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

Call it the latest take on the independent practice association (IPA), or perhaps the evolution of the group purchasing

organization (GPO). Rather than building coalitions for management efficiencies or purchasing power, 

, a year-old organization that bills itself as an oncology service company, brings together physician practices around common clinical practice guidelines, with a heavy dose of information technology.  “We’re at the end of the arms race in terms of squeezing out efficiencies,” says J. Ike Nicoll, named in June as president and CEO of Cancer Centers for Excellence (CCE).  “Now, IPAs have to stand for something.” In this case, the goal is to make CCE stand for guiding care based on standards. “The GPO strategy has run its course,” agrees 

, Dallas and Plano, TX. “The oncology drug business has basically become commoditized,” says Sharma, whose practice is not affiliated with CCE. He believes there is little value for a practice to switch from one of the two major oncology GPOs to the other:

, formerly Oncology Therapeutics Network, a unit of 

. The seeds of CCE were planted nearly three years ago, when some OTN-affiliated physicians decided that they needed to start working more closely together to help advance care in their field. The privately fi nanced company formally started in April 2007. Since that time, they have been developing treatment protocols and working with practices and software vendors to build the electronic infrastructure to facilitate collaboration.

CCE is set up as individual, physician-owned practices under the umbrella of a holding company, with no real headquarters location.  “We’re the classic virtual company,” Nicoll says. The practices own a majority of CCE, and McKesson Specialty is a corporate partner; its McKesson Specialty division has two seats on the seven-member CCE board. McKesson, the $102 billion drug distribution giant that also has an information technology unit, serves CCE with drug distribution, technology, consulting, and specialty pharmacy services.  Th e specialty pharmacy market in particular has been changing rapidly, thanks to longer survivability of cancer patients and expensive biologics. “For the fi rst time, insurance companies are starting to recognize oncology as a chronic disease,” Nicoll explains.  Sharma sees two drivers of the shift in strategy among oncology practices: the advent of pay-for-performance and the desire for more consistent treatment guidelines. “Th e main thing that attracted us was that we saw oncology changing with the [2003] Medicare Modernization Act,” says Cathy Beaker, CEO of 

 of the Northern Rockies in Montana and Wyoming. That law changed how Medicare reimbursed for physician-delivered cancer drugs and in-offi ce oncology services. 

Hematology-Oncology Centers had been part of OTN, purely to obtain better prices on expensive chemotherapy drugs, but jumped at the chance to be a charter member of CCE. “We felt that the vision they had was our vision,” Beaker says. That vision includes the application of evidence-based treatment protocols (ETPs) among several like-minded practices that want to provide the highestquality care possible. Beaker was in on the initial planning meetings, where practice leaders discussed such collaborative eff orts as group purchasing for pricey biologic drugs and information technology. “More than anything, we really wanted to start doing evidence-based treatment protocols,” she recalls. “We want to have a forum to go to payers and say, ‘We’re doing things the right way,’” Beaker adds.  “It’s a psychographic, not a demographic,” Nicoll says of the type of practice that fi ts the CCE model. Instead of picking physicians based solely on geography or even EMR vendor, the doctors have to buy into the organizational philosophy. “This is a big commitment to step up to,” Nicoll says.

It also is geographic, to a point. CCE is starting by focusing on certain regions, including Southern California, Massachusetts, Georgia, and Florida, though it currently has operations in 14 states. Th ere has to be a critical mass in each market it plays in to provide leverage in contract negotiations with payers.  Employers that purchase insurance are increasingly looking for accountability for their substantial healthcare dollars, and guidelines have a way of holding healthcare providers accountable. “Insurance companies have very little granularity,” Nicoll says. CCE hopes to fill that void.

“Before CCE, we were using a care plan, but we weren’t doing any reporting and didn’t have any way of monitoring compliance,” Beaker says.

“The biggest thing is to be able to have the impact of several people looking at the same thing,” says Maureen Middlebrook, director of communications for 

, a Santa Rosa, CA-based oncology and radiology practice with locations in four Northern California counties. “It can only benefi t our patients [for our doctors] to see how others with the same conditions are being treated.”

The ETPs help practitioners know they are providing the most appropriate care for each patient, says Middlebrook, of Redwood Regional Medical Group, which has 43 physicians and nearly 400 employees, and joined CCE in June 2007. CCE has created or adopted best practices in a variety of care scenarios, including a logic tree to help determine if a patient is eligible to participate in certain protocols, Nicoll says. A clinical council and clinical quality committee create and review the ETPs. By midyear, CCE had developed 49 treatment protocols, including complete sets for ovarian and prostate cancers. In the coming months, they will bring online protocols for certain forms of breast and lung cancers. “We have to help educate doctors and practices on the guidelines,” says Nicoll. To deliver the protocols and support best practices, McKesson Lynx Mobile clinical informatics software, including inventory management and charge-capture functions, is in place or is being installed at all CCE clinics, according to Mike Kelly, chief information officer for McKesson Specialty.  Th e ETPs are on a Web-based common technology platform run by McKesson, regardless of where the EMR is hosted. Practices that do not have an EMR yet—and only 20% of CCE members currently do&mdash;still can access the ETPs via the Internet. “We work with each CCE member practice to get them implemented on the protocols,” Kelly says.

“We plan for evolving the technology based largely on user feedback,” Kelly adds. “We are working very closely with our customer base to provide the most pragmatic technological solutions on a daily basis.”

Many of the practices’ websites have a common look and feel, including physician portals to access the EMR and ETPs remotely.  According to Kelly, the practices are mostly ready for the switch, without major workfl ow changes. “We haven’t seen radical deviations from one site to another,” he says.  CCE requires its practices to use or at least make progress toward implementing EMRs but allows each member to choose a suitable system and timetable. “One-size-fits-all doesn’t really work,” Nicoll says. With one in five CCE practices using EMRs now, the organization actually is more technologically advanced than the medical profession as a whole. Harvard Medical School researchers reported in the July 3 edition of the 

 that a mere 4% of US physicians in ambulatory care had “fully functional” EMRs and another 13% had basic systems.  Redwood Regional Medical Group is among the 80% of CCE practices that does not have an EMR yet. In fact, the practice is not done installing a new 

 practice management system. Although MedInformatix off ers an integrated EMR and practice management system, Redwood has not yet chosen its clinical records vendor. About two-thirds of the practice—everybody but the radiology department&mdash;is up on the Informatix system. Once that rollout is complete, the practice will move toward EMR selection and planning, Middlebrook says.

It is a long process for sure, but oncology practices have only a few specialty-specific EMRs to choose from. 

, a unit of Swedish medical technology firm 

, has interfaced its medical oncology EMR with OTN’s Lynx Mobile software. Hematology-Oncology Centers of the Northern Rockies have had an Impac EMR since April 2005, helping to tie together far-fl ung clinics in Billings and Butte, MT, and Sheridan and Cody, WY, with a patient base covering 150 miles east, 235 miles west, 150 miles southwest, and 150 miles southeast of the Billings headquarters. “We use technology to do that,” says Beaker. Telemedicine and physician assistants also help the eight medical oncologists, and two radiation oncologists serve this vast geographic footprint.

McKesson also has a partnership with Los Altos, 

, producer of OncoEMR, a Web-based EMR and management system for oncology practices, Nicoll says.

Another system popular among cancer specialists is the ARIA oncology information system from 

, Palo Alto, CA. Th is is the EMR that Sharma uses in his own practice and is bringing to another organization, 

, which is following a similar strategy as CCE. “It’s an oncology company with an emphasis on technology as an enabler,” Sharma says.

Nicoll says CCE is working with vendors to put clinical guidelines for cancer treatment into the EMRs, regardless of whether the records system is designed specifi cally for oncology. Sharma says his organization wants to do the same, though NexGen Oncology—no relation to EMR vendor 

 primarily is focusing on the ARIA system. “We are embedding algorithm-driven care into the EMR,” Sharma says. Personalized medicine is a big part of the future plans for NexGen. “It’s all about mass customization,” Sharma adds.  All of NexGen’s systems follow 

 messaging standards for transferring clinical data between the oncology practices, primary care physicians, and hospitals, Sharma says. “We are moving to extend our platform for surgeons, medical oncologists, and radiation oncologists so the cancer patient’s journey is on a single EMR.”

Sharma is working to consolidate practices into a single medical group and expects to have the fi rst mergers done by the end of 2008. In that sense, NexGen will be less like CCE and more like 

, but there are commonalities in the reasons for doctors banding together. “Care in the last century was about fi nding the great clinicians. Care in this century will be about great clinicians enabled by great systems,” Sharma says. On that point, Nicoll heartily agrees.

Neil Versel is a freelance healthcare journalist.

Articles

The seeds of CCE were planted nearly three years ago, when some OTN-affiliated physicians decided that they needed to start working more closely together to help advance care in their field. The privately fi nanced company formally started in April 2007.

Building a Smarter Community: Cancer Clinics of Excellence is redefining the business of modern oncology practice

There are an estimated 200,000 cases per year in the United States in which the patient’s primary tumor site is uncertain. Diagnosing such hard-to-identify tumors can be time-consuming, expensive, and frustrating for both physicians and patients. Accurately identifying the site of origin is necessary in order to begin cancer-specifi c treatment per National Comprehensive Cancer Network (NCCN) guidelines. This is especially important given the increasing availability of new, targeted therapies.  These difficult primary cases often occur in the following situations: 1) the cancer was found in an unexpected location; 2) the tumor cells are poorly diff erentiated or undiff erentiated, making them diffi cult to interpret; and 3) the cancer was found in multiple locations demonstrating metastatic disease, with no apparent primary site. Traditional diagnostic approaches for such cases are subjective, time-consuming, and often do not produce a defi nitive diagnosis. Even with the use of immunohistochemistry (IHC), electron microscopy, and advanced imaging procedures, the primary site is identified in only about 20-25% of living patients with metastatic tumors for which the primary site is not apparent after the initial workup. Patients in whom the primary cancer is diagnosed have been shown in a prospective study to have a longer survival compared to patients in whom the tissue of origin remains unknown.

A number of different methods are available to aid physicians in evaluating hard-to-identify tumors. These include such imaging tests as computerized tomography, MRI, and PET scanning to locate the primary tumor mass. These imaging techniques may pinpoint the anatomic location of the tumor, but cannot confi rm the origin of the tumor.  Further tests on the biopsy sample—such as IHC stains&mdash;have proven to be highly useful tools for narrowing the diff erential diagnosis of candidate primary sites. However, they have limited specifi city and sensitivity and do not address the full range of potential tumor types. The most commonly recommended staining phenotypes (CK7 and CK20) produce enough false positives and false negatives to make a definitive diagnosis difficult.

Gene expression tests that use microarray and real-time polymerase chain reaction (RT-PCR) technology are helping to fi ll the diagnostic gap in cases of uncertain tumors. Microarrays simultaneously measure expression levels of large numbers of genes, enabling multiple diagnostic questions to be answered at once. Probes representing a short section of a specifi c gene’s DNA sequence are arranged on a chip. RNA is extracted from the tissue of interest, labeled with a fl uorescent marker, and spread over the microarray. The RNA from the tissue of interest binds to complementary genespecifi c probes on the array in a process known as hybridization. Th e relative fl uorescence intensity is then measured, which refl ects the hybridization level and thus the expression of a particular gene.  Once confi ned to the research lab, microarrays are increasingly being used in clinical diagnostics. 

 Tissue of Origin Test, for example, uses more than 1,500 genes to compare an uncertain tumor’s gene expression profi le to those of 15 known tumor types, representing more than 60 morphologies, in order to provide an objective, probability-based score for each potential tissue. The test demonstrated a sensitivity of 89% and a specifi city of 99% in a validation study of 487 metastatic and poorly diff erentiated and undiff erentiated tumors, in which the primary had already been identifi ed using current methodologies. The test is currently off ered through Pathwork Diagnostics’ CLIA-certifi ed laboratory. With RT-PCR, the expression of a small number of pre-selected genes (generally <100) can be measured by amplifying the gene segments of interest using appropriate primer pairs. MD Anderson Cancer Center, for example, is studying a 10-gene RT-PCR assay to identify certain types of unknown tumors, which may respond to targeted treatment. RT-PCR is a cost-eff ective and accurate method for measuring the expression of a small number of genes but cannot provide as much information as a microarray. The ability to analyze large numbers of genes is especially important for diagnosing uncertain primary tumors because numerous potential primary tumor sites must be evaluated at once.

New genomics-based tests are increasingly being used to help oncologists identify uncertain primary tumors. This can benefit patients by enabling cancer-specifi c treatment to begin sooner and by allowing patients to potentially access appropriate clinical trials. Ultimately, such genomics tests should improve patient outcomes, while reducing costs in the healthcare system.

Dr. Henner is the Chief Medical Offi cer for 

New genomics-based tests are helping oncologists answer one of the most basic, yet often challenging, questions in cancer care: What kind of cancer does the patient have?

Diagnostics: Genomics-based Tests Can Help Diagnose Uncertain Cancers

1 Why are self-survival and self-renewing pathways such promising areas of discovery at this time for Cephalon?

If we can understand the methods and the pathways by which cells are able to either prolong their survival or sustain their own proliferation as tumors grow, then, by identifying targets along those pathways, we have the opportunity to develop drugs to interfere with and block those pathways, leading to cell death, or at least prevention of the growth of the tumors. What this means at the patient level, of course, is that if we understand the molecular pathways, we can get treatments that are much more targeted toward the tumors rather than the healthy cells so that we hopefully can get more accuracy with less toxicity than we’ve experienced with drugs in the past.  Most of monoclonal antibodies are clearly directed at single pathways within cancer cells, and they have been very therapeutically successful; and most of them are pretty well tolerated. And then you have the smaller molecule approaches—Gleevec perhaps being everyone’s favorite example of a drug where by targeting a very specifi c known molecular mechanism, you’re seeing very strong results in fairly specifi c tumor types with relatively low toxicity. That has become an approach that many researchers are seeking to emulate for many targets.  It’s a very fruitful area for drug discovery, and hopefully it’s a very fruitful area of therapeutics for cancer patients.

2 How would you characterize Cephalon’s current hematologic cancer research and treatment efforts?

One of the reasons that companies like Cephalon and others are engaged in hematology research now is that we have a good understanding of the molecular mechanisms. In a sense, it’s the same reason why people are going after smaller indications like GIST and renal cell carcinoma. Because we understand those mechanisms, we can develop successful agents in areas of

considerable medical need. One of the things I really enjoy about working for Cephalon is the opportunity to look beyond breast, prostate, lung, and the bigger tumor targets, and instead focus on some of these areas that have historically been underserved by drug development and really look for opportunities to bring new therapeutics forward. That’s good for the company, good for patients, and hopefully good for physicians to have more options for their patients.

3 Is Cephalon involved in any awareness or educational eff orts to promote clinical trials and make people more aware of the benefits of enrolling in a clinical trial?

I think that is an area where we do need to give more consideration.  Part of the challenge across the industry and across academia, and anywhere where we’re doing clinical research, is that the results of clinical trials always make big news, but unfortunately I’m not sure if people are adequately aware of the process that actually goes into getting those trial results. In the information age, where all new therapies can be found by people very quickly, there seems to be great reluctance to accept the uncertainty that goes with a clinical trial. I think that there’s a lot we need to do—industry needs to work with investigators, with academia, and particularly with the patient groups.  I think publications like yours have a role in this as well, to really help people understand the importance of clinical research, because without the trials, the experimental drugs don’t become the new therapeutics that we need. It’s a struggle to recruit patients in the US, so we are looking to use international data to a much greater extent. There are economic reasons to do that and time reasons to do that, but I think we also know that people will always feel more comfortable with a significant proportion of US data within the clinical trial programs, so we really have to do everything that we can to support that.

4 What can you tell our readers about Cephalon’s near-term pipeline?

 now marketed, and a second indication for Treanda for refractory non-Hodgkin’s lymphoma is currently under review at the FDA. That is the next drug that we will hopefully bring to market; we will also continue to develop Treanda for a number of other indications related to chronic lymphocytic leukemia (CLL) and non-Hodgkin’s lymphoma (NHL).

We’re particularly interested in understanding the potential of Treanda in combination therapy, at least with rituximab, which is such an important agent in this area. We will be doing studies in CLL in combination with rituximab, and we’re completing a frontline study with Treanda and rituximab for NHL [results of which were recently published online in the 

The next drug we hope to bring to the end of phase III is CEP-701 (lestaurtinib). This drug, among other activities, inhibits a number of kinases, including one called FLT-3, which is expressed and gives a poor prognosis to a subgroup of about 25—30% of patients with acute myeloid leukemia (AML). CEP-701 is currently in a phase III study in patients with relapsed AML.  We hope to complete the recruitment for that study this year, and if that’s positive, we hope to submit to the FDA for consideration during 2009.  That drug also has activity against a target known as JAK2/STAT, which has become widely known as an important target in myeloproliferative disorders such as polycythemia, essential thrombocytosis, and myelofibrosis. It is currently in phase II in that setting.  Earlier in the pipeline is CEP-11981, which is targeted at the VEGFR receptor and the TIE-2/pan kinase receptor. TIE-2 is another angiogenesis pathway, and we’re hoping that by targeting more than one angiogenesis pathway, we may be able to see greater efficacy relative to the other smallmolecule angiogenesis inhibitors. CEP-18770 is in phase I testing. It is a proteasome inhibitor that we hope to explore in programs focusing on myeloma therapy. Also in the pipeline, the next IND that we hope to submit would be for a PARP inhibitor, which we would see as a potential chemosensitizer for solid or hematologic malignancies.

The next program after that is an anaplastic lymphoma kinase (ALK) receptor tyrosine kinase inhibitor that we hope will have efficacy in a subgroup of patients with lymphoma and, interestingly, in a subgroup of patients with small-cell lung cancer.  Overall, we are looking broadly at anti-proliferation targets and survival pathway targets that will take us into a broad range of both solid tumors and hematologic malignancies. The sheer amount of effort that is going into this area at the moment is starting to really bear some fruit, and the emphasis on the pathways that we’ve talked about and the technologies that are coming through means that there isn’t any single answer to what is the most promising approach. There is so much focused research going on leading to greater understanding of the unmet medical needs and an improved understanding of the genetics and biology of the disease that we really are making some progress. All the new science that has become available over the last 20 years is now translating into new therapeutics for patients. I think that is really exciting.

5 Questions with Charles Morris, MD, VP of Worldwide Clinical Research, for Cephalon Oncology.

5 Questions... with Charles Morris, MD, VP of Worldwide Clinical Research, for Cephalon Oncology

Last month’s Health 2.0 issue got me thinking about the concept of communities on the Web. Many of our patients are using the Internet to look up their diagnoses and medications as soon as they get home from our offices. (Although they may be uncomfortable admitting this to us, thinking this implies they are second-guessing us and seeking medical information “behind our backs.”) Unfortunately, with the amount of biased and non-evidence-based medical information available online, our patients run the real risk of getting bad information. This is especially true if they frequent the myriad bulletin boards and online communities surrounding nearly every conceivable disease state.

	There are two primary ways that patients get healthcare information from the Web. The first is by reading articles written by doctors, healthcare workers, journalists, and anyone else who can get published. When you type “diabetes” into Google, the first page results include the 

, the American Diabetes Association, Wikipedia, and other sources of information from well-established mainstream sources. But further down the list are links to bulletin boards and forums.  If you type “diabetes community” into Google, the first listings include support networks and communities of people who have diabetes or who know someone with diabetes.  These communities allow people to share information with one another on a peer-to-peer level, frequently without the guidance or influence of a healthcare professional. Bulletin boards let people write a question or make a comment and then “post” the message so it can be read by anyone. Messages are organized into “threads” that read much like a conversation—but instead of two people talking there can be an unlimited number of participants sharing their advice and opinions.

	It wasn’t always like this. A few years ago, a patient diagnosed with type II diabetes would have simply accepted the information you provided. Maybe they would have gone to a bookstore or library, or shared information if they happened to know someone else with the same condition.  Today, most patients will go to their computer as soon as they leave your office. They will read whatever they can and then start interacting with others who share a similar interest.  Most doctors don’t realize the extent to which patients use the Internet to learn from and converse with other nonhealthcare professionals.

	Back in the 1990s, I co-created a website that focused on medical issues people were too embarrassed or uncomfortable discussing with their physician (aptly named 

). We added a bulletin board to the site, and over the past fi ve years, people have posted hundreds of thousands of messages.  The most popular topic, male genitalia, currently has more than 36,000 messages organized into more than 4,000 discussion threads. There are also discussions on a host of other topics, including Lyme disease, breast cancer, masturbation, bowel movements, and more.

	It is fascinating to read messages from the board. Some are touching, others repulsive; most are somewhere in-between, providing information and personal experiences of the writers.  Some contain good medical information; others spread myths and misconceptions, usually corrected by other concerned posters. Patients need to be forewarned that bulletin boards can, and frequently do, contain erroneous information. A wise approach is to assume your patients will be looking at these sites and let them know you support them, but advise that they should consult with you before taking any kind of action, or if they have concerns or fears generated by the information they find.

	Despite the pitfalls and potential false information, Web communities should be celebrated because on balance they do much more good than harm. People can gain valuable information from peers that we don’t always have the time to give them during an office visit. They also get to commiserate and empathize with people who share similar experiences.  Because people can maintain their anonymity, they are also more willing to open up and share things they would never tell their doctor, parents, or spouse. This is powerful stuff, and it allows for some amazing interactions that would rarely occur in the brick-and-mortar world of medical offices and hospitals.

Dr. Bertman is Physician Editor-in-Chief of 

. He is also a Clinical Assistant Professor of Family Medicine at Brown University and president of 

, a leading developer of electronic health record (EHR) software. He also is the founder and president of 

, a consumer website focusing on personal medical topics.  He is in private practice in Hope Valley, RI.

Many of our patients are using the Internet to look up their diagnoses and medications as soon as they get home from our offices.

Patients are Doing it for Themselves

Imagine the following scenario: You’re on a vacation and need cash.  You go to the nearest ATM and insert your card. Th e machine replies with, “I’m sorry. I do not know you. And, I have no idea how much money you have to withdraw.” You try another and another ATM with the same results and come to the inevitable conclusion that “someone has to do something about this.” We have become so accustomed to the ease of electronic banking that we would find the above scenario extremely frustrating and demand change. And yet, we continue to tolerate similar episodes in healthcare on a daily basis. We act on incomplete information, we duplicate testing performed elsewhere, and we spend an inordinate amount of time collecting information that others have already collected. We must overcome all of the technical, political, and economical obstacles NOW. The need for system efficiency and patient safety demands it.

Now imagine a vision in which the patient, and when appropriate the patient’s family, as well as any physician, allied health professional, hospital, or laboratory that have appropriately delegated access to that patient’s medical records, can input data to contribute to his or her management. Is it possible? Of course it is. Think about the ATM machine in our example: It is relatively agnostic about where its data is coming from; it functions because agreedupon verification processes exist, and there are industry-standard defi nitions for “balance,” “withdrawal,” “deposit,” and other terms.

Progress is being made in healthcare, albeit slowly. Many justify this by pointing to the relative complexity of medical data versus that used in the banking or airline industries. Is this really true? Or is it an excuse for some other agenda? Is our data really that much more complex?

There are basically three models that have been developed that fulfi ll the requirements of a portable, unified medical record:

There are totally independent information systems, from which defined baskets of information are downloaded to some portable storage device. The radiology industry was one of the first to adopt this technology, burning CDs with MRI, CT, and other digital images. The patient is the primary “owner” of the information and carries it from provider to provider, who try to read and incorporate it, as best they can, into their native systems. Obviously, this was, and still is, a reasonable method of achieving some degree of portability of what has become relatively standardized information, although the amount and type of information conveyed are rather limited. Some patients have taken things a step further by manually converting their lab data into impressive spreadsheets, graphs, and MS Word documents. Patients were the first to recognize that, in the absence of system solutions, they would need to take control of data organization and portability. Source data integrity and cross-compatibility between systems generally remains problematic, except for radiology images.

Vendors develop centralized, usually Web-based, repositories to house relevant clinical information organized on a per-patient basis. With proper access security, any given provider can go to a centralized database and access pertinent patient information. Depending upon the systems utilized by the provider, some of this information may be amenable to importation into the provider’s native electronic medical record. The Web-basis of this design facilitates portability and relieves the patient of the responsibility of being the most current source of data.

Data integrity is generally improved, especially for those elements with relatively standardized vocabularies—such as demographics, laboratory, and radiology&mdash;but falls off when data is less standardized, such as with dictated reports. Nonetheless, this industry continues to grow and evolve, awaiting more formalized and complete data definitions. Despite significant efforts toward secure systems, numerous polls have shown patients remain reluctant to have their medical data “out there” on the Web.

The assumption is that the majority of the care for any given patient is delivered at one primary location. Generally, this applies to large, multi-specialty centers. It is less true for community-based providers, given that the balance of care is delivered in outpatient, smaller clinics as compared to care delivered in an inpatient setting. In that situation, hospitals continue to investigate and navigate the many obstacles associated with sharing electronic medical record systems with their physician staff. Patient input and access has been slowly adopted.

Model #3 is the approach we have decided to pursue at MD Anderson, where we are in the process of enhancing our patient-centered EMR. A guiding philosophy, however, has been to include both community physicians and the patients themselves as part of the input and output system. Patients who are technologically savvy now input the information about which they know the most (eg, demographics, medical history, family history), and this is “imported” into our EMR, after being verified by the provider. Additionally, patients have access to defi ned elements of the EMR, such as scheduling and secure e-mail to communicate with select providers. Other accesses are in the development stage. To complete the circle, outside involved providers are given access to the EMRs of those patients with whom they have a direct relationship, granted by the patient. 

Technology and policy drives the particular aspects for which access is available. The days of waiting for a summary letter about a recent discharge or treatment plan have been shortened potentially to hours or even minutes, thus facilitating communication and increasing patient safety. None of these models are the perfect solution for all circumstances. Each meets certain needs and requirements, given the limitations in current systems integration. Nonetheless, the goal should be the same: unifi cation of the patient and all providers to provide the highest quality and safest medical care.

Dr. Walters is the associate vice president of medical operations and informatics at the University of Texas MD Anderson Cancer Center.

We must overcome all of the technical, political, and economical obstacles NOW. The need for system efficiency and patient safety demands it.

The Next Big Thing: We need a team approach to the electronic medical record

In the course of covering the latest healthcare information technology news for physicians, there are times we wonder whether it’s all that it’s cracked up to be—whether the products and their capabilities warrant all the hyperbole.

 last visited this issue in our July 2007 cover story, “

?” mainly as it pertained to e-prescribing initiatives and lessthan-successful EHR systems. A year later, as we read and watch the breathless coverage devoted to recent moves by Google, Microsoft, and Apple, we are left asking “is healthcare IT worth the hype?”

With healthcare seemingly in permanent crisis mode, there’s a natural tendency for people in the industry to frame every issue in terms of needing a comprehensive solution to avert certain disaster. The more enthusiastic health IT boosters certainly haven’t shied away from casting their favorite applications in the role of healthcare’s savior, confi dently asserting that adoption will lead to thousands of lives saved and billions of dollars recouped. When numbers that large are thrown around, people tend to pay attention. Combine that anticipation with our societal belief in the innate value of technology and unwavering faith in our ability to innovate our way out of any problem, and you have a recipe for runaway hype. Even the merest hint of a rumor that 

 is planning to unveil “something big” is enough to send the tech industry media on 24-hour alert. So when the news hit that these companies were fi nally making long-anticipated forays into the healthcare market, the health IT community was abuzz with speculation and anticipation. However, at the end of the day, have these companies and their new products really succeeded in introducing ground-breaking ideas to the healthcare industry, and are they worthy of all the hype? And will they hog the spotlight from smaller health IT companies that may be short on notoriety but on the path to creating truly valuable technologies?

The past year has seen Microsoft launch the online health record platform 

; Google launch its online health information portal, 

that supports numerous, new third-party medical applications. A May 2008 MSN article captured the eff ects of the media frenzy surrounding all this, stating that society is “officially in bizarro world when 

 for absolutely no reason.” The article even cited an official Apple analyst who said users should not “expect revamped iPhones until 2009.” Th is, predictably, did little to dampen anyone’s enthusiasm.  Merely attaching the name “Google” or “Apple” to a product gives it authenticity in many people’s minds, regardless of its merits. Th us, these tech darlings are often given the benefi t of the doubt, with their previous successes (or at least the perception of their success) building up an enormous reservoir of goodwill in observers, making them inclined to assume continued success in all the companies’ endeavors. Th is uncritical embrace only fuels the hype and sets the stage for potential disappointment down the road.

However, some people are already pushing back and challenging the notion that all the hype is justified. Keith Schorsch, founder and CEO of 

 that he thinks Google especially has lost sight of what consumers (healthcare consumers, especially) really want and is focusing too much on user control. However there are companies that haven’t lost sight of what consumers and physicians need, companies whose products are designed to fill more modest but well-defi ned niches. Let’s turn our attention from the Googles and Microsofts and highlight some of the more notable “little guys.”

There are many smaller companies that have made great strides in developing truly useful healthcare technology applications that have yet to receive the attention accorded to their larger counterparts. 

and editorial board member Nancy Tice, MD, says free EHR platform 

 is among her favorites. The program allows physicians to integrate

applications without the use of onsite software, relieving practices of the burden of supporting traditional enterprise software products.

“Everything is automated—from scriptwriting to templates for commonly done exams,” Tice says. “One very important feature on PracticeFusion is that after the patients visit, when you close out the note, you may edit it. This is key for malpractice. So key, in fact, that your carrier is supposed to give you a discount if you use an EHR that does this.”

Another success story among the lesser-known tech companies is Hakia.com, a new, still-in-beta-stage semantic search engine with significant health and medical search coverage. “We started Hakia in 2004 with the potential to provide the first semantic search technology on the Internet,” says CEO Riza Berkan, PhD. “Search engines provide users with a popularity perspective. What Hakia does is provide credibility without relying on collecting votes. Semantics enables us to harvest databases with full potential (PubMed is one example). Hakia is the first search engine to rely on quality-stamped results.”

Berkan notes that Hakia was able to demonstrate quite a bit of success in semantic searching, even when comparing results to Google, the gold standard of online search in many people’s minds. “We are proud to be instrumental in that vision,” he says. “Popular information is not always correct, and correct information is not always popular. We went to medical associations and picked up their recommended sites for credibility measurement. That list is available on the website at 

 under ‘verticals.’ As an end-user, it’s not your job to determine which is credible information and which is not; the Googles of the world are not providing that to you.”

So what does this all mean for physicians? Lynn Ho, MD, runs her own micropractice in Kingstown, RI, and claims to not be easily influenced by the hype or media coverage devoted to larger companies, preferring the information that she finds through various e-mail listservs.

“I listen to the technology masters on listservs; word-of-mouth recommendation has worked well for me,” says Ho.

How else can a physician avoid the trap of going for the most-hyped technology versus the most beneficial? Hakia.com beta tester and physician John Boockvar, MD, takes it back to the basics and refuses to be swayed by the charm of the larger, better-known search engines. “From my use of [Hakia], it has shown promising signs of performance,” he says. “The articles it finds are not easily reachable through PubMed’s own search engine, nor with Google’s site search.”

Getting peer feedback is clearly another method for physicians to make the best informed decision about where to obtain their information. “Get personal recommendations from people that have tried the technology you are about to embark on, ask pointed questions, and see if it will fit your needs, not the hyped needs,” says Ho. Small companies aren’t immune to hype and

infl ated expectations. Their products still receive attention from media that focus on their industry, just on a much smaller scale. 

So, will the Hakia’s of the world live up to expectations? Berkan says, “It’s too early to make any judgments, but it’s been a bit of a feeding frenzy. Commercialism is okay, I’m not against it, but as with many health sites, I don’t see these kinds of distinctions, and that bothers me.” 

On the flip side, even the larger companies themselves appear to be less than enthused by the hype their names often generate. “I’ve always been a bit of a hype skeptic,” says Grad Conn, Senior Director of Product Marketing for Microsoft’s Health Solutions Group. “There’s a lot of energy in healthcare right now in terms of changes that are coming. I don’t want hype to get ahead of itself. People have a tendency to get overanxious, and then we’re disappointed. We’re encouraging everyone to boil the ocean 10 gallons at a time. We shouldn’t be too hard on ourselves if we haven’t completely transformed the healthcare system in a year.”

Despite the many triumphant predictions of greatness, it’s still too early to tell whether Microsoft and Google will succeed or fail. The public’s fi nal judgment may not even depend on the actual merits of the technologies themselves, but rather on of the products themselves. Health 2.0 Conference co-founder Matthew Holt is doubtful that health IT will be the solution to the current healthcare crisis. “I think anytime you’re talking about something as complicated as the healthcare system, saying that we’re going to change [it] using health 2.0 is over-ambitious… If you say health 2.0 is going to change healthcare as we know it in every aspect completely, immediately, you’re going to be disappointed. If you say we expect to see health 2.0 as the use of these tools adopted by more and more patients, physicians and healthcare organizations, I’m sure it could slowly change the way healthcare is delivered and the way people manage their health.” 

For more thoughts on healthcare IT from Holt, see the June 

…”. The reality is that most of these companies set out to do what they do best, which is create unique technology platforms for home and business that can be built upon and integrated with other existing technologies—not change the American healthcare system.

A year later, as we read and watch the breathless coverage devoted to recent moves by Google, Microsoft, and Apple, we are left asking "is healthcare IT worth the hype?"

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