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.

More than four years removed from the end of the beginning of the national Health Insurance Portability and Accountability Act (HIPAA) experience, the legislation’s requirements regarding data security continue to baffle clinicians in thrilling new ways from month to month. To describe recent progress in this area as “glacial” would be a gross insult to glaciers. A recent poll by 

, found that 44% of providers are still not compliant with the HIPAA Security Rule finalized in February 2003—a stirring improvement of 1% since January 2006. Because failure to protect sensitive patient data may have practical and ethical implications quite apart from those associated with HIPAA, the issue of data protection has never been more critical. Changing interpretations of HIPAA guidelines, and the continuing evolution of the technology used by and against would-be data thieves, means that constant attention is necessary; a practice that is airtight today may be vulnerable tomorrow. Among the key issues of the moment:

By now, most practices are aware that the creation of backup copies of important data is a critical defense against data theft, destruction, or corruption. Generally, backups are created at pre-specified intervals; a typical practice might backup data once every 24 hours. Unfortunately, the eight-hour workday is fast becoming an outmoded concept; physicians may work at any time, and it is often the most recent data that is the most valuable. If a periodic backup is scheduled for 5:00pm, and data corruption occurs at 3:15pm, all changes entered in the 20+ hours since the last backup may be lost.

Continuous data protection (CDP) is a concept designed to deal with this problem. CDP solutions create a real-time record of all changes made to every file by automatically saving a fresh backup copy to a secure independent location after each change. In practical terms, this means that the user can instantly restore a file to any point in time— be it minutes, days, or weeks earlier. Because CDP systems save only the changes to a given file instead of saving the entire file each time

(if a user changes only three bytes of a 500GB file, CDP will save only three bytes), this approach will also save disk space. CDP is different from other data protection strategies, such as the Redundant Array of Independent Drives (RAID) concept or replication/mirroring, which create copies of the most recent changes only. Whereas CDP can restore data to a point prior to corruption or damage, these other approaches can only restore the corrupted or damaged data.

Until fairly recently, the market leader in the area of CDP was 

 exploring CDP in more detail may be found. In 2005, Goliath entered the ring with the launch of 

. Some products marketed as CDP allow only restoration to pre-specified time-points; users interested in the ability of CDP to restore to any point in time should be sure that any product they purchase actually has this ability.

Data theft is a significant concern for business in general. A 2005 Computer Security Institute/FBI report estimated that approximately one-quarter of all information security-related financial damages derived from the theft of proprietary information. In a simpler time, when storage devices were larger and limited in capacity, actual physical theft of computerized data was extremely difficult (imagine having to transfer a huge sensitive file onto dozens of 51/4" floppy disks). The recent proliferation of fl ash drives and other inconspicuous devices capable of storing very large amounts of information—a typical 51/4" floppy could store about 100KB of information, while the iPhone boasts internal fl ash memory of up to 8GB, or nearly one million times as much storage space—and interacting with a wide range of other devices has made it much easier for would-be information thieves.

, the Department of Health and Human Services suggests that “covered entities should be extremely cautious about allowing the off site use of, or access to, electronic protected health information (EPHI).” However, completely outlawing the use of removable media may be counterproductive—a flash drive may allow a physician to legitimately review a series of case files out-of-office, or allow for quick sharing of relevant data among treatment team members&mdash;so providers must develop policies and procedures for managing this kind of risk, including restricting use of removable media not justifiable from a work standpoint. In some cases, providers may wish to institute an IT system in which an administrator controls and monitors all access to removable hardware.

No aspect of the HIPAA Safety Rule is responsible for quite as much confusion and gnashing of teeth as the so-called “minimum necessary standard,” described by the 

University of Miami’s Data Protection Project

. In essence, this standard is a “need to know” rule; for situations in which providers must disclose, use, or request patient information in furtherance of patient care, it requires them to disclose, use, or request only the minimum necessary to accomplish the goal of the disclosure, use, or request. There are a host of exceptions to the minimum necessary standard, most importantly disclosures made for the purposes of treatment (information uses related to treatment are subject to this standard). Couldn’t be clearer, right?

The treatment exception affords practitioners considerable leeway, facilitating collaboration on patient care. However, there is much confusion over the proper application of the standard. Many providers may be unaware that the standard does not apply to disclosures for the purpose of treatment, or unfamiliar with the distinction between use and disclosure—thus leading them to apply 

. Further confusion stems from the absence of a system-wide definition of “minimum necessary;” left to develop individual definitions, institutions or providers may withhold information when they should not. Providers with electronic medical records tend to have an easier time adhering to this standard, as records with only the necessary information included can be readily generated. Providers with paper records “were having to print out copies of charts and manually redact information before faxing it,” according to the article linked above. Readers are urged to review their own minimum necessary policies to be sure they are adhering to, but not unduly limited by, the standard.

At its outset, many pundits expected that 2007 would be the year that meaningful health IT legislation finally saw the light of day (and the President’s desk). Earlier this year, a coalition of patient groups and other organizations formed 

, an advocacy group headed by a pair of former Congresspersons and dedicated to supporting this cause. In June, efforts of this and other groups were rewarded when a Senate Committee passed the 

, an initiative sponsored by a bipartisan group of Senators including Utah’s Orrin Hatch and New York’s Hilary Rodham Clinton. The Act would earmark $163 million in 2008 and 2009 to provide grants to healthcare professionals supporting health IT adoption, help establish state-level loan programs for other providers, and create a national coordinator for health information technology. Unfortunately, this legislation, like similar bills proposed in the past, has been hamstrung by concerns about privacy and data protection.

Patient Privacy Rights Foundation founder Deborah Peel says that the current Act is even worse in the area of patient privacy than the 2005 health IT bill that passed the Senate and died in the House of Representatives; the new bill “doesn’t even have a definition of what privacy is,” she notes. Peel says that at present, electronic medical records are more susceptible to theft than paper records. The Veterans Administration (VA) is well-known for its system-wide Vista Electronic Health Record system. In 2006, a VA laptop was stolen, resulting in the compromise of the private medical information of 26.5 million patients. Privacy advocates call for data protection measures to be built into any proposed health IT legislation; it seems unlikely that any such legislation will become a reality without addressing these issues directly.

Most practices are wise enough to require users to have passwords in order to access sensitive data. However, if it’s possible to wander by and access protected information every time a logged-on user needs a bio break, password protection is of little value. HIPAA regulations—and good data protection policy&mdash;mandate that all workstations should automatically log-off after a brief period of idleness.

Malware is a catchall term for viruses, spyware, and other software programs that infect your system and steal, alter, or damage data. Malware can enter your system through an open network connection with no precipitating user action, making it difficult to prevent. Antivirus and anti-spyware programs can help, but are useful only against known threats; a more reliable solution is the hardening of overall security using firewalls and related protections. For more, see the 

HIPAA requires you to obtain a signed form from each patient indicating that he or she has been informed of his or her privacy rights. Some may need guidance and clarification, and will naturally turn to their physician for both. For this reason, it is critical that providers become familiar not only with the rules and restrictions that affect them, but also with basic patient rights under HIPAA. The links in this article, especially the educational modules available through the Privacy/Data Protection Project, are an excellent place to start.

Frank Ferrara is a freelance writer and former editor of

Articles

More than four years removed from the end of the beginning of the national Health Insurance Portability and Accountability Act (HIPAA) experience, the legislation's requirements regarding data...

The Data Protection Primer 2007

On September 20, 2007, the first-ever conference devoted to “Health 2.0” convened in San Francisco. Co-produced by health industry consultants, Matthew Holt and Dr. Indu Subaiya, this well-attended event showcased the latest products designed to help consumers and physicians filter, sort, and comprehend health information.

Holt, who trademarked it, defines Health 2.0 as the application of Web 2.0 tools (blogs, search engines, etc) to health. Physician-blogger 

 categorizes it as a “new concept of healthcare wherein all the constituents (patients, physicians, providers, and payers) focus on healthcare value (outcomes/price) and use competition at the medical condition level over the full cycle of care as the catalyst for improving the safety, efficiency, and quality of healthcare.”

Shreeve’s view of Health 2.0 is attractive, because it is all-inclusive. Rather than focusing on technology, he is talking about how these tools can solve the health system’s structural problems. Unfortunately, many at the Health 2.0 conference were not thinking this broadly, as prominent entrepreneur and investor Esther Dyson observed on the blog she writes for the 

. She wrote: “The companies [at Health 2.0]... can’t simply dissolve a hairball, as someone described the healthcare system earlier in the day. They need to take on the calcified mess at the bottom of the drain—or to be more anatomical about it, they are clearing the capillaries and buffing the nerve endings, but at the center of everything there’s a calcified heart pumping blood/information/money in the wrong direction through a tangled mass of arteries that misdirects resources to tumors and useless vestigial organs.”

Dyson was concerned that some of the companies exhibiting at the event were more interested in pursuing their exit strategies than changing the healthcare system for the better.

The US health system has many problems, but these rise to the top of the list:

• Access: Ensuring everyone can enjoy good, quality healthcare

• Practice Variation: Streamlining the system to reduce gaps/differences in care between geographic regions and socioeconomic groups

• Administration: Reducing bureaucracy, duplication of services, and paperwork

• Consumerism: Helping consumers successfully assume the position of primary health manager

• Health Illiteracy: Reducing the proportion of American adults who are functionally health illiterate

• Caregiving: What can we do to help younger generations get ready to pay for and manage their parents’ (and grandparents’) care? Dyson’s (and my) frustration with the current Health 2.0 movement is that it is very fragmented. Because of this, it is not well-prepared to tackle the big issues. Granted, technology can only play a limited role in improving access, but it can help to solve other seemingly intractable problems.

Competition is good and necessary, but Health 2.0 companies should be looking for ways to enter into mutually beneficial partnerships when possible. In addition, while there is a great debate about the future of the US health system, there has been very little conversation about how innovative entrepreneurs can inject themselves into the policymaking process. Marty Tenenbaum, creator of 

, has suggested that businesses in the Health 2.0 space come together to form a network that would achieve some of these goals.

 post, he wrote: “[M]any energetic entrepreneurs are exploring the seemingly limitless opportunities and obstacles of [the] huge and important [health] market. Each provides useful but highly fragmented data or services (eg, PHRs, search, patient, and doctor communities). Aggregating data across communities and integrating services into complete solutions (eg, selecting the best treatment or physician for you) is much more valuable to consumers, and essential if we’re actually going to impact healthcare in meaningful ways.”

Fard Johnmar is the founder of Envision Solutions, LLC, a full-service healthcare marketing communications consulting firm.

 to learn more about the company and the services it offers

On September 20, 2007, the first-ever conference devoted to Health 2.0 convened in San Francisco. Co-produced by health industry consultants, Matthew Holt and Dr. Indu Subaiya, this well-attended...

The Health 2.0 Movement Must Keep its Eyes on the Prize

Our lives are full of choices: paper or plastic… chocolate or vanilla… Windows or Mac. For nearly two decades, people have been divided into two camps when it comes to computers. Die-hard Windows adherents point to the thousands of business and specialty software applications that are available only for the Windows environment. They also boast that Windows PCs are more economical to purchase and operate and support a wider array of peripheral options.

Meanwhile, Mac acolytes rave about the Mac’s superior design and intuitive user interface, including the ability to start using the computer as soon as you plug it in, without any complicated set up or hardware driver installations. Macs are also safer than PCs from a security and vulnerability standpoint. And nothing can compare with Apple’s superbly usable suite of applications for music, photos, and making movies. However, Apple’s decision to start putting Intel processor microchips into their computers means that the days of having to choose between the Mac and Windows are over. Macs can now run Windows “natively,” which is a technical way of saying that Windows applications now enjoy speedy performance on a Macintosh computer comparable to that of a native PC.

Let’s say your practice uses Windows PCs (as most do). Your critical applications might include an EHR and some practice management software. You also may use Microsoft Outlook for e-mail and Word files for your various writing needs. At home, however, you enjoy using your child’s Mac, the iPod is your favorite gadget, and you are quietly hoping to get an iPhone soon. However, thanks to new programs like Boot Camp and Parallels that allow you to run Windows software on a Mac, you no longer have to live this dual life. It may well be time to make your next office computer a Mac, and get the best of both worlds.

Boot Camp and Parallels take advantage of the Intel chip now used in many Macs, and can run the Windows platform natively. Unlike emulator-type software, such as VirtualPC for the Mac, which must add a layer of translation for Windows programs to function, these newer programs tie directly to the processing chip and can run programs just as well as they would run on a Windows PC. Boot Camp beta is currently free and can be 

. As with all these programs, you must supply your own copy of Windows XP or Vista (which costs a few hundred dollars), but the installation process is fairly painless. After installing the software, you designate either the Mac OS or Windows as your “most of the time” start-up operating system. You can also choose which operating system to use each time you start up the computer. To do this, hold down the “option” key (that’s the “alt” key for longtime Windows users) at startup and make your selection. After starting up, your Mac runs Windows natively, just like it would run on a PC. To move to the Mac OS and its software, however, you need to restart the computer. This is not only time-consuming, but it means you cannot cut and paste between Windows and Mac applications.

Personally, I think a better approach is using one of the virtualization programs, like 

. Virtualization allows multiple “virtual” machines to run simultaneously on a single computer. In plain language, this enables you to live on the Mac desktop and seamlessly run Windows applications whenever you want, without rebooting. Virtualization programs let you launch, dock, and close individual Windows applications; cut and paste between programs; and even drag and drop files between your Windows and Mac desktops. Read the 

 titled “Mac Virtualization: VMware vs. Parallels” for a good summary and evaluation of these products’ capabilities. The newest Macintosh computers even include USB 2.0 interfaces that will work quite readily with most “Windows-only” PC peripherals, including digital cameras, printers, keyboards, mice, and other input devices. Occasionally, you may have to search and install an obscure driver to use some advanced functionality, but that’s the exception, not the rule.

Now, we can finally have the best of both worlds—the aesthetic beauty and elegance of the Mac and the extensive software options available on the Windows platform. There are a few caveats of course, including the added cost of a second operating system and the Mac’s higher price tag. In the end, until Apple lowers Mac prices to PC levels, you will have to decide if that extra $400 (approximately) dollars is worth the improved aesthetics you’ll experience with a Mac.

Dr. Bertman is Physician Editor-in-Chief of 

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

, a leading developer of EHR software. He is also the founder and president of 

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

Our lives are full of choices: paper or plastic& chocolate or vanilla& Windows
or Mac. For nearly two decades, people have been divided into two camps when it comes to computers.

Running Windows Vista on a Mac

Before he got an electronic health record, David Fairbank, MD, was on the brink of bankruptcy. "A month later than that, and I would have been under," the Lacey, WA, family physician says. His practice, the Clinic at Panorama City, located in a 1,200- resident retirement community, has a patient population that is 60-70% Medicare, so it was more than just an inconvenience when the clinic's third-party billing service had a software glitch that prevented Dr. Fairbank from receiving a single Medicare reimbursement from July 17 to Oct. 6, 2006.

"Our billing company went into bankruptcy and almost took me with them," Dr. Fairbank says. At the time, he relied on the billing service to verify patient eligibility. "It was a poor way of checking it," he admits. He estimates the practice lost $30,000 one year, simply because the billing service wouldn't follow up on invoices worth less than $100. On top of that, Dr. Fairbank is a member of the 

, a prepaid insurance network, in which the IPA and its members assume all risk. "We didn't have a handle on our finances," the solo family practitioner says. It was an all-too-frequent refrain for a small, semirural practice. But not an insurmountable problem.

Thanks to electronic health records (EHRs) and even the Internet in general, small-town and rural doctors and their patients no longer have to suffer due to geographic isolation. They can deliver the same kind of care as their big-city counterparts and also thrive financially. On July 17, 2006, the same day his old billing service went on the fritz, Fairbank took up the IPA on its offer to install an EHR in his office. The IPA is an EHR and e-Prescribing test partner for 

, a St. Louis-based vendor, and Fairbank's clinic in Panorama City now is a beta testing site.

At the time of the billing crisis, Fairbank had three people working at the front desk. One subsequently left, but the remaining two were able to handle the workload with the help of the new system. Dictation and transcription had been costing Fairbank $4,000 a month. The cost is now down to $200. Overhead expenses ate up 61% of revenue from January to May 2006. In the same period a year later, overhead was down to just 51%. The EHR also represents a better way to evaluate practice performance, Fairbank says. It now takes about 7-10 days instead of 20-30 to get reimbursed by most payers, including Medicare. This is key because, as the physician states, "You've to watch your cash flow." Fairbank also is fairly certain he's delivering better care to his patients with the EHR. This is not just about putting paper charts into the computer," he explains, "this is about the clinical decision support. He specificlally cites the benefits of drug interaction checks, reminders about preventive care, follow-ups with patients, and even coding, since the software handles risk adjustment for Medicare. As soon as the coding is done, the bill goes out electronically, marking a huge advance from the old method. Previously, the practice's billing service would pick up charts twice a week, "meaning bills only went out twice a week. Now, bills get sent to the proper payer as soon as his documentation is completed for each patient encounter, helping to ensure a more constant revenue stream.

Although Fairbank has proof that an EHR saved his practice, other small-town, small-practice, primary care physicians only have their gut feelings to go on. Still, Joseph Perkinson, MD, of Victoria, TX, is glad he didn't "leave anything to chance when he hung out his shingle in January 2001 without a previous patient base in the area. "I was tarting from nothing," he recalls. "I had only served that there was not much longevity in solo family practices. That troubled me." Dr. Perkinson knew that the only way he was going to make it was to operate efficiently and provide good care. Based on his experience as a resident at 

 in Houston, an EHR was a necessity. "It encourages me to be honest [with patients]," he says.

Once he's done documenting an encounter, Dr. Perkinson shows the computer screen to the patient so the patient can visualize health trends, such as historical testing values. For example, he might otherwise have danced around the issue of alcoholism with a patient, but a spike in HDL cholesterol" one symptom of alcohol abuse "that both can see, forces him to confront the issue as early as possible. "I see these tools as a Herculean leap, a huge advance in the tracking of diseases," Dr. Perkinson explains. Unfortunately, patients tend to choose physicians on "superficial" bases, "especially in small-town America," according to the small-town doctor. A doctor's perceived reputation tends to carry more weight than actual performance. "They really don't care about the tools that you use," he says. 

But it sure does help around the office. "We've never had charts, ever," Dr. Perkinson adds. That means he didn't have to lease extra space just to store thousands of paper records, nor did he have to hire file clerks. He started out with two staff members, and his wife provided some part-time support; now, he employs four full-time staff and one part-time employee to support his practice, significantly less than the national average of about seven full-time workers per family physician. Clearly, the EHR has enabled him to do more with less. "Because of automation, it allows non-clinical people to participate in the clinical process to a degree," Dr. Perkinson says. For example, staff at the front desk can access patient records to handle refill requests with minimal involvement by the physician.

, a solo family physician in Watertown, WI. He has two physician assistants, the equivalent of three full-time nurses, three front-office workers, some part-time clerical help, as well as one person who wears the hats of x-ray and laboratory technician, document scanner, and business manager. "Our entire staff is paperless," Dr. Turke says. More importantly, he believes the EHR empowers the nurses to be real caregivers, and not spend half their time chasing paper. "They like the responsibility of being part of the team and participating in the patients' care."

, topping 17 other practices in terms of following metrics related to generic drug usage and pill-splitting in diabetes care." I'm convince that as mostly our good staff and our electronic health record," he states. Before he found the right nurses, Dr. Turke did have some trouble recruiting suitable people to Watertown, about halfway between Milwaukee and Madison. The presence of an EHR means his nurses must have typing skills. When he first started with electronic records, and for many years after, many candidates lacked those skills.

The Wisconsin physician could rightly be called an early adopter, since he has had SOAPware, a product of 

, since 1995. "I was one of the pioneering folks," he says. Even back then, various medical journals had been saying plenty about EHRs, although computerized patient records and electronic patient records were the preferred terms at the time. "It just made so much sense to me because every other business was electronic," he recalls.

In October 1994, Turke attended the annual meeting of the 

, which had just begun to show an interest in EHRs. He remembers participating in what was dubbed a "Computer Petting Zoo," where doctors could test out the offerings of 20 or so vendors. "I decided after going there that I would go electronic," he recalls. Prior to the meeting, he hadn't even seen an EHR before. It was at that meeting that he met SOAPware developer Randall Oates, MD, himself a small-town, small-practice family physician. "I spent a lot of time at the Computer Petting Zoo," Dr. Turke says. "When I got home, I just decided to do it."

Like so many early adopters, Dr. Turke took a leap of faith with his vendor. Nowadays, with the market's gradual maturation and the 2006 advent of a 

, it's less of a gamble. "Whichever one you decide [on], I'm sure it will be fine," he advises. "Just pick one." After all these years, through plenty of trial and error, Dr. Turke has refined his workflow as technology has improved. Twelve years ago, he was doing all the data entry himself. "Nobody in their right mind would do it that way now," he says. Today, he has a series of preformatted templates to help document common conditions, but that also means he has to pay attention to what he's doing. "It's so easy to use the "canned template" so you don't have to read every word," Dr. Turke notes. "If you say the bowel sounds are normal, you'd better darn well have listened to the bowels."

According to Dr. Perkinson, "The single biggest impediment to the adoption of the digital health record is data entry." In April 2005, when he moved to a larger office, he overhauled his local-area network and started with speech recognition as an alternative to templates and free-text entry. "I have never used dictation, ever," he says. Instead, he relies on a hybrid of typing, point-and-click templating, and speech recognition, with a USB microphone attached to his computer. Perkinson is also a fan of "scribing" where by the assistant follows him and does the typing. "It keeps me from looking at the screen when I'm evaluating the patient."

Perkinson's office has wireless laptops on carts, known in hospital circles as COWs, for computers-on-wheels. "I have never liked leaving computers in the exam room," he says. "That, of course, is a personal preference. Dr. Turke has computers both in his personal offi ce and in the exam room. Nurses, PAs, and the front office staff are all connected to the clinical system. Nurses or other staff take the patient's history, then he goes in to conduct the examination, reviewing the information along with the patient. "I see patients] in the exam room, they get dressed, and then they come into my office."

Patients leave the office with a printed summary of Turke's notes, including the diagnosis, treatment plan, and list of medications. He tells older patients to carry a copy of the report with them, particularly in case of emergency. "I think if I had a dollar for every time a patient told me this was a good idea, I'm sure I would have paid for [the EHR] by now," Turke says. Actually, he is certain the EHR has paid for itself in many ways. "When I'm gone I'm virtually connected to the Internet, and I can still review the charts, " Dr. Turke says. In the past, whenever he took time off , he would bring in a locum tenens physician, then come back to a large stack of charts to review, adding to expenses and slowing him down.

Although the Internet is pretty ubiquitous across America, technology can and does have its limitations in rural areas. In 2001, Perkinson purchased a Logician EHR, a system now sold by 

GE Healthcare under the Centricity brand name

, which was developed more for group practices than solo physicians. He chose a Millbrook practice management system, also now part of GE's Centricity line, mostly because that was what Baylor had for its outpatient billing and management.

Now, he's working on setting up a patient portal to gather clinical information and report test results over a secure connection, but residential bandwidth issues in his community are making that difficult. And the lab he uses is not yet capable of reporting results directly into the EHR. "I would like a two-way interface, but this town isn't ready for it yet," he admits.

Neil Versel is a freelance healthcare journalist.

Before he got an electronic health record, David Fairbank, MD, was on the brink of bankruptcy. "A month later than that, and I would have been under..."

Small-Town Tech, Big-City Service

On a hot June afternoon in Palo Alto, more than 100 people stood in line outside the Apple store for a much-anticipated new release. The mood was festive. While children got their faces painted and watched balloons twist into animal shapes, the adults were getting antsy. They were impatient to get their hands on the Next Greatest Thing.

A 20-something guy in cargo shorts and a Green Day t-shirt who works in the IT department of an airline told me he flew “jumpseat” from Arizona to stand in this line. Further up, a middle-aged Silicon Valley marketing exec named Susan explained she’d been waiting since noon. Behind her, a pencil-thin 19-year-old fashonista, carrying an expensive looking bag with “Duchess” spelled in rhinestones, yapped on her Motorola Sidekick, telling her boyfriend that the crowd was “ridiculous.” I was there sweltering in my blue hospital scrubs, and when a store employee offered a bottle of water, I gratefully accepted. A young Asian woman, identifying herself as a CNN reporter, asked me who I was, and why I was there. “I’m a physician, and I work at a hospital nearby. I took the afternoon off to buy an iPhone,” I replied.

“Why do you need an iPhone?” she asked. Caught off -guard by the notion that anyone would ask such an outlandish question, I tried to explain. “Well…um…I don’t actually need one, but I want one.”

“He’s a gearhead, he can’t help himself,” said the IT guy, blithely.

“Actually, we all are,” Susan added, making a point to include “Duchess” in the “we” (ostensibly to mitigate the geek factor). “We are gadget freaks, and this is the next greatest thing!” I was saved by Susan’s words. Yes, we were shameless gearheads, and we spanned the spectrum in age, income, and “coolness.” Beauties and geeks alike stood side by side in line. That is the genius of Apple’s iPhone: a gadget that unites us all.

You, too, will be seduced by the iPhone this holiday season. If the bleeding-edge technology and sleek design don’t grab you, then the recent, dramatic price reduction should. Th e iPhone, a combination iPod, telephone, and Internet device, manages the first two functions very well, and the last with reasonable aplomb. As an early adopter, my expectations were sensibly low. I expected some problems, but hoped they would not be deal breakers. As a physician, I needed the phone to work flawlessly. I worried that software problems might interfere with my ability to return pages and make important calls, but not for long. In my area, AT&T cellular coverage is head-and-shoulders above my previous carrier. Now I can receive calls and cellular data via the EDGE network in our operating rooms at Stanford, and residents can reach me directly when they have urgent questions. In this respect, the timing of my new iPhone purchase, shortly after the new residents arrived at Stanford, could not have been better.

There is of course, a plethora of other functions that make this my choice gadget for the season. Google maps; gorgeous video playback on the 320 x 480-pixel screen; instant, “anywhere” e-mail access; device convergence (I love being able to bike to work in my scrubs without carrying a separate cellphone and iPod); and, of course, the famous Apple user interface and innovative multi-touch screen. Steve Jobs should not rest too long on his laurels, however. The iPhone does have a serious Achilles’ heal: AT&T. As an Internet device, the iPhone relies predominantly on AT&T’s EDGE network to provide data access. Th is network is s-l-o-w. Envision AOL-circa-1997-dial-upmodem slow and you will have a sense of what it’s like browsing the Web on the iPhone with EDGE. Jobs acknowledges this drawback, citing conservation of battery power as the reason Apple avoided using much faster 3G network chips. He claims that wi-fi access should make this a non-issue for many users. However, if other hospitals are similar to Stanford, wi-fi access is locked down tighter than Fort Knox, and restricted to hospital equipment. Fortunately, IM texting, e-mail, Google maps, and many lower-bandwidth functions work very well on EDGE.

There are other issues for Apple to address. Durability and build quality are generally excellent, yet I managed to push the phone to its limits. My touch screen stopped working after I dropped my iPhone for the 20th time (more on this in a minute). Fortunately, the Apple store offered a hassle-free exchange. The Safari browser on the iPhone doesn’t support common media files like Flash, degrading the browsing experience when visiting certain sites (and causing crashes with others). As iPhone-haters like to point out, the iPhone lacks memory-card expansion, a video camera, and an unlocked SIM card. But, at the end of the day, none of these are deal-breakers for me. The iPhone is a revolutionary communications device. Gearheads unite!

You will drop your iPhone at some point, so prepare for the inevitable and buy yourself a case. Just make sure you don’t use the belt clip that comes with many Griffin cases. This holder just doesn’t work on scrubs, and your iPhone will come lose at the slightest touch. After dozens of drops, I finally found the perfect solution: keep your iPhone in your inner scrub or shirt pocket to keep it safe. Many iPhone users will hack the phone using installer.app to install lots of fun third-party software.

Because I depend upon my iPhone for hospital communications, I refrain from hacking the OS to prevent problems. However, one very cool software accessory doesn’t require hacking. With Signal, you can control your Mac or PC’s iTunes playback using your iPhone, iPod Touch, or PocketPC as a remote.

Now that we’ve gotten my number-one, must-have gadget out of the way, let’s move on to other intriguing devices. I hope this brief gadget guide will help you fi nd the “next greatest thing” for your loved ones (or yourself!) this holiday season.

If the Apple iPhone is the beauty, then the Nokia N800 is the beast. Released this January, more than six months before the iPhone, it’s received comparatively little press. Despite its provenance, the N800 is not a cellular telephone—it’s a portable Web browser and Internet device built on a Linux OS that’s dependent solely on wi-fi connectivity. It’s not necessarily beautiful, nor does the screen respond to my caresses the way my iPhone’s multi-touch display does. But it does several things very well: it browses the Web and supports Flash, checks e-mail, provides good media-player functionality on a large 640x480-pixel screen, and supports third-party application development. My favorite use for the N800 is during travel, especially on international trips. The four-hour battery life is great for watching movies on the plane. The real killer application is its built-in Skype functionality, the leading Internet-based telephony service. On a recent trip to Buenos Aires, I pulled the N800 out of my pocket and called friends and family over the Internet for pennies a minute using wi-fi at a beautiful outdoor café. I also easily received calls in my hotel room, which provided free wi-fi access.

The Palm 755p is one option to consider for those of us who absolutely have to have a physical QWERTY keyboard on a smartphone, or need to run Palm OS medical software. Currently available only from Sprint, the 755p runs on the

company’s fast EVDO data network. There’s not much difference between the 755p and the old Treo 750, however. The 755p sports a smaller frame, sans external antenna, and has an upgraded 1.3 megapixel camera. Despite these improvements, it still runs a five-year-old version of Palm OS 5. Let’s face it; the Palm OS is in need of a serious overhaul. However, due to financial troubles, Palm has delayed its hotly anticipated successor, Palm OS II, until 2008 or later. Despite these shortcomings, a majority of physicians still depend upon Palm OS for medical software, and this latest Treo allows us to keep running them a little bit longer.

Bose QuietComfort 3 Noise-Cancelling Headphones QC3

The monotonous, constant, low rumbling of airplane engines is mercifully silenced by these wonders of modern engineering. The world owes a debt of gratitude to Dr. Amar Bose and his company for bringing such silent relief to our ears. The QC3 works by inverting sound waves 180 degrees to “cancel out” ambient noise. Unlike its over-the-ear cousin, the QC2, these are much smaller, and sit on top of your ears. They also require a separate charger because of the special rechargeable battery in the earpiece. If you are not sure which you prefer, take advantage of Bose’s 30-day return policy and buy both. Then test them out inflight, and return one pair. Those of us with smaller budgets (and tinier carry-ons) may wish to consider the Sony MDR NC-22 ear bud noise-canceling headphones. They aren’t nearly as effective, but they are much smaller, and easier on your wallet.

I travel extensively to South America, Europe, and Asia, where cell phone usage is ubiquitous. Yet, I shudder to open my bill and see roaming charges of $1.29 a minute for a call from Paris or $2.99 a minute from Buenos Aires. This is where a cheap, unlocked, quad-band cell phone like the Motorola V220, and a SIM card from companies like Brightroam, come in handy. Pop in the Brightroam SIM card, and you can get a local telephone number in Paris (or whatever city you are in) and receive calls for free. When you place calls to the US, you only pay a fraction of what your US provider would charge. Brightroam also offers a connect service that provides you with a toll-free US telephone number for your friends and family to call, then forwards calls to your cell phone.

I love this gadget, despite the fact that nobody else seems to know about it. Roughly 5x7 inches in size, and weighing barely nine ounces, the Sony is a fantastic way to read on the go. Using a special display technology called E Ink, the reader lets you carry 160 average ebooks in its internal memory and hundreds more using optional memory cards. A layer of encapsulated pigment spheres modulates white and black pixels using an electronic charge (and yes, the E Ink company has developed a full-color display that may be released as early as next year). Best of all, the device only uses power when it changes the display—Sony claims you can get 7,500 page turns before needing to recharge the device. In addition to ebooks, you can catch up on your latest blog updates or download new content in a variety of supported formats.

I have been quietly lusting after this $1,500 keyboard from Art Lebedev’s studio in Russia for more than a year. Each of the 113 keys is made from a 48x48-pixel organic light-emitting diode (OLED) that can display a full-color lighted image. Lebedev calls it a “million keyboards in one” because each key can be assigned a unique character or function dynamically. For instance, if you press the “Shift” key, all the characters and symbols on the keyboard change in response. Function keys can also be uniquely assigned to display dynamic information and even moving images. Ultimately, the beauty of the keyboard has blinded me to any true practical benefit such as improved productivity. If you can figure out how to justify this as a business expense, Lebedev is taking preorders now for a delivery of only 200 keyboards arriving on December 20, just in time for Christmas. For the rest of us, a smaller Optimus mini three-key keyboard is available for a much more reasonable $150.

The ubiquitous TiVo and other digital video recorders have established time shifting as a popular way to watch TV. No longer tied to the broadcast schedule, we can watch our shows whenever we like. Now Slingbox is taking TV to a whole new level with place shifting. Slingbox lets you watch programs from wherever you happen to be. I use my Slingbox in my call-room at the hospital to access HBO, on-demand movies, and pre-recorded programs through my home TiVo and cable box. I’ve also logged in from a hotel room in Tokyo. The newest version of the device even allows you to view your shows from a Windows Mobile, Palm OS, Symbian cell phone, or PDA.

Active video games for the Wii require users to get off the couch and swing a virtual tennis racket or golf club or dance real steps to win virtual competitions. There is a reason the quintessential technology blog Engadget picked the Wii as its gadget of the year: it’s addictive for all ages. Unfortunately, Nintendo hasn’t been able to keep up with demand. These gadgets are in short supply, so if you see one, snap it up. Reggie Fils-Aime, president of Nintendo America, recently said manufacturers won’t catch up to demand until early 2008.

Apple has rolled out a great new selection of iPods for the holiday season that incorporate the enhanced user-interface featured on the iPhone. Priced at $100 less than the iPhone, the 8GB iPod Touch is a great choice for people who long for the user-interface and Internet functionality of the iPhone, but aren’t yet ready to switch their cell carrier. Enjoy coverfl ow (that cool effect seen in Apple ads where the album artwork dramatically glides by with a swipe of your fi nger); multitouch, Safari Web browsing; and many other iPhone features. For about $100 less than the iPod Touch, the 8GB iPod nanos are also enhanced with a larger 320x240- pixel screen, coverflow, and a new user interface.

Sometimes, a personal touch is needed for folks put off by the cold utilitarian feel of electronic gadgets. Zazzle is a great

place to put your creative juices to work. Upload a photo, logo, or piece of artwork and begin placing your mark on items ranging from t-shirts to mugs to mouse pads. My personal favorite is their customized postage stamps, perfect for mailing holiday greeting cards.

It may take some time to put one together, but you’ll wow friends and family with a personalized photobook from Blurb. Using free desktop-publishing software from their website, you can create gorgeous coffee-table books that allow you to showcase your family vacation to Africa or share mom’s recipe book and family photos. Blub uses Indigo liquid toner electronic printing presses from HP to create a unique “expensive” look, yet prices start at a very affordable $12.95 for a Digital Spectrum and 40-page book.

Nothing says “I’m loved” quite as well as a family photo on your spouse’s desk at work. Digital photo frames are the gift that keeps on giving. Digital Spectrum’s MF8104 Wireless Photo Frame is a 10.4-inch, 800x600-pixel, Vista-compatible photo frame that runs Windows CE and updates content live from the Internet over wi-fi . Point it to a Flikr RSS feed, and your spouse can watch this morning’s photos of your kids at the park stream in and update automatically from his or her desk at work. For the less technically inclined who don’t have Internet access, Ceiva digital photo frames offer a telephone dial-up service that automatically updates photos each evening for a monthly service charge of $9.95.

Wow Wee is a Hong Kong-based company that specializes in robotic toys, ranging from the famous Robosapien humanoid, to roboboa, robopanda, roboraptor, robopet, and others. It’s mesmerizing to watch their Flytech Dragonfly’s wings beat rhythmically and rise in self-powered flight. These are toys that cry out for some adult “testing” before passing them on to the kids.

Finally, we’ll round off the list with a gadget useful for patients. The Glucophone is a glucometer and cell phone in one device that electronically transmits blood glucose values for monitoring on a disease management website. The device was awarded FDA 510K approval in June 2006, but roll-out details have been kept under wraps. Keep your eyes peeled for possible release in 2008.

2007 has been a great year for gearheads and our gadgets. For many of us, this year’s highlight has been Apple’s ascension from computer manufacturer to gadget style-maker, capable of bringing together an IT geek, a marketing executive, a style-conscious teenager, and an academic physician on a sweaty June afternoon. As I left the Apple store in Palo Alto, Steve Jobs himself stood in the doorway talking to a man in a striped polo shirt. I could clearly see that he was passionately engaged in conversation, much the way a proud parent would be on his kid’s fi rst day of school. Jobs’ passion is lost on some people (like the reporter from CNN) who view gadgets the same way a spendthrift might look at a pair of new shoes: superfluous and unnecessary. Yet, Apple’s gadgets evoke passion in their devotees: they inspire us to see the potential greatness of new technologies and new ways of thinking. As I opened the door, cameras flashed and I held my two black iPhone bags up high. Sometimes it’s okay to be just a little bit superfluous.

Buyer’s Guide References (Prices sourced as of 10/12/2007)

From $199.00, depending upon carrier service plan

Sony MDR NC-22 Noise-Cancelling Ear Bud Headphones

Optimus Maximus and Mini Digital Keyboards optimus

Maximus from $1500 and mini from $150 (varies based on current USD exchange rate)

Digital Spectrum’s MF8104 Wireless Digital Frame

From $9.99 (Mini Roboraptor) to $299.99 (RS Media Robot Entertainment Unit) 

On a hot June afternoon in Palo Alto, more than 100 people stood in line outside the Apple store for a much-anticipated new release. The mood was festive. While children got their faces painted...

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