This month, our physician reviewers share their experiences with two apps they recently had the opportunity to review.

MedCalc is a free, physician-developed medical calculator featuring more than 100 calculations, support for US and SI units, “formulas within formulas,” and a unique translucent floating keypad for data entry. The “formulas within formulas” feature links to medical calculations that require results from another calculation (such as the APACHE II score requiring the results of the Glasgow coma score) in such a way that users do not have to copy and manually enter the results in the main calculation. The floating keypad is always on screen, but nearly transparent. The keypad becomes fully visible when tapped and will advance the data entry focus in the formula when swiped to the left or right. This floating keypad feature may be frustrating to some users.

MedCalc maintains a history of previous values entered for each calculation, which is helpful for repeat calculations on the same patient. The app also includes detailed information about each calculation, including links to primary source articles.

MedCalc is an excellent addition to the iPhone of any healthcare professional who uses scoring systems to assess the severity of illness or uses medical calculations.

One of the first apps I recommend to new iPhone purchasers is a replacement for the calendar app that comes with the iPhone, as most busy professionals find it to be too simple and inflexible for their needs. There are quite a few potential replacements out there, but I consider Informant to be the most feature-packed and flexible, and it’s well worth the $12.99 price tag for the full version (Pocket Informant Lite is available for free).

In terms of sheer aesthetics, Informant allows for multiple views, including Day, Week, Month, and also a unique List feature that allows for scrolling through upcoming appointments and tasks. The app also changes its view when the iPhone is rotated to landscape mode, providing an alternative way to look at the entire week. To-do tasks are integrated into the calendar, and there is great flexibility in how one can categorize and prioritize them; Informant also provides support for the Franklin-Covey ABC/123 method, which is what I use.

The To-Do feature allows for synchronization with Google Calendar, providing a cloud-based solution and the ability for multiple users to synchronize to a single calendar and coordinate schedules in real-time; the feature is a great way for work colleagues or even family members to synchronize appointments and events. Each user can select when he or she wants to view the ‘shared’ calendar, and can even create a local, ‘private’ calendar that others cannot see. This solution also allows one to pull up the same public calendar from a Web browser an make changes.

One of the major disadvantages is the lack of To-Do synchronization with Google’s To-Do. Informant uses a second application, Toodledo, for synchronization of tasks if one wishes for a cloud-based task solution. I opt to keep task synchronization off, which still allows for full functionality.

Settings are quite detailed and allow for an enormous amount of customization, and even the most demanding organizers will find satisfaction with this. Informant also takes advantage of push notification, allowing users to set alarms for to-dos and appointments without the application running. The integrated search function is robust, and necessary, since the iPhone’s innate search function cannot ‘see’ into Informant.

I highly recommend Informant for demanding and busy people who expect a lot from a calendar app. Outlook and previous BlackBerry users will feel at home with the high  degree of control provided with Informant.

From the HCPLive.com Network Partner iMedicalApps

The First Native iPad Electronic Health Record — An Interview with the Dr. Chronos EMR Development Team

The American healthcare system is finally on the road to a modern national IT infrastructure. Recently, the iMedicalApps team had the opportunity to speak to a small but ambitious group of IT professionals who aim to be at the forefront of this  modernization by targeting the physicians with the lowest penetration of electronic health records, those in smaller private practices.

Should Medical Professionals Get an iPhone, Blackberry, or Android Phone? It's

Lately, I’ve often been asked the question, “What type of smartphone should I get?” by my medical peers. I’ve been asked this by physicians, residents, medical students, and others. The answer to this question is not easy. Rather, as Facebook nomenclature would demand, “it’s complicated.”

Articles

Cover Story

App Wrap

International Osteoporosis Foundation: About Osteoporosis

Among the many resources available to professionals at this site is the FRAX page. Information provided here includes the significant improvements FRAX has made in helping physicians identify patients who are at high risk for fractures, reviews from physicians, and a FRAX slide kit. The “Health Economics” page will allow physicians to gauge the social and economic burden of osteoporosis, as well as understand how the condition impacts people in other parts of the world. The “Quality of Life Questionnaire” featured here will provide physicians with another tool for assessing patients. The site also features national and regional guidelines and a “Special Topics” page, which includes information about fracture risk assessment, exercise, and more.

National Institute of Arthritis and Musculoskeletal and Skin Diseases: Osteoporosis

Patients recently diagnosed with osteoporosis who want to know more about how bones are affected by osteoporosis should visit the “What is Bone?” section of this site, which provides an explanation of the functions bone serves in the body, and how it is affected by osteoporosis. Under “Detection,” patients can learn more about the value of a bone mineral density (BMD) test. The “Treatment” section will provide more information about the possible avenues a physician may take after a BMD test. Patients who are concerned about falling, one of the biggest problems associated with osteoporosis, should check out the “Fall Prevention” section, which provides advice for both indoor and outdoor environments.

Causes of osteoporosis, testing, and helpful exercises are just a few of the topics covered at this extensive site. The symptoms of osteoporosis are explained with detailed written descriptions as well as images. Two sections of the site are dedicated to nutrition and osteoporosis and explain how a poor diet can lead to and increase osteoporosis-related problems, and what foods an individual with osteoporosis should be eating. Under “Osteoporosis Exercises,” patients will find workouts that will help with the condition, as well as tips for dealing with the physical changes of osteoporosis.

Bone Mineral Density and Respiratory Muscle Strength in Male Individuals with Mental Retardation (with and without Down Syndrome)

 Research in Developmental Disabilities (June 11, 2010)

 Maldaner da Silva V, França Barros J, de Azevedo M, et al.

 The purpose of this study was to “assess the respiratory muscle strength (RMS) in individuals with mental retardation (MR), with or without Down Syndrome (DS), and its association with bone mineral density (BMD).”

 “Individuals with MR, both with and without DS, have lower FEV1, FVC, MIP and MEP (p < 0.001) compared to controls. Individuals with DS also had lower BMD, which was associated with lower MIP and MEP. Hypotonia, sedentary lifestyle and obesity are factors that may explain lower MIP and MEP in DS. Strategies to increase RMS could decrease the risk of osteoporosis in the DS population.”

Trial of Lithium Carbonate for Treatment of Osteoporosis-pseudoglioma Syndrome

 Because “studies in the mouse model of osteoporosis-pseudoglioma syndrome (OPPG) showed that lithium normalized their bone strength,” researchers are pursuing “a pilot study of up to 10 patients with OPPG from the Old Order Mennonite community, who will be given lithium for six months and have dual energy x-ray absorptiometry, peripheral quantitative computerized tomography and lab assessment at baseline and six months.”

A Postmenopausal Woman with Low Bone Density

Designed to “narrow practice and knowledge gaps in the management of osteoporosis,” this program discusses the case of a 57-year-old woman who presents with concerns about the results of her BMD because of her age and a family history of osteoporosis. Diagnostic steps, possible treatment options, and follow-up care are reviewed, as well as the possible causes of secondary osteoporosis and bioidentical hormone therapy. A discussion of the FRAX model, and the limitations of using it to assess fracture risk, is also included in the activity.

Osteoporosis, as defined by the National Institutes of Health Consensus Conference, may co-exist with renal bone disease or renal osteodystrophy, skeletal disorders caused by chronic kidney disease (CKD). This activity reviews the definition of CKD and the diagnosis of the condition in patients with osteoporosis, causes of fragility fractures in CKD, and treatment options. Completing the program should also enable physicians to “describe the limitations of determining renal function as an outpatient using only serum creatinine concentrations as opposed to estimating glomerular filtration rate (eGFR) by derived equations” and “recognize the difficulties associated with applying WHO osteoporosis diagnostic criteria to CKD patients.”

Efficacy and Safety of a Once-yearly IV Infusion of Zoledronic Acid 5 mg vs a Onceweekly 70 mg Oral Alendronate in the Treatment of Male Osteoporosis

 Journal of Bone and Mineral Research (April 30, 2010)

 Because “zoledronic acid (ZOL) has shown beneficial effects on bone turnover and bone mineral density (BMD) in postmenopausal osteoporosis,” researchers sought to determine whether a once-yearly IV infusion of ZOL would be a safe and effective treatment in men with osteoporosis. Further, they compared efficacy and safety to that of a weekly regimen of oral alendronate (ALN).

 “ZOL increased BMD at lumbar spine, total hip, femoral neck and trochanter, and was noninferior to ALN at 24 months... At Month 12, the median change from baseline of markers for bone resorption…and formation…were comparable between ZOL and ALN groups. Most men preferred i.v. ZOL over oral ALN. The incidence of adverse events and serious adverse events was similar in the treatment groups.”

Zoledronic Acid for Osteoporosis in the Elderly

 Researchers will assess the “safety, efficacy and feasibility of a single dose of intravenous zoledronic acid in the maintenance of skeletal integrity for frail, institutionalized women, who are most at risk for the deleterious outcomes of osteoporosis.”

New Understanding of why Common Drugs Cause Bone Loss

Two studies published in Cell Metabolism, focusing on glucocorticoids and the insulin sensitizer rosiglitazone, examine the ways in which these drugs result in bone loss and increase a patient’s risk for bone fractures.

www.hcplive.com/rheumatology/articles/bone_loss_drugs

Osteoporosis Drug may also Be Effective in Schizophrenia

Researchers at Monash University conducted a study to determine the efficacy of Raloxifene, a synthetic estrogen, for the treatment of schizophrenia, finding that women showed a significantly greater improvement in symptoms of psychosis after taking the medication.

www.hcplive.com/psychiatry/articles/estrogen_treatment_for_schizophrenia

Practicing Fall Techniques Could Help Patients with Osteoporosis

Martial arts fall training may help osteoporosis patients as long as appropriate safety measures are taken, according to study results published in BMC Research Notes.

www.hcplive.com/pain-management/articles/Martial_arts_fall_training_osteoarthritis

Feature Articles

We searched the Internet for osteoporosis resources so you don't have to.

Net Guide: Osteoporosis

This National Geographic Channel feature presents the case of Kate Meyers, a woman who struggled with obesity for 16 years, only to discover that she had two tumors on her pituitary gland that were stimulating an overproduction of cortisol. In six minutes, you’ll watch Ms. Meyers’ journey from being an active 23-year-old weighing 140 pounds, to 300 pounds at age 40, and finally recovery three months post-surgery.

Because your patients may not have ever heard of adrenoleukodystrophy (ALD), pointing them to the FAQ page at StopALD.org is a good place for them to begin working toward an understanding of the disease, and learning what they can do to try to manage its progression. Here, the site addresses current therapies used in the treatment of ALD (bone marrow transplant, gene therapy, Lorenzo’s Oil), the differences between ALD and adrenomyeloneuropathy (AMN), what female carriers of the ALD/ AMN mutation need to know, and current research into ALD and AMN.

Per usual, the Mayo Clinic provides an excellent primer for patients being introduced to a particular disease, in this case, primary aldosteronism. The write-up includes information on symptoms, causes, complications, tests and diagnosis, treatments and drugs, home remedies, and lifestyle issues. Mayo Clinic provides additional links to outside resources, an image of the adrenal glands, and a DASH diet nutritional guide. The meat of the resource, however, is the “Basics” tab.

Authored by Paul Margulies, MD, FACP, FACE, this guide may be a bit technical for some patients, but for those already versed in Cushing’s basics, this more advanced tutorial will be a more welcome read. In addition to a downloadable Cushing’s fact sheet, this page addresses the causes (Iatrogenic Cushing’s Syndrome, ectopic ACTH production, adrenal cortex tumors), symptoms, and diagnosis of Cushing’s Syndrome; the reasons why a Cushing’s patient should consult an endocrinologist; and the lifestyle challenges of living with cortisol excess.

Housed under the “Health and Money” section at Cigna.com, and authored by Healthwise, this extensive and thorough disease overview covers causes, symptoms, diagnosis, and management of Addison’s Disease in brief, as part of a topic overview, before expanding upon each in dedicated sections. The page also lists full contact information for the American Academy of Family Physicians, the Hormone Foundation, National Adrenal Disease Foundation, National Endocrine and Metabolic Diseases Information Service, and the National Organization for Rare Disorders.

Controversies Surrounding the Use of Etomidate for Rapid Sequence Intubation in Patients with Suspected Sepsis

 “To evaluate the risk of adrenal insufficiency following a single dose of etomidate in patients with suspected sepsis requiring rapid sequence intubation.”

 A literature search “revealed seven studies that specifically evaluated clinical endpoints in septic adults receiving etomidate for induction prior to intubation.” Three “evaluated risk factors associated with adrenal insufficiency in critically ill patients [and] determined that etomidate exposure was independently associated with an inappropriate response to cosyntropin stimulation testing;” two “found no significant difference in hospital mortality rates when evaluating patients receiving induction with etomidate compared with alternative regimens; and three “found an increased risk of adrenal insufficiency in patients exposed to etomidate.” The authors note that a “majority of studies that evaluated the use of etomidate in sepsis were underpowered, leading to difficulty in establishing a causal relationship between drug-related adrenal insufficiency, morbidity, and mortality,” and that “until further studies are available, etomidate should be reserved for hemodynamically unstable patients who cannot tolerate an alternative induction agent despite the administration of fluids or vasoactive agents.”

Sexual Function and Surgical Outcome in Women with Congenital Adrenal Hyperplasia Due to CYP21A2 Deficiency: Clinical Perspective and the Patients’ Perception

Journal of Clinical Endocrinology & Metabolism

 Nordenström A, Frisén L, Falhammar H, et al

 Because little is known about how “females with congenital adrenal hyperplasia (CAH) due to a CYP21A2 deficiency…feel that the disease has affected their lives regarding surgery and psychosexual adaptation,” researchers examined “the correlation between the surgical results, the self-perceived severity of the disease, and satisfaction with sexual life and relate the results to the CYP21A2 genotype.”

 Excluding genital appearance, sexual function score “was higher in the patients satisfied with their sexual life,” which “was also true of the patients who were satisfied with the surgical result.” It should be noted that “there were discrepancies between the patients’ perception of the impact of the condition on their sexual life and what health professionals would assume from clinical examination. The patients in the null genotype group scored lower on sexual function and satisfaction with their sexual life and had more surgical complications, also compared with the slightly less severe I2-splice genotype group.”

A Phase III Trial of Lorenzo’s Oil in Adrenomyeloneuropathy

 Eunice Kennedy Shriver National Institute of Child Health and Human Development

 Researchers will monitor “clinical progression of the disorder” and “determine the degree to which newly developed methods to assess spinal cord function and structure in adrenomyeloneuropathy, namely quantitative sensorimotor tests and spinal cord imaging, can act as early surrogate markers of disease progression.”

 “Patients will be randomized to receive either hydrocortisone 50 mg IV every six hours for seven days (control) or hydrocortisone 50 mg IV every six hours until 24 hours after achievement of hemodynamic stability (MAP > 65 mm Hg off of vasopressors).” The number of hours a patient receives steroid dosing will serve as the primary outcome measure; investigators will use “the difference between daily glucose levels, insulin requirements, and length of stay in the ICU” as secondary outcome measures.

Pilot Study Assessing Oxidative Stress in Children

 “Since cortisol levels alone don’t always show adrenal insufficiency (AI), and children with normal hormone levels still benefit from steroids, doctors are looking for a better understanding of AI.” Emory University researchers hope to gain more insight by examining oxidative stress (OS), which “increases steroid resistance by changing glucocorticoid receptor structure and function.” They will: 1) Find out how many sick children have OS in the pediatric intensive care unit; 2) Find out the normal OS level of healthy children; 3) Decide if OS causes adrenal insufficiency.

Hormone Therapies for Adrenal Disorders Hydrocortisone

 Tablet; 5 mg, 10 mg, 20 mg (oral administration)

 Hormone substitution or replacement in patients with Addison’s Disease

www.pfizer.com/files/products/uspi_cortef.pdf

 Aldactone, Novo-Spiroton, Aldactazide, Spiractin, Spirotone, Verospiron, Berlactone

 Tablet; 25 mg, 50 mg, 100 mg (oral administration)

 Blocks the effects of aldosterone in patients with adrenal hyperplasia

Rite Aid Prescription Error Results in $2.5 Million Verdict

A Montgomery County, Alabama, jury awarded a multi-million dollar settlement over a mistakenly filled prescription for rheumatoid arthritis which confined Reva Tosh to a wheelchair with Cushing’s Syndrome.

www.hcplive.com/rheumatology/articles/rite_aid_prescription_drug_error

Stress Peptide and Receptor May Have Role in Diabetes

Researchers at the Salk Institute for Biological Studies have found that the neuropeptide corticotropin releasing factor also plays a part in the pancreas, where it increases insulin secretion and promotes the division of the insulin-producing beta cells.

www.hcplive.com/endocrinology/articles/stress_peptide_receptor_diabetes_role

We searched the Internet for adrenal disorder resources so you don't have to.

Net Guide: Adrenal Disorders

Use this site to follow the progress of a nine-nation European study that seeks “to define the prevalence of LADA in different European countries by screening 10,000 adult patients with recently diagnosed non-insulin requiring diabetes with the hope of obtaining 1000 patients with LADA.” Researchers will attempt “to characterise genetic, immunological, and metabolic features of patients affected by LADA,” and administer DiaPep227 in a double-blind trial comprising “350 LADA patients with defined positivity for autoantibodies to glutamic acid decarboxylase and islet cell antibodies but who are initially non insulin requiring.”

Diabetes Forecast featured this highlyaccessible article on LADA in its May 2010 issue. It does an excellent job of explaining the science and history behind the disease without being overly technical, while at the same time emphasizing to at-risk patients the importance of being tested for this specific type of diabetes. At the end of the article, readers will find a link to a complementary story about yet another relatively unknown type of diabetes: maturity-onset diabetes of the young.

Diabetes Information — Latent Autoimmune Diabetes in Adults

Because of the age of onset, LADA is often misdiagnosed, initially, as type 2 diabetes. This website, put together by the Islets of Hope organization, differentiates the two illnesses with a thorough description of each and a chart that highlights a characteristic of diabetes—such as genes, triggers, and contributing factors&mdash;and explains how these characteristics are different among individuals with each type of diabetes. Other components of the site, such as treatment options, daily medical concerns, long-term complications, and prognosis, will provide patients with the skills and medical knowledge to actively participate in the management of LADA.

This site features three main categories of information: explanations of how LADA differs from type 2 diabetes, characteristics of adults with LADA, and treatment for the condition. The listing of the disease’s characteristics will help patients understand, in more detail, the symptoms they may be affected by, and also serve as a way for their loved ones to monitor their health if they are concerned about LADA. In addition to written explanations of the disease, the site also features fully detailed images of the organs, hormones, and cells involved in LADA.

10 Facts about Latent Autoimmune Diabetes

This is not an in-depth resource, but it can be useful as a printed hand-out at the time of diagnosis. The article covers the disease’s other names, antibodies, insulin dependency, insulin resistance, classification, family history, appearance, age at diagnosis, treatment, and complications.

Diabetes Education Online: Type 1 Diabetes

Type 1 Diabetes Included in this type 1 diabetes primer, produced by the Diabetes Teaching Center at the University of California, San Francisco, is an explanation of the three sub-categories of type 1 diabetes (type 1a, type 1b, LADA) and how it is determined into which type of diabetes a patient has.

Clinical and Metabolic Characteristics of Patients with Latent Autoimmune Diabetes in Adults: Absence of Rapid Beta-cell Loss in Patients with Tight Metabolic Control

 Chaillous L, Bouhanick B, Kerlan V, et al.

 To compare the clinical and metabolic characteristics of LADA with those of type 2 diabetes.

 Patients with LADA demonstrated lower residual beta-cell function than individuals with type 2 diabetes, although “those who achieve tight metabolic control do not present with a rapid decline in beta-cell function.” In regard to these patients, the researchers suggest that more research be done “to determine the optimal treatment strategy in such patients.”

Latent Autoimmune Diabetes in Adults: A Case Report

 Bermúdez V, Aparicio D, Colmenares C, et al.

 To review the clinical case of a 23-year-old male diagnosed with type 2 diabetes since six months of age and then later diagnosed with LADA.

 Although there were no pathologic findings during the physical exam, “anthropometry and laboratory test results were as follows: body mass index (BMI) = 19.66 kg/m2, basal and postprandial glycemia = 108, and 276 mg/dL respectively, glycated haemoglobin = 8.9%, basal and postprandial Cpeptide (2 hours) = 1.9, and 3.2 ng/mL, homeostasis model assessment of beta cell function: 87.5%, homeostasis model assessment of insulin resistance: 1.6.” The presumed diagnosis of LADA was later confirmed through the presence of autoantibodies anti-tyrosin-phosphatase and GAD65.

Altered Natural Killer Cell Frequency and Phenotype in Latent Autoimmune Diabetes in Adults Prior to Insulin Deficiency

 Because “a decrease in the frequency of peripheral blood natural killer (NK) cells has been reported recently in recent-onset type 1 diabetes and in high-risk individuals prior to the clinical onset,” and “NK cells in LADA patients have been investigated scarcely,” researchers used “multicolour flow cytometry to define possible deficiencies or abnormalities in the frequency or activation state of NK cells in LADA patients prior to insulin dependency.”

 Certain observations—1) “all patients were glutamic acid decarboxylase 65 autoantibody-positive and metabolically compensated, but none were insulin-dependent at the time blood samples were taken;” 2) “LADA patients exhibited a significant decrease in NK cell frequency in peripheral blood compared to healthy individuals (P = 0.0018), as reported previously for recentonset T1D patients;” 3) “NKG2D expression was increased significantly (P < 0.0001), whereas killer cell immunoglobulin-like receptor (KIR)3DL1 expression was decreased (P < 0.0001) within the NK cell population”&mdash;“highlight a defect in both frequency and activation status of NK cells in LADA patients and suggest that this immunological alteration may contribute to the development of autoimmune diabetes by affecting peripheral tolerance.”

In recent years, researchers have discovered another form of diabetes, referred to as latent autoimmune

diabetes in adults. Some other names for LADA include diabetes type 1.5, slow-progressing

type 1 diabetes, and late-onset autoimmune diabetes. Although different names have caused confusion,

they all refer to a subset of patients with type 2 diabetes who have antibodies and genetic factors

commonly found in those with type 1 diabetes.

www.pharmacytimes.com/issue/pharmacy/2009/october2009/FeatureFocusLADA-1009

 Insulin analog, 100 U/mL (injectable; subcutaneous)

 For use by type 1 and type 2 diabetics who use insulin

http://pi.lilly.com/us/humalog-pen-pi.pdf

 Amylin analog, 100 U/mL (injectable; subcutaneous)

www.symlin.com/170-important-safety-information.aspx

www.novolog.com/NovoLog_Prescribing_Info.pdf

 Insulin analog, 100 U/mL (injectable; IV [infusion], subcutaneous)

We searched the Internet for LADA resources so you don't have to.

Net Guide: Latent Autoimmune Diabetes

Cloud computing—along with its close technology cousins, SaaS (Software-asa-Service) and ASP (Application Service Provider)&mdash;is all the rage. It seems like every healthcare software vendor is throwing around these buzzwords, as if they are the Holy Grail of healthcare technology. Typically, the advantages touted include the following:

• Eliminate all local computer software

• Reduce the risk of hardware and/or network outages

• Lower cost of installation and maintenance

• Easily scale to virtually unlimited computing horsepower and storage capacity

While all of those advantages are technically somewhat true, most of them are an oversimplification, and there are also significant risks and disadvantages associated with this technology.

Cloud computing has applicability in many, but certainly not all, business and technology settings. And for many healthcare organizations and physician practices, it’s the wrong solution.

It is IT outsourcing on steroids, and in many ways, it is merely a new name for technology that has been around for a long time. Back in the dot-com boom in the late ‘90s, there were many technology hosting companies that developed service offerings, and they coined the name Application Service Providers—or ASPs. But it goes back even further, to the early days of mainframe computers, where large companies like Boeing Computer Services and Computer Science Corporation had the means and resources to build large-scale computer centers, and smaller companies would purchase blocks of CPU time and other services. This was known as time sharing (not to be confused with vacation properties); so cloud computing is not really new.

What are the risks and disadvantages of SaaS/ cloud computing?

When faced with the one-time costs of a new server/ storage/networking platform, a smaller, pay-as-you-go monthly number might look appealing to a medical practice considering an EMR or new practice management system. But while cloud computing may offer users the advantage of quick start-up, some have found that investing in your own IT platform is a better value in the long term. Depending on your level of use, you can typically hit a break-even point between nine and 18 months; beyond that time frame, the monthly costs of the SaaS/Cloud model can be much higher. And even after paying the monthly fee for 24 months, you still don’t own anything and have to keep paying every month.

If monthly cashflow is an issue, a three-year, lease-to-own model provides roughly the same monthly payment amounts, and when the lease ends the payments also end, and you own the equipment free and clear for another 1-2 years of its useful life. Over time, investing in your own equipment costs far less—provided there are no major issues with the equipment.

There are still significant technology risks

In fact, in some ways SaaS/cloud computing risks are greater than having your own equipment. For example, with a typical client/server setup in your own office or clinic, if you lose your Internet connection you can still work, although you may lose some functionality. With SaaS/cloud, what happens if you lose your Internet connection? Are you able to save your work on a local hard drive if power is lost, then upload to the cloud when it is restored? This is the type of question you need to ask a provider if you’re considering going the cloud route.

That round blue cable in your clinic is called Ethernet, and it runs at 100 Megabits per second (Mbps). A T1 circuit, which is a fairly standard broadband Internet connection, runs at only 1.5 Mbps, or only 1/60th of that speed. Plus everyone in the office must share the T1, whereas every workstation gets 100 Mbps on your local Ethernet network. So the response time for your SaaS application may be very slow. This is particularly critical for EMR, PACS, and digital images, where a single patient study can easily be 100 Megabytes. The SaaS provider may show you fast response, but that is a demo. And they may tell you of the many happy clients who are using their service today, but since SaaS is relatively new, in our experience we’ve found that most of those customers are not fully using their applications across their whole clinic, and probably don’t have many years worth of business and clinical data loaded into the system yet.

When you ask this question of the provider, they might glibly reply that it’s “in the cloud.” Well, what, exactly, does that mean? They all say they have it secured in some kind of Fort Knox-type data center somewhere, but we have seen many of those so-called data centers, and some are just glorified offices with computers and other gear lying around literally on the floor. And what happens when you want to get your data back, either at the end of your contract, or earlier? Are you comfortable with not only putting your trust in the service provider’s software, but also irreversibly linking your vital business and clinical operations—and giving all your data&mdash;over to them? If not, this is something that needs to be ironed out before you agree to anything.

On top of that, you’re trusting not only your SaaS/Cloud provider, but also its choice of hardware and implementation vendors as well. Recently there was a case of a large national cloud provider losing the data of approximately 7,500 customers (

). The company sued its hardware storage vendor and its IT implementation vendor. But that did not do anything to get their clients’ data back. Is your data really safe? What if someone at your Cloud/SaaS provider —or an outside hacker&mdash;decides to get the data and sell it or use it inappropriately? There have been stories of internal IT staff stealing client data from an online service provider, and external hackers breaking into large corporate databases (4.2 Million Credit Card Numbers Stolen From Supermarket Chain; 

,and Heartland Data Breach Could Leave100 Million Accounts Exposed; 

). What’s to prevent that from happening to your data? No company can totally prevent data loss or theft, but by putting your data with your provider, you are assuming they are taking all the necessary steps to keep your data safe. Before you commit to a SaaS/Cloud service provider, you should investigate everything possible about their operations; obtain detailed information about the company’s security system, including how often tests are conducted.

You can only get the software that your provider gives you, and on their release/rollout schedule.

All software has updates and new releases. When you control your own IT destiny, you can decide when—and even if&mdash; you want to migrate to a new software release or do a technology upgrade. If someone else is providing IT as a service, you only get what they offer you, and the schedule is based on their timeframe. We know many clients who have developed their own report and interfaces based on a certain software platform (SQL Server 2005, for example). They had invested a lot of time and energy, and they did not want to automatically upgrade to SQL 2008 when it first came out, because their reports and interfaces would not work with SQL 2008. If they had been using a SaaS provider, they would have had no choice.

When there is an outage, where do you stand as far as restoration is concerned?

If you share an IT platform that is also used by United Airlines, the city of Los Angeles and Pfizer, who is the service provider going to get back up and running first? You may be much lower on the pecking order than you think. There may be service level agreements (SLAs) that give you some future credits for outages, but that doesn’t do much to help your with the operational costs of the outage and its impact on your clinic. And these outages are more common and more widespread than you might think. Some of the largest SaaS/Cloud providers have suffered multiple major outages, including Google’s Gmail (Gmail Outage Marks Sixth Downtime in Eight Months; 

) andBlackBerry (BlackBerry Outage Not Winning Any Fans for RIM; 

You May Already Be Using Cloud Computing!

These services, which you might already be using, take advantage of cloud computing:

): So, Google has quite a grasp on the cloud computing

market. Gmail allows for less spam, mobile access, and virtually endless storage.

): store and share your photos using these services.

You are not only completely locked into your service provider’s software, but to its infrastructure as well.

In essence, you have put both your software and your hardware “eggs” in one basket. Your SaaS/cloud provider may tell you that you can cancel if you want to down the road, but keep in mind that your provider knows, that they have your data and that you have no internal IT infrastructure. Therefore, they know you are pretty much totally dependent on them and can’t move your technology services without a major headache and even more downtime.

Not all SaaS/cloud companies have the resources of Amazon, Google, and Microsoft

They may not own/manage their own IT infrastructure platforms, opting instead to rent space, power and access in another company’s data center. If this is the case with the provider you choose, you aren’t just dependent on the vendor, you may also unknowingly be dependent on their hosting provider. Be sure to demand transparency with a Saas/cloud company, covering all the bases in terms of whether it manages the data and where the data center is located.

Opening up your network to your SaaS/Cloud provider may provide a gateway for them to access other information on or within your network.

When Google first released their free desktop search tool, which is a type of cloud application, there were concerns from many IT security experts that Google would be able to “see” everything on your hard drives. And there have been other applications that have raised similar security concerns. (Google, Microsoft Online Apps Raise Security Questions; 

So is this virtual, on-demand IT model all bad?

Cloud computing has good applicability in certain situations, such as when your business largely consists of a virtual workforce, where you do not have a centralized office. In this case, locating IT infrastructure at the “central” office would not work, since there is not a centralized office. This is not the case in a typical healthcare setting, where patients come to a physical office and the transaction is largely done face-to-face.

If you have thoroughly researched the service offering(s) of the provider and they offer exactly what you want and need for your business, then a cloud-based system may be right for you, if you are comfortable:

• Sharing your vital business and clinical data with them;

• Building your business and clinical processes around their offerings and services;

• Relying on them to provide your desired services—both softw

Other situations in which SaaS/cloud computing may be a good fit include:

• You only need a set of generic applications that are generally not considered that mission- or business-critical, such as instant messaging, webmail, blogging, etc. In fact all common Web applications are essentially “on-demand” applications, so the use of SaaS/Cloud Computing is already widespread. However, a small number of organizations, including Beth Israel Deaconess Medical Center in Boston, MA, have begun using cloud computing to enable physicians throughout the system to access to electronic patient records (

• The business and clinical model comprises a largely federated data structure, such as with a health information exchange. In this case, data is shared among and between many disparate entities, none of which is really the controlling entity. In this case it is necessary to have a neutral repository for the data.

• A practice with a lack of capital, poor cash flow and/or inability to access credit. However, you are going to have to fill out a business credit application, so chances are if you can qualify for the SaaS/Cloud monthly payment terms, you could also qualify for a lease.

• You want to expense everything possible, and do not want to have capital expenses and/or carry capital assets on your books.

• You need to conserve your capital for expansion or other investment. However, here again a leasing model can provide the same capital preservation advantages.

In summary, cloud computing has some advantages in certain situations, but most healthcare settings do not fit the model. Cloud/SaaS computing takes IT outsourcing to an extreme level, and represents a potentially irreversible 3-5 year decision. In addition, there are many disadvantages, and each application needs to be examined carefully. There is definitely no one-size “cloud” that fits all situations.

Marion K. Jenkins, PhD, and Randall E. Scott, BS, CS, are co-founders and CEO and CTO, respectively, of QSE Technologies, which provides IT consulting and implementation services for medical facilities

nationwide. Learn more about QSE Technologies at 

More than one technology pundit has claimed that desktop software and computing that relies on local servers is on life support, soon to be replaced by an Internet-based approach that relies on a "cloud" of applications and virtual resources that are delivered over the Web

Cutting through the Fog of Cloud Computing

Before I launch into this month’s topic, I would be remiss if I failed to acknowledge the technological phenomenon sweeping the nation this spring. I am speaking, of course, about the “magical and revolutionary” iPad, which hit stores April 3 and almost immediately altered the course of history as we know it. Or so the hype would have us believe.

Don’t get me wrong: the iPad is a cool new device, but its applications to this point don’t seem as absolutely essential as its proponents would have us believe. So, while the rest of the world focuses on the iPad, I’m actually more interested in another recent development that might end up having just as great an impact on all our lives: flexible screen technology. I know, it’s not nearly as sexy as whatever the latest iThingy is, but trust me, if you haven’t heard about flexible screen technology yet, you will soon.

That’s because the latest research indicates that flexible and even “rollable” displays, a space-age concept touted for years in movies like 

series, are actually just around the corner. Imagine computers that can be folded up and put in your pocket, televisions that can be bent to view, and of course, cool new tools for your practice.

About two years ago, a company called Polymer Vision introduced e-Readius, an e-reader with a five-inch diagonal flexible screen, sporting a 320x240 resolution in 16 shades of gray. I haven’t used one myself, but the company claims its proprietary active-matrix electrophoretic display is as thin and light as paper, cannot be torn or broken, and can be rolled or folded into something as small as a finger.

Unlike the iPad, this product has not yet grabbed the public’s attention, which is interesting since it would be a boon to those who now get their daily news fix by scanning the headlines on an e-reader but miss the way they could roll up their old newspaper to swat a fly or smack their dog.

Looking further out into the future, Organic LED (OLED) may be the ultimate winner of this race. OLED is a light-emitting diode (LED) whose electroluminescent layer is composed of a film of organic compounds. The LED backlighting required by conventional liquid crystal displays (LCDs) is rigid, expensive, and complex to manufacture. On the other hand, OLED displays are easier to manufacture, more flexible and, as an added bonus, consume less energy.

That’s why industry giants like Sony, Samsung, and Kodak are all devoting significant time and money to the development of flexible OLED display screens. In October 2008, Samsung showcased the world’s thinnest OLED display, which was also the first to be bendable. It measured just 0.05 mm (thinner than a sheet of paper) and triggered a rumor that Apple would be using this OLED technology for their iPad.

The reality is that glitches, such as size and resolution limitations, and the difficulty of structuring the organic compounds so they won’t distort when bent, have kept designs from actually coming to market. But with the recent strides made with rollable displays (which, unlike the OLEDs, are enabled by plastic electronics rather than glass), we could be closer than ever to using these technologies in our everyday lives.

Practically speaking, the benefits of these flexible screens are boundless. Imagine, for instance, an EHR device as thin as paper, which can be as large as necessary, then completely rolled up or folded away when not in use. By closely mimicking paper, an EHR on this type of device might be more natural for many physicians to use during a patient encounter than a conventional PC or laptop. This may finally render obsolete the traditional paper chart, with its illegible writing, limited dynamic information, and all-round general unwieldiness.

I, for one, cannot wait for the day when I no longer have to lug my laptop around. And that is why I’m more excited about this developing story than the iPad which, frankly, is simply regurgitating existing technology (the iPhone) in a clever looking new package.

(Disclosure: I don’t have enough Apple stock.)

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Professorof Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Columns

Dr. Bertman discusses flexible screen computers.

Flexible Computer Screens May Soon Be Ready to Roll

One of the topics addressed at this year’s HIMSS conference was “the power of no,” a term coined by 

that refers to the concept of limiting a patient’s right to treatment if those in power decide that the care is too expensive, the patient is too old, or the treatment is not likely to deliver enough value. At the heart of this debate is electronic health record (EHR) technology and the impact it may have on patient care (

The problem that I have with all of this is that putting the concept of “best practices” to work can hinder or even eliminate the nuances involved in the art of treating patients that are learned through many years of medical training. There are situations that unfortunately cannot be programmed into a computerized medical chart.

You cannot supplant the learned experience of a physician with a computer system and subsequently call it “quality.” You cannot deny care to patients using a computer algorithm and call it “decreasing costs.” You cannot replace the mistakes that can occur with paper records with new mistakes using the EHR, and call it “reduction in errors.” This is not progress; in fact, some believe this increased bureaucracy is a form of “digital socialism.”

I agree with the points that David Blumenthal, MD, made during his speech at HIMSS, where he said the EHR can be a very powerful instrument that can help the physician see patients in a more organized manner, and can be a tool by which the physician can provide better care.

Where I disagree with Dr. Blumenthal is that I believe the physician should have the freedom to choose the EHR that is most compatible with his style of documentation and is more in line with what he can afford. We should not have the government forcing physicians into choosing expensive, complicated EHR systems that can be used to track patient behavior—or worse yet, to mine patient data for the purpose of limiting care.

In his speech, Dr. Blumenthal proudly stated that he was a friend of HIMSS. I feel that it is inappropriate for a powerful bureaucrat, a direct representative of the President of the United States, to align himself with one of the most powerful political lobbying organizations in the country, and to take part in crafting legislation that will benefit HIMSS members—possibly at the expense of physicians. Can we ensure that improving patient care is the top priority if there is a conflict of interest like the one Dr. Blumenthal appears to have (

President Obama and many in Congress want to take the failed concept of “managed care” and resurrect it with the use of expensive, powerful EHR systems and turn the US healthcare system into a European-style socialized medical system. Those in favor of this are ignoring the fact that 93% of physicians are not currently in the position to achieve “meaningful use” as outlined in the ARRA-HITECH legislation (

They are ignoring the will of the people, 55% of whom say they are against the new healthcare bill (

). They are ignoring the fact that in Massachusetts, the cost of healthcare centered around the use of powerful HIT systems has cost 15% more than the national average, and the fact that although 97% of the population has universal coverage, it does not mean universal access to a doctor, because of critical shortages of primary care physicians who since 2006 have opted to either leave the state or retire (

They are also ignoring the situation in Arizona, where in 2005, then-Governor Janet Napolitano passed a mandate that all physicians adopt HIT systems; four years later, EHRs were being uninstalled at a rate of more than 20% (

). They are hiding the fact that more than 50% of EHR implementations failed in 2007, according to the Office of the National Coordinator for Health IT (

One of the topics addressed at this year's HIMSS conference was "the power of no," a term coined by The New York Times that refers to the concept of limiting a patient's right to treatment if those in power decide that the care is too expensive, the patient is too old, or the treatment is not likely to deliver enough value.

June 2010