest in health IT is well worth it. We have non-healthcare, non-IT industries participating in order to create incentives for adoption, because they understand the important impact that adoption of this technology will have on their bottom lines. The traditional statistic that people give is that General Motors pays more for health insurance annually than it does for the steel it uses to make its cars. The cost of healthcare is interfering with the competitiveness of American companies. We need to do something to improve the quality and decrease the cost of healthcare in this nation.

7. What needs to happen in order for a nationally interoperable network of EHR systems to be developed?

	The activities we’ve been working on are designed to achieve that. We need to set standards that are implemented in a variety of systems (both EHRs and personal health records), and we need to enable secure, confidential exchange of information among those standardized islands of information. As part of this effort, we will have to identify quality standards and further integrate decision-support mechanisms into these systems, so that they enable providers to deliver higher-quality, safer care, which translates into more efficient care. Doing all this will help enable us to address rising healthcare costs in the future. After we get all of the technologies in place and those tools become an integral part of physicians’ practices, there will be a very subtle but important shift in the delivery of care. Finally, I think we will also see increased use of personal health records by patients and the community, and that particular technology will fundamentally transform the relationship between providers and patients in a very positive way.

Articles

...with Dr. Robert Kolodner. Before becoming interim National Coordinator, Dr. Kolodner was the chief health informatics officer of the Veterans Health Administration.

7 Questions... With Dr. Robert Kolodner

 robotic system years ago, enabling “healthcare professionals to provide more effective and efficient healthcare by allowing them to 'be in two places at once.'" Standing at 5'5" with a price tag of $4,000-7,000 per month, the 

 is guided by a joystick from a computerized ControlStation, typically located at a physician’s home or office, through the Internet and an 802.11 wireless network. It is equipped with a flat-screen computer monitor that displays the physician’s face, infrared warning sensors to avoid bumping into people or objects, and two-way cameras, microphones, and wireless technology that allow the physician to review the patient’s chart, lab work, and x-rays without being at the hospital. 

, chairman and CEO of InTouch, about the RP robotic system, upcoming improvements, and physician and patient feedback.

	Dr. Wang explained that his inspiration for creating the RP robot was based on his knowledge about robots and the healthcare industry and problems associated with the overall delivery of healthcare. He said these problems are “created by our aging population where the demands on healthcare are [increasing] dramatically [and] healthcare resources are shrinking simultaneously, so you have this perfect storm happening.” To provide quality healthcare at lower cost in facilities short on physicians, InTouch merged robotics, the Internet, and wireless technology to better leverage available healthcare resources.

	InTouch is focusing on four scenarios in which the RP robot can assist hospitals and physicians:

 — “There’s a big shortage of intensivists and there’s a lot of literature that says if intensivists monitor ICU patients on a 24/7 basis, it greatly helps to reduce costs and reduce morbidity and to reduce mortality and length-of-stay,” said Dr. Wang. “Since you can’t hire the intensivists, you get better outcomes if you leverage this technology.”

Shortage of specialty specific physicians in the emergency department (ED)

 — “Hospitals are struggling to be able to have what’s called the call-panel for their staff ,” Dr. Wang explained. “When a patient comes into the ED and needs a consult from an orthopedist, cardiologist, neurologist, or general surgeon, hospitals are using these robots in order to enable these specialists to beam in because often it can take hours for the specialist to get to the ED.”

 — “The system [can] connect a larger hospital to a smaller hospital that doesn’t have all of the expertise it needs. It brings the expertise into these outlying rural communities."

 — “When physicians are rounding on patients, [they] typically stop by once for maybe fi ve minutes in the day. Our system allows the physicians to easily come back and see the patient again from their clinic or their home for whatever reason—a new test result could be back, the family members could be there who also wanted to talk to the doc, or [if] discharge is possible,” Dr. Wang said.

	Feedback on the RP robot has been encouraging. In 2004, 

 using the RP-6 to determine how comfortable patients were with being treated by their physician through a robot and found that “many hospitalized patients prefer visits from their own physician to those of the physicians on duty, even when those ‘visits’ are virtual ‘telerounds’”. Physicians who use the RP robots find that they are more efficient in their medical practice. Dr. Wang told 

, “They can actually be in their clinic, [with] five minutes between patients, and go see their hospital-based patients and get something else done in a period of time they otherwise wouldn’t be able to. In fact, I got an e-mail from the Chairman of Surgery from the Los Angeles Children’s Hospital who was at a conference in India and he rounded on a patient in LA.”

	Already on its seventh-generation robot (RP-7), InTouch is currently working on improvements for both the robot and the control station, including creation of a kit that Dr. Wang said “can make virtually any computer into a control station [which provides] more and more flexibility” for the physician. Regarding the robot, the developers are looking to expand functionality by offering a stethoscope and otoscope, giving physicians greater capabilities.

	Said Dr. Wang, “The need to better leverage medical expertise is a common problem everywhere in the world. The opportunity for us, we believe, is with every hospital in the world. Obviously things evolve and take time in order to move from larger places to smaller places, and also the Internet has to be there. Given that that evolution is undoubtedly going to take place, I think that it will happen with this technology as well."

We profile InTouch Technologies' Remote Presence (RP) robotic system, a modern-day "Rosie" from the Jetsons...is it for you?

The Remote Presence Robotic System

 employs "over 100,000 people, has more than 80 manufacturing sites in 37 countries, and makes almost four billion packs of medicines and healthcare products each year,” according to the 

 corporate brochure. In the area of R&D, the pharmaceutical company spends $14 million every day, or $562,000 every hour, on work performed by more than 15,000 people at 22 facilities and which includes more than 65 million screening tests a year.

	A major part of GSK’s R&D eff orts are in drug discovery, consisting of seven research units the UK-based company calls 

, which focus on cardiovascular and urogenital diseases; metabolic and viral diseases; microbial, musculoskeletal, and proliferative diseases; neurological and gastrointestinal diseases; psychiatric diseases; respiratory and inflammatory diseases; and biopharmaceuticals. Once promising targets are discovered, GSK researchers shepherd them through the pipeline, investigating biochemical and physical properties, bioactivity, and other characteristics using proprietary strategic technologies, novel analytical technologies, and other tools and resources.

	In the area of physical properties, a “team investigates the physical characteristics of the materials to make a medicine.” The team uses such techniques as x-ray powder diffraction (

 “is an instrumental technique that is used to identify minerals, as well as other crystalline materials,” used for fingerprint characterization and structure determination of crystalline materials

, a thermoanalytical technique, is used as a quality control instrument for evaluating sample purity and studying polymer curing.

 is used to test weight changes of samples in relation to change in temperature as a means of determining material characteristics, degradation temperatures, absorbed moisture content, and levels of inorganic and organic components, and solvent residues.

, according to Ohio State, consists of a microscope using electrons instead of light to form images, resulting in a large depth of fi eld, and a large focus area for viewing closely spaced features at a high resolution.

	Strategic technologies provide “technology innovation primarily focused on new product development platforms with a three-year delivery timeframe,” concentrating on exploratory pharmaceutics and drug delivery systems. The former “deliver technologies that require intensive training, high capital investment, and/or tight networks with internal or external groups while also supporting current GSK projects through 

 and animal models.” The gamma-emitting radioisotope judiciously introduced through gamma scintigraphy allows, through the intended delivery site, the transit of a dosage form to be non-invasively imaged in vivo, which can in turn be correlated with the rate and extent of drug absorption.

	Scientists working with GSK novel analytical technologies are at the very cutting edge of modern drug discovery. The tools at their disposal include high performance liquid chromatography (

. Used frequently in biochemistry and analytical chemistry, 

 separates, identifies, and quantitates compounds in any sample that can be dissolved in a liquid. Helpful in measuring mass-to-charge ratio of ions, mass spectrometry’s applications include identifying unknown compounds, determining a compound’s structure, “studying the fundamentals of gas phase ion chemistry,” determining elements’ isotopic composition in a compound, and “quantifying the amount of a compound in a sample." Near infra red spectorscopy is also used to identify compounds and investigate samples’ compositions.

: www.gsk.com/responsibility/cr_report_ 2005/research/index.htm

What's in the pipeline as far as new technologies for pharmaceutical giant GlaxoSmithKline? We investigate...

GlaxoSmithKline

	Today’s healthcare organizations face many issues and bottlenecks, including the impact of severe workforce shortages, longer and more detailed reporting requirements, and constrained financial resources. These issues could have a negative impact on the quality of care that a patient receives. That’s why some progressive healthcare organizations have started to utilize workforce technology solutions, like 

solutions, as a way to realize even greater operational efficiencies and to improve patient care.

	NextMail and SkyMail are mobile dictation and documentation solutions available nationwide. Both allow healthcare professionals to record, document, and share critical information from the field with their office via e-mail by simply using their voices. 

 is available to Nextel Walkie-Talkie subscribers only from Sprint Nextel, Inc. For customers who do not have Nextel Walkie-Talkie service, PDV developed 

, which works across all major US cellular carriers. Both services operate in a similar way.

	Here’s how the technology works (we’ll use SkyMail in our example): A healthcare professional meets with a patient. Once the visit is completed, the professional dials a pre-programmed number on his or her phone and records the patient’s charting information. This voice recording (yes, the treating physician’s actual voice) is sent directly to the e-mail inbox of the recipient as a hyperlink within an e-mail, along with a text reply box that enables the recipient to type and send an immediate text message back to the sender’s phone. The SkyMail is time/date-stamped and contains a customized e-mail “subject line” to provide more detail about the message before it is opened.

	By using SkyMail, healthcare organizations can more easily meet reporting requirements, while at the same time reduce paperwork and improve work processes, which can typically translate into hours of added administrative time. These solutions allow healthcare professionals to immediately dictate necessary information, rather than filling out forms by hand, enabling them to see more patients each day.

	With SkyMail and NextMail, there’s no software to download and no capital investment. Using the technology is simple: SkyMail is just another phone call, and NextMail is just another walkie-talkie call. Just scroll down the phone’s contact list, select a contact, press the button, speak your message, and hang up. The voice documentation is automatically sent.

For more information about NextMail and SkyMail, and for a free 30-day trial, visit 

. Resources are available to help the individual physician, the physician’s office, or a home healthcare agency become acquainted with these solutions.

We profile two innovative mobile dictation and documentation solutions that are sure to keep doctors connected to their office and patients.

NextMail/SkyMail

, Chief, Health Services Division, US Coast Guard Air Station, Cape Cod, MA; flight surgeon for Coast Guard District I, which extends from the Maine-Canada border to Northern New Jersey.

How would you describe your job to our readers?

My day-to-day job at the clinic includes seeing patients and performing physicals, but operationally I am involved in medical evacuation and search and rescue with the Coast Guard. If someone calls the Coast Guard and says, “We have someone injured,” the District Main Office will patch me through so I can talk directly with the person requesting medical support. Flight surgeons have a five-question mantra: 

I make a recommendation on whether a person needs medical evacuation, but I fi rst have to decide if it’s a valid mission. Th e last thing we want is to launch in horrible weather and dangerous conditions and get somebody who didn’t need saving. If we do launch, it’s my job to make sure that the patient is packaged correctly before putting him or her into our aircraft, and to provide needed care in transit. 

Is there extensive use of health IT in your field?

Most of the time we’re dealing with commercial fishing vessels out on the Banks, so usually there aren’t any IT resources. There was, however, one case when I was in Kodiak, Alaska, where a fishing vessel was hundreds of miles out in the Bering Sea. One of the crew had injured his ankle, and I was trying to figure out what I could do for this guy, so the captain asked if I wanted a picture e-mailed of the dislocated ankle. I was able to explain the process of how the crew was going to help reduce the  man’s ankle. When everybody was in the right position, the captain e-mailed me a picture, and I told them, “That looks right. Now start pulling like I told you.” I heard the patient moan, then the sigh of relief. “That sounds good. Now take another picture.”  I told them how to tape the ankle, received pictures of it taped, and communicated with them several times over the next couple of days while they got to port. 

Can you give us an idea of what search and rescue and medical evacuation entails?

Prior to being stationed in Cape Cod, I was at Coast Guard Air Station, Kodiak, Alaska. It’s a huge geographical area with a fairly small population, so the Coast Guard was relied on a little more heavily compared to Cape Cod, particularly for aero-medical evacuation. We frequently would launch and fly to remote Native American villages, particularly in the Aleutian chain, when women would go into unanticipated labor. I was also Medical Unit Leader for the Coast Guard Incident Command System in downtown New Orleans following Hurricane Katrina. My job was to make sure that Coast Guard personnel responding to the crisis had a medical intervention evacuation treatment plan and appropriate protective equipment, and to set up medical aid stations at the larger Coast Guard response areas and staff them with corpsmen. In 2005, I spent three months on the hospital ship Mercy in Banda Aceh, Indonesia, after the tsunami. My job was to go ashore every day and visit all of the on-land hospital facilities to identify the patients who needed to come aboard the ship for care.

Was it always your intention to become a flight surgeon? 

I went to medical school on a Navy Health Professions Scholarship and was a medical officer for eight years in the Navy. In 1988, I left the Navy and went into private civilian practice in Alabama. In 2002, I got a call from the Coast Guard, who told me about their critical shortage of medical officers and flight surgeons. My kids were grown and gone, my wife and I were interested in the idea of adventure, and our parents were healthy and retired. We looked at it as an opportunity to return some service to the country. I’m having a great time. I love what I do. The best decision of my career was to have the courage to leave a very comfortable, fun, private practice and do this, because it’s a blast. I would also be very happy and enthusiastic if you would mention to your readers that we are short on qualified individuals for Coast Guard medicine and flight surgery. 

Who can our readers contact for information on becoming a flight surgeon?

Readers can contact Commander Wade McConnell at the following address: 

The job is for people who like challenges, problem solving, and are willing to take some risks. If you like adventure, if you like a challenge, if you like never having a dull moment, it’s a great job.

We talk to Dr. Kenneth R. Harman, Chief, Health Services Division, US Coast Guard Air Station, Cape Cod, MA; flight surgeon for Coast Guard District I, which extends from the Maine-Canada border to NJ

So You Wanna Be a...Flight Surgeon

	Video games have become a way of life for many children and adolescents, made possible by the advent of game consoles (eg, Xbox, Playstation), computers, and the Internet. Although some people frown upon the amount of time some kids spend playing these games and decry their lack of educational value, the gaming industry has begun to evolve beyond solely providing entertainment and turned its attention toward designing games that address “

a wide range of public and private policy, leadership, and management issues

”. As part of this effort, designers are working with physicians and researchers to develop games that combine entertainment value with education in a revolutionary approach to disease management that could be particularly effective in children and adolescents. Video games may not be an instant cure, but research has demonstrated that people have the ability to learn more when engaging in an interactive game, a phenomenon that game designers hope to leverage to help improve outcomes in a variety of diseases, including cancer.

Currently, games are being developed in three categories

: 1) Simulated- and virtual-reality, which can be used to alleviate anxiety and distract from pain; 2) “Exergames,” which incorporate exercise into playing; and 3) Learning games, which educate children about various health conditions. 

, says “distraction…is a well-documented technique for helping children manage anxiety and fear in the hospital,” and “video games ‘sound like another, higher-level form of distraction.’”

	Numerous trials have been conducted to determine how effectively video games help patients cope with pain. 

 published in the July 16, 2005 issue of the 

, “these studies reported that distracted patients had less nausea and lower systolic blood pressure than controls (who were simply asked to rest) after treatment and needed fewer analgesics”.

—founded by the Woodrow Wilson Center for International Scholars based in Washington, DC&mdash;established the 

 to “help foster and support a community of researchers, developers, and users of applications that use game, game technologies, and game development talent to create entire[ly] new ways of improving the management, quality, and provision of healthcare worldwide.” Games for Health is funded by the 

 and seeks to improve the health of patients through the application of video gaming and interactive multimedia technologies. The Project does this by focusing on four questions: 

		Can games improve the provision, and quality, of healthcare? 

		What existing and emerging game technologies (such as multi-user, virtual environments) might be particularly useful when applied to healthcare issues? 

		How can we expand the application of computer-based game technologies to face key challenges in the healthcare sector? 

		How do we identify and proactively deal with any social, ethical, and/or legal issues that might arise through the application of game-based tools to healthcare issues?

 in Baltimore hosted the third annual Games for Health conference, which brought more than 250 researchers, medical professionals, game developers, and consultants together in order “

to explore how video games and game developers are driving new strategies in health care

” through case studies, a demonstration expo, research, lectures, panels, and discussions about a variety of topics and projects. “Game developers have the skills to create programs that will help patients learn about disease and disease management,” said 

, vice dean for academic aff airs, University of Maryland School of Medicine. “There is real promise in the video game industry to bring needed health care information to patients in a familiar and exciting format.”

	The American Cancer Society estimated for 2006 that 9,500 new patients age 0-14 years would be 

. These patients would then most likely undergo aggressive treatments ranging from surgery to chemotherapy to radiology, most likely accompanied by side effects (eg, nausea, rashes, hair loss) and pain that significantly diminish their quality of life. This is where video games can help, both as a distraction from the pain and as educational tools. Game designers have created several games, available in a variety of formats to meet the special needs of pediatric cancer patients.

, which teaches young patients about leukemia and its treatment through puzzles, games, videos, and animation. They also created an interactive CD-ROM for adolescents with solid tumors called 

Conquering Cancer Network: Empowering Teens with Tools, Info and Inspiring Stories

. This program educates adolescents about tumors, treatment, side effects, and coping skills through music, videos, and interactive games, among other methods. Similarly, the 

Starlight Starbright Children’s Foundation

 has focused on educating “today’s tech-savvy kids” about various diseases, including cancer, “

in a way that appeals to them: through the Internet

”. Patients can visit the Foundation’s website to access eight video games, three of which are at least partially related to oncology and hematology: 

Radiology Center, Uncovering the Mysteries of Bone Marrow

Blood Tests: Exploring Our Incredible Blood

 Patient Education Resources section, we briefly profiled 

, which was inspired by a 12-year-old leukemia patient, 

 (who has since received a bone marrow transplant and is in remission) and was made possible by the combined eff orts of the 

. During his illness, Ben turned to computer games as a way to cope with his pain and treatment side effects and wanted to create a video game to help children deal with the stress and frustration of cancer treatment. The Greater Bay Area Make-A-Wish Foundation announced on November 2, 2005 

the availability of Ben’s Game for downloading

 in nine languages—English, Dutch, French, German, Greek, Italian, Japanese, Russian, and Spanish. The game has been downloaded more than 200,000 times worldwide since its public release on the Internet. Ben and Eric Johnston, the game’s creator and a senior software engineer and technical director at LucasArts, were honored in a meeting with the Dalai Lama in which Ben was recognized as an “Unsung Hero for Compassion” because of his generosity with this unique project.

 is to destroy all mutated cells and collect seven shields for protection against the common side effects of chemotherapy; snow monsters represent colds, vampires represent bleeding, and cue balls represent hair loss, among others. Through three levels of diffi culty, players have the option to use a pre-created character or customize one for themselves (

www.gamasutra.com/features/20050927/bogost_01.shtml

 is available to download in both PC and Mac versions at no charge.

	Game developers are also designing games to “

, based in Palo Alto, CA, “is a non-profi t organization dedicated to combining rigorous research with innovative solutions to improve the health and quality of life of young people with chronic illness”. The company’s founder, 

, created a video game for adolescents and young adults who are battling cancer called 

. Officially released to the public in April 2006, 

 is a third-person “shooter” with 20 levels featuring different types of cancer to be overcome using a nanobot named Roxxi “who destroys cancer cells, battles bacterial infections, and manages realistic, life-threatening side effects associated with cancer."

27th Annual Meeting & Scientific Sessions for the Society of Behavioral Medicine

 with 375 patients age 13-29 years to determine how eff ective 

 was in helping them adhere to cancer medications and increase their knowledge about cancer, quality of life, and self-efficacy. More than 80% of those who played the game increased their cancer-related knowledge, allowing them to be better able to talk about cancer and manage the side effects. Young people who played 

 maintained higher blood levels of chemotherapy and showed higher rates of antibiotic utilization, both suggesting that 

 helps patients adhere to cancer therapy regimens. Visit 

 to learn more about the game; cancer patients can download a copy at no charge.

	Although the majority of the games related to cancer are geared toward patients who have already been diagnosed, some focus on cancer prevention. The 

 that educates site visitors on “how to protect themselves from overexposure to the sun.” Under the “Kids” section are interactive games through which children can learn about the importance of wearing sunscreen, dressing properly when going outside, and other skin cancer prevention measures.

	Incorporating video games into patient treatment shows that the healthcare industry is making steps to incorporate high-technology tools into practice. Videogames and other interactive technologies provide cancer patients with the opportunity to learn more about their disease and vent their frustration and release stress during the treatment process.

Video games helping kids with cancer? A novel approach, but it's a good one. Games are not just for kids anymore, after all. Read on to find out more.

Video Games for Health: A New Approach to Educating and Treating Pediatric Cancer Patients

Daryl A. Rosenbaum, MD, assistant professor and director of the sports medicine fellowship at Wake Forest University School of Medicine, has been working as a volunteer physician with the US Soccer Federation since July 2003. He took some time to speak with us about his experiences.

How did you start working with the organization?

	I wish I could say it was because I was one of the greatest doctors in the world. Truthfully, my brother became an equipment manager with the US Soccer Federation, traveling with various teams. He’s the one who let me know that they have doctors who could get involved as well. My brother put me in touch with the director of sports medicine for US Soccer, and we talked a few times. I traveled to Charleston, SC to meet one of the teams my brother was traveling with and met some of the administrative staff of US Soccer. They decided to give me a chance to go on a trip. Now, I’m the team physician, and it’s not an official title or position because I’m a volunteer.

With how many teams have you actually traveled overseas?

	I’ve made six trips; three with the under-17 men’s national team, one with the under-15 boy’s national team, and two with the under-21 women’s national team.

Are you usually the only physician that travels with the team?

	There’s one physician for each team that travels with them. We also work with an athletic trainer who’s a healthcare provider, and we work together to help take care of the team. We take care of not only the athletes, but as the team physician I’m responsible for the health of the staff .

How many times on average are you consulted when you’re overseas with the team?

	It can vary, but it tends to be a few times a day. When you’re traveling and living with the team, you don’t have set office hours. You’re available whenever somebody needs you. I’ll be consulted for two or three injuries per trip, but I also am asked questions about general health, nutrition, and past medical issues that an athlete has had, among other things. My role is to see key injuries and act as a health counselor. I am available to the team all the time; people are asking me questions on the bus and at dinner, as well as set times in the training room.

Medically speaking, what injuries or illnesses have you encountered with any of the players during your time as a volunteer physician?

	Fortunately, I haven’t encountered any serious emergencies. We had to manage a significant concussion, [ultimately] taking the athlete to the emergency room for some tests and observations. I’ve taken some athletes for x-rays of twisted ankles and other similar injuries. Of course there’s the typical illnesses people may acquire while traveling like traveler’s diarrhea, sleep problems, jetlag, colds, and illnesses.

How long do you plan on continuing as a volunteer physician?

	As long as I’m able to practice sports medicine and can balance with my family life and my job, I hope to continue as a volunteer physician.

What is your main goal that you hope to achieve working as a volunteer physician?

	I feel that this position allows me to, in a small way, help some athletes who are already competing at a very high level achieve some of their dreams. I also enjoy being able to travel and to work with an organization like US Soccer. I am thrilled with where this has taken me. Sure, it would be a dream-come-true to work at a World Cup or another big tournament, but I like the way it fits in with my professional and family lives. It would be hard to ask for more than what I already get to do.

How could one of our readers become a volunteer physician for any sport or for any team? 

	It is surprising how many high schools still don’t have medical coverage on the sidelines at their home football games, let alone for other high-risk sports. Simply ask the athletic director or athletic trainer/first responder at your local school. Most would welcome any type of help that you can offer. Not only is this a nice way to market yourself but, more importantly, it is a great service to the community and just plain fun.

Volunteer Soccer Doctor Travels the World With U.S. Teams

Daryl A. Rosenbaum, MD, assistant professor and director of the sports medicine fellowship at Wake Forest University School of Medicine, has been working as a volunteer MD with some soccer folks!

A Day in the Life: Soccer Doctor

	Modern oncologists have a vast array of tools and information at their disposal that can help them deliver better care to their patients, run their practices more efficiently, and stay up to date with the latest research. In fact, there are so many tools available that it can be next to impossible to sort through them all and determine which ones are truly the most useful. We consulted several 

 editorial board members to determine which tools and resources they rely on and compiled this list of the top tools every oncologist should at least be familiar with, if not use in his or her everyday practice.

	Adjuvant! Online is designed “to help healthcare professionals make estimates of the risk of negative outcome (cancer-related mortality or relapse) without systemic adjuvant therapy, estimates of the reduction of these risks aff orded by therapy, and estimates of the risks of side eff ects of the therapy.” The cancer-specific Adjuvant! bases these estimates on information entered by the physician regarding individual patients and their tumors and displays the estimates in graphical and text formats that can be printed out for use during consultations with patients. Information is drawn from the SEER database (explained by Dr. Fogel below), clinical trial overviews, individual clinical trial results, and the literature in general. Healthcare professionals, before printing out the estimates, can modify the program’s output however they see fit.

	Three versions of Adjuvant! are currently available for breast cancer: for use in decision making for patients with early breast cancer at initial diagnosis and staging; as a decision aid for patients with nodenegative ER-positive early breast cancer; and for making decisions for ER- and/or PgR-positive postmenopausal patients. The Adjuvant! version for colon cancer “allows the user to perform analyses that provide projections of the net benefit of adjuvant therapy for colon cancer.” The Adjuvant! version for lung cancer is “primarily for weighing the options for systemic adjuvant therapy for patients who have undergone definitive surgery and pathological staging leaving them apparently disease free.” Healthcare professionals can also obtain the Adjuvant! software for Pocket PC and Palm OS handhelds. When new cancer versions of Adjuvant! become available, users can log in to the site as usual and open them under the Adjuvant! menu.

	Actually a collection of tools rather than one individual tool, the frequently updated Practice Management Resource Center from Caring4Cancer offers registered users (registration is free) “all the information you need to manage, bill, and code correctly.” Tools located here include the Oncology Office On-Line Job Exchange for finding billers, coders, managers, and administrators; the Medical Oncology Survival Kit, containing forms comparing ASP quarters 1-4 2006 with 2004, chemotherapy audit information, a chemotherapy flow sheet, demonstration sheets, and advice on how to survive CMS rule changes; a Medical Oncology Medicare Regulatory Library that features information and advice on complying with Medicare regulations; the Five-Minute Practice Manager that offers tips on managing an oncology office, with monthly updates; presentations that can help your practice maximize coding and billing effi ciency; Handy Dandy Forms for Your Practice, a collection of more than 70 forms “to make your life easier,” including those for patient signatures, notice of privacy, and E&M documentation; and an event calendar.

	The newest, and perhaps most useful tool provided by Caring4Cancer, is the 

Practice Business Intelligence System (PBIS),

 a Web-based tool offered free for the first year that works with any practice management software “to provide management summaries, daily collection aids, and trend analysis singularly focused on increasing your claim revenue.” Users can isolate and possibly eliminate denial trends with the system’s analysis tools, work denials more quickly and effectively with collection tools, and instantly recall any EOB from any remittance processed by PBIS. Download the brochure here to receive more information and to sign up for the introductory offer. 

	This free “timesaving PDA tool” for both Pocket PC and Palm OS handheld users was designed to “provide you with instant access to the most recent cancer information.” The software package consists of 12 applications, developed to help physicians and their support staff “prevent, diagnose and treat cancer.” The Cancer Screening Tool offers disease-specific reviews and information—covering cancers of the breast, cervix, colon and rectum, endometrium, and prostate, along with cancer-related checkups&mdash; designed to aid physicians in identifying and selecting patients for cancer screening and help them determine when and how those patients should be screened. Directories of contact information, Web resources, and other information for helping patients to quit using tobacco substances make up the content of the Tobacco Cessation tool, designed for guiding physicians in helping patients quit smoking. The software’s Drug Calculator will compute dosage equivalents for any two drugs included in the C-Tools database. A Pain Medication Database houses lists of “oral and parenteral equi-analgesic doses, as compared with a standard dose of 10mg or parenteral morphine.” Common indicators of skin cancer, with detailed photos of each type, are included in the Skin Cancer Tool. The Pain/Symptom Management application features lists of “pain definitions, types of pain, categories of pain, scope of the problems, effects of untreated pain, assessing pain, treating pain and specific pain sites, resources, and JCAHO Standards.” The Emerging Technology Tool keeps oncologists and their patients informed on the latest screening techniques. Symptoms and warning signs of cancer in young patients are covered in the Warning Signs of Childhood Cancer tool. A BMI calculator, the Communicating with Patients about Bad News tool, the Questions Patients Ask tool, and a Prostate-Specific Antigen Information application round out the contents of C-Tools 2.0. 

	Although not a tool in the traditional sense of the word, the questions listed below— from an article appearing in 

Topics in Advanced Practice Nursing eJournal

— are useful for physicians who want to discuss with their patients’ use of the Internet to learn more about cancer and treatments. Th e-questions include:

		Have you used the Internet for medical information or support? 

		Can I recommend some websites that may be helpful to you regarding your medical condition? 

		Have you been following any treatment recommendations that you read on a website or heard about from an online support group? 

		Is there any information that you read on a website or heard about from an online support group about treatment that you would like to discuss?

	Read the full article, “Internet Use and Advanced Practice Oncology Nursing,” 

NCCN Clinical Practice Guidelines in Oncology

	Covering more than 97% of all cancers, the continually updated NCCN Clinical Practice Guidelines in Oncology are “the recognized standard for clinical policy in the oncology community.” Developed without industry support, the guidelines “are based upon evaluation of scientific data integrated with expert judgment by multidisciplinary panels of expert physicians from NCCN Member Institutions.” Specific treatment recommendations are displayed mostly through algorithms that guide the oncologist from step to step. Along with coverage of many cancer types, the guidelines also address cancer detection, risk assessment and reduction, and supportive care. Guidelines for Treatment of Cancer by Site cover everything from acute myeloid leukemia to uterine sarcoma, including central nervous system cancers, head and neck cancers, hepatobiliary cancers, and neuroendocrine tumors. Guidelines for Detection, Prevention, & Risk Reduction of Cancer cover breast cancer risk reduction, cervical cancer screening, prostate cancer early detection, breast cancer screening and diagnosis, colorectal cancer screening, and genetic/ familial high-risk assessment of breast and ovarian cancers. Among the 11 Guidelines for Supportive Care are those focused on adult cancer pain, fever and neutropenia, and venous thromboembolic disease. The complete library of guidelines is available online or by requesting a free copy on CD-ROM. Also available from the NCCN are the NCCN Guidelines With 2006 CMS Oncology Demonstration Codes.

	This free, comprehensive search tool “provides fast access to a database of evidence-based clinical literature selected and reviewed by physicians on [NexCura’s] medical Editorial Boards, who are recognized experts and leaders in their respective specialties.” Searches for studies relevant to an individual patient’s clinical presentation are narrowed to those that only define the current standard of care. Using NexCura’s Virtual Case Model (VCM), oncologists can search for relevant published literature by describing search parameters based on clinical presentations, such as age, performance status, stage, and test results. To ensure that search results include scientifically correct literature that is relevant to the VCM, results can be generated based on each study’s inclusion criteria. Users can also change parameters to produce “what if” scenarios and view single-treatment studies separately from head-to-head treatment comparison studies. Further, as a way of supporting recommendations given to a patient, oncologists can provide patients with full citation information along with literature summaries.

	From the Food and Drug Administration’s Center for Drug Evaluation and Research comes this collection of tools that provide common toxicity criteria and assist users in determining patient performance status ratings and disease stage and performing calculations for drug dose and fl uid and caloric requirements. Use the Common Toxicity Criteria tools to look up standard grades for adverse events in summary format, including versions one, two, and three of the National Cancer Institute Common Toxicity Criteria, the NCI Common Terminology Criteria for Adverse Events, Southwestern Oncology Group Toxicity Criteria, Radiation Therapy Oncology Group Radiation Morbidity Criteria, and World Health Organization Toxicity Criteria, each offering information for an extensive number of adverse events. Enter a Karnofsky score, Eastern Cooperative Oncology Group or Zubrd score, or Lansky score for children using the site’s Performance Status rating scales to determine a corresponding performance status. Use the Disease Staging Manual to obtain in-depth, standardized descriptions for staging anything from acute lymphoblastic leukemia to Wilm’s tumor and more than 30 other cancer types. Perhaps the most useful tools located here are the calculators; the dose calculator converts doses in mg/kg or mg/m2 to total doses, and also converts doses from several species, such as those used in preclinical trials, to equivalent human doses. The Human Fluid and Caloric Requirements calculator, using either an active or sedentary patient’s height and weight or weight alone, determines fluid and calorie requirements, as well as calculates body mass index and estimated body surface area.

	Providing “oncologist-approved cancer information from the 

,” the People Living With Cancer (PLWC) site serves as a tool for supplementing the information you provide your patients, as many of the resources provided here are available in “printer-friendly” versions to serve as patient handouts. PLWC provides in-depth information on the basics of cancer, well over 100 cancer types, diagnosis and treatment, coping, and survivorship. Oncologists can also direct patients to the PLWC library, containing weekly articles on such topics as specimen processing, a medical illustrations gallery, medical dictionary, drug information resources, financial resources, support, and information on advocacy and legislation. The latest oncology-specific news, answers to frequently asked questions, and information on managing side effects round out the site’s tools. PLWC is also available en español for your Spanish-speaking patients.

The Surveillance Epidemiology and End Results (SEER) Website

 Editorial Board member Joshua Fogel, PhD, Assistant Professor of Behavioral Sciences, Department of Economics, Brooklyn College, Brooklyn, NY

	Oncologists are faced with numerous tasks to accomplish while treating their patients. Sometimes, questions are asked by patients or their caregivers that involve research and answers that may not be readily available from a journal or reference text in one’s office. Many of the more tech-savvy oncologists have gravitated toward using the Internet as a source for information, because it allows one to rapidly research a question online. Here, I provide an overview of a tool from the National Cancer Institute that is available for free online. It can be useful for helping oncologists address such questions as “Doctor, what are the survival rates for this particular cancer?”

Surveillance Epidemiology and End Results (SEER) website

 from the National Cancer Institute offers a number of ways to obtain survival information for a number of cancers and is based upon extensive data collected from many regions over many years. The specifi c dates for which the data are provided are dependent upon the search option chosen.

 offering suggestions about the different available resources. Below are examples of four approaches for obtaining cancer survival data information. Each is relatively simple to perform and does not involve any specialized computer program knowledge or biostatistical expertise. The example and approaches used will refer to a 50-year-old woman of white race/ethnicity who is informed that she has stage I breast cancer.

	The simplest approach is to choose one of the relevant “Cancer Stat Fact Sheets” shown on the left side of the SEER homepage. Based upon the above example, choose “breast” and click “go” to view a page with information on five-year relative survival rates, including separate information for white and black race/ethnicities and also information by stage type. However, it will not provide information for combinations of race/ethnicity and stage, nor will it provide age-specific information.

	The other approach shown on the left side of the webpage is “FastStats” information on many cancers. Choose “breast,” click “go,” and, on the new page, choose the tab titled, “Survival & Stage.” If “by race category” is chosen for one of the relevant age categories, a graph with information on 10-year relative survival rates is provided. Choose “by stage at diagnosis” to see a graph with information on 10-year relative survival rates for race/ethnicity. However, this FastStats approach does not provide information on the combination of age category, race/ethnicity, and cancer stage.

“Cancer Statistics Review” search option

 uses three drop-down menus: for statistic type, choose “survival;” for cancer site, choose “breast;” and for race/ethnicity, choose “white.” Click “search” to see results compiled from the pages in the Cancer Statistics Review that are relevant to this search. Check all four relevant items, and click on “merge” to allow for a custom-made PDF file for the information compiled from this larger manual on this topic. This will include information on survival rate by sex, by race/ ethnicity, and also information on combinations by age group of <50 versus 50+ years, race/ ethnicity, and cancer stage.

	To tailor information by approximate or exact age range, race/ethnicity, and cancer stage for a particular patient, the “CanQues Cancer Query Systems (CanQues)” is the best approach. It is found at 

, where clicking on “SEER Survival Statistics” opens 

www.seer.cancer.gov/canques/survival.html

. On the first page, leave the defaults of “relative survival rates” for database and “vertical bar chart” for report type. Th en click “next” and choose what to select. For example, click “site” in the upper “selections” section and then click “breast” in the lower “values” section. It is important to remember to unselect “all sites” by clicking on that option. Then click “update” and notice that it will show site=breast in the upper “selections” section. One would similarly choose, select, and update the appropriate parameters for race, sex, age at diagnosis, and stage at diagnosis. Then click “next” to see a summary of the chosen specifications. At this point, it is important to either disable or turn off any pop-up blocker. Then click “execute,” and a chart will display all the relevant information.

	As with any tool, some limitations exist. With all the approaches reviewed above, one cannot plug in the exact age of the patient, and with some of the approaches, the closest is a 10-year age range. Also, not every ethnicity has ethnic-specific data. Typically, there are only extensive results for blacks and whites. Once the brief steps for performing any of the above search approaches is mastered, users can utilize the Internet to provide tailored survival estimates to patients with only minimal effort.

If you're an oncologist, hematologist, or some other type of healthcare professional treating cancer, these tools are essential to keep and reference on a daily basis.

January 2007 | Oncology Live®