I’M A SPORTS GUY. I was not the most gifted athlete in high school, but nevertheless, I can talk sports and compete in a pick-up game of almost anything and hold my own. I know the rules, the teams, the athletes, the standings, and the usual nuggets of information that separate the casual sports fan from the guy who can tell you who the backup goaltender is on the Minnesota Wild (Nicklas Backstrom, by the way).

Now, our office is a pretty docile place. Many of us get along, and the conversation during the day as we work feverishly to put these magazines together for you each and every month runs the gamut from technology, to movies, to American Idol, to healthcare, to Lost, to 24, to bad songs, to sports, and mostly everything in-between. The chatter is good—despite being trivial most of the time&mdash;but when it comes to sports, things take a dark turn. There are the typical conversations that you would expect from a company in western New Jersey whose employees come in from Pennsylvania and the Garden State. The Eagles and Giants are well-represented, as are the Yanks, Mets, and Red

Sox. Rangers, Devils, Flyers, and even Islanders are represented in the forgotten league known as the NHL. NASCAR is a hit too. As for the NBA, I don’t think anybody cares. Th e Memphis Grizzlies? Th is is a real team?

Anyway, every time, whenever the sports conversation rears its head, whether over bagels on Friday or at the Monday editorial meetings, somebody brings up a question, and every time, it’s a question that I know is going to eventually make my blood boil, my head spin, and likely ruin my weekend: “Are they athletes?” This simple question enrages me not only because I know they know it enrages me, but for the fact that I argue it every time, always—always&mdash;to no avail.

It all started when I opened up my big mouth to complain about the World Cup of soccer and how boring the sport was. That led to an exchange about the most conditioned athletes, and I said something about Tiger Woods being the greatest athlete of our generation. The collective reply was seemingly more confused than Tom Cruise. I then heard it, after seeing it in their eyes: “Tiger Woods isn’t an athlete. He’s a golfer.” Was I here right now? Did I just hear this correctly? Tiger Woods, probably the greatest golfer to ever play the game, is not considered by some to be an athlete? I was wrecked. After all, I consider anybody that competes, whether professionally or not, against somebody else to be an athlete. 

Webster’s defines an athlete as “a person who is trained or skilled in exercises, sports, or games requiring physical strength, agility, or stamina.” Doesn’t golf require physical strength, agility, and stamina? Walking up to 4.5 miles with a 40-lb. bag between holes? Stamina. But am I wrong in thinking Tiger is an athlete? Let me hear your thoughts, you golf-playing docs! E-mail me at 

Anyway, where do we draw the line? Are NASCAR drivers athletes, or do “the cars do the work for them,” as our production guy John Salesi claims? How about cross-country skiers? Billiard pros? Fencers? Sport fishermen? Bowlers? Pro video game players? Bullfi ghters? Sumo wrestlers? Equestrians? Competitive eaters? Archers? Poker players? Curlers, for that weird ice sport (not hockey) from Canada?

The list can go on and on, but I think you get the point. Looking at all of these sports or games, the distinction may lie in the public perception of what’s an athlete versus who is considered athletic. A 350-lb. offensive lineman is an athlete, no question. But is he athletic? For me, yes. If the sport/game requires some kind of physical and/or mental strength, agility, or stamina, you’re an athlete, plain and simple. So whether you’re throwing horseshoes with a beer in one hand, whacking a ball with a mallet through a bunch of wickets out on your lawn, or, as the reigning grill jockey champion, stoking a charcoal fire and prepping some wood for an annual BBQ contest, be proud. You may not be competing in Beijing in 2008 or Vancouver in 2010, but you compete, nevertheless, and for this, I salute you! 

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I'm a sports guy. I was not the most gifted athlete in high school, but nevertheless, I can talk sports and compete in a pick-up game of almost anything and hold my own.

Downtime: Athletic Supporters

And with eight out of every 10 Internet users searching for health information--according to 

 President and CEO Wayne Gattinella--the online portal has become "the most recognized and trusted source of health information today." In fact, Gattinella told 

 that more than 35 million people visited the site each month in the fourth quarter of 2006. There's no questioning WebMD's popularity; we've highlighted resources found there dozens of times during OncNG's eight-plus years, you've probably seen their advertisements on television, and we bet more than one of your patients have come to the office with printouts of information they found at the site. 

Although WebMD has carved out a prominent place on the Internet, recent trends have threatened to make the company's products and services less relevant to some health consumers. Most importantly, Americans are increasingly being exposed to and using content on blogs, wikis, online forums, and other forms of user-generated media. For example, according to an Envision Solutions study, 5% of people searching for information about the antidepressant Lexapro between mid-December 2006 and mid-January 2007 went to Crazymeds.org. This is a popular blog featuring insights on the safety and efficacy of psychiatric medications. Web 2.0 technologies like blogs are increasing the visibility of citizen medical experts, and consumers are increasingly relying on them for "straight talk" about health issues. People are also using these tools to share tips about treatment and caregiving. The Internet has also helped to fuel a more patient-focused model of healthcare delivery. 

Armed with information from a variety of online and offline sources, consumers are asking physicians more questions about their care. In addition, baby boomers are taking steps to preserve their health and vitality in a bid to stave off the aging process. These changes in how people view their health have created a cadre of active patients who require more support and information than what WebMD has traditionally provided. Clearly, there is an opportunity to deliver new online services to consumers that combine peer-to-peer communication with financial, medical, and provider information. Recognizing this, a number of new companies are feverishly developing and launching products they think will satisfy consumers' needs, in the hopes of capturing a significant percentage of WebMD's audience. 

. Appearing in late December 2006 and with a planned full 2007, Revolution Health--backed by America Online (AOL) founder Steve Case, as well as Colin Powell, Carly Fiorina, Jim Barksdale, and Frank Raines--is WebMD's strongest competitor, currently offering at no services, disease information, articles, forums, more than 100 fun tools to help people and their families stay healthy--"why does healthcare always have to be so boring?" asks Case in his welcome letter--calculators, a physician finder, symptom checkers, and more. 

"We believe that the transformation of healthcare entails three principles," Revolution Health Chief Medical Officer Jeffrey Gruen, MD, told 

. "The first is to make healthcare simpler, more consumer-friendly, easier to access, easier to use, and more comprehensive. The second is to build a strong bond between physicians and patients. We would like to help raise again the nobility of the profession of medicine in the public's eye and to help patients and physicians connect in new, more meaningful ways. We'd like to make it easier for patients to find physicians who they feel they'll be able to resonate with. We have tools to help them there. We also have tools to help physicians know more about their patients, including a tool called Know Your Number, which includes scientific data on risks for contracting certain diseases that we can provide to patients to then bring to their physicians." 

Dr. Gruen said Revolution Health's third guiding principle is the belief that "an important part of health is for people to be connected, so we built powerful social networking capabilities. Having an illness can be very isolating, and we want to try to solve that by providing the support of the community. We also believe it's important for people to connect with the feeling of being healthy, so we're providing support online for people to choose healthier lifestyles. We're also revolutionizing that kind of support through a product we call Membership. This is really like AAA for health. It helps you with whatever breaks down in the system, including making positive lifestyle changes." Among Revolution Health's top features is "Revolution Ratings," which allows site visitors to rate the site's information and tools--licensed from Mayo Clinic, Cleveland Clinic, Harvard, and Healthwise--in the "Learn from Others" section. Visitors to this section of the site can also read or write about health experiences, post a question, or respond to others. 

Revolution Health members can rate providers and facilities in the "Doctors and Hospitals" section, enabling consumers to browse information on nearby doctors, specialists, and hospitals and select the best provider based on what others have said. Visitors can rate treatments and medications in the "Conditions and Treatments" section, where patients will also find information about diagnoses, living with a vast number of conditions, from allergies to heart disease. "Isn't it crazy that we have ratings to help us pick movies, restaurants and hotels--but no comparable tools to help evaluate doctors, hospitals and treatments?" asks Case. "We aim to change that--and with your help, we will." Consumers who register with Revolution Health can create and maintain a personal health record that allows them to enter and update their health information and provide access permission to their physician or other healthcare provider as they see fit. 

"We have a lot of trust that consumers can be a lot more effective than they are now; they just need the tools," says Dr. Gruen. "We're providing good tools, because consumers are being asked more and more to help take care of themselves and manage their healthcare. Physicians are also being held more responsible for patient outcomes, so patients--to achieve good outcomes--need to be motivated. And one of the motivations is to see your values over time and see how they change. Also, when patients show up in a physician's office, it's very important for the physician to know reliably what the patient's history is. Oftentimes, patients can't keep it all in their head. Wouldn't it be great for a physician next time a patient shows up to be able to look at all the past medical files right there online?" 

Dr. Gruen notes that Revolution Health offers many tools and resources that none of its competitors currently offer. One is an insurance marketplace that "helps consumers really understand what they're getting when they buy insurance. The marketplace brings consumers a wide variety of insurance options, as well as tools and information to help in making the right health insurance provider and plan choices." 

When Revolution Health's online resources aren't enough, or when a consumer needs someone to talk to regarding a diagnosis, finding a doctor, or navigating the complex healthcare system, the membership program steps in, allowing anyone who joins by April to make a call 24 hours a day, free of charge (an annual subscription price of less than $100 will begin thereafter). Revolution Health says they'll intervene and handle the situation, whatever it may be, on the consumer's behalf. 

According to a January 23 article in the 

, EverydayHealth.com has received 5 million unique visitors per month since its October 2006 launch as a no-cost site designed to provide simplified health information. Everyday Health plans to revamp this year to offer more personalized services. The site was developed after its founders asked the public what it wanted in a health site and learned that consumers are looking for credible information from unimpeachable, trustworthy sources; practical information for managing a condition on a day-to-day basis; easy-to-use, customization features; and support from people in similar situations. Using this information, the Everyday Health site currently offers detailed information from Harvard Health on diagnosis, management, and prevention of hundreds of diseases and conditions, question and answers from board-certified medical specialists from top institutions across the country, more than 10 thriving condition- and health topic-specific message boards for patients and caregivers and the "3-Minute Health Check," an online exam that helps consumers evaluate the everyday habits that affect their health, analyze their habits, and tells them the "3 Things [They] Can Do Today" to improve their health. The Health Check also serves as a springboard into the personalized information available based on consumers" answers to questions asked within. 

An expansive video library, condition-specific recipes, and an impressive and robust drug library round out the site's content. The HealthCentral Network This collection of condition-specific sites--founded in the late 1990s and recently revitalized after being acquired by a team of blue-chip investors--receives 7 million unique visitors every month, according to the same Washington Post article referenced above, and provides "timely, indepth, trusted medical information, personalized tools and resources, and connections to a vast community of leading experts and patients for people seeking to manage and improve their health." 

Under the categories of "Mind," "Body," "General Health," and "Our Affiliates," the 

 provides more than 40 sites that combine "medically-reviewed original content from doctors, researchers and expert patients, as well as news, information, video and other multi-media content from leading authorities such as A.D.A.M, HealthDay News, and Ivanhoe. "The sites under the "Mind" and "Body" categories have a similar layout and design. Visitors can find answers to common health-related questions, symptom information, and other resources in the "Find" sub-section. The "Manage" sub-section offers support and advice that can help patients take action, achieve goals, and resolve health problems. 

Under "Connect," visitors will find support, advice, and the opportunity to share opinions, serving the Network's goals of fostering "a rich community of patients and experts who share their experiences, "real-world" learning and support as they manage their day-to-day lives and their health" and capturing "the rich knowledge base these people have absorbed through their own experiences to be shared and expanded upon by others." Patients and caregivers can also create their own personalized website for keeping in touch, offering support, and staying informed by linking from most of the Network's sites to the CareCentral Tool. 

Launched in October 2006, the Organized Wisdom website provides access to HealthWise content. Organized WisdomCards' uniqueness lies in the ability for consumers who have registered with the site for free to easily create and post "," which tell the consumer's story about how they handled a specific health issue and provide recommendations on where patients can find information, treatment, and advice, thus helping others learn from their experience. The "health-focused, social-networking site" also "enables consumers, physicians, healthcare professionals, and health organizations to collaborate on more than 6,500 health topics" and provides free access to doctor-reviewed information covering these topics. More than 1.3 million people visited the site in January, a portion of whom were rerouted from 35 condition-specific sites. 

Based on the premise that most people face "a serious personal challenge themselves or [have] someone close to them who does," DailyStrength hosts "a collection of safe, anonymous, online support groups focused on more than 500 specific challenges to help people overcome their personal challenge or support a loved one through theirs." After signing up for a free account that allows for as much anonymity as desired, consumers start a "Wellness Journal" that allows them to share their story with others, invite their friends and family to participate, join one of the hundreds of communities to instantly meet others who share their challenges, make online friends with other members and stay up-todate with each other's progress, send private messages, and receive e-mail updates regarding recent community progress. When community members are having difficulty meeting their health challenges and are in need of support, DailyStrength will alert fellow members of the community so that they can take action. 

The most popular communities currently focus on asthma, breast cancer, celiac disease, chronic pain, depression, divorce, grief, and parenting issues. Site users will also find community-provided recommendations for doctors and healthcare facilities, and even restaurants and parenting advice. Those with a challenge who can't find a community that serves their needs can contact DailyStrength, and they'll create one for the individual. 

Although the sites and organizations described above all provide, to some degree, information on preventive care and how to decrease the risk of acquiring certain diseases and conditions, US Preventive Medicine has found its niche in providing "consistent services and methodologies, strong brand recognition, and a turnkey business model that will make the "prevention experience" a winning proposition for healthcare providers and consumers" by creating a "comprehensive prevention ecosystem." US Preventive Medicine believes that "proactive, preventive health management is a necessary and imminent revolution in medical care" and that "economic necessity and medical evidence are driving the transformation of health care from a legacy of treatment to a culture of prevention." The site's most useful consumer information and resources include a newsletter focused on preventive medicine and how to protect oneself from preventable disease, a virtual library, and a medical glossary. 

The highlight of the site is by far the virtual library, which asks site visitors to mouse over a virtual body part--much like the symptom checker offered by WebMD--or choose from a "list of conditions, tests, procedures and anatomical descriptions" of the body. Instead of providing detailed text information, like WebMD's symptom checker, the US Preventive Medicine virtual library offers slides, brief text, and illustrated videos with audio for every one of the dozens of featured topics, including angioplasty, bronchitis, skin cancer, and thyroid scan, allowing for a more inviting, interesting experience than reading the straight text found at more robust sites. 

WebMD is not sitting back and letting its competitors capture its marketshare by providing peer-to-peer networking tools, more relevant online searches, and other services. "Just yesterday [February 21], we launched our new, next-generation consumer portal," Gatinella explains. "The objective for the new WebMD consumer portal was to bring a new level of personalization to the user experience in order to create an even more personalized view to peopleï¿½s health question." WebMD's most recognizable tool is probably the symptom checker, advertised on television for years, which was revamped for the launch of the new site and features "a fully interactive graphical interface that allows people to click on the area of the body that their physical symptom might be related to," explains Gatinella, "and from that we then present the most targeted and appropriate content related to the condition, its potential treatment, and other related information." 

Extending the personalized feel of the site, the "new WebMD health search product is designed to deliver a new level of search results when looking on a related health term, and even personalizes those results based on a symptom related to the term or its diagnosis, treatment and care, prevention, and other types of things," adds Gatinella. "Another exciting part of the new site is our collection of new community centers. This is where we're really taking advantage of peer-to-peer capability, where people can benefit from the experience of others with similar health needs. We have more than 140 peer-to-peer health ports. 

The new site also includes expert blogs lead by some of the nation's top health experts in their respective fields, and 60 new health and wellness and lifestyle centers to help guide users through all the relevant information in their area of inquiry. These centers provide access to "new WebMD videos on each of those topics that create a more engaging experience by combining sights, sounds, and motion to enhance health information," notes Gatinella. The new WebMD consumer health portal also gives consumers the ability to build, for free, their own personal health record for securely storing and maintaining their health history. They can also take advantage of an assessment tool that lets users learn their "personal health score," which they can use to help in devising plans to take a more active role in managing their health. 

"The best way to get people involved in the topic of health--other than 'I have a question, give me an answer'--is to get them truly involved in health management programs that can improve their health," explains Gatinella. "The best way to do that is to start by asking consumers questions about their personal health history, and that's what we call our personal health assessment. We store that information, and give users access to it; it's their information, so the individual determines who else, if anyone, should have access to it. And if you so choose in the future, you have the ability to take your personal health information, based on self-reported data and other medical information that you update your record with, and communicate that to others. How many times can a person sit in a waiting room in a doctor's office and be handed the clipboard and be asked to fill out this information? It really becomes a test of memory, instead of a test of a person's real health history." 

WebMD personal health records are password-protected, and the site's developers are working on secure e-mail communications and the capability of integrating them into physicians" electronic medical records. "Those enhancements are evolving and will be occurring later this year," explains Gatinella. 

Clearly, WebMD isn't going to be pushed around. If anything, it has become stronger due to the recently added competition. "We've been able to build the largest audience online," concludes Gatinella. "The WebMD brand has become the most recognized and trusted brand of health information out there today. And the continued investment we're making in our business--both with delivering a new consumer health portal and with continuing to drive innovation in the marketplace--we think is something that will help us maintain our leadership in this market as it continues to grow in the future." 

Ten years ago, the first consumer health site, WebMD (www.webmd.com), was launched. 

The Plot to Bring Down WebMD

As healthcare costs continue to soar out of control, the push to contain costs by tying physician reimbursement to patient outcomes that conform with pre-determined quality indicators is gaining momentum, with the Centers for Medicare and Medicaid Services and other federal programs leading the way. Many professional medical societies are at least nominally supportive of the concept of pay-fo-rperformance (P4P), with many crafting official position statements in the past year or two that outline goals for programs that measure physician quality. Many of these documents also express concerns over the validity of some measurements, the need to provide incentives for physicians to invest in the information technology and other tools that will be necessary for participation, and other necessary components and provisions of these programs. This feature provides a snapshot of the current dialog about P4P, with links to reports, articles, and other online resources that present a variety of perspectives and opinions. 

. Although supportive of the general concept, the Society’s statement notes that  "A pay-for-performance infrastructure is contingent upon the development of evidence-based performance measures--a task that has proven challenging. To date, several groups are working to develop and test measures for implementation. However, it is difficult to develop standardized measures across medical specialties. In addition, developed measures must be tested, which can be tedious, time-consuming, and expensive. A proper infrastructure is critical to ensure appropriate and systematic collection of data from practices, as well as protect patient privacy." Like many groups, the Society is leery of ceding too much decision-making authority to the dictates of "best practices," noting that "variations must be allowed to meet the unique needs of an individual patient based on the physician's clinical judgment." The Society also has specific concerns related to linking P4P to changes in the physician payment system, especially where Medicare is concerned--the Society comes right out and claims that "any P4P program will not work under the current sustainable growth rate (SGR) payment formula. The two are inconsistent methodologies, and the Society believes that the SGR must be repealed if P4P is to be successfully implemented." The Society is also concerned that "data collection requirements intrinsic to P4P programs should not place financial or administrative burdens on providers." The ability of small practices to comply with P4P reporting requirements, as well as the ability of practices that care for underserved patient populations and practices that do not possess sufficient hardware and other technology resources, must also be taken into consideration. 

The Endocrine Society P4P position statement raises the issue of how to account for treatment outcomes in the current health-team approach to care. Given the overlap in care provided across specialties, how can P4P programs incorporate outcomes that rely on multidisciplinary approaches while holding each individual provider accountable for his or her performance? 

. "However." That word inevitably comes up before too long in just about everything we read about P4P. And the ACC's position statement is no exception. The American College of Cardiology Foundation, we are told, "recognizes the importance of, and supports the concept of, paying for performance to inspire greater focus on improving care delivery systems. However, physician pay-for-performance programs should be designed to support and facilitate the quality improvement process and strengthen the patient - physician relationship, not just reporting performance and outcomes." The ACC goes on to outline 12 important principles that should guide P4P program development, including the usual suspects of providing "adequate incentives for investments in structure, best practices and tools," determining performance targets through a "national consensus processes" that addresses a variety of factors, ensuring programs "emphasize success and reward achievement," and that provider rating methods should be transparent. 

One interesting note: the ACC makes it a point to express its support for programs that "favor the use of clinical data over claims-based data," in contrast to the contention made by some CMS officials that risk-adjusted claims and billing data tracks closely with clinical data. 

The ACC, as do many other professional organizations, holds the more-or-less unassailable position that "physician pay-for performance programs should be built on evidence-based, well-established, and proven performance measures."

However, given the rather fierce ongoing debate over whether we can safely at present use any of those three descriptors when talking about P4P, are we putting the cart before the horse a bit, leaving no alternative but to preface P4P pronouncements with normative statements similar to the quote from the ACC? 

. "The ACP views pay-for-performance (P4P) programs that focus on quality as a tremendous opportunity to align incentives in a way that rewards internists for eff ective care. However, ensuring that a P4P program is designed the right way is a challenging task. As new systems of payment linked to performance are being explored, ACP must ensure that the right measures are used; that data collection is accurate and reasonable; that appropriate and adequate financial incentives are provided; that quality--not just cost reduction--is always the overriding measure of success; and that savings realized by improvements in care are proportionally shared with those responsible for providing the care, which results in the savings." 

. More so than any other specialty society, the AGS is concerned with how Medicare-specific P4P measures will be implemented (for obvious reasons) and also with how these programs will apply to the care of patients with multiple chronic conditions, noting that "a value-based purchasing system for the Medicare system must address the care of the large portion of Medicare beneficiaries who have multiple chronic conditions, are frail, of advanced age, or require palliative care and not focus only on the care provided to the typical beneficiary." The AGS echoes the concerns regarding unintended consequences raised by other groups when it states "it is essential that a pay for performance program not unwittingly lead to a decrease in quality for vulnerable elders or those who may have different clinical care goals. Assessing and rewarding performance using indicators that have been developed for a commercially insured population and may not be relevant to vulnerable older adults has the potential to detract attention away from essential care and services." 

As each medical society weighs in with its concerns and questions regarding how P4P applies to the patients and conditions that fall under the society's medical specialty, the question arises as to how to devise quality indicators that take into account the needs of a heterogeneous patient population. To what extent are specialty-specific or even disease-specific standards and indicators necessary, and how will we account for the diffi culties of managing patients with atypical disease presentations and/or multiple conditions? 

to share your thoughts, especially if you have been involved with any of the various work groups or committees tasked with devising these benchmarks.

The descriptions "untested," "unproven," "yet-to-be-validated" and similar constructions pop up again and again in the ongoing discussion about pay-for-performance. One of the basic tenets of statistical measurement is that you have to defi ne what exactly you're trying to measure and then ensure that whatever metrics you decide upon actually measure what they're supposed to measure. With so much ongoing debate over the definition of terms such as "quality," and despite several ongoing and successful (in quite a few cases, though that probably depends on one's point of view) P4P pilot programs and initiatives, we're getting the impression that a sizeable percentage of the physician community remains skeptical that meaningful P4P is even possible at this point. We'd like to get some more information from providers who have first-hand experience with P4P. 

If you'd like to help us out, send an e-mail to

. Statement of purpose: "The Academy recognizes the need for experimentation in physician payment methodology, including pay for performance as one approach. However, there are a multitude of organizational, technical, legal and ethical challenges to designing and implementing pay for performance programs. The Academy also recognizes that there are both advantages (increased reimbursement, improved effi ciency and quality) and disadvantages (cost of acquiring information technology, multiple programs and guidelines, data collection) to such programs as they are currently envisioned and being tested by various employers and their contracting health plans and third party administrators." Performance Measures Criteria and more from the 

 (Kevin, M.D.) asked "Is pay-for-performance leading to antibiotic overuse?" citing a study that looked at how an externally mandated treatment standard (in this case, the administration of antibiotics within four hours of arrival at the hospital in all patients with suspected pneumonia) may be adversely distorting treatment outcomes. This is what can happen, wrote the blogger "when you use a blunt instrument, like global performance measures, to improve quality." As with any blog worth its salt, the real action is to be found in the comments to each post. This case is no exception; favorite quote from commenter: "If there was a cut and dried practice to medicine, don't you think computer programs would already be implemented in the emergency rooms to help triage patients?"  

Another of our favorite blogs, DB's Medical Rants (written by Dr. Robert Centor), has featured many thoughtful and eloquent 

 on the subject of P4P. Recurring themes include the unfortunate (but unavoidable) reality that measuring physicians using performance measures will often lead to what economists call "perverse incentives;" the difficulty of reconciling the individualized needs of unique patients with broad-based quality measurements; and the folly of attempting to base compensation entirely on a single, disputed, nebulous concept ("quality"). Favorite quote: "Medical care is not a symphony, it is jazz. Each performance is unique; each patient is unique; each set of treatment decisions must be unique." Second favorite quote: any response to frequent commenter "CJD," attorney-at-law. 

P4P Reports Rewarding Provider Performance: Aligning Incentives in Medicare

This September 2006 report is from the Institute of Medicine Committee on Redesigning Health Insurance Performance Measures, Payment, and Performance Improvement Programs. Read the whole thing for free 

Paying for Performance: A Call for Quality Health Care

An excellent report that explores the rationale for P4P programs and provides an overview of current efforts in this area. The section on future predictions for P4P makes for especially interesting 

Advancing Quality Through Collaboration: The California Pay for Performance Program

 examines the five-year history of one of the largest and most prominent pay-for-performance programs in the country. There are several additional healthcare blogs that have provided interesting takes and commentary on this subject and that definitely are worth regular visits, including 

What Does the AMA Have to Say About All This? A press release updated in January 2007 quoted then-AMA Secretary John H. Armstrong, MD, on the subject of P4P. Dr. Armstrong stated that "Pay-for-performance programs may serve as a positive force in the health care industry if the programs are designed primarily to improve the effectiveness and safety of patient care. Fair and ethical pay-for-performance programs are patient-centered and assess physician performance with evidence-based measures." 

What are the hallmarks of a quality P4P initiative? The AMA believes such a program should conform to five key principles: 

Foster the relationship between patient and physician 

More info on the AMA Physician Consortium for 

As healthcare costs continue to soar out of control, the push to
contain costs by tying physician reimbursement to patient outcomes
... is gaining momentum.

Assume the Position!: Major Medical Society Statements on Pay for Performance

When “Mary Smith,” suffering from osteoarthritis, meets with her primary care physician, she’ll have in her hand a PDA device that holds a complete record of her chronic pain management regimen, including instructions for the exercises her physical therapist prescribed and the treatment notes from her chiropractor visit last month. She may even use the device to watch a video on how to perform the exercises when at home. 

     In the not-too-distant future, patients who suff er from chronic pain may be able to use a handheld computer to easily access and manage all their personal health activities and information, from reminders of medication schedules and guidance for exercise regimens, to tracking and monitoring how diff erent therapies aff ect their psychological well-being. 

     That’s the vision driving a new project being undertaken jointly by the University of Massachusetts Medical School (UMMS) and Aptima, Inc. (

), a company specializing in human-centered engineering, with the help of a grant from the Robert Wood Johnson Foundation program “HealthDesign: Rethinking the Power and Potential of Personal Health Records” (

www.projecthealthdesign.org; www.aptima. com/news.php?id=3

The UMMS-Aptima team envisions the system helping patients to manage their chronic pain in three ways: 

The PDA will provide secure exchange of and access to patient health data for patients and all types of providers, whether or not they have an electronic health record. 

Patients will be able to easily record pain-related symptoms, the effect of pain on physical activity, and adherence to prescribed treatments. Patients will be able to update their status in pain and activity levels after a treatment or exercise, or in relation to a new medication, giving physicians a better picture than can be obtained from infrequent visits, when patient memory may be fuzzy. 

Patients will have access to health information tools and be able to download resources from the Internet, such as details on new medications and exercise programs. For patients without regular access to computers and Internet, the PDA will provide a portable source of information to use in their daily routine. 

In addition to the technical challenge of collecting and presenting diverse medical and personal information, a key to the system’s success will be the ability of users of all ages and capabilities to easily handle the PDA device. This is especially challenging, given that the patients will be pain suff erers and will need a device that is exceptionally user-friendly. 

     To make that happen, Aptima will employ an approach known as “patient-centered” engineering, which will utilize the close involvement and feedback of chronic pain patients throughout the product development cycle. In this way, designers can systematically develop user-tested functionality while avoiding common design mistakes, such as building a product that’s too complicated for patients to use or that doesn’t integrate well into medical practitioners’ workflow. 

     Aptima designers believe the PDA device is the best hardware option for providing the functionality required in the project, because PDAs are a mature, widely available technology that can exchange information with existing electronic medical records systems, can connect wirelessly to the Internet, and can be used as stand-alone tools for sharing information with practitioners who may not have electronic records, such as acupuncturists and massage and physical therapists. 

Currently in the initial six-month phase of the project, the design team is working with chronic pain patients to determine how a PDA application could best assist them in the areas of medication management, physical therapy and exercise treatment management, and tracking and monitoring of behavioral therapies. One of these areas will be chosen for developing prototypes for further testing and development, a process that is expected to take about one year. And someday soon, the team believes, chronic pain sufferers will have a painless way to manage their treatment regimen. 

Dr. Luckmann is a primary care internist and Associate Professor at UMass Medical School in the Department of Family Medicine and Community Health, where he serves as a clinician, educator, and informatics/health services researcher. He can be reached at 

Dr. Tyler is an expert in human experimental psychology and computer science, and the Principal Scientist for Human-System Integration at Aptima, Inc. He can be reached at 

Designing a New Toll for Chronic Paint Management

Putting Patients at the Center of Care

"New technologies and areas of research are the basis for today’s revolution in medicine,” according to the Roche Breakthrough Technologies research area website (

www. roche.com/home/science/sci_res/sci_res_tech.htm

). “In combination with information technology, automation and new chemical techniques, biosciences have the tools to develop new and better drugs.” Below, we explore what Roche is doing to provide these tools, through the company’s investment of nearly $3 billion annually in the discovery and development of new products and technologies in both diagnostics and pharmaceuticals (

www.roche.us/portal/eipf/us/portal/roche/rd

Using genomics and bioinformatics, Roche researchers identify genes and gene mutations that play key roles in disease development. Chip technology allows them to examine thousands of genetic sequences simultaneously on a DNA chip the size of a square centimeter and analyze their results in seconds, enabling healthy and diseased tissue to be compared, important disease causes identifi ed, and treatment targets found. 

Once targets are found, Roche utilizes laboratory robots to test many substances simultaneously, with the goal of finding “molecules that react with the biological target and therefore have potential as new drugs.” A “huge amount of molecules” can then be stored in Roche’s new large compound depository and smaller substance libraries throughout the company’s research sites. 

In the area of Computer-Assisted Drug Design and Combinationatorial Chemistry, Roche identifi es potentially interesting substances, the chemical structures of which are optimized by computer-assisted drug design and combinatorial chemistry (

http://en.wikipedia.org/wiki/ Combinatorial_chemistry

), permitting production of approximately 50,000 variants of the substance in a year. 

Much of the technology used by Roche occurs at the company’s Palo Alto location, where “researchers employ the most advanced tools and technologies available today,” primarily in the areas of biology, chemistry, and informatics. Among the tools and technologies used by Roche biologists (

http://paloalto.roche.com/randd/ToolsBiology.html

www.aff ymetrix.com/products/arrays/index. aff x

) probe arrays for understanding gene function in the context of human disease and identifying new targets, high-res separation techniques with mass spectrometry and informatics to study genome expression at the functional protein level, integrated robotic systems, automated pipetting stations, and the Flurometric Imaging Plate Reader (FLIPR) workstation for cell-based assays. 

http://paloalto.roche.com/randd/ToolsChemistry. html

) use x-ray crystallography for protein production and high-throughput crystallization condition screening, UC Berkeley’s Advanced Light Source (

), and commercial and propriety software for enabling virtual screening, fl exible docking (

http://en.wikipedia.org/wiki/ Protein-protein_docking

), and bioinformatics. These tools and technologies allow the chemists to increase their “efficiency in the lead identifi - cation and optimization stages of drug discovery.” The chemists also use such state-of-the-art instrumentation as NMR, Fourier transform Raman, and circular dicrosim spectroscopy (

http://en.wikipedia.org/wiki/ Spectroscopy

http://orgchem.colorado.edu/hndbksupport/GC/ GC.html

http://en.wikipedia.org/wiki/ Gas_chromatography-mass_spectrometry

http://paloalto.roche.com/randd/ToolsInformatics. html

) uses in-house-created and vendor-provided tools, such as ActivityBase software (

) throughout its “research sites to manage data from functional assays to ultra high-throughput screening;” a self-developed application for scientists to retrieve chemical, biological, and inventory information that uses a “multi-tier architecture with a Web user interface, Java-based components and an Oracle back end;” and licensed applications like Spotfire (

) to perform “sophisticated analysis of their data in multiple dimensions.” 

In the area of diagnostics, Roche “is leading the way in developing ‘actionable health information,’ so that tomorrow, caregivers and their patients will have the right information at the right time in the right place” (

). Roche’s recent acquisition of Aff ymetrix, a leading microarray maker, led to generation of the AmpliCHIp CYP450, which allows healthcare professionals to identify certain naturally occurring variation in two important genes in drug metabolism, and therefore obtain information that can help physicians to avoid administering or prescribing drugs that could cause a serious reaction. Roche is also working on a new generation microarray- based diagnostic tool that will allow for better cancer screening and understanding of cancer types.

How Roche is using the latest technologies to develop pharmaceuticals and devices.

PharmaTech: Roche

When the Institute of Medicine released its Preventing Medication Errors report in July 2006 estimating 1.5 million adverse drug events per year (

), as a practicing physician, I dreaded the inevitable list of abbreviations banished from appearing again in patient’s notes and charts. Others, however, reacted by taking a more constructive approach. Glen Tullman, CEO of medical software giant Allscripts (

), came up with a revolutionary plan. He set about to provide all physicians with free electronic prescribing capabilities. He challenged his board to answer the following questions: 

• How can we give every physician this software for free? 

• How do we make it as easy to use as Google? 

• How do we make it so easy that even someone who doesn’t know anything about medicine can use the program to write a prescription within fi ve minutes? 

• How can we enlist the large payers in this country to step up and provide incentives for using electronic prescribing? 

Tullman then assembled a dream team of technology firms, insurance companies, and clinicians to design the system and provide the best opportunity for this project to succeed. The resultant conglomerate, the National ePrescribing Patient Safety Initiative (NePSI), launched in late January. 

NePSI is built around Allscripts’ eRx NOW™, a standalone electronic prescription-writing program that may be used on any device with Internet access, including desktops, tablet PCs, PDAs, and smartphones. Since the vast majority of physicians probably already own and operate one or more of these devices, using NePSI does not require physicians to invest in any additional technology. The program enables prescription writing and submission to the patient’s pharmacy from any location with Internet connectivity. All data submitted is fully secure and HIPAA compliant. Like other top-of-the-line ePrescribing programs, eRx NOW™ provides dosage verifi cation, formulary adherence, and drug—drug interaction checking at the point of patient care. 

Physicians who are not currently ePrescribing by means of a more comprehensive electronic medical record (EMR) are the NePSI target audience. Given the existence of an inverse relationship between medical practice size and technology adoption, this program is targeting the large percentage of physicians that practice in groups of less than 10 practitioners. 

How is This System Superior to Other Products?

A tremendous amount of thought and planning has gone into producing an ePrescribing software solution that combines an easy-to-learn interface with the ability to rapidly generate prescriptions. With NePSI, a new prescription can be produced in about 30 seconds. This speed of prescription generation is facilitated by the following unique features: 

• The ability to interface with an existing practice management system. Once in place, such an interface will automatically update patient demographics so that the ePrescribing system will contain current information. 

• An embedded Google search engine that allows users to populate patient data simply by entering the patient’s phone number. A reverse number lookup provides the rest. 

• Automatically populated patient medication profi les. eRx NOW™ has the capacity to retrieve prescription data from multiple pharmacies, as long as the prescriptions were purchased under insurance coverage. 

• eRx NOW™ allows users to associate an indication (diagnosis) with each medication prescribed. Medications may be searched by diagnosis, and NePSI reminds physicians of what they usually prescribe for a given diagnosis. 

• Physician ease-of-use for every step of prescription writing. This physician bias will be apparent to users who are familiar with other ePrescribing systems. 

• Allscripts plans to “close the loop” on prescriptions sent via the SureScript Network (

). They realize that it would take a very small number of unsuccessful prescription transmissions to sabotage the program. NePSI is dedicated to ensuring a positive physician experience each and every time. 

Allscripts and its technology consortium are offering a cutting-edge product that succeeds in eliminating two of the barriers to technology adoption: expense and ease of implementation. I recommend eRx NOW™ and applaud NePSI for their vision and commitment to improving the quality of medical care by off ering this program. For further information or to sign up for this service, go to 

Dr. Zuckerman is a solo-practice neurologist in Baton Rogue, LA, and a juror for the Certification Commission for Healthcare Information Technology.

What program is used, who is expected to take adavantage of NePSI, and how the system is superior to other products.

The National ePrescribing Patient Safety Initiative

In fact, medical identity theft is so significant, it is the first 

 that could actually jeopardize your life. In the face of this growing epidemic, healthcare companies are jumping on the security bandwagon with RFID (radio frequency identifi cation devices) technology, bar-coding, and related identity management schemes. 

According to Healthcare IT News, this response is due in part to new advances in healthcare that are outpacing security procedures, leaving companies vulnerable to identity theft and other forms of data theft. The remedy? Tracking devices complete with patient medical history and identification that is electronically embedded on the medication bottle. 

RFID provides a response to this frightening trend in identity breaching with tags that can be attached to a product for the purpose of identification, using radio waves. Chip-based RFID tags contain silicon chips and antennas. The tags have their own internal power source, used to fuel an outgoing signal, transmitting high-powered radio waves with an average battery lifespan of 10 years. As a result, this technology permits optimal tracking of medications in and out of warehouses and supplier divisions. 

 is one of several pharmaceutical companies eager to implement such a technology. In preparation for its first RFID trial, Pfizer has started tagging individual bottles of Viagra. Th at way, supply chain partners can easily collect information for identifi cation when working with the company. Pfizer has also partnered with 

 to verify the authenticity with RFID tags on the drugs they receive. The Service assigns a serial number to every pharmaceutical package, referred to as an Electronic Product Code (EPC), which can be authenticated before consumer distribution. It makes use of RFID tags to store the drug information, which can be verified by pharmacies through the Internet. To date, more than 300,000 authentications have been performed on RFID-tagged Viagra bottles. I guess you could say they're "raising the stakes." 

"The use of reliable, high-performance RFID adds an important security layer [in combating counterfeit products and preserving brand integrity]," says Dimitri Desmons, VP for RFID Marketing at Impinj, Inc., a public relations and communications company. "Impinj's UHF [ultra-high frequency] Gen 2 products are ideal for pharmaceutical applications, because they are field-proven, exhibit high performance, meet or exceed rigorous industry standards and pass robust interoperability and functionality tests," he says. Impinj is a fabless (meaning they do not manufacture their own) semiconductors company, whose Self-Adaptive Silicon" technology is responsible for the output of their RFID products. 

, Mark Roberti, advocates RFID use. "Kimberly-Clark is now tracking promotional displays using RFID and has found that in some cases the retailer gets the display out on time 99 percent of the time, and sometimes it is less than 60 percent of the time, depending on the type of promotion and product involved," he says. "K-C is now acting on the RFID data to get the displays to the retail floor on time when the promotional advertising hits." Kimberly-Clark was the fi rst US company to ship an item tagged with an EPC off a commercial line, in April 2004 (

Since then, the international organization has established the standards for RFID tags. The company is already able to selectively tag more than 144 of the items in its product line and has even built a 5,000-square-foot warehouse for the sole purpose of testing its use of RFID. Surely that's enough radio waves to power even the highest definition TV set. 

The next time you're at Wal-Mart arguing with the cashier over the posted price of granola bars, ($.06 less in the weekly circular than at the cash register), remember the barcodes don't lie. In fact, it's more likely the employee assigned to snack foods that week forgot to scan the new price into the system. A barcode is a machine-readable representation of information imprinted on a product (say a medication bottle), in the form of patterns of dots, circles, or hidden within images. Barcodes can be read by scanners called barcode readers, and are widely used to improve the accuracy of computer data entry. Medical Bar-code Systems, LLC, is making headway in identity theft with their barcoding TrackIt inventory management system. TrackIt is designed to track all physician or patient use, maintain a perpetual inventory, and replenish medication. 

In the hospital setting, TrackIt provides inventory on a per-patient basis at each nurses' station and automatically replenishes hospitals' supply stock. The system also allows for manually created purchase orders to be tracked. "By incorporating [barcodes] directly into the package, the drug manufacturer has inventory visibility from the moment of receipt of the bottle--even before it is filled," says Desmons. "Higher tag throughput rates and higher read reliability allow manufacturers to improve filling line speeds and accuracy. Customers also benefit from the extensibility of a single system to support global supply chain applications from items to pallets and from the fill line to the pharmacy shelf. These benefits flow through to distributors, wholesalers, and pharmacies in the form of improved labor efficiencies and more accurate return and expiry control." 

 magazine calls healthcare identity management the "Holy Grail of healthcare administration." The seriousness of that management, as it applies to medication errors, is not lost on hospital staff. Northern Michigan Hospital in Petoskey, MI reduced medication errors significantly in 2006 with the use of barcoding, preventing 400 serious medical errors. Since implementing the technology in 1998, more than 21,000 medication errors and fi ve fatalities have been avoided at 

. A reduction in medication errors can truly mean the difference between life and death. 

The application of RFID-based systems is projected to grow substantially in the United States from $2.7 billion in 2006 to $26 billion in 2016. A 2006 report by 

 predicts improved productivity and increased efficiency as a result of a continued need for data accuracy in healthcare.

According to Roberti, "RFID has been around for several decades. It has been a niche technology that's been used to solve specific business problems, such as ... tracking work in process and so on. When I launched RFID Journal five years ago, the market for low-frequency and high-frequency tags was pretty well-established. There were standards for access control systems and contactless payments, but using RFID in open supply chains, where the same tag is used to identify the goods as they move from manufacturer to distributor to retailer, was only a concept. Since then, the introduction of UHF tags with longer read range and standards for sharing RFID data has created a lot of optimism that RFID can bring new efficiencies to the supply chain, and there is now a tremendous amount of innovation in tag design, reader design and software." 

With regard to the "ideal" RFID products for pharmaceutical and healthcare applications, Desmons mentions EPCglobal's Generation 2 (RFID). "The first development is the ratification and adoption of [Gen 2] specifi cation," he says. "A single, open standard with worldwide compliance that meets the requirements of high-volume supply chain users, Gen 2 defines the air interface and communications protocol used by RFID tags and readers to exchange information. Gen 2 resolves all of the shortcomings of the previous ... specifications by innovating and improving on global compliance, tag throughput, rewritability, security, privacy and robustness in high density reader environments." The emergence of products that operate exclusively in the UHF band is also making RFID a reality for healthcare professionals. "UHF products are far more robust and flexible than legacy high frequency (HF) products, and they also address security and authentication requirements," says Desmons. "UHF Gen 2 RFID products, such as the Impinj GrandPrix solution, also improve track and trace capabilities at the case, pallet, and item-levels and are, therefore, ideal for healthcare and pharmaceutical supply chain applications." 

E-discovery--which involves electronic metadata discovery and how electronic data is stored--also plays a critical role in the healthcare security environment. E-discovery specifically concerns the access, use, disclosure, preservation, and litigation of data--including e-mail and other computer-generated documents that is transmitted, stored, and backed up electronically (www.physiciannews.com/law). New rules went into effect on December 1, 2006 concerning the format in which documents are produced as it applies to 

. What this means for the world of healthcare technology is that electronic documents are now subject to discovery proceedings in litigation. Medical practices and other healthcare providers will be required to produce all relevant data under subpoena. The rules present an opportunity for Health Information Management (HIM) professionals to consult with legal counsel and information technology representatives in the development of policies and procedures that conform to these regulations. 

In other words, after being converted to electronic formats such as "tiff" (tagged image file format) images or "pdf" (portable document format) files, documents must also be produced in an easy-to-use electronic format that facilitates searching and analysis. The argument, of course, is that this format somehow degrades searchability options and limits its user-friendliness. Gone are the days of hard copy documentation. The American Health Information Management Association (

 in the September 2006 issue of the Journal of AHIMA, which suggested that healthcare professionals should follow certain policies in the destruction and storage of electronic records management. These policies include: "Identifying and documenting the method, location and native file format of information created (eg, .pdf, .tiff , .gif); Determining "good faith operations" of a company or organization's electronic information system; Establishing controls to measure compliance with records management storage, retention and destruction; if not followed, there is a potential liability. 

The Coleman v. Morgan Stanley & Co., Inc., 

 of March 2005 set a landmark in e-discovery. The jury placed a $1.4 billion judgment against Morgan Stanley due to the financial company's misconduct and concealment surrounding potentially damaging e-mails. Following such a revolutionary case, HIM professionals are being called upon to ensure a systemized approach to electronic record management that conforms to state and federal legal requirements. HIM professionals should maintain ongoing competency in recognized 

, such as HL7, HIPAA, ASTME, ANSI, and CCHIT. It is further suggested that HIMs establish a subpoena response plan for objections to producing certain types of data, including requiring a court order when expensive data requests are made. Because they are so aware of the ever-changing compliance responsibilities, there is a momentum to stay on top of e-discovery policy. 

With change comes resolution, however. E-discovery provides the means to cover your ass--legally speaking. Bar-coding and RFID utilize monumental systems of reliability and authentication, respectively. As far as the likelihood of medication errors are concerned, these security measures have you protected from even the slyest identity thieves. 

It is the fastest growing crime across the country. It affects everybody. There is little you can do to prevent it, and you can't detect it until it's too late.

Emerging Healthcare Technologies: Putting the Padlock on Health Security

Information technology has become an increasingly important part of the healthcare industry. The latest tools and resources promise to not only decrease the workload for many healthcare professionals by making practice more efficient, but they also will enable practitioners to deliver higher quality care to their patients. Current technologies such as electronic health records (EHRs) have streamlined the process of collecting, storing, and updating patient information. However, it often seems that for every successful new application of technology, there is also one that does not meet expectations. 

For some technologies, initial failure may only briefly derail their development. In other cases, the failures are beyond repair, and the project is eventually pushed aside to be replaced by a newer, better one. Technologies often fail because of poor designs that do not sufficiently take into account the needs and habits of the intended end user. This can be annoying or inconvenient when the technology in question is as trivial as a video game controller, but “

 in the use of medical devices can lead to patient injuries and deaths.” Because the stakes are so high, human factors engineering (HFE), “the study of human abilities and characteristics as they affect the design and smooth operation of equipment, systems, and jobs,” is becoming an increasingly vital design component in high-tech healthcare applications. 

 spoke with several experts who are actively involved in HFE and patient safety, and learned that some of the biggest contributors to technological failures are usability issues, poor implementation, the lack of evaluation before and after implementation, and inadequate application of HFE. When asked to identify an underlying reason for technology failures, Dr. Alex Kirlik, professor of human factors and acting head of the Human Factors Division at the 

University of Illinois in Urbana-Champaign

, said, “[tech failures] highlight the fact that the performance of humans and technology are inexorably linked. But even more importantly, [failure] also reveals the very common attitude, shared by most technology designers and an increasing number of technology users alike: that if the technology fails, it’s the user’s fault, but in most cases, exactly the opposite is true. Those of us involved in human factors engineering have worked to successfully combat this attitude in areas such as nuclear power, and we are now trying to bring the same mindset to medicine and healthcare.” Kirlik believes that “behind many, if not most, human errors are faulty designs, whether they [are] bad computer interfaces or cultural workplace practices that compromise safety.”

Although many physicians have successfully incorporated a variety of high-tech tools into their practices—handheld computers, electronic medical records, automated billing&mdash;and tracking systems&mdash; many other physicians are hesitant to embrace new technologies, skeptical of designers’ promises of a better tomorrow. This reluctance is understandable. During the last decade, there have been many technological developments that were initially touted as being the first shots in the “healthcare revolution,” but that ultimately failed to live up to the hype. Voice recognition software systems and smart cards come to mind. In addition, computerized physician order entry (CPOE) technology, billed as the ultimate in patient safety-enhancing technology, has had some well-publicized ups and downs following implementation in several healthcare institutions.

CPOE systems may play an integral role in improving healthcare safety. Unfortunately, conflicting studies have demonstrated drawbacks and benefits to this technology. In fact, some physicians believe that CPOE is the “

 in health information technology,” not electronic medical records (EMR).

Dr. David Bates, Chief of the Division of General Medicine at Brigham and Women’s Hospital and Medical Director of Clinical and Quality Analysis for Partners Healthcare System in Boston, MA, told 

, “I think [CPOE] is one of the most important technologies for improving safety in healthcare today. That being said, it’s clear that it needs to be implemented carefully and implemented well for it to have the desired benefits. There’s evidence that if you implement it, it reduces the medical error rate by more than 80%, and it also can substantially reduce the cost of delivering care.” However, despite some initial encouraging results, there are still some documented problems associated with CPOE technology. 

Discouraging findings from a study conducted at the 

 in Pittsburgh, PA, were published in the December 2005 issue of 

. Researchers found that mortality rates increased from 2.80% to 6.57% within the first five months of CPOE implementation. Additional problems included usability issues and workflow problems, including “delays in obtaining needed medications because of how CPOE was 

 with other hospital systems and departments.” The 

Hospital of the University of Pennsylvania

 in Philadelphia had similar problems. Ross Koppel, PhD, a medical sociologist from the University, conducted a study to evaluate CPOE and identified 22 persistent types of 

 a CPOE system that was used between 1997 and 2004.

 in Los Angeles, CA, actually turned off its CPOE system. Providers were frustrated with the slow process of entering orders and the increased risks of the orders getting lost in the system. “I’m not opposed to change…but it’s got to be new and better,” said 

, a urologic surgeon who helped organize physician opposition. “This was new but certainly not better” than paper.

Nine Unintended Consequences of Computerized Physician Order Entry

5. Changes in communication patterns and practices

6. Negative feelings toward the system and those responsible for it

8. Unexpected changes in the power structure such as the committee designing the computerized protocols making judgments about best practices

When voice recognition technology was first introduced in 1994, there were high expectations that it would be 

 tool to assist healthcare providers in keeping their patients’ records up to date. It was important for the first 

 to be user-friendly and accurate to establish the technology within the healthcare industry, but instead of quickly and efficiently producing notes and charts with an easy-to-use system, available products’ lack of vocabulary and understanding of medical terminology frustrated physicians. Additionally, voice recognition systems require doctors to learn how to “talk” to the computer rather than the computer learning to “listen” to the doctor (even to this day), forcing physicians to adjust their manner of speaking in order for the system to process what’s been said. Considering the price tag of some early systems (the Voice Med system by Kurzweil cost a whopping $27,000 per workstation), it’s no wonder that physicians quickly began to question the value of a technology that ended up being more trouble than it was worth.

There are two types of voice recognition processes: 

. Programs based on the discrete speech system require users to pause between words, because they can only recognize individual words one at a time, increasing the amount of time a physician spends dictating. 

 enable physicians to speak normally, without pauses, and have been hailed as the “single most important improvement in the technology as far as breaking down barriers to user acceptance in the healthcare industry.”

Even with this breakthrough, voice recognition still hasn’t lived up to the initial hype. When asked for his opinion regarding voice recognition software, Dr. Bates said, “Voice recognition is a technology that’s been around for some time, and it’s not widely used in clinical care largely because the technology has not been sufficiently robust to work in a noisy clinical environment. It’s continually getting better and it works very well if the environment is a quiet one. It’s just been a challenge to get it to work in environments that are noisy. We offer it [at Brigham and Women’s Hospital], but it’s not widely used by our clinicians.” 

Voice recognition technology continues to improve, assisted by the development of noise-canceling microphones and other new hardware, but as of 2004, only about 6,000 healthcare institutions within the US had implemented this technology.

New healthcare technologies promise to make the practice of medicine safer, more efficient, more transparent, and more effective. But what happens when things donï¿½t go according to plan?

March 2007