Is a wireless practice right for you? If so, what components would benefit you most, and what should you know about them before making the jump? 

It is easy for physicians who are responsible for making purchasing decisions for their practice to become overwhelmed when confronted by the abundance of new technologies. Web-based vs. local server-based electronic record systems; standalone vs. integrated applications; and dozens of other decisions await the physician who wants to implement health information technology solutions into daily practice. Even questions regarding basic connectivity must be answered, including whether to go the traditional wired route or opt for the freedom and versatility of a wireless medical practice. The allure of mobile technology is that it gives you the ability to practice anytime and anywhere, but it also comes with significant challenges, including privacy and security concerns and risk of data loss. 

Data security is an important element when selecting technologies for implementation; no one wants their practice to become a HIPAA violation cautionary tale. Clinicians could be forgiven for imagining they need the same level of computer security implemented at the Pentagon to avoid privacy violations and data theft, but not everyone can afford to keep their computers in an isolated room with several levels of security doors restricting access. It is important to realize that although mobility may increase vulnerability, one must strike a balance between benefit and risk. 

There are many reasons for using laptops or tablets in lieu of desktop machines as your primary computers. If your EMR system relies on a multitude of check boxes and drop-down menus for data entry, a tablet PC may be ideal. However, unless your idea of a workout includes carrying around a 10-pound, 17-inch widescreen notebook, you may have to sacrifice some computing speed and hard drive capacity in the name of mobility. Ultramobile personal computers and netbooks are two lighter-weight options that provide full functionality. 

The mobile computing device you purchase hinges on the type of wireless network you opt to install. Many readers no doubt have set up a wireless local area network (LAN) at home, enabling convenient Internet access from practically anywhere in their house. Many medical practices have also opted for this setup, especially primary care and pediatric clinics that have several patient examination rooms; physicians enjoy the convenience of being able to carry their notebooks with them from room to room. Some practices, such as psychiatric practices, that tend to have just one patient encounter location have less need for wireless mobility, and instead may opt for the enhanced security of wired LAN access in designated locations for patient interviewing. 

Wide wireless area networks (WWAN) allow Internet access anywhere and anytime. WWANs (which also includes mobile wireless broadband) typically are USB or PC card devices that can be used with different computers. WWAN access is already built into new notebook computers, which eliminates the need to carry additional hardware; however, this feature often locks users into a specific WWAN service provider. These technologies rely on the mobile service provider’s data network for Internet access, so, depending on your geographic location your access may be widely available or frustratingly limited. WWAN data speeds are usually significantly slower than wireless LAN; however, unless one is downloading and uploading large amounts of data, WWAN speeds are sufficient for most Web browsing. WWAN Internet is best for users who must have Internet access at all locations and who cannot wait until they can access a wireless LAN. For example, many airports and coffee shops offer wireless LAN, but they are not always available for free. Frequent travelers may purchase a time-limited (eg, 24 hours) or monthly wireless LAN service from a provider such as 

. The advantage of Boingo is that it is not the main provider of wireless LAN service, but has relationships with numerous providers so you don’t need an account with each separate provider.  

After you settle on a wireless network option, it’s time to consider hardware. 

 were considered the cutting edge of computing technology when they entered the market several years ago. These devices typically weigh less than two pounds and are often quite small, with four-to-five-inch screens. Many boast standard wireless LAN via 

 a/b/g/n and even WWAN Internet access via a provider such as Sprint or AT&T. The main drawback with ultramobile computers is their relatively underpowered central processing unit (CPU). The small screen and keyboard can also be frustrating for users. Ultramobiles may be a good fit for practitioners who work at several sites with access to a full-size keyboard, monitor, printer, etc via a docking station at each location. 

 is a leading manufacturer of these ultramobile computers, and one of the few dedicated to this market sector. 

 are basically just smaller versions of notebook computers, with 8-10- inch screens, keyboards at 80% normal size, slower CPUs, and a basic operating system such as Linux or Windows XP. They often lack an integrated CD/DVD drive, which saves weight and power and keeps the cost below $1,000. These computers are not geared for digital movie editing or other intensive data manipulation tasks, but are well suited for Web browsing and office document editing. They are adequate for day-to-day office use, but are ideally suited for use when traveling to a conference or when making a house call. 

When you’re away from the office, it helps to have a few handy tricks for accessing files wirelessly when needed. Some Web-based EMR systems, such as 

, allow you to access your data via a mobile phone (Life Record supports the Apple iPhone, Google Android phone platform, and the BlackBerry Storm). Users can wirelessly view, add, and edit patient records, issue prescriptions, and review images. 

 is another Web-based EMR that plans to offer mobile device access this year. 

Physicians with a desktop-based office EMR can access records using a mobile device via virtual network computing (VNC) software, which enables users to see the desktop of a remote machine and control it with their mobile device. The server software must be installed on the host computer, and the client software needs to run on the mobile device. Macs already have VNC servers installed, and the 

 for the iPhone and iPod is easy to use. Computers running Microsoft Windows or Linux can use 

, a free version of the VNC software. VNC clients are also available for Windows Mobile phones and BlackBerry devices. One of the disadvantages of VNC software is that it can be a bit difficult to set up because the software communicates via a “port” on the network—the wireless router firewall often is setup to block certain ports and thereby prevent unauthorized access to the network. Users have to “open” these ports in order for the VNC software to work, which may be a daunting task for those without the requisite computer geek skills. 

, a remote desktop program that is easier to install. Once the software is installed on the host computer, the remote computer only needs to have Internet access and a Web browser to access the host. Setup is simple because the routing goes through ports that are already open for the Web browser. LogMeIn also offers an iPhone application called Ignition for $29.99. 

If you want to use your mobile device to remotely view files, programs like 

 may be the way to go. These programs install software that remotely duplicates files from the computer onto the server. An advantage of using Dropbox and SugarSync is that more than one computer can be connected to the account, and the same files will be synchronized among all the computers. These files are all transmitted over the Internet via 

, and they are stored on the server with encryption. SugarSync and Box.net offer iPhone applications for accessing files, such as Adobe .PDFs and Microsoft Word documents. They also support BlackBerry and smartphone access. Dropbox does not have an iPhone application, but its site is optimized for the iPhone when accessed. 

Physicians often receive medication renewal requests when they are away from the office. Without computer access, the time-honored method is to write down the pharmacy number and medications and then call them in. Physicians who have created a free account with the National 

 can use their iPhone or Windows Mobile phone to access the website and renew or prescribe new medications for patients, which has the added benefit of adding to the log of prescriptions. Unfortunately, prescriptions that require tamper-proof paper cannot be filled in this manner, and the BlackBerry is unable to properly access the site for prescribing. 

Many physicians are often on the run or at multiple locations throughout the week. The mobile devices and services discussed in this article provide relatively inexpensive access to information, enabling physicians to continue practicing medicine 24/7. Although cutting the cord has freed the physician from the office, it is still important to consider boundary issues, such as getting coverage while away, so that a vacation is truly a vacation. 

Dr. Luo is the chief of Consultation and Liason Psychiatry at UCLA Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry, and the physician editor-in-chief of 

Articles

Feature Articles

Is a wireless practice right for you? If so, what components would benefit you most, and what should you know about them before making the jump?

Cutting the Cord: The Guide to Wireless Practice

Viruses and other malicious software can quickly and easily ruin a computer’s program and files. What should you know about malware, what can you do to protect your computer, and what should you do if your computer becomes infected?    

Healthcare providers spend their professional lives fighting attacks on the human body. Do they need to worry about attacks on the computers they use in day-to-day practice? Unfortunately, the answer is yes. The dangers to computers today are greater than ever. 

The good news is that protective technologies provide ever-better methods for safeguarding computer systems. Those tools are complex, and applying them appropriately as part of an overall security strategy requires some technical expertise. Although large groups and institutions have professional IT staffs to worry about all this, physicians in small groups or solo practice have to be more self-reliant.  

The malware problem really is worse than ever 

The threat from malicious software continues to grow at an explosive rate. The number of new viruses, worms, and other types of “malware” detected in 2007 was double that for 2006; new variations detected in 2008 were triple the 2007 numbers. Indeed, there were more 

 discovered in 2008 than in all the previous years for which records are available combined. 

Do lots of variations translate into lots of actual threats? Indeed, yes, and the threat is nearer than you probably think. You may have heard that countries like Russia and China were What Is Malware and Viruses and other malicious software can quickly and the sources of most of the Internet’s plagues. Those may be among the more popular points of origin, but more malware is actually hosted on American websites, and more spam is relayed from American computers, than in 

This doesn’t mean the US is full of Internet criminals. It means it’s full of computers that have been infected and hijacked by Internet criminals to do their nefarious work. It’s 

 that 10-15% of all computers worldwide are infected.

What is malware, and how do infections occur? 

Malware is an umbrella term for destructive entities, such as viruses, worms, Trojan horses, and spyware. The common factor is that these digital invaders alter the way a computer operates, without the permission or knowledge of the user. 

In a simpler time, the primary way a computer got infected with malware was by physical contact—sharing files on portable storage media like floppy disks. Today, malware more commonly arrives in e-mail messages, either in an infected file attached to the e-mail or via an enticing Web link within the message. 

Malware can also be embedded in a downloaded file (eg, an image or music file from a peer-to-peer service). Or it can enter through an open network connection, without any inadvertent abetting action by a human user, if a computer does not have appropriate security protections. 

Some malware inflicts damage directly on the computer that has become its host, by altering data files or programs. Particularly vicious malware can destroy the contents of a computer’s hard disk entirely, or other wise render the system unusable. 

Other varieties commandeer the infected system to use for reproduction. Destructive possibilities include using the compromised system as a “bot”— also sometimes called a “zombie host”&mdash;with the collection of such infected systems forming a massive “botnet” of infected computers. The infected bot systems can be used for launches of denial-of-service attacks (flooding a target website with requests) or for mass export of questionable materials (such as pornography or spam).  

In addition to wreaking obvious havoc with files and programs, malware may announce its presence by displaying text, graphics, or audio (some creators like to brag). Alternatively, malware may operate entirely in silence unless/until discovered or an internal “sunset” clock shuts it down. Lack of obvious symptoms is no guarantee of a clean bill of health. 

www.f-secure.com/en_EMEA/security/security-lab/latest-threats/security-threat-summaries/2008-4.html

Can protective software prevent malware infection? 

The traditional method of defense is to rely on detecting the “signature” of malicious software—that is, the unique bit pattern of the computer code that constitutes the malware. Protective software should be set to check all incoming e-mail and e-mail attachments, all files downloaded from websites, and all files transferred from removable media (floppies, CDs/DVDs, flash drives). It should also be set to scan a system’s entire hard drive regularly, to detect malware that has made it past the initial scans. 

Most anti-malware software now also looks for the suspicious network communications and traffic patterns typical of malware—sometimes called “behavioral” detection. New malware variations disperse through the Internet so fast that it is not possible to rely on signatures alone, even if those signatures are continually updated. Hence, the reliance on behavioral tools as well. 

Other forms of protection, like “intrusion detection/prevention systems” and “firewalls,” rely on varying combinations of signature and communications pattern approaches. Here, as in so many other areas of information security, it’s usually necessary to have more than one form of defensive strategy, so that all is not lost if one barrier is compromised. 

In a large corporate network, antimalware software (and hardware) is deployed in multiple layers: on the network routing devices, on the server computers providing shared services, and on each individual personal computer connecting to the network. In a small office, you need to worry mainly about the personal devices. “Firewall” software (or hardware) to detect intrusions over network connections is also highly recommended for small office networks and at-home systems. 

As noted at the outset, putting these pieces together appropriately requires some technical skill. It’s recommended that you consider contracting out for this, unless you are confident in your own skills. Security is one area of computing life in which it does not pay to pinch pennies. 

When appropriately deployed, the combinations of automated defenses are quite robust. But human behavior is still the key. By clicking on a link in an e-mail or on a website, you can instantly infect your computer—and very quickly possibly infect other computers in the same part of the network&mdash; before the pattern and signature defenses have had time to react and isolate the infection. 

Fortunately, the human behaviors to prevent this are relatively easy to list: don’t click on a link unless you have complete confidence in the e-mail or website containing that link. Make a habit of checking where a link is actually going; the address will typically display when you hover your cursor over the link. And never provide your user ID and password to a website unless you are sure it is a site authorized to ask for those credentials. 

What do I do if my computer gets infected? 

Anti-malware software will intercept and isolate any problems it detects and attempt to un-do any associated damage to critical system files. But not all infections can be reversed, and some data files may not be recoverable. In extreme cases, you may be required to re-install your computer’s operating system, which will erase all your data files. You will need to re-install other software as well. 

For this reason—as well as the ever present risk of hard drive failure&mdash;I strongly recommend that you have secure backup copies of your files. If the files relate to something critical, like your clinical operations, you can’t have too many backups. The countervailing constraint is the expense of storing those backups in a secure place. It is fine to keep some of the backups close by, but some should also be transferred to a physically distant location safe from both human and environmental threats. The latter are particularly important to consider; fire and water hazards show up much more in the insurance claim statistics than you might imagine. 

Most people, in my experience, plan to make adequate regular backups— the reason to do so is obvious, after all&mdash;but nearly nobody does. Your best bet is to install software that automates the process.  

#1 Be cautious about e-mail attachments. Unless you are sure the e-mail is from a reliable source, don’t open the attachment. Scanning with anti-malware software is a good safety step, but the newest viruses may still get through. Be conservative about your own use of attachments. Cut and paste plain text into e-mails whenever possible. 

#2 Be cautious about file downloads. Even files from seemingly reliable places can contain malware. Downloads from malware havens like peer-to- peer networks are practically guaranteed to produce an infection sooner or later. 

#3 Be cautious about links in e-mails and online. Links can trigger file downloads or start up executable files. 

#4 Use appropriate security settings. Your computer’s operating system, browser, and e-mail software can be set to protect you against the most common forms of attack (eg, by disabling macros and scripting languages). 

#5 Keep your anti-malware software up to date. Protective software must be regularly updated with new “signatures” in order to be effective at detecting the newest infestations. Fortunately, most products can be set to install updates automatically. 

#6 Keep up with upgrades for your computer’s operating system, Internet browser, and e-mail software. Malware designers target software vulnerabilities, particularly those for which “patches” have recently been issued. Use whatever automatic update features are available for these, too. 

It is common to refer to all malware as “viruses”—and protective software is still sometimes called “anti-virus”&mdash;but there are also worms, Trojan horses, spyware, and other virtual life forms with which to contend. Today’s malware writers build increasingly complex hybrid beasts that blur the traditional categories. The formal differences are these: 

 require a host for survival and reproduction, just like their biological namesakes. Viruses must insert their code into an application like Word or Excel, or a data file for such programs, particularly ones that have macros or a scripting language capability. Worms, by contrast, are self-replicating programs that do not need a separate software host. 

 are generally “network-aware” creatures that can propagate by seeking out other connected computers within adequate defenses. 

 are programs or data files that appear benign but carry a malicious payload, like a virus. The term owes its origin to the famous wooden horse from Homer’s Iliad, doing to the host computer what the Greeks did to Troy. 

 is any software that aims primarily to extract information, either by harvesting data stored on computers or by monitoring a user’s computer activities. Companies that promulgate the less-invasive forms of spyware—designed primarily to track your behavior for marketing purposes&mdash;prefer the term “adware.” However, since spyware is generally installed without users’ knowledge, and does things that most users do not desire, it probably deserves to be labeled as malicious, too. Spyware once required different protective software, but most “anti-virus” software can detect it now. 

Do you maintain up-to-date anti-virus protection and other safeguards for your office computer systems? Has your system ever been infected with a virus or other form of malware? Have you ever hired an outside IT consultant for your practice?

Dr. Cushman is the director of operations and user support in the Medical Information Technology department of the University of Miami Health System and School of Medicine. 

What should you know about malware, what can you do to protect your computer, and what should you do if your computer becomes infected?

What Is Malware and Why Should I Worry About It?

 How can you create your own medical podcasts? How do you distribute them? Why should you even bother?   

Podcasting is a powerful tool for communicating and expressing ideas that is available to anybody with access to a microphone and an Internet connection. A podcast is a set of digital media files (audio or video) published on the Internet on a regular basis and available to consumers through a subscription, which is usually free. 

The possibilities for podcasting in medicine are endless. Podcasting can be used to record and distribute medical conference presentations from leading experts and discussions on breakthroughs in research and treatment. Many medical schools provide students with podcasts of their class lectures, allowing them to review the material whenever and wherever they want. 

Think about all the times you’ve explained a complicated treatment option to a patient and wondered if they would be able to retain the information. How helpful would it be if they could go to your website and download a podcast in which you explain that treatment option using visual aids and even interviews with people who have had the treatment? 

Podcasts are housed online and distributed to subscribers via RSS feed, which stands for “Really Simple Syndication.” Every time a podcaster uploads a file to his or her website, subscribers get the new file delivered to their computer as soon as it’s posted. RSS tells a software program called a “podcatcher” where on the Internet to find a particular podcast and when a new episode of that podcast has been posted. Inexpensive online services like 

 automatically generate an RSS feed for a podcast that is hosted on their servers. iTunes is the most popular “podcatching” software for both Mac and PC, and is available as a free download from the online Apple store at 

Subscribing to a podcast using iTunes is easy. Search through the well-organized iTunes library of podcasts by category and subcategory to find an interesting podcast. Podcasts can be sampled, and a subscription can be initiated by clicking the “Subscribe” button. From that day forward, every new episode of that podcast will appear in the podcast folder of your iTunes software. 

There are only a few basic steps to creating an audio podcast, and they’re easier than you think. (These steps would be similar for a video podcast, but recording and editing video is more challenging.) 

1. Decide on what topic your podcast will focus. 

2. Obtain appropriate recording gear; this could be a simple USB microphone for your computer or a semiprofessional recording studio. 

3. Record your first podcast, and edit it with sound-editing software on your computer. 

4. Compress the edited audio file into mp3 format so that it is small enough for easy uploading and downloading from the Internet. 

5. Publish the file as a podcast with its own RSS feed. 

6. Submit your podcast RSS feed to the popular podcast directories, especially iTunes and 

7. Produce new podcasts, and publish them at regular intervals.  

The appropriate recording gear includes a microphone and some means of recording a digital audio file. If you own a Mac, you already have a program called 

 that comes equipped with a feature specifically designed for recording and editing podcasts. You can buy a USB microphone online or at most electronics stores for under $100. 

If you own a PC, you can download a free audio recording/editing software program called Audacity, which is popular among podcasters and available for both Mac and PC users at 

. Although other recording software programs, like 

, offer more features, they’re also more expensive; Garageband and Audacity will enable most people to produce high-quality podcasts. 

You can buy more expensive microphones and record to separate digital recorders using mixers and preamplifiers if you really want to go all out and create the best quality podcast possible. Two good places to find such equipment are 

. These online retailers have knowledgeable staff and offer podcasting packages that include the gear you need to create a high-quality podcast. 

Recording a quality podcast requires a quiet room with cushioned furniture to absorb echoes; be sure to check for background sounds before recording. Podcasters seeking the best possible sound quality can also buy specialized acoustical foam, and even portable recording studios. Products like this are available at 

Write a script before you hit the record button. That might seem like extra work, but it will save you time by allowing you to make a point in one or two sentences, whereas improvising often leads to rambling podcasts that are a waste of time for the listeners. Read the script with the same enthusiasm that inspired you to make a podcast in the first place; monotone podcasts are not interesting. 

Interviews can be done by telephone or in the field with a portable digital recorder and microphone. The easiest way to record telephone interviews is with the voiceover Internet-program 

. Skype allows you to call other people either on their telephone or on their Skype account from your computer. Additional software can be used to record the calls. 

 for PCs. By the way, don’t forget to tell the person you’re interviewing that the call is being recorded. 

If you’re going all out and setting up a studio, you will want to get separate microphones for as many people as you plan to have on each show, connected through an audio mixer to a single digital recorder. 

Once you’ve made an audio recording and edited it, you need to convert the file to mp3 format so that it is compressed enough to send around the Internet. Typically, this is as simple as selecting “File,” then “Export As,” and then “mp3” in your audio-editing software. Now, you’re ready to publish. 

I’ll explain how to publish a podcast using 

 as an example, because it provides everything you need—it even allows you to create your RSS feed and walks you through the process of getting your podcast listed at important podcast directories. Libsyn also provides a blog that you can use to write about your podcasts and to post photographs and links to references elsewhere online. You can customize your Libsyn website using several provided templates. 

When you create a Libsyn account, you will see that several monthly rates are offered based on the amount of file storage space you require. In addition to storage space for your archived mp3 media files, Libsyn offers unlimited bandwidth, an essential feature (bandwidth refers to the volume of data that flows in and out of a server). Some Web-hosting services put a limit of just a few gigabytes on your bandwidth. If you have a 20MB mp3 file, and 1,000 people download it in a month, that is a band width of 20,000MB, or 20GB. That would be too much bandwidth to handle for many Web services, but it’s no problem at Libsyn. 

After logging in to your Libsyn account, select “Publish” to access a tutorial that explains how to publish your podcast, including uploading the mp3 file directly from your computer to the Libsyn server. 

If you use a Web-hosting service other than Libsyn to post your podcasts, you will need to make sure that you manually submit your podcast RSS feed to iTunes and other podcast directories. It will be difficult for people to find your podcast if it isn’t listed at iTunes. Click the “Submit a Podcast” button in the podcast section of the iTunes store, supply the requested information, and your podcast will appear within a few days in the category to which you assign it. Do the same thing at Podcast Alley and any other directories in which you want to be listed. Once your podcast is listed in a directory, every new episode you post will appear in the directory—thanks to your RSS feed. 

If you upload your podcast files to a Webhosting service that doesn’t provide an RSS feed, you can get one for free by using a service called 

Among the numerous books on podcasting are, of course, Podcasting for Dummies, and the Podcasting Bible by Mitch Ratcliffe and Steve Mack, which describes the technical details of podcasting. Rob Walch, author of Tricks of the Podcasting Masters, is a well-respected podcast authority who has a website and podcast called 

 that covers all aspects of podcasting. The website 

 offers online video tutorials for a reasonable fee on much of the software mentioned in this article, including Garageband. The site also features a thorough tutorial on podcasting. 

Podcasting is a tool with huge potential. Start exploring the thousands of podcasts already available, and think about starting your own for your medical practice. Check out the “Health” and the “Science and Medicine” podcast categories at the iTunes store to see what other physicians are doing with podcasting. Plan carefully, and be prepared for your podcast to evolve as you learn more about this exciting medium. 

www.hcplive.com/mdnglive/other_podcasts/Ladner

 to listen to an 11-minute podcast from Dr. Ladner in which he interviews Dr. Edward Campion of the New England Journal of Medicine and Dr. Nanette Clare, associate dean of academic affairs, the University of Texas Health Science Center at San Antonio, regarding their experience with creating podcasts.

Dr. Ladner is the producer and host of the Fitness Rocks podcast at 

How can you create your own medical podcasts? How do you distribute them? Why should you even bother?

Can You Hear Me Now? Podcasting Basics for Healthcare Professionals

Does it seem like everyone in the world has suddenly created a profile on Facebook and wants to become your “friend?” If you already use social networking sites like Facebook, MySpace, Friendster, and Twitter, then read no further. But if you think a Twitter produces the high notes in your stereo speakers and a Facebook is your old high school yearbook, this column is for you.    

For most of our lives, “socializing” meant attending a function or event in person, meeting people, and making small talk. “Networking” meant meeting someone through a common bond with a third person. Today, thanks to the Internet, social networking has an entirely different meaning. In place of face-to-face meetings, social networking now occurs online, mediated through a “profile” or some other form of Web page that represents you to the rest of the world. People frequently use these pages to express themselves, share their interests, and post updates about their personal and professional lives. People become “friends” or “colleagues” by linking their pages together. 

The 800-pound gorilla of the social networking space right now is 

. Started by a college student who wanted to create the online equivalent of the “facebook” typically given to freshman at college orientation, Facebook today has tens of millions of members. When you join Facebook, you select a user name and password and then create a profile page. You can add pictures, videos, and as much information about yourself as you want. If you enter your school and work affiliations, Facebook will automatically seek out and find people you may know based on those associations. 

Something strange will happen not long after you set up a Facebook page: old friends and colleagues you haven’t heard from or thought about in years will invite you to become their “friends.” Unless you accept their invitations, these people cannot see your page or any of your personal information. Once you do accept, you can view the other person’s page and be added to their network and vice-versa. Facebook pages can also be created for companies, organizations, and groups. So, your Facebook page might have connections with your college alumni page, medical school alumni page, and a Grateful Dead fan page. 

If you’re part of the Gen-X or baby boomer generations, this decade’s earlier social networking phenomenon, MySpace, almost certainly passed by you unnoticed. MySpace seemed to be tailor-made for hormone-crazed pre-teens, teenagers, and adults obsessed with acting youthful. MySpace offers much less privacy than Facebook; anyone can see your MySpace page (Check out my attempt at 

Twitter deserves special mention, not only because it is currently all the rage, but also because I believe it represents one of the worst aspects of social networking—the narcissistic need some people have to update everyone in their network on exactly what they are doing at that very moment. In all seriousness, people use Twitter to broadcast things like: “I just ate an apple” or “I’m stuck in traffic.” To be fair, I have seen it used for slightly more productive purposes, including providing live, near-instant updates from meetings and conferences. 

There are also several professional social networking sites for physicians and other healthcare providers. Probably the most popular of these is Sermo.com, but others include DoctorsHangout.com, DoctorNetworking.com, and PhysicianOnline.com. I don’t use these sites, but they offer a highly focused forum for professional and social exchange between medical practitioners. 

Whether you want to locate an old boyfriend or girlfriend from college, or just network with other pediatricians practicing in Chicago, there is probably a social networking site for you. Don’t be afraid to try social networking, but don’t be foolhardy in how you approach it. Try to minimize the amount of financial or personal identity information you give out online, and don’t download software or files from anyone you don’t trust. And remember: the information you post is now public information that will be online forever, so don’t brag about anything that could derail your chances to become the next Surgeon General. 

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Professor of 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

Does it seem like everyone in the world has suddenly created a profile on Facebook and wants to become your "friend?" If you already use social networking sites like Facebook, MySpace, Friendster, and Twitter, then read no further.

Social Networking Comes of Age

Physicians who see Medicare patients are practicing in very difficult times. The Obama administration wants to continue to not only cover the elderly who pay for an insignificant portion of their healthcare but to also add on an extra 40 million people who currently are uninsured. President Obama wants to 

 primarily through taxing the rich and Medicare cutbacks. 

The administration wants to set limits on payment growth for medications, hospitals, and physicians by implementing a nationwide certified EHR (c-EHR) system, which can be used to control physician independence, to further strain the physician—patient relationship, and to facilitate 

 by government bureaucrats of the way that healthcare is administered. 

On February 13, Congress passed the $787 billion economic stimulus bill, which, among other things, calls for up to an eventual 5% penalty for non-participation in new HIT mandates if 

 75% of physicians are “meaningful c-EHR users.” Through the bill, Congress wants physicians to pay for a c-EHR system that is costly in terms of software, hardware, and training. The Department of Health and Human Services (HHS) has yet to define what constitutes “meaningful use” of a c-EHR, but pundits say it will include e-prescribing, decision support, and quality data reporting, functionality that will require increased computer time for physicians and less face-to-face patient time. Adopting these technologies may well hamper a physician’s ability to see enough patients in order to maintain the financial viability of his or her practice. This administration wants to 

 who perform according to the stringent usage and reporting parameters up to a paltry $44,000 over five years, if they do manage to get paid at all. 

PC_HR.1_0409.JPGThose physicians who are not planning to comply with these new Medicare mandates have options that can actually stabilize, and possibly increase, their gross office incomes: 

1) Change your Medicare participation status from a participating provider to a non-participating provider, which allows you to legitimately increase reimbursement by charging the “limiting fees,” which represent the maximum allowable reimbursement (15% over Medicare’s approved amount). To learn more about the plusses and minuses of becoming a mid-level participant, check out 

www.acponline.org/pmc/ medicare_options08.pdf

2) “Opt out” and quit your Medicare participation altogether. Generally, you need to sign an opt-out affidavit that, among other things, states that you cannot re-apply for Medicare participation status for two years. The good thing is that you can then contract any fair payment arrangement directly with patients. 

3) Add an extra patient a day (say, $75 x 200 days) for an off set of $15,000 a year, or an increased income of $75,000 over five years. 

4) Start a cash-only ambulatory acute care clinic, which is associated with-on-the-spot payments and no third-party intermediaries. 

5) Start a “concierge clinic,” charging patients a yearly amount that covers issues such as availability and expediency. 

6) If you’re in a solo practice and it becomes untenable, but you still wish to provide patient care, then join a group, begin visiting nursing homes, become a hospitalist, or become a full-time clinical professor at your local medical school. There will be no overhead costs, and you’ll receive a stable paycheck. 

7) Change careers—become an author, a researcher, or a professor. 

These are all difficult choices, but the practice landscape is changing quickly, requiring all of us to make important, well-informed decisions regarding our futures. 

Whatever alternative choice you make will send a message to Congress that the bailout bill HIT provisions are driving out physicians from the Medicare program. 

Alberto Borges, MD, is in private practice and is an associate clinical professor of medicine at the George Washington University in Washington, DC. Check out his website at 

The opinions expressed in this column do not necessarily reflect those of 

Physicians who see Medicare patients are practicing in very difficult times.

Congress Passed the Stimulus Bill; What Should You Do Now?

In these difficult economic times, every little step and adjustment to increase efficiency can have an effect on the financial health of your practice. Although their makers would have you believe otherwise, too often, many of the technology resources that promise to save time, increase efficiency, and improve productivity in fact have the opposite effect, at least in the short term. Cumbersome user interfaces, laborious data capture processes, arcane operating procedures, and a host of other design “features” often mean that big-ticket health IT solutions like full-featured EHRs and e-prescribing systems create immense workflow disruptions, increase inefficiency until staff catch up to the learning curve, and ultimately reduce productivity (potentially resulting in less face time with patients and loss of revenue). 

That worst-case scenario doesn’t always hold true, however, especially in the case of low-friction tech applications and solutions like the ones profiled in this issue. I call them “low-friction” because they can be put in place with minimal effort and often produce surprisingly little “heat” (frustration, despair, and disruption). This is technology the way it’s supposed to be: low risk, low effort, and high reward. I’m talking about simple-to-use software and applications that can help you solve real, everyday challenges and simply get things done smarter and more efficiently, to borrow a phrase from the excellent Lifehacker.com (which, if you have never visited, you should do post haste). Online forms are one good example. MDNG Healthcare IT Advisory Board member Steven Zuckerman, MD, explains how you can easily create your own online forms for your practice and “turn information into knowledge.” And, as Dr. Z points out, you can do this using a program you most likely already use every day. He even went to the trouble of creating a video tutorial (available at HCPLive.com) for the visual learners among us. If you download a couple other simple programs, with just a little more effort, says the good doctor, you can create fairly complicated “intelligent” forms and templates that you can put to good use in a variety of ways in your practice; you can even create forms that will allow you to easily capture PQRI data and earn that 2% bonus. Now, that’s low-friction technology at its finest. 

What other tips, tricks, how-tos, downloads, advice, and tutorials will you find in this issue? Turn the page and find out. We also invite you to visit HCPLive.com and share your own stories about how you’ve brought technology into practice in unique and unexpected ways. We look forward to hearing from you. 

Editor's Note

In these difficult economic times, every little step and adjustment to increase efficiency can have an effect on the financial health of your practice. 

Low-friction Technology 

Make patient information available everywhere, build intelligence into your information collection process, and turn information into knowledge by moving to electronic forms.  

Let’s face it: the world of healthcare revolves around filling out forms. When a new patient comes to your office for the first time, the first interaction he or she has with your practice is to follow the receptionist’s instructions to take the clipboard with its attached paper forms and fill in all pertinent demographic, insurance, and clinical information. Your staff then takes that paper-based information and inputs the data into your practice management software, possibly also into a separate EMR, and perhaps even into a freestanding e-prescribing system. You then produce a consult or progress note (yet another type of form), which must contain sufficient information to justify the coding level you charge, as well as document the PQRI requirements (not to mention actually provide some medically relevant information). You probably also order lab and radiology tests, requiring additional forms to be filled out, and then you send the patient on his or her way to begin form-filling activities at several more locations. The point is that the same information ends up getting collected, recorded, and exchanged in numerous settings for multiple purposes, but each time the process almost always begins with a piece of paper. 

The first step in avoiding all of this tremendous inefficiency is to capture the information electronically. Unfortunately, there is an appalling lack of interoperability among existing electronic medical systems. There is good reason, however, to believe that the situation will steadily improve over time. In the meantime, it is fairly simple to create your own electronic forms so that the collection of information that you need to practice medicine can become more efficient. 

A form is simply a tool for collecting important information. Paper-based forms are simple but limited in scope. Electronic forms, on the other hand, offer several advantages: the information submitted is available everywhere, the data can be checked for accuracy at the time the form is filled and submitted, “intelligence” can be built into forms to find the correct information, and the data can eventually be analyzed to turn information into knowledge. 

An electronic form is basically just a template; it does not change each time it is used. Instead, the filled-out form becomes a new document (an analogy from biology would be a strand of mRNA—it never changes but codes the production of multiple protein molecules). These templates usually consist of two elements: the non-changing explanatory text that instructs the user as to what information should be provided, and the variable user input, which is the data being sought (biology analogy #2: constant and variable regions of an immunoglobulin molecule). The information for these “fields” can come in a variety of formats: 

• Text fields allow the user to type in a response (eg, an empty box for users to type in their name). These may be limited by how many characters may be typed, as well as the complexity of the formatting. 

• Drop-down lists are useful when the desired information comes from a limited set of responses and only one  answer is permitted. For example, in filling out an address form, placing a drop-down field listing all of the states to enable users to select their correct state simplifies the process. 

• Radio buttons present the user with a limited number of choices, from which they can select only one (ie, the responses are mutually exclusive). An example would be asking the sex of the user and requesting they click the radio button for male or female. 

• Check boxes can present several answers and request the user to check all that apply (ie, permit multiple correct responses). For example, in a “Medical History” field you may want to present a list of common diagnoses and allow the user to check all that apply. 

More complicated field types exist, but these four are sufficient to gather most routine information. Depending on the sophistication of the program producing the form, fields can be made visible to the user based on previous responses. For example, if the response was “yes” to a question about smoking, a field would then ask “how many packs per day?” However, if the answer was “no,” the follow-up question would not be displayed. 

The next step is to decide on which program or format you want to use for form creation and then follow a few simple procedures for producing the form templates. Most people don’t realize it, but Microsoft Word actually boasts some rather robust form-creating capabilities. Word 2003 has more creation tools than Word 2007, possibly because Microsoft is now promoting its server-based form creation program, 

. Interested readers are encouraged to view a 10-minute 

 that explains the InfoPath form-creation process. 

A more versatile form can be created in .PDF format, which has the advantage of being platform-independent (ie, readable by Windows, Macintosh, and Linux operating systems). These forms can be filled out on a website, via e-mail, or by printing and submitting. They also allow for electronic signatures so that identities may be verified. Word documents can be converted into .PDF format via one of several free programs available online, including 

. Creating a full-featured form requires Adobe Acrobat, which can be expensive—the Standard version costs about $300; Acrobat Pro costs about $450. Students or teachers at recognized educational institutions can purchase Acrobat for about $150. 

A less expensive approach takes advantage of “

,” which provides software and other resources as services over the Internet. With cloud computing, you do not need to store software and other applications on your computer—everything is accessed via your browser and run on distant servers. Google has many such applications, including 

. With a free Google account, you can create many types of documents. Under “New” in the Google Docs navigation bar, select “Form” from the drop-down menu of document types to create a template into which you can insert text boxes, drop-down selection lists, check boxes, radio buttons, and other features. The form can then be embedded into a website or sent via e-mail to be filled out offline or online. Data entered into the form is presented in a spreadsheet format, which can then be searched, providing an easy and convenient way to collect simple information. 

In order to incorporate your form into a website, you’re going to have to learn in your spare time how to program in HTML, JavaScript, SQL, or PHP. What’s that? You don’t have any “spare time?” Don't worry, you can use a Web service that does all of the heavy lifting (and programming) for you. One such service is 

, a user-friendly site that allows for the simple production of forms for gathering registration information; it even integrates easily with payment services such as PayPal and Google Checkout. WuFoo offers three free forms you can build and try out before subscribing to the service. 

Another online service that offers more technically advanced form creation capabilities is 

. I have used this application to make several kinds of forms and have been impressed with the sophisticated options available. I have designed a registration form that can generate an e-mail appointment reminder; forms for collecting PQRI data, which will make qualifying for the 2% PQRI bonus relatively painless; and forms for evaluating patients with neurological disorders for driving restrictions in accordance with AMA guidelines. These forms include multiple pages with branching logic depending on responses. Logiforms is available for $20 a month, a reasonable fee for the powerful features offered. 

What you do with the data submitted is left up to you. Logiforms, for example, has several ways to filter, sort, and manipulate the information contained in its database. In addition, Logiforms enables users to export the information into Excel or Access and use these programs to further analyze their information. What is more difficult, however, is to import the data into the other programs already in use in your practice. It is this “last mile” of data importation that will need to be traversed in order to make electronic forms truly universally accepted. 

www.screencast.com/users/DrZuckeman/folders/Forms

 to view online video tutorials created by Dr. Zuckerman that demonstrate how to create electronic forms using Microsoft Word, Microsoft Office, and Google Docs. If you’re inspired to create your own how-to video (or have done so already), e-mail 

 and we’ll share the news with the rest of our readers. 

Healthcare IT Advisory Board member, and the Chief of Neurology and Medical Information Officer at Baton Rouge General Hospital in Louisiana. “ 