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.

Harriet Berman, PhD, executive vice president of clinical programs, The Wellness Community — Greater Boston, Newton, MA, explains the pros and cons of cancer patient blogging, as well as what oncologists need to know about the topic. 

1 What outlet does blogging provide cancer patients that they never had before?

The act of writing has been shown to be very healing and productive for people who have serious illnesses. One thing you’re doing when authoring a blog is writing, and you are taking your experience, and in a way, putting it outside of yourself so you can feel you have more mastery over it. It becomes something you can manipulate as you write about it, and one of the things about having cancer is this feeling that you’ve lost control.

One thing that’s hard for people when they become ill is that they begin to feel very isolated. They have the label “patient” slapped on them and become passive in the hands of the medical world; at the wellness community where I work, we try to help patients become “patient active” and get heard. Blogging is a chance to have your voice heard and explain to the world what the real experience is. I think there’s the opportunity to communicate about something that is essentially your whole life when there aren’t a lot of people who really either want to or are capable of talking to you about it in person. And it creates a community; bloggers need other bloggers. The public forum is the opportunity for people to say “here’s the reality of what cancer is like. I think you can learn from this. I think it’s important that my voice be heard. By writing about this, I make it less scary for everybody.”

2 What dangers are there to patients who write cancer blogs? 

I think the dangers are minimal. Th ey’re the same as any other danger that people face when they go public with anything, just as when they create a Facebook page or when they send an e-mail that they regret the next day. It’s not like people are posting their social security numbers. But in any public forum, you have to be thoughtful about what’s out there, because there could be a danger of a very blatant blog that says something nasty about a doctor, and that doctor could see it and become alienated.

There’s also a danger to other patients who read your blog if you post misinformation, or if you say something like “I would never go to ‘XYZ’ hospital again because all the people there are incompetent.” If other people read that, and that’s the hospital they go to, it may make them wonder about that hospital.

3 What should patients know before reading a patientauthored blog? 

Every person’s experience is different, and every cancer is different. If you read things that are alarming or of concern, go to your doctor and say “I read this. Can you help me out?” To some extent, maybe doctors aren’t thrilled with that, because they’re fielding a lot of questions that they wish their patient hadn’t read on a blog or on a support group’s website. But we live in the information age, and that’s something doctors should be becoming used to. The big thing is that what you’re reading on a blog is someone else’s experience; it may resonate with you, but it’s in no way predictive of what you can expect. What patients should look for is what they can learn from the author that will be helpful.

4 What do oncologists need to know about patient-authored cancer blogs? 

There are blogging tools that are well organized and passwordprotected that oncologists should be alerting their patients to, like carepages.com, caringbridge.com, and lotsofhelpinghands.com. By giving them these resources and by being familiar with them and others like them, they can know that their patients are blogging in a reasonably safe way.

Know what the resources are for your patients, in your community and online, and value that writing can be a very benefi cial part of their treatment. The Institute of Medicine published a report last year about how important it is to tend to the psychosocial needs of cancer patients and that if you’re not attending to that, you’re not attending to the whole person and the whole disease.

Doctors may not have time to sit with the patient and go over what they’re going to write in their blog, but they do have time to provide a brochure or a list of websites. Also, some patients have never thought about writing, but hearing from a caring nurse who says “I know other patients who found if very helpful” may help them feel hopeful and not so alone. People can never tell their story too many times; every time they do, they gain a little more control over it. There’s something about telling your story that helps people realize “I’m not just a cancer patient; I’m a person who has cancer, and I can tell people about it.”

Articles

Harriet Berman, PhD, executive vice president of clinical programs, The Wellness Community ï¿½ Greater Boston, Newton, MA, explains the pros and cons of cancer patient blogging, as well as what oncologists need to know about the topic.

4 Questions... About Cancer Patient Blogging

The type of asset protection planning you need depends on where you are in your career. Because the amount and form of your investments and the particular risks you face will vary over time, your initial planning should be appropriately fl exible and capable of adjusting to meet these changing needs.

Physicians at the start of their career must address two key issues. First, they should set up a good business plan and determine which legal entity they will use for their practice. Sometimes a C or S corporation may be the best choice; other situations may call for an LLC or sole proprietorship. The goal is to select the option that confers the best tax results and lawsuit liability protection (see “Pros and Cons of Professional Corporations” at 

www.rjmintz.com/pdf/prosconsprofessionalcorporations.pdf

The next step is to create a plan that will protect personal assets from business liabilities. The best early career plan is to allocate enough income to pay personal bills, loans, and household expenses and place remaining income intended as savings for a home or other investments into a protected entity such as a family limited partnership or family savings trust (see “Asset Protection Strategies” at 

). With a plan in place, the business of the practice will be well organized and efficient from a legal and tax standpoint and personal assets can accumulate in a protected fashion. Proper basic asset protection planning provides a foundation on which to build more advanced strategies as your needs change over time.

After a number of years in practice, with some good luck and planning, you can build a comfortable lifestyle and retirement nest egg. Although it’s hard to believe right now, even your family home will probably have substantial equity at some point, and you may also have other business ventures or investments. The flipside of this is that as wealth builds over time, the degree of liability risk also increases. Unlike other business owners who can use corporations or LLCs to limit their risk of personal exposure, physicians and other professionals cannot insulate themselves from malpractice liability. Additionally, a busy practice may increase the odds of lawsuits and disputes not only from patients, but also from employees, partners, insurers, and other business associates.

As savings and investments grow and diversify, asset protection needs generally broaden to include protection for the family home, investment real estate, and other business interests. Potential strategies include a personal residence trust for your home, one or more LLCs for properties and business interests, and perhaps a children’s trust to minimize tax on appreciating assets. Estate planning with wills, living trusts, and appropriate insurance becomes an important part of the overall plan. You may also want to consider buy—sell agreements among business partners designed to establish a firm plan to tackle the economic issues associated with retirement or death. Some of our more entrepreneurial clients sometimes incorporate offshore LLCs or trusts into their planning (see “Is Offshore the Right Asset Protection Choice?” at 

www.rjmintz.com/MDNetGuideNovember2004.pdf

By the time they are ready to retire, most physicians’ lawsuit risks have diminished substantially and their asset protection needs shift to maximizing their income and reducing potential estate taxes. Physicians who want to work on a part-time basis may encounter problems with insurance coverage, the cost of which can be quite high relative to the potential income, creating a continuing liability risk. Also, pediatricians and obstetricians may face continuing liability issues because the statute of limitations for claims is extended until minor patients reach legal age. So even after retirement, they may need tight asset protection coverage for a number of years. As your wealth grows (or shrinks) and the asset mix changes, your asset protection planning should accommodate what you have and the degree of risks you face at that point in your career. A solid basic structured plan in the early years can be added to and enhanced as life and business grow more complex.

Robert J. Mintz, JD, is an attorney and the author of the book Asset Protection for Physicians and High-Risk Business Owners. To receive a complimentary copy of the book call 800-223-4291 or visit 

The type of asset protection planning you need depends on where you are in your career. 

Covering Your Assets: Tailoring Your Asset Protection Plan to Your Career Stage

In preparing an organization for IT transformation, the most important step is organizing and managing people. Even in an IT-enabled environment, it is still the people who get things done, or who are often the fi rst indicators of something being amiss. 

The biggest reason that IT projects fail is lack of buy-in from staff . Many times, embracing IT transformation also means embracing a culture of change. It is a perpetual path that requires new ways of thinking and relating. The fundamental human communications and interconnections of the organization are altered. How will interactions with patients be aff ected? How will things be different if many direct personal communications are transformed into sending an e-mail or instant message embedded in the workflow of an EMR tool? If the organization does not accept the changes in tools, it doesn’t matter how carefully they were selected.

It is important to have a clearly defined management team that will drive the IT initiative with careful prospective planning. Apart from the obvious process of hardware and software selection, this group is key to helping set expectations and managing and supporting staff through the changes.

The composition of the IT management team needs to be representative not only of IT technical experts, but also various areas of the organization that will be impacted by the changes; most importantly, the clinical areas need to be represented. The ideal clinical personnel are well respected by their peers and also have some understanding or interest in IT. The most successful IT transformations are frequently led by a physician champion who can bring other clinicians along. Mid-level providers and nursing staff in a busy clinic are often aff ected most, and it helps to involve them early in the planning process. Many times, it is out of these personnel that clinical super users are created.

These super users are not only an accessible resource for other staff , but they can also provide insight into why the effort is so important to moving forward. Lab, pharmacy, operations, and revenue cycle managers should be considered. We not only want to provide great care and service, but also get paid for the work we do in the environment of perpetually declining reimbursements. Not all of these members need to be present at every meeting, but input from all the key areas is important.

Potential pitfalls of planned changes need to be identifi ed as early as possible. It is diffi cult to get an IT project back on track if there are one or two major disasters, and the organization loses enthusiasm and faith that the transition eff orts will lead to a better set of processes and a more effective organization.

Most organizations carve out time for IT planning as a part of the workweek. Because it is diffi cult to move these initiatives forward with a group of volunteers working after hours or spending uncompensated time away from other activities that generate income, compensating the team for their time is important and is a way of communicating the commitment to transforming through technology.

The IT planning team will develop its own agenda for adoption. However, some key areas include:

- If things get more diffi cult why do we need to put in the effort to accomplish them?

- How can the organization best prepare for these changes?

The IT management group will take the executive drivers and direction and expand them. Once the people are organized and their needs addressed, the remaining principles and processes will guide the crystallization of the IT architecture. Th is is the point at which true IT architecture planning is ready to begin!

Dr. Sharma is CEO of Texas Cancer Associates, a midsize oncology practice based in Dallas/Fort Worth, TX. He is also CEO of HealthIT, an Internet services company that supports the patient/ provider network with technology solutions, and founder of NextGen Oncology, which works to provide next-generation solutions for the diagnosis, management, and treatment of cancer. E-mail Dr. Sharma at 

In preparing an organization for IT transformation, the most important step is organizing and managing people.

Oncology Outlook: End-users Should Ultimately Drive IT Adoption

Are you neo-Amish? It’s the hot new buzzword in Silicon Valley, describing technophiles who’ve eagerly adopted almost every new gadget, but then, incongruously, decided to reject one. The neo- Amish include the computer scientist who spends his days writing innovative software but can’t be reached by e-mail, the serial entrepreneur who refuses to own a cell phone, and the Web guru who doesn’t have a blog.

Medicine, though, is the original homeland of the neo-Amish. Hospitals rush to get the latest multi-Tesla MRI machines, physicians eagerly prescribe the latest biotechnology-derived medicines, and medical laboratories happily deploy cutting-edge genomic tests on a daily basis. Meanwhile, many clinicians still keep patient charts with paper and pen, communicate with hopelessly outdated pagers, and often transfer information by entering it manually from one computer system to another.

Regulatory and financial barriers may keep some of these antiquated approaches active for a while longer, but gadget-loving doctors can take comfort in a new crop of technologies that will transform other aspects of medicine. That’s especially true in oncology, where vibrant collaborations between clinicians, researchers, and engineers are producing intriguing new tools. Ranging from electronic resources that are already available to future diagnostic and treatment systems, a sampling of these technologies shows how they could change your practice dramatically.

At the University of Colorado medical center in Denver, CO, the oncology pharmacy of the future is already up and running. Sealed inside a containment chamber, a robot makes a series of precise movements, measuring and mixing chemotherapeutic agents and loading them into syringes or IV bags for delivery to patients. The robot, called CytoCare, was designed to overcome a slew of problems that have plagued chemotherapy administration for years.

“The first element was sort of the patient priority, and making sure that we are delivering...the right dose to the right patient,” says Jack Risenhoover, Senior Partner for North American operations at Health Robotics, the system’s manufacturer. Besides using both bar codes and computer vision technology to ensure that the medications are correct, CytoCare also weighs each dose and the fi nal mixture to be sure they’ve been measured accurately.

That alone provides a significant improvement over human pharmacists who measure doses with plastic syringes. “The variation just of the syringe marks can be plus or minus 5%, so CytoCare is usually at least 50% more accurate...than what you could do manually if the only thing that you looked at was the variation in the black lines on the syringe,” says Risenhoover. In addition, the robot is immune to the errors that can creep into human judgment, such as technicians’ natural tendency to underdose toxic medicines.

Pharmacists need not fear that robots will take away desirable jobs, however. Indeed, recent research has highlighted the many hazards that chemotherapy poses for pharmacy technicians— from exposure to the cytotoxic drugs themselves to repetitive strain injuries from drawing each dose into and out of a syringe.

The contamination doesn’t stop at the pharmacy doors, either. “Aerosols happen, aspirations happen, errors happen, leaks happen, and it doesn’t take very many of them for you to have contaminants in a variety of places, from the laminar fl ow hood where the technician performs that initial survey...to the fl oors where the syringes and bags are administered,” says Risenhoover. With the robotic system, pharmacists simply insert the sealed, bar-coded bottles of medicine through an air lock, and collect the sealed, fi nished bags or syringes for each patient’s dose from the same portal a few minutes later.

A complete system costs about $1 million, but the company estimates that it will save money in the long run by limiting errors and freeing pharmacists for other tasks. Because the robot documents each measurement and movement meticulously, it could also provide important new data on drugs. “It gives you a much more fertile, accurate field of information for future research to be able to evaluate which drugs had what kind of consequences downstream when you have an electronic medical record of all of the compounding activities that took place,” says Risenhoover.

Technophile oncologists don’t need to wait for a new robot if they want to be at the cutting edge of patient management, however. Through the National Cancer Institute’s (NCI) new Cancer Biomedical Informatics Grid (caBIG), anyone with an Internet connection can now tap into a trove of useful data about cancer.

Scientific and medical databases are certainly not a new idea, but most of these tools have amassed so much raw data, in so many diff erent formats, that they are virtually unusable by anyone but hardcore bioinformaticians. Over the past few years, caBIG has been connecting these disparate databases, standardizing their content, and equipping the whole interlinked system with user interfaces that working physicians can understand.

For example, caBIG recently released the fi rst version of a clinical trial software suite. “This is different from typical clinical trial software that’s really designed for the sponsor, for drug companies, and so on to operate,” says John Speakman, Associate Director of Clinical Trials Products at the NCI in Bethesda, MD.

Instead of simply collecting data for the drug company, the new programs track and unify the information that oncologists and hospitals actually need, such as which patients are participating in multiple trials, when their chemotherapy appointments are scheduled, and which adverse events they’ve experienced. “Typically, what you do with adverse events is you just send a report off to the sponsor or the FDA or whoever and you don’t keep local track of it,” says Speakman.

The caBIG suite helps prepare those reports, but also tracks non-serious side effects, makes sure the patients’ electronic medical records mention the problem, and modifi es the treatment schedule automatically. “If the patient experiences an adverse event, chances are that their schedule of treatment will have to be modifi ed, and so you don’t actually have to keep track of these things yourself,” says Speakman.

Other software from caBIG, all of which is free and open source, includes an application that can transfer data from non-standard clinical laboratory systems into a hospital’s central database, eliminating manual data entry, and a program that tackles the onerous but essential regulatory paperwork associated with clinical trials. Another system, called caMATCH, provides a portal for oncologists and patients to fi nd clinical trials that might benefi t them.

Most of the current users of caBIG are physician-researchers at large medical centers, but that could change as the system develops. Indeed, one of the NCI’s goals with the program is to make it easier to manage clinical research so that any oncologist can do it. “What we want to do is lower the barriers ... toward regular physician practices, community medical centers, and so on participating in clinical trials,” says Speakman.

Unsurprisingly, the NCI is also working on several other cancer-fi ghting technologies. Th e fi rst tools practicing oncologists are likely to see from these tightly linked eff orts are new biomarkers. In recent years, numerous projects have promised to fi nd new cancer biomarkers, but in this case, they might actually materialize.

The difference is that the NCI is focusing on the core problem in the cancer biomarker fi eld, which can be summarized in three words: validation, validation, validation. Researchers seem to report a new marker for diagnosing or staging cancer every day, but further studies often reveal these tests to be unreliable or impractical. Now, the NCI has stepped in and built a complete pipeline for biomarker discovery and validation, and some physicians are already taking advantage of it.

One of the effort’s most popular programs right now is the rapidly expanding Cancer Genome Atlas, which aims to collect the signifi cant DNA mutations that appear in all major types of cancer. So far, the project has amassed a large data set on glioblastoma, and data on ovarian cancer and lung cancer are now pouring in as well. “We do have clinicians who are starting to look at the Atlas already in terms of how they’re classifying their patients. You might use these data to try to stratify patients into treatment groups,” says Anna Barker, PhD,, Deputy Director of the NCI.

The institute also wants doctors to start giving something back to the program, in the form of more carefully collected clinical specimens. “This is an area that we’ve had to work on a great deal, because there were no standards for collecting these tissues, [and] we want to be sure that we’re measuring in these tissues the changes in genes related to disease, not related to something like anesthesia,” says Barker. Indeed, the Atlas’s initial focus on glioblastoma was driven partly by a shortage of wellcharacterized tissues for other tumor types, so getting oncologists to collect better samples is critical for the project’s future.

To make the Atlas more accessible, NCI is collaborating with the FDA and other agencies to ensure that new biomarkers and sample collection procedures will be both approvable and billable. “It’s going to be expensive... to do these kinds of things well, you’re going to have to have very highly characterized, clinically annotated samples, which is not something that people have been accustomed to doing,” says Barker.

“Expensive” will probably also describe another breakthrough technology now on its way into the clinic: the combined PET/ MRI machine. While PET/CT systems have become standard equipment in recent years, combining the functional imaging of PET with the fi ne-grained structural imaging of MRI has remained more a dream than a reality.

“Often, in order to interpret the signal you get from the PET, you really need to understand exactly where that signal’s emanating from anatomically. That’s particularly true in cancer, because you know if you’re looking at metastasis, exactly where those metastases are has a big impact on how you treat the patient and the patient’s outcome as well,” says Simon Cherry, PhD, Chair of Biomedical Engineering at the University of California in Davis, CA. The higher resolution of MRI compared to CT could be especially useful when tumors are buried in soft tissue, such as in the pelvis or the brain.

Getting PET and MRI into a single system, however, has been hard. The MRI machine’s massive magnetic fi elds and powerful radio frequency pulses will obliterate a standard PET scanner, which, in turn, generates more than enough electromagnetic noise to befuddle the MRI. By carefully redesigning both systems, however, Cherry and his colleagues recently managed to install a PET scanner inside an MRI machine, creating a system that performs both scans simultaneously.

That design contrasts markedly with the layout of a typical PET/CT scanner, which runs the two scans in tandem rather than simultaneously. For Cherry, research needs drove that decision: “If I wanted to study both the permeability of the brain to [a] drug and then also see what happens, where the drug actually goes inside the brain, I could measure permeability with MRI, and I could measure the drug itself, radiolabeled, with PET and look at both of those things at exactly the same time.” He adds, “if I had to take the scans, 10, 20 minutes apart, I wouldn’t be able to do that.”

For hospitals, the simultaneous scanning should improve patient throughput, and might also enable new types of data analysis. Physicians won’t have to wait long to fi nd out if the system lives up to its promise. Siemens (Munich, Germany) has already delivered a prototype of a clinical PET/MRI system to Massachusetts General Hospital in Boston, MA.

Whatever modern imaging technique physicians use, the final product is inevitably a kind of digital photograph. In order to shoot those pictures faster and for less money, oncologists may soon be using a somewhat counterintuitive technology: the one-pixel camera. “This doesn’t sound so exciting at first. Everyone wants megapixels; this has one pixel, but in terms of medical imaging, pixels are really expensive,” says Kevin Kelly, PhD, Assistant Professor of Electrical Engineering at Rice University in Houston, TX.

The problem is that medical imaging relies on electromagnetic signals well outside the visible light range, where the cheap silicon detector chips used in consumer cameras become useless. Instead, medical imaging systems must use more exotic detectors, giving clinicians Hobson’s choice between sub-optimal resolution and an unaff ordable price.

Rather than try to come up with a cheaper high-resolution detector, a goal that has so far eluded researchers, Kelly and his colleagues pull more information out of each pixel. “Our single-pixel camera technology is something that will allow you to take maybe 10,000 measurements and build up a 1-megapixel image, and it does this with some really cool mathematics,” says Kelly.

In a typical experiment, the researchers take an incoming electromagnetic image, then apply a known modulation signal to it and feed it through the single-pixel camera. “The reason you don’t normally want to do that is, if there’s light hitting your eye or light hitting your camera sensor, if you threw all the light together you wouldn’t understand the picture, but it turns out through special mathematics and controlling the modulation, we can easily understand the picture and pull back out a visual image,” says Kelly.

The process is superfi cially similar to image compression techniques such as JPEG, which shrinks large digital pictures into fewer bits and then expands them again later. However, the mathematical algorithm Kelly uses can actually reconstruct the original image perfectly, with no loss of fi delity.

When the one-pixel system enters clinical use, which Kelly predicts will be within fi ve years, doctors could face a much happier choice in imaging systems. A relatively cheap one-pixel setup could enable smaller clinics and practices to aff ord sophisticated imaging technologies, while higherpriced units might incorporate larger detectors to accelerate the pace of care at big hospitals. “You could think about it as higher throughput of patients through there, or you could think about it as cheaper,” says Kelly. For CT and other radioimaging techniques, faster scans could also reduce patients’ exposure to radiation. The one-pixel camera—and all of the other new medical technologies now in development&mdash;still have to prove themselves both clinically and economically before becoming standard tools. Th ere’s little doubt, though, that at least a few of them will change your practice, if they haven’t already. Now, if only we could do something about those darn pagers.

Alan Dove, PhD, is a freelance healthcare and science writer.

Hospitals rush to get the latest multi-Tesla MRI machines, physicians eagerly prescribe the latest biotechnology-derived medicines, and medical laboratories happily deploy cutting-edge genomic tests on a daily basis. 

5 Technologies That Could Change Your Practice

More than ever before, healthcare professionals are strapped for time. The pressure of managed care, the need to deal with more patients in less time, and the ongoing care of an increasing number of patients who suff er from chronic disease make the task of eff ective physician—patient communication more challenging than ever. Particularly in the area of chronic care, the need for ongoing monitoring of a patient’s symptoms and the eff ectiveness of treatments require a long-term dialog with the patient. Wouldn’t it be wonderful if technology could provide a way for healthcare professionals to communicate more eff ectively with patients over time? 

For many of us born before 1984, the Internet still feels like a relatively new tool, something we go to for information, and a network that allows us to send e-mail. Today, we are experiencing a new phenomenon, coined with the term “Web 2.0,” which is truly the next generation of how the Internet can be used. The concept of Web 2.0 sees the Internet as more than just a repository for information and embraces it for the unique opportunities it off ers for connecting people across the world. Most often, Web 2.0 is associated with blogs and social networking websites like MySpace or Facebook, where users share photos, interests, ideas, and anything else that fi ts on a Web page. In these settings, sharing information is fairly casual, social in nature, and done with little concern about confi dentiality.

Others are developing social networks and Web-based applications that enable people to connect with others in a more private, secure fashion, taking advantage of the dialog facilitated by Web 2.0 technologies. One of the hottest areas for development of this type of Web 2.0 application is “Health 2.0.”

Among the players in the Health 2.0 movement is 

, a website dedicated to helping patients with pain to better communicate key aspects of their condition with their doctors and others caring for them. The HIPAA-compliant Web service functions like a patient diary. Using known and proven tools that have been in use in pain management over the past 30 years, the site collects and timestamps patient pain readings and related information.

ReliefInsite consists of a number of modules that allow patients to record pain location and intensity on gender-specifi c body map images; (A); note the characteristics of their pain, symptoms, and impact on lifestyle (eg, work, enjoyment of life); and track their medications and treatments. Th is information is organized into reports consisting predominately of charts and graphs that are easy to interpret and provide a longitudinal perspective of the patient’s condition (B).

The portal also functions like a virtual nurse that reaches out to patients to collect specifi c information about their condition and then responds to that information according to pre-defi ned protocols. Alerts can be sent to the patient when specifi ed thresholds have been exceeded. Rules associated with medication compliance or symptoms can be set up to notify the patient to take specific action. For those who do not use the Internet, an interactive voice interface enables patients to make their entries over the phone. This feature, in combination with automated reminders, helps to improve patient reporting adherence.

Whether made on the Internet or over the phone, all entries are aggregated into a secure online reports module, where they can be viewed, printed, saved, and shared with healthcare professionals.

As the business world embraces Web 2.0 social networking technology to improve communications with customers and constituents, the healthcare world needs to also take advantage of these technologies to create a more private space for secure interactions between healthcare providers and their patients. By automating and reporting on key aspects of information tracking and compliance monitoring, such sites provide more time for physicians and patients to have a focused and meaningful dialog about conditions and treatments.

More than ever before, healthcare professionals are strapped for time. 

TechSectors: Connectivity: Improving Physician-Patient Communication

	"Nobody knows the form of the information tool that may transform medicine, but we can begin to discern some of its characteristics. The tool must be able to answer highly complex questions and so will have to be connected to a large valid database. Inevitably, it will be electronic, but it must be portable, fast, and easy to use."

Healthcare computing is unique. First, healthcare is mobile. It is practiced wherever the patient resides at the moment. Second, time is scarce for clinicians. Our interactions with our tools must be effi cient and seamless. Finally, healthcare information is sensitive, demanding high-level security to ensure our patients’ privacy. As evidenced from the opening quote, physicians have long anticipated a device that will satisfy our distinctive information management needs. Could it be the tablet PC?

	What is a tablet PC? According to Microsoft, tablet PCs are computers powered by Windows operating systems that support functionality for input using digitizing screens designed to interact with a complementary pen. Tablet PCs have the full functionality of laptop PCs, but are primarily distinguished by pen input capability. One can use the pen directly on the screen just as you would a mouse to do things such as select, drag, and open fi les, or in place of a keyboard to handwrite notes and communication. By interacting directly with the screen, the PC becomes both more comfortable and easier to use (especially for poor typists).  

	Handwriting recognition, which translates handwritten screen input into editable text, distinguished the original tablet PC versions of Windows XP. Windows Vista now incorporates integrated support for tablet PCs, which, according to Debbie Martin, Microsoft’s OEM account manager for mobility, refl ects Microsoft’s solid commitment to the tablet PC platform. “We’ve always felt that the tablet is an important technology,” Martin said. “Some people at Microsoft believe that tablets are already mainstream,” which is why support for tablet PCs was embedded within Vista, and why further improvements in pen input and inking were included in Windows XP’s successor.

	Physicians should know that contemporary tablets also have the hardware horsepower to run voice recognition applications. Thus, one device can off er a variety of input options (keyboard, handwriting recognition, digital ink, point and click, speech), depending on the need and the user.

	In addition to pen input, the tablet PC’s form factor off ers additional advantages to clinicians. Most tablet PCs are designed as “slates” without an attached keyboard (although keyboards are available as optional accessories), or as “hybrids” with attached keyboards that can be optionally folded out of the way beneath the screen. Therefore, there is no need to find a fl at space on which to use the device, nor does a vertical screen impose a barrier between clinician and patient. The form factor lends itself well to use during rounds and other patient settings, much like the ubiquitous clipboard. Screen size for most tablet PCs is about 12” (measured diagonally), resulting in a device that is similar in size, or in some cases, smaller than a clipboard.

	Some tablet PCs, such as Motion’s new C5 model, are engineered specifi cally for healthcare environments and include features such as shock-resistance, integrated RFID readers, optional bar code scanners, and cameras for documentation of clinical findings. The C5’s case is even designed to allow for disinfection.

	Tablet PCs are generally priced between $1,000 and $2,500, and are off ered by a variety of manufacturers. Tablet PCs should not be confused with ultra-mobile PCs (UMPC). Although UMPCs might be considered smaller siblings of tablet PCs, the two devices are not functionally interchangeable. A UMPC is about the size of a paperback book and weighs less than two pounds. UMPCs feature displays of 4-7 inches and touch capabilities (using pressure-sensitive touch screens as opposed to the digitized screen input used in tablet PCs). Th ese devices also use the Windows Vista or Windows XP operating systems. However, their small screen size and hardware limitations currently make them inadequate replacements for tablet PCs for clinical computing tasks.

	In 2001, Bill Gates proclaimed that the tablet PC “is a PC that is virtually without limits, and within fi ve years I predict it will be the most popular form of PC sold in America.” Based on the device’s usability, such a prediction might indeed have seemed justifi ed (even considering the source). Yet even in healthcare, an industry that would seem ideally suited to adoption of the device, tablet PCs are not yet commonplace. Why not?

	Many experts, such as Joel French, vice president of Motion Computing and general manager of its Healthcare Business Group, appropriately emphasize that the hardware interface is only one component of the total computing experience. “It’s a mistake to think of [a tablet PC] as a discrete device,” he says. Successful design “has to encompass infrastructure, software, user needs, and hardware.”

	As an example, consider wireless networking. Mobile clinicians must be able to depend upon seamless and reliable network access. Without it, even the best hardware interface is unlikely to be used. Yet a survey by Spyglass Consulting found that 64% of nurses believe that currently available wireless infrastructure is not reliable enough to support point-of-care computing solutions.

	Similarly, software vendors must specifically tailor their interfaces to best exploit pen input. Motion Computing, in designing their C5 model specifi cally for use in healthcare, began working with software suppliers two years before the device was marketed. Recognizing the importance of the platform, clinical software vendors are increasingly developing applications that are optimized for use on tablets.

	In the age of HIPAA, security is a critical component of healthcare computing— especially for a device designed for mobility. According to Microsoft’s Martin, “Vista was a huge leap forward in making the tablet more secure.” Some tablets, such as Motion’s C5, also off er biometric user authentication.

	As for the device itself, battery life remains one of the most frequently cited limitations. Battery life for most current tablet PCs is at best about 3.5 hours. French rhetorically asks, “Should a clinician ever have to change a battery during a shift? No. Clinicians shouldn’t have to do things that detract from patient care.”

	In studying clinician workfl ow patterns, Motion found that clinicians often place their tablets on a desktop surface while doing other tasks, suggesting that the devices might instead be dropped into a docking station for a quick charge. When docks are provided in patient care areas in ratios of 2-3 docks per device, battery life becomes “a non-issue,” according to French. Another approach, of course, is to build a better battery. TabletKiosk, another manufacturer of tablet PCs used in healthcare, is now off ering an optional extended battery capable of 10 hours of continuous use in a wireless setting.

	Given the tablet PC’s evolution, it seems surprising that the devices are not yet more ubiquitous. The reason undoubtedly has more to do with the healthcare environment than it does with the device. As French puts it, “There’s a digital threshold below which it’s not worth migrating to a mobile device. As the threshold of digital information increases, [we] expect to see a multiplier effect.”

	Once healthcare exceeds that threshold (and it won’t take long), I suspect the tablet PC may yet prove to be “the information tool that may transform medicine.”

	As part of my research for this article, I decided to make hospital rounds with a tablet PC. The only device available to me was an aging fi rstgeneration device with an anemic battery. Given those limitations, here are my thoughts.

	I found the device to be unobtrusive. (I’m not even sure that all of the patients recognized it as a computer instead of a clipboard.) The pen interface worked pretty well for selecting patients and retrieving clinical results. (We have not yet implemented computerized provider order entry, so I can’t address data input.) It was fairly easy to transport, and it was convenient to have immediate wireless access to our enterprise electronic medical record. I did have to restrain my tendency to multitask between reviewing data and interacting with the patient so as not to distract my attention from the latter.

	My frustrations paralleled those of other clinicians. I intermittently lost my connection with the wireless network as I moved around the hospital. Each dropped connection resulted in having to go through several login screens to re-establish access. (Th is was obviously not a fault of the device.) Also, the tablet I used was powered by an old battery that didn’t last through rounds.

	My conclusion? Given a more contemporary machine with faster performance and better battery life, coupled with a more reliable wireless network, I suspect that I might make the tablet part of my routine. (Perhaps readers using tablets in other settings would share their experiences?)

editorial board member and an assistant professor of clinical medicine and associate program director, department of medicine, University of Illinois College of Medicine at Peoria.

Tablet PCs are computers powered by Windows operating systems that support functionality for input using digitizing screens designed to interact with a complementary pen.

Where's the Love for Tablet PCs?

Although I am known as a techie, I am not much of a gadget guy. My office does not employ any “exotic” equipment, other than standard medical instruments, desktop and laptop computers, printers, and of course an EHR. At home, my family and I tend to be late adopters, waiting to purchase a tech product or device until it has been proven in the market and comes down in price. But we do have several favorite “can’t live without” devices, even though they are probably well known to most people. 

If you watch television and you haven’t started using a digital video recorder (DVR) yet, you need to take a closer look at what this gadget can do for your life. DVRs are basically giant disk drives (similar to the one in a computer) used to record TV shows. The first and most wellknown DVR was TiVo, though nowadays, most cable and satellite providers have their own DVRs built into their settop box. Depending on the size of your DVR’s hard drive, you can record dozens or even hundreds of hours of programming. Better yet, these devices allow you to pause and rewind live television, fast-forward through commercials, and record a season’s worth of shows with the press of a button.

What’s really great about DVRs is their ability to “timeshift” your television watching. This is a fancy way of saying that you can watch the shows you want anytime, instead of when the network programs them. For example, when my wife and I sit down to watch television after the kids have gone to sleep, we don’t just flip channels until we find something interesting and then sit through interminable commercials; instead, we look at the list of shows prerecorded on the DVR and then select whatever we want to watch. We skip the commercials, cutting 20 minutes off an hour-long show. Our children benefit as well, since we can be more thoughtful about what they watch, choosing educational and enriching shows in advance so there is always something good for them to watch. Basically, I won’t watch live TV since being introduced to the DVR.

Another family favorite is satellite radio, which has numerous advantages over plain-old terrestrial radio, starting with the outstanding programming. There is a channel for nearly every genre of music out there. It goes way beyond the typical rock and country fare found on FM and AM stations. Enjoy listening to bluegrass or reggae? How about opera or gospel? The channels for kids are great for long trips, as is the classic radio show channel. Speaking of road trips, one of the best things about owning a satellite radio is being able listen to the same stations from coast to coast. In addition to music, satellite radio offers a plethora of sporting event broadcasts; talk shows; news from CNN, BBC, NPR, CNBC, etc; and 24/7 weather and traffic. Personally, I love jumping from joke to joke through the various comedy stations (though, on family trips this can be a bit difficult, because many of these channels are unedited, and cursing is common).

The last gadget on my short list of tried-and-true products is the wireless data networking card for my laptop computer. I travel a lot in my role as president of AmazingCharts.com, and I cannot always count on getting access to a wireless network hot spot. Wireless data networking “AirCards” plug into a laptop using a USB port, PCMCIA card slot, or an ExpressCard slot. I use Sprint for the data service and have found it to be signifi cantly faster than Verizon, but you should research which carrier provides the best coverage in the geographic areas where you plan to use your laptop most.

AirCards first look for a WiFi connection, and if they can’t find one, they connect to the wireless service carrier’s data network using cell phone technology. Theoretically, with AirCards, you could stand in the middle of Death Valley and still be able to surf the Internet and send e-mail. The truth, though, is that service coverage can be spotty, particularly in remote areas. The carriers promise “broadband speeds where available,” but you will think it crawls compared to your high-speed connection at home or the office. Still, it is better than no Internet access.

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.

If you watch television and you haven't started using a digital video recorder yet, you need to take a closer look at what this gadget can do for your life.

Tech Talk: Great Gadgets

Throughout history, the public’s pursuit of good health has, in the absence of scientific method or even common sense, motivated the creation of some downright ridiculous medical devices. For example, what possible use could devices like the 

 offer? Let’s take a closer, historical look at a few examples of medical devices that never should have seen the light of day. 

. The units were basically just an X-ray tube “wholly or partially enclosed in a shielded box.” After penetrating the shoes and feet, the X-rays then struck a fl uorescent light, resulting in an image of the feet within the shoes. This image (a refl ection of it) could be viewed at ports on the top of the unit.

The use of these devices intentionally exposed people to ionizing radiation for nonmedical purposes. Also, the machines were often out of adjustment and constructed so that radiation leaked into the surrounding area. Because of the unacceptable risks and high doses, this type of application was banned in most states. However, a functioning and employed shoe-fi tting X-ray unit was found in a shoe department in 1981. 

 was invented by Dinshah P. Ghadiali, who presented the “Science of Spectro-Chrome Metry” in 1920.

Although we know that colors can infl uence mind and mood (as appreciated by interior decorators, for example), Ghadiali claimed a far greater and more specifi c medical eff ect. He insisted that almost any medical condition, except for broken bones, was amenable to color therapy. The word “cure” was later substituted for “

” the body. According to Ghadiali, every element exhibits a preponderance of one of the seven prismatic colors. Healthy people have balanced color, but disease is associated with imbalanced colors.

How do you cure a given disease? Just administer (literally shine on the patient) the colors that are lacking or reduce those that have become too strong.

The Spectro-Chrome device itself was in fact a box with a 1000-watt light bulb and an opening fi tted with colored fi lters. Th ese fi lters, named “Attuned Color Wave Slides,” could be used to produce 12 diff erent colors, and an accompanying Spectro-Chrome Th erapeutic System guide detailed which colors to choose. For example, green light was described as a pituitary stimulant and germicide, whereas scarlet was a genital stimulant.

Joe Schwarcz, PhD, has written extensively about the device at 

 and notes that (rather manipulatively) the inventor also “maintained that the Spectro- Chrome was especially suited for 

, because ‘drugs quickly upset the nervo-vital balance of persons of high mental and spiritual development.’” In 1945, the inventor was “charged with introducing a misbranded article into interstate commerce.” His star witness in the following proceedings, who was apparently “cured” of seizures through color therapy, had one on the witness stand. 

The Toftness Radiation Detector was patented in 1971 and intended to scan a patient’s spine. The inventor claimed that an area of neurological disturbance (

) would emit a greater amount of radiation, and his device relied upon this.

 would be placed (often held by a mechanical arm) over a patient lying in the prone position, and talcum powder would be placed within it.

Rubbing the back (the lens) of the device with the fi ngers in a circular manner while applying talcum powder would apparently cause a characteristic stick or squeaking sound when the device passed over an area of nerve stress. “The squeaks were counted; the more squeaks, the greater the nerve interference, disease, or subluxation. A lower number of squeaks indicated the patient was beginning to improve.”

The device itself strongly resembled PVC piping and couplings and, in fact, was exactly that, with the addition of six plastic lenses. Perhaps, unsurprisingly, the device was deemed completely worthless and outlawed by the FDA in 1984. 

The answer to the question “Do breast developers work?” is quite simple: The FDA states that “For decades, millions of dollars have been spent on devices, creams and lotions advertised as breast developers. All wasted. There is no device or system of exercise that will increase the size of the breasts. At best, devices promoted as breast developers merely strengthen and develop the muscles that support the breasts, and exercising these muscles will not appreciably increase breast size…The only proven method of increasing breast size is 

However, bust developers remain popular products, with millions of US women having purchased the Foot-operated Breast Enlarger Pump in the mid-1970s. The device had all the visual appeal of a contraption for torture and consisted of a pump, clear plastic tubing, and two cups—all, remarkably, in large sizes. Perhaps unsurprisingly, the gadget served only to create bruising as the user pumped the foot pedal and generated a 

The String galvanometer is able to detect and record the small electrical currents produced by the human heart and therefore provided the first practical 

However, in the early 1960s, an apparently “scientific,” but in fact worthless, machine called the 

 was being sold. The gadget featured a rather impressive exterior but was actually a string galvanometer and simply measured electric currents.

It was wrongly promoted for diagnosing or curing many diseases and conditions, but the device was found via the courts to be “worthless and hazardous to health when relied upon by patients.” In fact, a court trial introduced evidence that readings given by the Micro-Dynameter actually showed no significant differences whether the “patient” was a living body or a cadaver 

Dr. Paton is a lecturer in Health Informatics at Otago University in New Zealand, the editor of the 

, a medical e-learning and website development company.

Throughout history, the public's pursuit of good health has, in the absence of scientific method or even common sense, motivated the creation of some downright ridiculous medical devices. 

October 2008 | Oncology Live®