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Since I can remember, I've been playing video games. I was a console junky in my early years, starting with the Atari 2600, moving to the ColecoVision and their ADAM computer, trading up to a Nintendo Entertainment System, then getting a Sega Genesis, the Sega 32X and CD, a Sony Playstation, Playstation 2, and finally an Xbox. Now, I’m a grown man playing an Xbox 360 with a Live account. I know: grow up. But wait, there’s more.

During my time as a console player, I can vividly recall Vic 20s and Commodore 64s and 128s taking up plenty of my time as well (

 anyone?). Now, I consider myself a PC gamer first, console gamer second, thanks to my custom-built system. Over the years, I've been ridiculed and made fun of by parents, colleagues, and friends alike for my love of digital action. But now, the video game industry is the real deal.

 to help kids and adults with various diseases and conditions, the 

 (ESA) recently reported that families are getting in on the act. The ESA report tells me that I’m part of the $7.4 billion spent in 2006 on video/computer games. But more importantly, I'm part of the 35% of American parents who say they play computer and video games. And although my oldest son is not even four years-old yet, I plan on playing plenty of games with him (he likes the driving games—only blue cars) when he learns how to use the controllers. Once this happens, I will be part of the 80% of gamer parents who say they play video games with their kids. I definitely agree with the 66% who feel that playing games has brought their families closer together. Although my wife doesn’t engage in any digital fragging or strategy sessions, I’m sure when the three boys and I are 

This information is important, because it shows that the stereotype of gamers as overweight, saucer-eyed, introverted, half-eaten-corn-chips-on-the-belly adolescents is now an antiquated notion; gaming is becoming a social event in the family setting, much like a movie night or board game night. Heck, 

! I definitely plan on integrating video games into my family's social setting, because gaming is something we can all do together, it's fun, and it allows us to explore competition, sharing, and sportsmanship in a contained setting. Now, I'm not saying you should abandon other forms of social activity/bonding with your kids; rather, I like the fact that sharing games is starting to become as mainstream as the tried-and-true outdoor activities, like playing catch, going fishing, or just wrestling on the grass—all things I love to do and plan to do with my three boys. But if they ever start LARPing, I don’t know if I can take it. (Go to 

, type in “LARP”... become horrified...)

As far as negatives regarding violent games and the amount of time kids spend playing games, I am fully aware of the 

's (ESRB's) designations and agree that they are highly effective in determining what’s good for my kids. But because I play and read about games on a daily basis, I'm pretty well-versed on what's appropriate for my kids. The ratings are good, but I agree with the ESRB that parents should take an active role in knowing what their kids are playing and not just rely on these ratings to determine what's suitable.

But let's get back to the business side of things: a 

 industry. With so many game developers, publishers, websites, companies, and magazines, there are plenty of jobs to go around and lots of money to be made. The video game industry has employed thousands of people as level designers, programmers, editors, sound designers, testers, etc, and paid them to do something they love—and isn't that what a career is supposed to be about?

What are your thoughts on this? Do you play games with your kids regularly? Have you integrated gaming into your usual social activities? Drop me a line at jmaillard@mdng.com; I’m always interested in learning what our docs are doing.

. Derived from “aggression,” it means you’ve “activated” monsters, usually in a MMO game, by moving

close to them and now they’re attacking you.

. The character in the game that represents you.

. A beneficial spell cast on a monster or player.

. Staying in the same area as a player or group of monsters to do the same repetitive actions.

. To repeatedly kill the same monsters in the same area, usually with the purpose of obtaining money or specific items.

. An insulting criticism or remark meant to incite anger.

. Gang killing. Also used to mean bullying of lower level players in PvP or to kill a player while he is engaged

. Staying in the same area fighting the same types of monsters for a very long time.

. A Massively Multiplayer Online Game (also called MMOG); a game that is capable of supporting hundreds or thousands of players simultaneously. 

. A modification to a game, either through provided tools or hacks, to change its original form.

. A new player in a game; usually referred to as Noob or N00b.

. A negative change; to downgrade or weaken something.

 Combat between players and computer controlled opponents.

. Slang term for "owned," which means to soundly defeat an opponent. 

Articles

Since I can remember, I've been playing video games...

Grow Up!

Prior to 2004, my exposure to information technology in healthcare had been limited to selling an early version of the Oracle database management system to a few hospitals. In 2004, our venture fund invested in a healthcare software company, RemedyMD, that was focused on helping providers and patients make better decisions. After a few weeks, the depth of the problem and the breadth of the opportunity began to manifest themselves. It was easy to see that the overall state of healthcare IT was a generation behind other industries with which I was familiar. Even our portfolio company that provided hardware and software solutions for grocery stores was more advanced than most large healthcare providers.

There are numerous reasons why healthcare has fallen far behind other industries in applying IT. In order to catch up, healthcare needs to carefully analyze how other industries have benefited from improved information technology and learn from them. I think the fi nancial industry is arguably the most advanced user of IT. So, what can healthcare learn from Wall Street? During the past 20 years, Wall Street has pioneered a concept called “predictive analytics” and invested billions to make it a reality. The objective of predictive analytics is to model past performance and use the model to predict future behavior. Those who become adept at predicting events gain a competitive advantage over those who cannot. For example, the ability to predict the outcome of a border war in Turkey could lead to significant gains in the market. Many anecdotal stories have been told about information systems that paid for themselves

in a single afternoon of heavy speculation.

There have been many attempts to apply predictive skills to healthcare informatics, because the need to recognize a pattern, predict a trend, and preempt an event is even more important in healthcare than on Wall Street. Why haven’t these efforts been as successful as they have been on Wall Street? The most signifi cant reason has to do with the way data is captured in healthcare. Data is typically collected in a non-computable format (eg, handwritten notes from a physician, free-form text entries, images, etc). Th is kind of information is virtually useless for any type of predictive analysis. In contrast to this data collection methodology, Wall Street relies exclusively on numeric data stored in a computable format (eg, stock prices, changes in the consumer price index, the popularity rating of the Prime Minister in England).

An additional data-related difference between the two industries is that Wall Street collects highly specifi c data sets and uses them to make predictions. For example, it might be that the unemployment rate in Kenya could be the most accurate predictor of the price of coffee futures. Healthcare has not collected data to this level of specificity because most clinical data is collected by “one-size-fits-all” systems. Many EMR systems are incapable of collecting and fully utilizing specialized data about a patient. For example, few, if any, EMRs can document and use a measurement like a patient’s wrist size. However, this is probably a better predictor of a person’s ideal weight than Body Mass Index (BMI).

A few weeks ago, I met with a US Senator in Washington, DC, to discuss how a new administration might change healthcare funding priorities. His agenda was diff erent than mine. He was preparing for hearings on the cost of healthcare and wanted a soundbite. He asked, “Can you just give me one or two thoughts on how we can control costs in healthcare?” I said, “It is very simple. If healthcare had the kind of pattern recognition and predictive analytics tools that exist on Wall Street today, this would squeeze billions out of total healthcare costs.” He nodded as if to acknowledge my point, but will this translate into action? Perhaps Wall Street can help us predict whether it will.

Dr. Kennedy is the President and Chief Executive Officer of 

Prior to 2004, my exposure to information technology in healthcare had been limited to selling an early version of the Oracle database management system to a few hospitals.

What Can Healthcare Learn From Wall Street?

The 23rd annual TEPR Conference & Exhibition took place May 19-23 in the Dallas Convention Center in Dallas, TX. This year’s event featured more that 2,000 attendees, more than 200 vendors and exhibitors, and multiple educational program tracks that covered new developments in EMRs and related health information technologies. The educational program included material for physicians in a variety of practice settings (large and small & medium hospitals, ambulatory care, specialty practices), material that focused on issues important to health networks and communities, a “Technology” track that addressed key issues in health information standards and data capture, and a track devoted to information technology in nursing.

As a poorly-reimbursed family physician and the president of 

, I arrived in Dallas for this year’s TEPR convention excited and nervous, with the goal of comparing electronic medical records and demonstrating my own at the EMRCompare event. One of the high points of this year’s TEPR conference was the complete overhaul of their flawed TEPR Awards. Up until this year, TEPR Awards were based solely on vendor-submitted reports stating what their products cost and what they’re capable of doing. Essentially, the TEPR Awards were just a vendor essay-writing contest offering little value to physicians searching for true objective data they could use when selecting an EMR. (Can you tell I wasn’t one of the essay contest winners?)

This year, however, in a refreshingly bold move designed to regain some of its lost relevancy and to silence much of the criticism regarding their previously biased awards, TEPR introduced EMRCompare, which merged their prior EMR awards and the Clinical Documenting Challenge. The goal of EMRCompare is to objectify EMR usability and affordability by asking vendors to demonstrate a standardized clinical encounter and report their system’s pricing and features.

Furthermore, TEPR has promised to make the process “transparent and permanent, trusted and unbiased”—a pretty bold objective given that TEPR derives much its revenue from EMR vendors, so making them compete with one another risks losing the vendors who offer overpriced or suboptimal products. To succeed in this goal of transparency and objectivity, TEPR is posting on their website the vendor responses on pricing and features, as well as videos of their live demonstration. To show they mean business, TEPR is also providing the ability for anybody to publicly challenge what the vendor has reported&mdash;a far cry from the prior closed-door award approach. With EMRCompare, if a vendor is challenged, they can either show the data that supports their claim, or correct their information (and pay a fi ne to TEPR).

This year, the following companies agreed to compete (listed alphabetically): Abelsoft, Amazing Charts, Bond Technologies, e-MDs, iMedica, iSalus, Medical Communications Systems, MediNotes, MedNet Systems, Noteworthy Medical Systems, Pulse Systems, Sage, SSIMed, and Waiting Room Solutions. The 20-minute presentations were timed and moderated by Drs. Edmund Billings, William Rollow, and Thomas Sullivan. While every exhibiting vendor was off ered a chance to compete (for an extra fee of $1,250), only a small percentage of the vendors actually did. According to TEPR, there was a backlash after announcing the new format from many companies over the fact that price was to be a judging point and that 20 minutes was not enough time to truly demonstrate what a product could do. Of course, for the vast majority of harried physicians struggling to get through the myriad of patients just to cover the practice overhead, being able to see exactly what a program can do in a limited amount of time, and the price being asked for the software, is exactly what is needed to truly compare products.

And so, at the end of the two-day TEPR competition, many physicians got their fi rst real chance to compare EMRs, seeing first-hand the variable usability and price for the systems destined soon to be found in all of our practices.

ePrescribing and Pharmacy Interoperability Mary Martin, Senior Director of Alliances for SureScripts, explained

how electronic prescribing (or “ePrescribing”) makes sense not only from an economic point of view but also, more importantly, from a patient safety perspective. She noted that the prescription writing and renewal process is “fraught with inefficiencies” under the current system of handwritten prescriptions, faxes, and phone calls, a situation that will become increasingly untenable as prescription volume continues to increase (some estimates say that the annual number of prescriptions written and/or renewed in the US will top four billion by 2010). ePrescribing and computerized physician order entry (CPOE) systems can improve patient safety and increase practice efficiency by reducing or eliminating the impact of errors caused by illegible handwriting, spelling errors, unclear faxes or phone orders, and the use of non-standard abbreviations.

She noted that one study indicated widespread adoption of ePrescribing could prevent two million adverse drug events (130,000 of them life-threatening) per year. She also cited an MGMA study that claimed practices that adopt ePrescribing can save $10,000 per physician per year just by eliminating calls to pharmacies. Further illustrating the time-saving benefits of ePrescribing, Ms. Martin noted that many practices spend four or five hours each day just managing prescription refills, time that could be cut in half (according to a Brown University study) with ePrescribing. Visit 

Getting Physician “Buy-In” of the EMR: Do They Love it or Loathe It?

Paul Schadler, MD, Co-Medical Director of the Health Center at Auraria College in Denver, CO, gave an entertaining and well-received presentation on the factors that can aff ect physician acceptance of an EMR system. Dr. Schadler told the audience that there is a poor understanding on the part of EMR designers of what goes on in a physician’s brain during a patient encounter, and that this lack of understanding is accompanied by an “extraordinary underappreciation” of the cost of cumulative “minor” encroachments on physicians’ time and brain power. This manifests in unwieldy EMR interfaces that result in more work for physicians. He cautioned that physicians should not expect to save much time in the months immediately following EMR implementation (unless they did a lot of dictation and billed poorly prior to adopting the EMR).

In order to promote physician acceptance of an EMR system, Dr. Schadler stressed the importance of developing and communicating a clear understanding of the goals and expectations for the system, involving physicians in the selection and implementation process, investing in training, and to “let people do it their way” while they’re still learning the ins and outs of the system.

Couldn’t get to TEPR this year? No worries; the EMR Road Show

 gives you a chance to catch up on all the latest EMR developments and implementation strategies. Attendees will learn how to select the system that best fits their practice, how to adopt an “outcome-oriented approach” to planning an EHR implementation, how to measure progress and success, how to maximize ROI, and much more. Visit for 

 and a schedule of upcoming dates and locations.

Dr. Bertman is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of Electronic Health Record (EHR) software. He is in private practice in Hope Valley, Rhode Island.

The 23rd annual TEPR Conference & Exhibition took place May 19-23 in the Dallas Convention Center in Dallas, TX.

Meeting Spot Recap: TEPR 2007

 is a “leading provider of medicines to fight cancer, cardiovascular and infectious diseases—including HIV/AIDS&mdash;and serious mental illness.” Bristol-Myers Squibb’s other businesses include 

, which offers high quality ostomy and wound therapeutics products and services.

 is a prescription medicine indicated for the treatment of acute manic and mixed episodes associated with Bipolar I Disorder and for maintaining efficacy in patients with bipolar disorder with a recent manic or mixed episode who had been stabilized and then maintained for at least six weeks.

Healthboards.com: Before You Start Taking Abilify

 provides useful information for patients who are being treated with Abilify for Bipolar I Disorder, including a calendar (to keep track of appointments and prescriptions), an automatically generated e-mail Refill Reminder, a body mass index (BMI) calculator, and a mood tracker.

 is an oral inhibitor of multiple tyrosine kinases, for the treatment of adults in all phases of chronic myeloid leukemia (CML) with resistance or intolerance to prior therapy.

The Cancer Blog: CML Patients who Have Stopped Responding to Gleevec Have Options

American Society of Hematology study results

 which demonstrate that treatment with Sprycel (dasatinib) provides better outcomes compared to administering higher doses of Gleevec (imatinib) in patients with chronic myeloid leukemia (CML). In the clinical trial, the patients were either treated with Sprycel or increased doses of Gleevec to see who had the better response.

Belatacept Conversion Trial in Renal Transplantation Study Type:

 The purpose of this study is to learn if conversion to belatacept from cyclosporine or tacrolimus will preserve kidney function in people who have had a kidney transplant. The 

An Exploratory Study of Changes in Synovial Immune Responses Following BMS-188667 Therapy in Subjects With Active Rheumatoid Arthritis on Background DMARDs Who Have Failed Anti-TNF Therapy

 assesses the changes in synovial tissue before and after treatment with Abatacept in subjects with RA who remained on their background disease modifying antiarthritis medications but who have failed previous therapy with anti-TNF (tumor necrosing factor) blocking agents.

Bristol-Myers Squibb is a "leading provider of medicines to fight cancer, cardiovascular and infectious diseases" including HIV/AIDS "and serious mental illness."

Bristol-Myers Squibb

 demonstrate that prescription errors account for a staggering number of deaths and adverse drug reactions in the US. Factor in related medical malpractice insurance premiums, prescription fraud, and time spent by healthcare providers creating prescriptions and conducting pharmacy call-backs, and one can see why prescription writing is indeed a key healthcare issue. Fortunately, there have been some incredible advances in the field of electronic prescription writing that significantly improve the process, eliminating the need for handwritten prescriptions and thereby helping to reduce the number of avoidable medication errors.

Electronic prescription writing (ePrescribing) has been defined as only prescriptions sent directly over the Internet, by either pharmacy-direct fax or via a pharmacy direct messaging gateway (a secure prescription sent over the Internet to a healthcare entity). The reality is that even printed prescriptions fall within this, so long as they have been created on a computer with the help of clinical database-powered software. The benefits of ePrescribing for both physicians and patients range from decreasing medical errors and prescription fraud to saving time and money. Using the right software, users can create legible prescriptions quickly. Clinical databases that check allergy and drug-to-drug interactions help flag problems before the prescription is written and processed. With this technology, pharmacy call-backs are significantly reduced, and on-screen formulary information at the point of prescribing helps with compliance. ePrescribing software is quickly making its way from novelty to necessary tool.

The government has not required physicians to use ePrescribing software as of yet, but the technology is providing a compelling case with healthcare entity grants, Stark Law exceptions, and new rules and regulations. For example, the 

Medicare Prescription Drug, Improvement and Modernization Act of 2003

 (MMA) states that ePrescribing is voluntary for prescribers but establishes mandatory standards for physicians who send and receive electronic prescription data for eligible covered Part D drugs. Despite the obvious benefits, it is estimated that less than 25% of physicians use any kind of ePrescribing or EHR system, hindered by a general hesitancy to incorporate more technology, the limited functionality of many of the available products, cost concerns, and the practical considerations of training a staff and adapting office infrastructure. The reality is that ePrescribing is an excellent first step for physicians who want to integrate an electronic system of some kind with the least cost and intrusion. With the right vendor, benefits can be realized quickly.

To choose the right software, one must know what to keep an eye out for. Cost is certainly a determining factor when purchasing any software; products that are relatively inexpensive—such as 

, which is available for as low as $99 per month—will help make the switch to electronic prescribing that much easier. A software program with the flexibility to act as a stand-alone ePrescribing system or operate in conjunction with an electronic medical record (EMR) is a good place to start. Ease-of-use is another major point to consider&mdash;drug organization and selection processes that allow for one-click prescribing are ideal. Below are several key features to look for, all of which are offered by ScriptSure.

The ability to print, fax, or message prescriptions directly to pharmacies provides convenient flexibility. Pharmacy-direct connectivity allows for refills to be requested online from pharmacies and can help reduce pharmacy callbacks and related communications considerably. This ability will more than likely become a requirement.

The ability to access information for nearly every drug on the market and check for possible interactions is a “must have” for any system. For example, instant access to onscreen allergy medications and drug—drug interactions based on what the patient has been prescribed provide obvious time and liability benefits.

ePrescribing systems should include flexibility with setup and customization. The ability to store relevant patient and prescription-related information and run reports on that information is crucial. The right ePrescribing software will help users avoid some of the pitfalls associated with EHRs and assist in breaking out of the mold of handwritten prescriptions. Clinicians who choose an eff ective system will likely quickly wonder how they lived so long without it. When you factor in time and cost savings, data availability, and convenience, ePrescribing makes a lot of sense.

Ensure you select the right ePrescribing software for your practice by asking prospective vendors the following questions:

· Can the software integrate with other systems?

· Can users print, fax, and message prescriptions?

· Does the software contain a clinical drug database with interaction and allergy checks?

· Does the software feature additional usability functionality (eg, stored data, reports, customization, and flexibility)?

· What is the cost to purchase, implement, and train staff?

Research studies published in JAMA and by the Institute of Medicine demonstrate that prescription errors account for a staggering number of deaths and adverse drug reactions in the US.

ePrescribing: What to Look For

spoke with Neal Goldman, MD, assistant professor, department of otolaryngology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, to learn how he juggles practicing both medicine and tango dancing.

How did you get involved in tango dancing?

I grew up in the Dominican Republic until I was about 13, so I was exposed constantly to Latin music. I would go to parties in 6th grade and hear merengue and salsa music. Later, I was on vacation in Venezuela, and I saw people salsa dancing. I walked up to them, and said “How do you do that?” Th ey said, “You can’t, it’s in the blood.” I took it as a little bit of a challenge. I agree that growing up with dance makes it a lot easier; hearing it every day of your whole life will make understanding and interpreting the music easier, but I was exposed to it later in life. When I was 30, I moved to Seattle, and thought I would be in a city where I could be anonymous in the back of a dance class. I started taking some salsa classes, and through salsa, got interested in tango.

How do you find the time to practice tango dancing while maintaining your medical practice?

It’s crazy, but I spend a lot of time dancing. I drive an hour-and-a-half (each direction) two days a week for two to three hours of dancing. Plus, I teach classes and go to diff erent events. Because I live in a smaller town, I find myself finding reasons to combine business with pleasure. If I’m going to a medical conference, I’ll make sure I fi nd where all the dance opportunities are in that city.

Do you see any similarities between your devotion to tango dancing and the dedication required by medical practice?

As a resident, you work really hard, long hours. I absolutely loved it, because I loved learning something new and could feel myself learning new skills and developing new abilities. Th at’s the only similarity I see between medicine and dancing; with tango dancing, I still find myself learning new things and feeling good about myself from learning them.

Does being able to get away and do something you enjoy help relieve the stresses of practicing medicine?

It makes me feel great about myself to be doing something physical, active, and social. It opens you up to new people anywhere you go. If you know how to dance socially, you can go to any city in any country, show up at an event, and you will find people who you immediately have something to do with. 

MDNG spoke with Neal Goldman, MD, assistant professor, department of otolaryngology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, to learn how he juggles practicing both...

Split Personalities: It Takes Two to Tango

Are physicians finally ready to embrace the EHR?

It’s a gradual thing, although from our perspective, it’s picking up. The issue has been that physicians look at EHRs and see a one-size-fits-all product; they say “this doesn’t meet any of my needs. I don’t want to practice medicine as a cardiologist the same way an orthopedic surgeon does.” Our approach has been that nobody’s going to buy an EHR unless it’s specialty-specific.

 press release claims that “the healthcare industry is severely restricted by siloed medical data that does not provide a holistic view of patients’ health.” What do you mean by that?

Right now, the data people have access to is typically one-dimensional. If you’re seeing a doctor, if you’re lucky, you’ll have the record of your previous visits. But you don’t have visits to other doctors or hospitals. We take a 360-degree view of the patient, aggregating 10 dimensions of data so we really can get a holistic view and recognize patterns. For our patients, we have specialty-specific information and hospital information. We track research data, and we add that to a patient’s profile. If a patient’s characteristics place them as part of a research project cohort, we track that cohort. That turns out to be very enlightening, because we try to extrapolate what other characteristics of the cohort apply to them. Then, we start adding metabolic, genotypic, proteomic, microarray, claims, and heredity data. Once you aggregate all of those in the product we call Mosaic, patterns begin to emerge.

 RemedyMD’s SMART Platform has built-in features that enable payers and others to track outcomes; is this going to be a key part of all EHR technology as we move into the era of P4P?

A better description for pay-forperformance would be pay-for-compliance with specified procedures, because very few people can measure performance, so they measure compliance. That’s a first step, but the next step is measuring outcomes, and then infl uencing outcomes. What we’ve built is the decision-support engine that uses all this data we collect and helps provide the information to make decisions. Our theory is that better decisions inexorably lead to better outcomes. I think the idea of pay-for-performance without decision support is not going to get anywhere.

 Why did RemedyMD decide on a Web-based EHR, rather than a system that relies on local servers?

The benefits of being able to have on-demand, anytime access, backed up without having to pay attention or having to buy or upgrade the hardware or hire a network administrator—you just plug it in and go&mdash;are compelling. In fact, we have several partners who are actively working with us to Web-enable their existing systems. What they found is that they could actually rebuild their practice management applications using our platform (SMART) for less money than they can Web-enable their old applications.

Where does the patient fit into everything you’ve discussed?

We created a patient portal called My Health Manager, not knowing how many patients would use it; we have about 170,000 who have. Many of those are using it daily to journal their habits. The only way to really monitor outcomes, unless you want to have a doctor who practically calls the patients every day, is to have patients be able to record outcomes. In other words, it’s not important whether they fill the prescription. It’s not even important whether the doctor wrote the right prescription. What’s important is whether the patient takes the prescription and how they feel after a week or two or six. And everything we built is tethered, so the doctor can log on every day to the patient’s record to see trends and discuss them with the patient.

It’s also important from a decision-support standpoint. We want to be able to recommend an intervention when a patient is still doing pretty well but we’ve recognized a pattern. If we can intervene early, then the benefits to the system are dramatic. Too many people are focused on transferring costs. The only real way to wring costs out of the system is to be able to dramatically improve and influence outcomes. If the healthcare industry had the decision-support and pattern recognition architecture that exists in Wall Street today, it would solve the entire healthcare costs problem. The whole basis for arbitrage is pattern recognition, and proactively taking actions before things happen. That’s the quest we’re after. 

The beat on the people, devices and companies shaping healthcare.

5 Questions... with Gary Kennedy, President and Chief Executive Officer, RemedyMD

End-stage organ failure is a growing problem in the US, due in part to the fact that the number of available donor organs is lagging far behind the number of people (

) suffering from end-stage organ failure who are on the waiting list to receive organ transplants, leading to approximately 17 deaths per day. Roughly 70,000 of the people currently on the waiting list are in need of a kidney transplant. 

The current system of organ allocation is not sufficiently addressing the inadequate supply of donated organs, or the concerns of patients who say they are unfairly restricted from procuring a transplant organ through alternate means. Various medical ethicists, economists, and patients’ rights advocates have proposed the controversial approach of creating a market-based system that treats donated organs as fungible goods, arguing that the financial incentives of such an approach would greatly increase the number of available organs and free patients from a growing medical bureaucracy. This concept, along with the idea of using the Internet to solicit donors and facilitate the buying and selling of organs, is at the center of a heated debate between the federal government, the healthcare industry, patients, and families. This is especially true when it involves voluntary donors who want to give an organ to someone in need.

Many patients and families have turned to the Internet as a way to find a potential donor by creating personalized websites or joining an online organ registry such as 

, which was created “to give people in need of transplant surgery an active way to search for a live organ donor” and “to increase the number of transplant surgeries and improve awareness of live organ donation.” 

 with Matching Donors pay $295 a month to “advertise their stories on the Internet and anywhere else potential donors and families might learn about them and decide to donate an organ.”

With approximately 4,000 potential donors listed on the Matching Donors website, many happy endings have already occurred, including one for Robert Hickey, PhD, Corporate CEO of 

, who was one of the first candidates to receive a kidney transplant (October 2004) through the assistance of Matching Donors. “I read about [them] in the 

… [and] initially I was convinced it was a scam,” Hickey told 

. “I hung up on the call when I was asked for a credit card number. After going through dialysis for another week, I took a chance for one month and was inundated with donation offers.” Although Hickey’s experience has made him a staunch supporter of permitting patients to use the Internet to locate a willing organ donor, the increasing popularity of organizations such as Matching Donors has raised questions as to whether online solicitation should be permitted.

Douglas Hanto, MD, Chief, Division of Transplantation at 

, is against such solicitation. “I have all of the respect in the world for people who are willing to come forward, but there are so many people on the list that are needy,” he says. “I think where the kidneys need to be donated is to the person who needs it the most: the next person on that center’s waiting list.” Hanto wrote the article “Ethical Challenges Posed by the Solicitation of Deceased and Living Organ Donors,” published in the March 8, 2007 issue of the 

 (NEJM). The article examines the potential ethical dilemmas surrounding a decision by living donors to choose a patient who is the same race or religion as they are, a decision that is highly opposed by the 

“The solicitation of organs from deceased donors bypasses the patient who is first on the waiting list; therefore, it violates the principles of utility and justice on which allocation policies are based,” wrote Hanto. Originally Beth Israel would turn away transplant patients who found a donor through the Internet or other media, but recently Hanto has 

. “We [Beth Israel] still feel the fairest way is for those donors to donate to the patients who need it the most—[those who are] at the top of the list,” he says. “However, for patients in our system, rather than have them leave the system, we’re trying to work with [them].” 

Francis Delmonico, MD, Director of Medical Affairs for 

, Advisor for Human Transplantation for the 

 (WHO), Professor of Surgery at Harvard Medical School, and Medical Director for the 

 (NEOB), agrees with Hanto, saying that using the Internet as a tool to find donors can be hazardous because there may be a risk if the donor is not evaluated carefully. However, Delmonico told MDNG that he “does not have any objection to relationships being formed under these circumstances.”

 (NOTA) was passed by Congress, making it “illegal for individuals to sell organs, whether they come from live donors or from people who have just died. Donors’ organs are to be made available by altruism, although that standard applies only to potential donors and their families.” NOTA deemed 

 a crime if a person were to “knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce.” Should a person get caught, it can lead to fi nes of $50,000 and/or imprisonment for up to five years. Richard Epstein, professor of law at the University of Chicago, says, “I think [NOTA] should lift [the ban] and see what happens.

There will be lots of intermediary tools that will emerge, and there will be an organized market, and the process will become safer, because the donors will be pre-selected to include those people who have minimum risks for transplants.” When asked for his opinion on the buying and selling of organs, Dave Undis, executive director of 

, said “If people were allowed to buy and sell organs, we could save thousands of lives every year.”

 and other chronic debilitating diseases increasing worldwide every year, it’s important to explore a variety of strategies designed to decrease the number of people on the organ transplant waiting list; whether it’s by perfecting xenograft transplantation (transplanting organs or tissue from one species to another) or implementing

, in which an incompatible donor/recipient pair is matched with another incompatible pair; the recipients then “swap” donors. Although better, more efficient means of assigning and matching organ donors will alleviate some of the strain on the system, the best approach to negating the organ donor crisis is to step up efforts to deliver preventive care and educate patients on the dangers they face. Delmonico says that preventing hypertension, diabetes, obesity, and atherosclerosis “would help a lot in reducing the prevalence of end-stage organ failure that we see in end-stage kidney failure.”

Summary of Arguments for and Against Solicitation of Organ Donors

1. Donor autonomy requires that the donor or donor family be able to decide where the organs should be directed.

2. The current allocation system may be unfair to certain patients.

3. Solicitation results in more public awareness and willing donors.

1. Donor autonomy is not absolute and must consider the fair rights of others.

2. Solicitation of deceased donors bypasses the fair policies of allocation and the person ethically entitled to the organ.

3. Solicitation permits discriminatory practices.

4. Solicitation favors the well educated and those with financial resources.

5. Solicitation risks the exploitation of donors or recipients and may result in the undetected buying and selling of organs.

6. Solicitation may divert organs to unsuitable candidates for transplantation.

Another Look at Transplant Tourism: Expert Opinions

[Transplant tourism is] unacceptable because it exploits the person who sells. I don’t think we can have the international community subscribe to look at poor people being victimized under these circumstances.

—Francis Delmonico, MD, Director of Medical Affairs for The Transplantation Society

I think people should do it, it’s the only thing that’s open to them, but I think it’s a riskier process than doing it at home. I think the way to stop the exports is to allow the domestic market to develop.

—Richard Epstein, Professor of Law at the University of Chicago

I think that it really is a bad idea. We discourage our recipients from doing that and we haven’t had good outcomes in the patients who have gone abroad.

—Douglas Hanto, MD, Chief, Division of Transplantation at Beth Israel Deaconess Medical Center

When those in need of a transplant are dying, they are entitled to do anything legal to save their lives. Transplant tourism, in some instances, is legal. My only concern is that only those of us with financial means can afford it. I would like it to be available to people of all means.

—Robert Hickey, PhD, Corporate CEO of Innovative Strategies, Inc.

I think it’s the inevitable result of the organ shortage. When people are dying waiting for organ transplants, you would have to expect them to do whatever they could to save their lives.

—Dave Undis, Executive Director of LifeSharers

End-stage organ failure is a growing problem in the US, due in part to the fact that the number of available donor organs is lagging far behind the number of people (approximately 96,000... 

And the Organ Goes to...

Whether you're a medical student on the cusp of graduation, a physician who has been practicing medicine for years, or an up-and-coming healthcare information technology (IT) specialist, you already know that it takes more than clinical skills and a degree to make it in this business. Healthcare is currently undergoing a revolution when it comes to the application of information technology. From the ways in which patient encounters are documented, stored, and accessed to the collection and analysis of outcomes data in order to create best-practice algorithms nearly every healthcare process and procedure is being radically reworked and reconfigured through the application of IT. 

Because these massive changes will likely accelerate and expand in years to come, knowledge of informatics and other tech-driven disciplines will soon become part of the basic skill set at all levels of healthcare delivery, from physicians, nurses, and other providers all the way up to health system executives. In the meantime, healthcare professionals who get ahead of the health IT curve will have an advantage over their competitors.

"If you're talking about a clinician in a clinical environment, one of the skills people talk about often now is their [knowledge of] informatics," says Morgan Passiment, Director of Information Resources Outreach and Liaison for the

 (AAMC), an organization that "represents the nation's nearly 400 major teaching hospitals and health systems and their associated clinical physicians. Comprising only six percent of all hospitals, AAMC members operate 47% of all organ transplant centers, 60% of all level one trauma centers, 67% of all burn beds, and provide nearly half of all hospital charity care nationwide."

The AAMC realizes that increasing potential physicians' knowledge of IT must begin early in the educational process. "When it comes to medical students, there's a certain level of information literacy that [AAMC] is trying to get incorporated into the curriculum, because even though students come into the schools very quickly with technology skills, they don't really know how to evaluate information and understand whether it's valid& that not everything you get off of 

 is going to be correct," says Passiment. "There are different levels [of knowledge]: one level is actually more of an information literacy level" understanding how to evaluate information. Another level is "how do you gather information and utilize that to improve care?'"

Beyond merely possessing a rudimentary understanding of the basic dynamics of an increasingly information-driven industry, healthcare professionals who wish to thrive in a changing practice environment will soon find they must expand their understanding of the field of informatics and its applications in medicine. 

 is defined as "the science of information and the practice of information processing." A health informaticist solves healthcare-related information problems; for example, he or she might design better ways for healthcare providers (HCPs) to access and manage patient records, telemedicine systems, patient-tracking and billing processes, and the efficient delivery of consumer health information over the Web. A nurse informaticist "knows healthcare and the work processes within it," says Donna Gloe, Chair, ANCC (

) Informatics Content Expert Panel. (See our recent Web Exclusive, "

Nurses are the Key to Linking IT With Better Patient Care

," for more on this topic). "That's an important part of the job. The other part is knowing the informatics part. "How do you use the database? How do you manage a project? How do you choose a vendor? How do you develop an ROI [return on investment] for this, and what are those factors?"

"The field of informatics nursing is growing very quickly because technology is so prevalent," says Todd W. Peterson, Senior Communications Specialist, ANCC. The ANCC represents more than 150,000 nurses throughout the US in 40 specialty and advanced practice areas of nursing. A national certification body of the 

 (ANA), the ANCC offers certification in approximately 30 different nursing specialties, including certification for 

"The [ANCC Content Expert Panel] of nurses who have a certification and are selected to speak for fi ve years keep [the informatics exam] current as technology changes or as the fi eld progresses," says James Finley, RN, MBA, Senior Manager for Healthcare Practice at 

 in San Francisco, CA. Finley, a member of the Panel, says that although the field is expanding, informatics is still a relatively small niche in the career marketplace for nurses.

The ANCC Content Expert Panel's process of evaluating and updating its certification examinations, including that for informatics nurses, involves a logical job analysis conducted every time the scope and standards are updated. Recommendations are made in between content outlines, and the committee reviews all of the submitted test questions and answers for the validity of the content. The written portion of the examination for informatics certification requires information on the length of time worked in a nursing specialty and any educational background specific to informatics that qualifies a nurse applicant. 

The nursing informatics certification is not an advanced practice certification, however, meaning interested providers don't have to be a nurse practitioner (NP) or clinical nurse specialist (CNS) to be certified in informatics. Download an 

Many professional medical associations have specific guidelines in place to ensure the highest caliber of its members. 

 (ACP), for example, requires a medical degree, a current license to practice medicine, and certification in internal medicine to qualify as an applicant for their society. Information technology expertise may soon be added to that list, and not just for practicing physicians. "At the association level, we increasingly need people, particularly in our policy area, who understand the problems that hospitals face, adapting these technologies, and the regulatory and the legal barriers that they may face, as well as the resource constraints," says Rick Wade, Senior Vice President, Communications, at the 

 (AHA). "We increasingly look for people who understand the world that our members are going through."

To illustrate one area of need, Wade mentions the limited ability of small rural hospitals to adopt new technology because of their limited budgets, compared with those of larger multi-hospital systems and those in more urbanized areas. "You need someone who can use the technology at the association level to communicate with the members and to make the best use of the member's resources," he says. The transformations being wrought by the application of new technologies throughout the healthcare system have changed the qualifications being looked for in healthcare executives and consultants. "The ideal candidate [now] is the one that can handle interfaces at the programming level--service-oriented architecture, system maintenance, and business continuity," says Jeffrey C. Bauer, PhD, a Chicago-based partner in management consulting for ACS (

Part of the challenge in finding the right physician or healthcare IT specialist is hiring the right recruiter or human resources staff. "You almost always hire a CIO to be part of your executive team and then lean on that person entirely to navigate those waters," says Wade. "Some of them have been very happy with the outcome and others have ended up with an ice bag on their head, wondering how they got there because they poured a lot of money into something and six years later, it's junk and they don't know what to do with it." Bauer agrees, citing lack of understanding about job roles as a reason for the high health system CIO turnover rate.

Passiment suggests that the people who are most successful in managing the clinical information and faculty in a medical school environment "have a broad understanding of where healthcare is going, where their institution is going, and have a good business sense." The modern healthcare industry needs people "who understand the practice of medicine and the operation of healthcare, who can influence the development of our solutions and software, and who understand the workflow and how that can change," says Julie Wilson, Chief People Officer and Vice President, 

, a healthcare technology solutions company that designs and implements software and services for healthcare organizations and clinicians. Professionals who want to get ahead in a changing healthcare environment "need to be adaptive to technology."

Physicians and allied healthcare professionals are expected to treat an escalating number of patients efficiently while maintaining the highest quality standards. Meanwhile, healthcare organizations must increasingly deal with clinical staff shortages. One solution to the personnel shortage in nursing and other medical specialties is to promote widespread adoption of cutting-edge information technology to streamline workloads and incorporate the clinical decision support tools that ensure safety, creating a quality environment for patients. Successful implementation of this strategy requires recruiting the right people for the job.

, a national executive search firm based in Oak Brook, IL, specializing in healthcare recruitment, understands that the healthcare industry is placing greater emphasis than ever on clinicians and executives who possess the skills and knowledge necessary to shepherd an organization through the often painful process of health IT adoption and implementation. Its Vice President and Region Co-director, Carson F. Dye, FACHE, developed a list of "Health Care's Top 10 Recruiting Mistakes" to aid health systems in hiring the best people for this new data-centric environment:

1. Placing haphazard emphasis on the importance of hiring senior leaders in health care.

2. Developing lackluster position specification documents.

3. Writing qualifications that detail the "walks on water" characteristics.

5. Letting "the bias factor" take control.

6. Sketchy position responsibilities and relationships.

8. Seeing executive recruiting as a one-way process.

9. Relying on ineffective evaluation techniques.

Conducting "more than 400 executive search assignments on behalf of leading hospitals, health systems, teaching hospitals and academic medical centers, and physician group practice organizations," Witt/Kieffer has 35 years of experience to back its initiatives. With more than 

reputable hospitals as Sacred Heart Health System and Columbia University Medical Center" the firm has a clear understanding of the candidate search process.

"I look for people with [informatics] experience when recruiting, putting information into a clinical information system as an analyst," says Finley, although this is not always currently possible. "Recruitment is a challenge in any area, for a staff physician, or hospital, or informatics person," he says. "It's probably more difficult because the area is so focused and there's not a plentiful supply of programs; most learn it on the job at hospitals or after being on a project, then become an informaticist that way. Those are hard positions to recruit for and there's a lot of people falling into it."

Whether you're a medical student on the cusp of graduation, a physician who has been practicing medicine for years, or an up-and-coming healthcare information technology (IT) specialist, you...

June 2007 | Oncology Live®