If you have partners in your medical practice, it’s a good idea to determine early on the value of the practice and decide how it will be divided if a partner leaves for any reason. There are a host of circumstances that can disrupt a partnership and have a powerful fi nancial impact on the business, including death, retirement, business disputes, disability, and divorce. How should the business be split up or paid out in these situations? Planning in advance with a written and detailed buy—sell agreement that addresses each possible scenario can help avoid costly litigation and fi nancial loss in the future.

The first issue to consider is which events should be covered by the terms of the buy—sell agreement. Under what circumstances should a partner have the right to be bought out? Certainly, death and long-term disability would be included, as well as planned retirement. But what happens if a partner quits, is “fi red,” or wants to sell his interest to a third party? What rules should govern each of these scenarios? You may want to consider whether the buy-out amount can be reduced in these situations.  Although everyone may agree that it’s fair to pay a “full” share on death, disability, or retirement, a partner who leaves voluntarily might face some type of penalty, such as valuing his or her share less generously, if the withdrawal creates a fi nancial burden on the remaining partners.

In addition to stipulating which events are covered, the buy—sell agreement should specify a method for valuing each share in the practice and how much will be paid under each circumstance. Sometimes valuation is pretty straightforward; in many medical practices, accounts receivable and equipment represent a signifi cant portion of the assets, the amount of which is easily determined. It is more diffi cult to determine the value of intangible assets—such as in the case of a practice with substantial goodwill&mdash;although there are a variety of techniques and formulas that can be used (See “Valuing Your Medical Practice” at 

A partner’s share of accounts receivable is usually discounted for collection losses and the amount of the liabilities of the practice directly associated with these assets. For example, Dr. A owns a 25% interest in a medical partnership that has $1 million in receivables. When he retires, his $250,000 share of the accounts receivable might be discounted by 20% (based on collection experience). It is important to also consider what share of other liabilities of the practice should reduce the payout. Is there an outstanding line of credit that Dr. A should pay back? Should overhead costs of labor and rent associated with the collection of the receivables be considered? Also, if there are possible chargebacks from Medicare or other insurers, who will be responsible for those payments? There is no right or wrong answer to these questions. Everyone involved should consider the economic impact of each decision before devising an appropriate formula.  I have seen buy—sell agreements that did not factor in liabilities and the costs of collection, and the remaining partners were stuck with much higher costs than they anticipated.

Once the amount of the buyout has been determined, how should it be paid? Th is often depends on timing, the partnership’s cash fl ow, and whether the buyout event has been funded. A buyout due to the death of a partner can be funded with insurance, making a cash payout feasible. However, immediate cash may not be available if the buyout is based on a partner’s voluntary withdrawal, unless the partnership has accumulated a reserve for the payments. A payout schedule over a period of months can be tied to the collection of the accounts receivable so that impact on cash fl ow is minimized. If goodwill is included in the buyout amount, the payout may be deferred for a number of years, unless adequate insurance or a reserve fund has been maintained.  Buy—sell agreements are an important legal component of every medical partnership. You should understand what will happen under each buyout scenario so that you can properly plan for this aspect of your fi nancial future. Discuss the buy–sell provisions of your partnership with your attorney, in advance, so that the agreement accurately refl ects the intent of the partners and all key issues are adequately addressed and resolved.

Robert J. Mintz, JD, is an attorney and the author of the book

 Asset Protection for Physicians and High-Risk Business Owners

. To receive a complimentary copy of the book, call 800-223-4291 or visit 

Articles

Feature Articles

There are a host of circumstances that can disrupt a partnership and have a powerful fi nancial impact on the business, including death, retirement, business disputes, disability, and divorce.

Covering Your Assets: Key Issues in Physician Partnerships

with Ed Silverman, author of the popular pharmaceutical industry blog 

. He was curious as to why, despite much sound and fury, many pharmaceutical companies have not started to market their products using various networking technologies, including blogs and social networks.

Some have suggested that launching a blog or participating in an online forum is anathema to Big Pharma because drug fi rms are unwilling to be open and honest with the public. For example, Matthew Holford, author of the blog 

 said this in response to the interview: “I don’t think any [drug] company could ever write a blog, simply because, with the attendant interest in suppressing information, it would lack authenticity, and would have the well-vetted look of an offi ciallysanctioned press release.”

Despite Holford’s skepticism, a couple of pharmaceutical companies have decided to launch blogs focusing on prescription and over-the-counter products. Most notably, 

 launched CNTO411 in March 2008. Th e blog has generated quite a bit of interest from industry critics, experts, and health consumers. However, it has not yet established its footing. When pressed by readers to defi ne the blog’s target audience, Centocor’s Melissa Katz replied: “everyone.” Th is response annoyed some, who believed that the blog would provide more value and have a sharper voice if it had a well-defi ned target and point of view.

In addition, GlaxoSmithKline in 2007 launched the blog, “

” to discuss issues related to weight loss and its OTC medication Alli. Because the blog is designed to support its marketing eff orts for Alli, the blog is much more focused than CNTO411. Yet the question remains, should pharmaceutical companies be marketing their medications using social media? Well, the answer is more complex than a simple “yes” or “no.” First, when it comes to marketing, there are many activities drug fi rms engage in that have nothing to do with producing 60-second commercials.  For example, there may be value in tapping into the opinions of dedicated and informed physicians and consumers in order to better understand patients’ unmet medical needs and how drugs are working in the real world. Pharmaceutical companies are currently partnering with social networks like 

 to gather outcomes and opinion data from both of these groups.  In addition, some physicians want pharmaceutical companies to stop relying on sales representatives and engage in more substantive and authentic conversations with doctors. Th is was one reason Pfi zer decided to partner with Sermo to open a dialog with its online physician community about a range of subjects, including how drug fi rms should communicate with doctors in a Web 2.0 world. While the relationship has generated some controversy, Sermo’s CEO Daniel Palestrant has said it represents a “win-win” for both parties.  Overall, I believe that pharmaceutical companies have much to gain from engaging people using social media—if it is done in an open and non-manipulative way. Transparent activities like the Centocor blog and 

 may be criticized, but at least everyone is aware of what is going on. If companies begin to attempt to infl uence the conversation in devious ways, then they have no business marketing their products using social media technologies.

So, why haven’t we seen more drug fi rms starting blogs or participating in social networks? A big reason is that many have not yet fi gured out how to participate in the online conversation while satisfying social media’s cultural requirements. Despite this, they are marketing in social media in other ways. For example, a number of companies have been advertising on the 

 health provider social network. In addition, LifeScan has initiated a partnership with a consumer diabetes social network, 

, to promote its OneTouch blood glucose monitoring device.

The important question is not if pharmaceutical companies should market via social media, but how. Only time will tell if they get it right.

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

 to learn more about the company and the services it offers.

In June 2008, I participated in an online interview with Ed Silverman, author of the popular pharmaceutical industry blog Pharmalot.

Should Big Pharma be Marketing via Social Media?

Last month’s Health 2.0 issue got me thinking about the concept of communities on the Web. Many of our patients are using the Internet to look up their diagnoses and medications as soon as they get home from our offices. (Although they may be uncomfortable admitting this to us, thinking this implies they are second-guessing us and seeking medical information “behind our backs.”) Unfortunately, with the amount of biased and non-evidence-based medical information available online, our patients run the real risk of getting bad information. This is especially true if they frequent the myriad bulletin boards and online communities surrounding nearly every conceivable disease state.

There are two primary ways that patients get healthcare information from the Web. The first is by reading articles written by doctors, healthcare workers, journalists, and anyone else who can get published. When you type “diabetes” into Google, the first page results include the 

, the American Diabetes Association, Wikipedia, and other sources of information from well-established mainstream sources. But further down the list are links to bulletin boards and forums.  If you type “diabetes community” into Google, the first listings include support networks and communities of people who have diabetes or who know someone with diabetes.  These communities allow people to share information with one another on a peer-to-peer level, frequently without the guidance or influence of a healthcare professional. Bulletin boards let people write a question or make a comment and then “post” the message so it can be read by anyone. Messages are organized into “threads” that read much like a conversation—but instead of two people talking there can be an unlimited number of participants sharing their advice and opinions.

It wasn’t always like this. A few years ago, a patient diagnosed with type II diabetes would have simply accepted the information you provided. Maybe they would have gone to a bookstore or library, or shared information if they happened to know someone else with the same condition.  Today, most patients will go to their computer as soon as they leave your office. They will read whatever they can and then start interacting with others who share a similar interest.  Most doctors don’t realize the extent to which patients use the Internet to learn from and converse with other nonhealthcare professionals.

Back in the 1990s, I co-created a website that focused on medical issues people were too embarrassed or uncomfortable discussing with their physician (aptly named 

). We added a bulletin board to the site, and over the past fi ve years, people have posted hundreds of thousands of messages.  The most popular topic, male genitalia, currently has more than 36,000 messages organized into more than 4,000 discussion threads. There are also discussions on a host of other topics, including Lyme disease, breast cancer, masturbation, bowel movements, and more.

It is fascinating to read messages from the board. Some are touching, others repulsive; most are somewhere in-between, providing information and personal experiences of the writers.  Some contain good medical information; others spread myths and misconceptions, usually corrected by other concerned posters. Patients need to be forewarned that bulletin boards can, and frequently do, contain erroneous information. A wise approach is to assume your patients will be looking at these sites and let them know you support them, but advise that they should consult with you before taking any kind of action, or if they have concerns or fears generated by the information they find.

Despite the pitfalls and potential false information, Web communities should be celebrated because on balance they do much more good than harm. People can gain valuable information from peers that we don’t always have the time to give them during an office visit. They also get to commiserate and empathize with people who share similar experiences.  Because people can maintain their anonymity, they are also more willing to open up and share things they would never tell their doctor, parents, or spouse. This is powerful stuff, and it allows for some amazing interactions that would rarely occur in the brick-and-mortar world of medical offices and hospitals.

Dr. Bertman is Physician Editor-in-Chief of 

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

, a leading developer of electronic health record (EHR) software. He also is the founder and president of 

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

Many of our patients are using the Internet to look up their diagnoses and medications as soon as they get home from our offices.

Tech Talk: Patients are Doing it for Themselves

Early detection of cardiovascular disease can reduce the huge human and economic impact of this group of diseases. Early lifestyle and medical interventions can reduce both the number and severity of serious cardiovascular events. The question remains how to screen individuals before late-stage signs, like hypertension and heart problems, arise.

Arterial elasticity measurement is an emerging technique for detecting cardiovascular deterioration long before it becomes symptomatic, and in ways that imaging techniques, physical examination, or in vitro diagnostics cannot.  Normal, healthy arteries are highly elastic. When the left ventricle contracts, blood passes through the arterial system, and the walls expand in response, a phenomenon reflected in the systolic blood pressure. The vessels then recoil to their normal state when the heart is at rest, the point at which the diastolic blood pressure is measured. Facile expansion and contraction depends on the integrity of blood vessels’ epithelial cells, and their ability to release nitric oxide (NO), endothelin, and other factors that induce arterial relaxation. When the left ventricle contracts, a pressure wave precedes blood flow. This wave propagates through the arterial system, and eventually is refl ected back to heart. If the arterial walls have stiff ened, the pulse wave travels much more quickly through the circulatory system, a fact that directly reflects the loss of arterial elasticity.  

Abnormally fast pulses refl ect back to the heart sooner than they should. Some researchers believe that this event can stress the left ventricle, thereby creating a self-perpetuating cycle of circulatory system damage.  Various risk factors, including aging, genetics, and lifestyle, aff ect the arterial endothelium, causing it to lose elasticity. Individuals with signs of early loss of arterial elasticity cannot change their genes, or the fact that they are aging. But lifestyle modifi cations can mitigate these factors somewhat, and perhaps reverse the eff ects of years of poor diet, lack of exercise, smoking, and other unhealthful practices.  It should be stressed that loss of arterial elasticity is a very early-stage, non-symptomspecifi c sign that something is wrong, whereas hypertension is a relatively late-stage event.  In other words, by the time an individual presents with high blood pressure the loss of arterial elasticity is well underway. One might ask why, if arterial elasticity measurements provide so much information, the US healthcare system has not embraced the technique more enthusiastically.

For mostly historical reasons, healthcare systems tend to be reactive, rather than proactive.  Th e paradigm of diagnosing and treating has only recently begun to be challenged by managed care and a small group of healthcare practitioners who recognize the value of prevention, early diagnosis, and intervention. Interestingly, insurers have led the way in many respects by readily reimbursing for preventive care.

A new instrument, the Digital Pulse Analyzer (DPA), from Meridian Medical, provides early detection of arterial wall stiff ness and arteriosclerosis.  As a system for measuring the biological aging pattern of arteries rapidly and noninvasively, DPA serves as an “early warning” system for cardiovascular health throughout a person’s lifetime.

Th e DPA uses a small probe fi tted around the patient’s fi nger, with a light-based sensor to detect the pulse characteristics. An arterial pulse wave, generated by the system software, provides an assessment of how large and small arteries behave when blood passes through them.  Unlike a high blood pressure reading, a lessthan-optimal arterial elasticity measurement does not indicate a person already has a serious medical condition, but it does indicate increased risk for developing such a condition. It is up to the patient, armed with information from their caregiver, to determine whether they will follow the road toward cardiovascular health, or the road toward higher risk. Rather than receiving a wakeup call through a serious cardiovascular event, the individual who has been monitoring arterial elasticity may receive the call years earlier.

Debbie Williams, RN, is VP of Medical Affairs at Meridian Medical.

Early detection of cardiovascular disease can reduce the huge human and economic impact of this group of diseases. 

TechSectors: Arterial Elasticity: The Key to Cardiovascular Health?

Researchers and healthcare professionals have speculated for years that the future of disease diagnosis is in the breath.  And that future may not be far off . Researchers around the globe are working on various breath-based technologies to not only diagnose illnesses, but identify the ingestion of drugs of abuse and provide defi nitive medication adherence documentation.  The science behind these technologies is based on previously unexpected fi ndings that many substances found in the blood show up in one’s breath. “Because the lungs have a huge surface area to exchange gases, what appears in the breath is a good refl ection of what is present in the blood,” reports Dr. Richard Melker, Professor of Anesthesiology at the University of Florida and Chief Technology Offi cer of Xhale, Inc. “We now believe that a large number of compounds of medical interest are available for analysis in the breath; a few years ago people wouldn’t have believed that. But, we’re on the cusp of a whole new medical era.” 

Currently, one of the most common uses of breath-based technology is the alcohol breath analyzer. Invented in 1954 by Dr. Robert F. Borkenstein, this technology has undergone a variety of changes over the years, but there have been no major advances in over two decades. But with new sensor technology, this decades-old tool is on the verge of a major transformation. Today’s alcohol breath analyzers face major issues with interfering compounds. At times, diabetics may have elevated acetone levels, which can result in false positive breath analyzer readings. Also, it has been reported that compounds in some common cleaning fl uids absorbed through the skin may cause erroneous results. Th e new generation of alcohol breath analyzers will have the ability to measure not only ethanol, but will be able to separate that measurement from other compounds.  Th is delineation will provide evidential proof of innocence or guilt.

Exhaled breath is an ideal non-invasive medium for many diagnostic tests. Breath-based tests will allow real-time results, because unlike other biological media, exhaled breath is present on a continuous, non-invasive basis. Th e collection of breath samples is straightforward and painless: no specimen has to be sent to a laboratory, no waiting for results is needed, no complicated steps exist, and mixing or handling of fl uids isn’t necessary, making it more convenient, effi cient, and cost-eff ective than blood- and urinebased testing systems.

As reported in the August 2007 issue of Cancer, 

researchers at Zhejiang University in Hangzhou

, China identifi ed potential biomarkers of lung cancer in the breath of patients with the disease. They identifi ed 11 volatile organic compounds (VOC) in the breath of patients with lung cancer that correlated with four VOCs found at the cellular level of four lung cancer types.  Breath-based research is also being conducted on breast cancer and heart disease diagnosis, and to correlate the levels of glucose found in the breath with levels of glucose found in the blood.  For diabetics, self-monitoring of blood glucose is the only way by which they can calculate drug dosage and maintain safe glucose levels. A breath-based monitoring system would eliminate “fi ngersticks,” making glucose testing painless and much more convenient for diabetics.

Another emerging area in breath-based technology is medication adherence monitoring. According to the National Council on Patient Information and Education (NCPIE), approximately 50% of patients are not taking their medications as prescribed. Lack of medication adherence leads to unnecessary disease progression, a lower quality of life, and even death. But one of the most serious results of poor medication adherence is the emergence of drugresistant strains in diseases such as tuberculosis and HIV/AIDS.  By tagging drugs with compounds that can be measured in the breath, medications can be detected via a small hand-held monitor.  Th is technology not only verifi es that a patient took the right medication and the right dose at the right time, it can also remind patients when to take medications.

In the near future, it can be expected that breath-based technology will overtake many medical markets due to its elements of convenience, non-invasiveness, cost eff ectiveness, and accuracy.

Ms. Casson is the Public Relations and Communication Coordinator for 

Researchers around the globe are working on various breath-based technologies to not only diagnose illnesses, but identify the ingestion of drugs of abuse and provide defi nitive medication adherence documentation. 

TechSectors - Medical Device: Medical Breathalyzer

In the course of covering the latest healthcare information technology news for physicians, there are times we wonder whether it’s all that it’s cracked up to be—whether the products and their capabilities warrant all the hyperbole.

 last visited this issue in our July 2007 cover story, “

?” mainly as it pertained to e-prescribing initiatives and lessthan-successful EHR systems. A year later, as we read and watch the breathless coverage devoted to recent moves by Google, Microsoft, and Apple, we are left asking “is healthcare IT worth the hype?”

With healthcare seemingly in permanent crisis mode, there’s a natural tendency for people in the industry to frame every issue in terms of needing a comprehensive solution to avert certain disaster. The more enthusiastic health IT boosters certainly haven’t shied away from casting their favorite applications in the role of healthcare’s savior, confi dently asserting that adoption will lead to thousands of lives saved and billions of dollars recouped. When numbers that large are thrown around, people tend to pay attention. Combine that anticipation with our societal belief in the innate value of technology and unwavering faith in our ability to innovate our way out of any problem, and you have a recipe for runaway hype. Even the merest hint of a rumor that 

 is planning to unveil “something big” is enough to send the tech industry media on 24-hour alert. So when the news hit that these companies were fi nally making long-anticipated forays into the healthcare market, the health IT community was abuzz with speculation and anticipation. However, at the end of the day, have these companies and their new products really succeeded in introducing ground-breaking ideas to the healthcare industry, and are they worthy of all the hype? And will they hog the spotlight from smaller health IT companies that may be short on notoriety but on the path to creating truly valuable technologies?

The past year has seen Microsoft launch the online health record platform 

; Google launch its online health information portal, 

that supports numerous, new third-party medical applications. A May 2008 MSN article captured the eff ects of the media frenzy surrounding all this, stating that society is “officially in bizarro world when 

 for absolutely no reason.” The article even cited an official Apple analyst who said users should not “expect revamped iPhones until 2009.” Th is, predictably, did little to dampen anyone’s enthusiasm.  Merely attaching the name “Google” or “Apple” to a product gives it authenticity in many people’s minds, regardless of its merits. Th us, these tech darlings are often given the benefi t of the doubt, with their previous successes (or at least the perception of their success) building up an enormous reservoir of goodwill in observers, making them inclined to assume continued success in all the companies’ endeavors. Th is uncritical embrace only fuels the hype and sets the stage for potential disappointment down the road.

However, some people are already pushing back and challenging the notion that all the hype is justified. Keith Schorsch, founder and CEO of 

 that he thinks Google especially has lost sight of what consumers (healthcare consumers, especially) really want and is focusing too much on user control. However there are companies that haven’t lost sight of what consumers and physicians need, companies whose products are designed to fill more modest but well-defi ned niches. Let’s turn our attention from the Googles and Microsofts and highlight some of the more notable “little guys.”

There are many smaller companies that have made great strides in developing truly useful healthcare technology applications that have yet to receive the attention accorded to their larger counterparts. 

and editorial board member Nancy Tice, MD, says free EHR platform 

 is among her favorites. The program allows physicians to integrate

applications without the use of onsite software, relieving practices of the burden of supporting traditional enterprise software products.

“Everything is automated—from scriptwriting to templates for commonly done exams,” Tice says. “One very important feature on PracticeFusion is that after the patients visit, when you close out the note, you may edit it. This is key for malpractice. So key, in fact, that your carrier is supposed to give you a discount if you use an EHR that does this.”

Another success story among the lesser-known tech companies is Hakia.com, a new, still-in-beta-stage semantic search engine with significant health and medical search coverage. “We started Hakia in 2004 with the potential to provide the first semantic search technology on the Internet,” says CEO Riza Berkan, PhD. “Search engines provide users with a popularity perspective. What Hakia does is provide credibility without relying on collecting votes. Semantics enables us to harvest databases with full potential (PubMed is one example). Hakia is the first search engine to rely on quality-stamped results.”

Berkan notes that Hakia was able to demonstrate quite a bit of success in semantic searching, even when comparing results to Google, the gold standard of online search in many people’s minds. “We are proud to be instrumental in that vision,” he says. “Popular information is not always correct, and correct information is not always popular. We went to medical associations and picked up their recommended sites for credibility measurement. That list is available on the website at 

 under ‘verticals.’ As an end-user, it’s not your job to determine which is credible information and which is not; the Googles of the world are not providing that to you.”

So what does this all mean for physicians? Lynn Ho, MD, runs her own micropractice in Kingstown, RI, and claims to not be easily influenced by the hype or media coverage devoted to larger companies, preferring the information that she finds through various e-mail listservs.

“I listen to the technology masters on listservs; word-of-mouth recommendation has worked well for me,” says Ho.

How else can a physician avoid the trap of going for the most-hyped technology versus the most beneficial? Hakia.com beta tester and physician John Boockvar, MD, takes it back to the basics and refuses to be swayed by the charm of the larger, better-known search engines. “From my use of [Hakia], it has shown promising signs of performance,” he says. “The articles it finds are not easily reachable through PubMed’s own search engine, nor with Google’s site search.”

Getting peer feedback is clearly another method for physicians to make the best informed decision about where to obtain their information. “Get personal recommendations from people that have tried the technology you are about to embark on, ask pointed questions, and see if it will fit your needs, not the hyped needs,” says Ho. Small companies aren’t immune to hype and

infl ated expectations. Their products still receive attention from media that focus on their industry, just on a much smaller scale. 

So, will the Hakia’s of the world live up to expectations? Berkan says, “It’s too early to make any judgments, but it’s been a bit of a feeding frenzy. Commercialism is okay, I’m not against it, but as with many health sites, I don’t see these kinds of distinctions, and that bothers me.” 

On the flip side, even the larger companies themselves appear to be less than enthused by the hype their names often generate. “I’ve always been a bit of a hype skeptic,” says Grad Conn, Senior Director of Product Marketing for Microsoft’s Health Solutions Group. “There’s a lot of energy in healthcare right now in terms of changes that are coming. I don’t want hype to get ahead of itself. People have a tendency to get overanxious, and then we’re disappointed. We’re encouraging everyone to boil the ocean 10 gallons at a time. We shouldn’t be too hard on ourselves if we haven’t completely transformed the healthcare system in a year.”

Despite the many triumphant predictions of greatness, it’s still too early to tell whether Microsoft and Google will succeed or fail. The public’s fi nal judgment may not even depend on the actual merits of the technologies themselves, but rather on of the products themselves. Health 2.0 Conference co-founder Matthew Holt is doubtful that health IT will be the solution to the current healthcare crisis. “I think anytime you’re talking about something as complicated as the healthcare system, saying that we’re going to change [it] using health 2.0 is over-ambitious… If you say health 2.0 is going to change healthcare as we know it in every aspect completely, immediately, you’re going to be disappointed. If you say we expect to see health 2.0 as the use of these tools adopted by more and more patients, physicians and healthcare organizations, I’m sure it could slowly change the way healthcare is delivered and the way people manage their health.” 

For more thoughts on healthcare IT from Holt, see the June 

…”. The reality is that most of these companies set out to do what they do best, which is create unique technology platforms for home and business that can be built upon and integrated with other existing technologies—not change the American healthcare system.

A year later, as we read and watch the breathless coverage devoted to recent moves by Google, Microsoft, and Apple, we are left asking "is healthcare IT worth the hype?"

Overshadowed by Giants

Imagine the following scenario: You’re on a vacation and need cash.  You go to the nearest ATM and insert your card. Th e machine replies with, “I’m sorry. I do not know you. And, I have no idea how much money you have to withdraw.” You try another and another ATM with the same results and come to the inevitable conclusion that “someone has to do something about this.” We have become so accustomed to the ease of electronic banking that we would find the above scenario extremely frustrating and demand change. And yet, we continue to tolerate similar episodes in healthcare on a daily basis. We act on incomplete information, we duplicate testing performed elsewhere, and we spend an inordinate amount of time collecting information that others have already collected. We must overcome all of the technical, political, and economical obstacles NOW. The need for system efficiency and patient safety demands it.

Now imagine a vision in which the patient, and when appropriate the patient’s family, as well as any physician, allied health professional, hospital, or laboratory that have appropriately delegated access to that patient’s medical records, can input data to contribute to his or her management. Is it possible? Of course it is. Think about the ATM machine in our example: It is relatively agnostic about where its data is coming from; it functions because agreedupon verification processes exist, and there are industry-standard defi nitions for “balance,” “withdrawal,” “deposit,” and other terms.

Progress is being made in healthcare, albeit slowly. Many justify this by pointing to the relative complexity of medical data versus that used in the banking or airline industries. Is this really true? Or is it an excuse for some other agenda? Is our data really that much more complex?

There are basically three models that have been developed that fulfi ll the requirements of a portable, unified medical record:

There are totally independent information systems, from which defined baskets of information are downloaded to some portable storage device. The radiology industry was one of the first to adopt this technology, burning CDs with MRI, CT, and other digital images. The patient is the primary “owner” of the information and carries it from provider to provider, who try to read and incorporate it, as best they can, into their native systems. Obviously, this was, and still is, a reasonable method of achieving some degree of portability of what has become relatively standardized information, although the amount and type of information conveyed are rather limited. Some patients have taken things a step further by manually converting their lab data into impressive spreadsheets, graphs, and MS Word documents. Patients were the first to recognize that, in the absence of system solutions, they would need to take control of data organization and portability. Source data integrity and cross-compatibility between systems generally remains problematic, except for radiology images.

Vendors develop centralized, usually Web-based, repositories to house relevant clinical information organized on a per-patient basis. With proper access security, any given provider can go to a centralized database and access pertinent patient information. Depending upon the systems utilized by the provider, some of this information may be amenable to importation into the provider’s native electronic medical record. The Web-basis of this design facilitates portability and relieves the patient of the responsibility of being the most current source of data.

Data integrity is generally improved, especially for those elements with relatively standardized vocabularies—such as demographics, laboratory, and radiology&mdash;but falls off when data is less standardized, such as with dictated reports. Nonetheless, this industry continues to grow and evolve, awaiting more formalized and complete data definitions. Despite significant efforts toward secure systems, numerous polls have shown patients remain reluctant to have their medical data “out there” on the Web.

The assumption is that the majority of the care for any given patient is delivered at one primary location. Generally, this applies to large, multi-specialty centers. It is less true for community-based providers, given that the balance of care is delivered in outpatient, smaller clinics as compared to care delivered in an inpatient setting. In that situation, hospitals continue to investigate and navigate the many obstacles associated with sharing electronic medical record systems with their physician staff. Patient input and access has been slowly adopted.

Model #3 is the approach we have decided to pursue at MD Anderson, where we are in the process of enhancing our patient-centered EMR. A guiding philosophy, however, has been to include both community physicians and the patients themselves as part of the input and output system. Patients who are technologically savvy now input the information about which they know the most (eg, demographics, medical history, family history), and this is “imported” into our EMR, after being verified by the provider. Additionally, patients have access to defi ned elements of the EMR, such as scheduling and secure e-mail to communicate with select providers. Other accesses are in the development stage. To complete the circle, outside involved providers are given access to the EMRs of those patients with whom they have a direct relationship, granted by the patient. 

Technology and policy drives the particular aspects for which access is available. The days of waiting for a summary letter about a recent discharge or treatment plan have been shortened potentially to hours or even minutes, thus facilitating communication and increasing patient safety. None of these models are the perfect solution for all circumstances. Each meets certain needs and requirements, given the limitations in current systems integration. Nonetheless, the goal should be the same: unifi cation of the patient and all providers to provide the highest quality and safest medical care.

Dr. Walters is the associate vice president of medical operations and informatics at the University of Texas MD Anderson Cancer Center.

We must overcome all of the technical, political, and economical obstacles NOW. The need for system efficiency and patient safety demands it.

The Next Big Thing: We need a team approach to the electronic medical record

	Stop us if you’ve heard this one before: A new technology is developed. Its creators promise the moon, claiming their idea will solve everything. Initial studies and testimonials appear promising, setting off a frenzy of speculative media coverage. As more attention and publicity is focused on the technology, a few early success stories cause expectations to inflate exponentially, overshadowing reports of disappointing or failed applications. Wider adoption exposes serious flaws in the technology and its applications, bursting the hype bubble and causing industry observers to move on to alternate options and ideas.

	Replacing the revolution with incremental change and modest goals, the remaining proponents of the technology settle down to the long, hard work of refi ning practical applications that find their niche in the marketplace. The pattern has repeated itself so frequently that information technology research and consulting leader Gartner, Inc., came up with a catchy name for it: 

. Nearly every technology-dependent industry has experienced hype cycles on scales both large and small, from e-commerce and finance to communications and media. Healthcare certainly hasn’t been immune, especially when it comes

	Although many of the hot-topic technologies and applications that are at the center of the debate have been around in one form or another for many years, it seems as if the hype surrounding their use in healthcare has grown in intensity in the last few years. From increased federal support for projects that study and promote the use of various IT applications in healthcare, to the burgeoning EHR industry, to dozens of other projects, initiatives, industry partnerships, and organizations, never has so much activity and attention been focused on healthcare technology—much of it driven by hype and promises of a healthcare landscape transformed.

	Exciting times, yes, but much of the initial rush of optimism has been replaced by the sober realization that successfully implementing and applying information technology solutions that effect truly meaningful changes in the healthcare industry is going to be a complex and diffi cult process. One reason for this emerging pragmatism has been the failure of many emblematic health IT applications to live up to the lofty expectations that accompanied their initial adoption. Whether due to insuffi ciently mature technical capabilities, flawed business models, faulty interpretations of the underlying challenges they were supposed to solve, unsustainable financial requirements, or any of a dozen other reasons, the technologies and ideas profiled on the following pages have fallen short of the mark.

EHRs: The alpha and omega of healthcare hype

	Perhaps the one application that best represents the tangled drama of potential, hype, disappointment, and redemption that has characterized the drive toward widespread health IT adoption, EHRs remain something of a paradox. They have demonstrated value for practitioners (less so for patients, at least directly) and are supported by a fairly robust and developed product market; but they are also prohibitively expensive, they accrue their benefi ts mostly to payers and insurers, they create extra work for practices that implement them, and they are still not very user friendly.

	EHRs are supposed to help physicians streamline the process of maintaining a patient’s medical record from start to fi nish. Physicians were told of the many benefi ts of installing an EHR in their practice, including how it can reduce costs, decrease medical errors, and improve quality of care. To date, though, too many physicians have experienced too many problems—system malfunctions, issues with accuracy and user interface design, and high costs. 

MDNG Physician Editor-in-Chief Jonathan Bertman

, MD, says, “Bringing technology into one’s practice has been hampered by greedy corporations charging thousands of dollars for software that is overly complex, poorly designed, and all too frequently unusable.” Little wonder then that the adoption of EHRs has been slow in the United States.

	Does this mean EHRs will not one day be as successful as everyone had originally hoped? Not so fast. Recently introduced EHRs are more functional and cost less, and the future is even brighter. “For EHRs to live up to the hype, physicians have to demand transparent pricing, an ability to try the products before they buy, and head-to-head comparison of products where vendors can show how they document a standardized patient,” says Bertman.

	Google the term “RHIO” and you’ll retrieve thousands of articles that talk about the potential usefulness of creating regional data networks that allow physicians and other providers in different health systems to seamlessly transmit and share medical records and other data. Although you’d think that solving the thorny technical problem of interoperability among disparate systems would be difficult enough to doom many of these projects, you’d also find that sooner or later, most of those articles get around to mentioning the real reason that many RHIO projects have failed: the unsustainable business model upon which many of them are based.

	Federal grants provided seed money for many RHIO projects—grants which proved in many cases to be non-renewing. Once those funds dried up, RHIO executives and organizers were forced to confront a variety of challenges, including reconciling the problem of misaligned fi nancial incentives among stakeholders (a classic business quandary in which benefi ts that accrue from capital outlay and other investments by one participant are not shared among all participants), and convincing all stakeholders to incur equal financial risks.

	The poster child for this outcome is probably the Santa Barbara RHIO that closed shop at the end of 2006. Much has been written about the causes of its demise, but perhaps the best summary is provided in a “lessons learned” report from the 

, the authors of which identifi ed “lack of a compelling business case, distorted economic incentives, passive leadership among participants, vendor limitations, software delays, and privacy and security issues” among the primary causes of failure. For more on the challenges RHIOs face, see Dr. Barry Chaiken’s piece in the March/April issue of 

	Clearly, the Internet has replaced money as the root of all evil. Most misunderstandings can be traced back to the online knowledge source Wikipedia, online fi rst-person gaming is undoubtedly responsible for the spawning of at least a few homicidal maniacs each year, and don’t even get us started on the worldwide epidemic that is repetitive strain injuries. While we’re here, let’s make the Internet the fall guy for all that’s wrong with healthcare.

	That may be overdoing it just a bit, but the Internet is far from blameless in the search for what ails healthcare. Take, for instance, the patient 

! In all seriousness, it’s impossible to ignore the profound impact the Internet could have on making patient records easily accessible, and consequently, speed the delivery of care by healthcare professionals. Think about how streamlined medical care would be if doctors’ offices, hospitals, and pharmacies could easily access the same information from their respective locations. Unfortunately, there are still a few roadblocks—namely security&mdash;that we have to overcome before we make this a reality. So, knowing the potential of the Internet, and realizing that it cannot yet be achieved, equals an HIT idea that has failed to deliver, yet still might pay off . But whether it’s this Internet or 

Patient portals offer a window into modern medical practice

	Patient Portals, which can be thought of as “a gateway or door (in the form of a Web interface) to related sets of data, content, and Web services,” have been touted as an excellent way to open the lines of communication between patients and providers by allowing users to request appointments, check lab results, examine statements, request prescription refi lls, and complete healthcare forms.  Earlier this year, the 

 published a study titled “Interest in the Use of Computerized Patient Portals: Role of the Provider—Patient Relationship.” The study found that “interest in the portal was linked to dissatisfaction with the provider–patient relationship, including dissatisfaction with provider communication/responsiveness, the inability to obtain medical information, and logistical problems with the office.” Further, the 

 found that “disinterest in the portal was linked to satisfaction with the provider—patient relationship, including provider communication/ responsiveness, difficulty in using the portal, and fear of losing relationships and e-mail contact with the provider.”  Much like EHRs, patient portals have the potential to transform the way healthcare is delivered. However, at the moment, the obstacles loom large.

	RFID, at least in the form of implantable microchips that enable patients to

	take their medical information with them wherever they go and make it available even if they are unconscious or unresponsive, certainly seems like a no-brainer. That’s why in April 2002, 

 began production and sales of its implantable ID microchip. Fast forward to December 2007 and you’ll fi nd that only 500 people nationwide are enrolled in the company’s system that uses the chips, and 

 deploy the RFID readers needed to access the information stored on the chip. A 2007 survey of 119 CIOs who are members of the 

College of Healthcare Information Management Executives

 found that 76% did not have RFID at their organization and had no plans to adopt it. Further, just 4% said their organizations use RFID systems, with only 4.5% in the process of adopting a system.

	Why the reluctance? For starters, the 16-digit patient identifi er housed on the chip “is not protected by [HIPAA], and there are no laws that regulate how and by whom it can be read,” said Ben Adida, research scientist, Children’s Hospital, Boston, MA. “Th eir unique identifi er is available to any reader in exactly the same way.” Further, the databases that store patients’ information “are not yet uniform in the sense of using the same data [and] the same defi nitions… so having access to one database does not give easily transferable information,” added Mark Levine, chair, council of ethical and judicial aff airs for the AMA. A 

 that stated “Though [RFID implants] are removable, their small size allows them to migrate under the skin, making them potentially diffi cult to extract,” certainly hasn’t helped increase adoption. The report also presented concerns regarding electromagnetic interference with electrosurgical devices and defi brillators, the implants’ possible eff ects on medication effi cacy, and information security.

	There are a variety of reasons why personal health records (PHRs) have been slow to catch on: wide variations in quality among the hundreds of products on the market; little-to-no support from physicians (who also worry about their legal responsibilities regarding the data stored in PHRs); limited compatibility with existing electronic record systems; uncertainty among the public regarding what exactly a PHR is for and how it is used; no financial incentives from payers; privacy concerns; and consumer inertia.

	Does anyone really want one of these things (saying “yes” to hypothetical questions on a survey doesn’t count)? What capabilities and features are consumers looking for in a PHR? We’re not alone in wondering this. Patricia Flately Brennan, RN, PhD, National Program Director of 

, a program designed to support the creation of a new generation of PHR systems, wrote an article in 

 earlier this year that asked “How can we make [PHRs] useful to consumers?” She claimed that “it’s simply not enough to create a [PHR] and then assume patients will use it.” If we want to “truly capitalize on the potential of PHRs and develop tools that can motivate individuals to better manage their health and coordinate their care, we must start by understanding what consumers need,” noted Brennan. 

development of computerized physician order entry

 (CPOE) was to decrease the number of medication errors. In fact, research has shown that should this technology be implemented in all US urban hospitals, approximately “907,600 serious medication errors could be avoided each year.”  As with EHRs, expectations were high for CPOE and its benefi ts for patients and physicians. The problem, in a nutshell, is that almost no one seems to be using CPOE. Concerns regarding system and training costs, implementation time, and unanticipated technical shortcomings (eg, physicians’ ability to override the safety alerts designed to make sure the information entered into the system is correct) are to blame. “You can’t just take a CPOE system off the shelf and plug it in,” says Leah Binder, CEO of Th e Leapfrog Group, a powerful coalition of healthcare purchasers. “It takes commitment and leadership from clinicians to make it eff ective in reducing errors.” As long as physicians are willing to take the time to carefully enter treatment instructions into CPOE, prescription errors will decrease. “CPOE is a technology that’s been slow in up-take, but certainly not for lack of evidence of its usefulness in terms of the number of lives and dollars saved from its implementation,” says Binder. Between all of the headaches associated with CPOE, it still does more good than harm if it is used properly… or at all.

Exam room computers don’t mean to intrude

 reads “Few clinicians in the United States use computers during patient encounters, and many still worry that computers will depersonalize their interactions with patients.” A decade later, exam room computers have been touted as improving access to information at the point of care, and allowing for better note-taking, among other performanceenhancing benefits. But it’s difficult to argue that much progress has been made.

Office of the National Coordinator for Health IT

 found that only 24% of physicians used any form of a computerized record system. The most commonly cited reason for not using computers in the exam room is the effect they have on patient—physician communication. 

 published in July 2005 stated that physicians who had poor communication skills tended to get lost in the computer, communicating with it instead of the patient.

	The study’s lead author, Richard Frankel, PhD, explained “You may have a great diagnosis, but if you can’t communicate it to the patient, he or she may not follow-up appropriately... If the computer is poorly positioned, it either gives you a really sore neck from turning around if you want to engage your patient or you wind up with the back of your head to the patient.” Early last year, 

 found that patients “more often agree that exam room computers decreased the amount of interpersonal contact.” 

 sums up the issues best, explaining that computers present more tasks to complete, with attention to the patient often suffering.

Personalized medicine: Is hype in our genes?

	Your patients have been promised maps of their individual genomes, drugs that are tailored to work perfectly for them without those pesky side effects, and advanced warning about disease risks based on a study of their DNA. So far, however, the personalized medicine craze has been a substantial letdown. Yes, there have been advancements regarding how individuals will

	metabolize some pharmaceuticals. But as for widespread applicability, it’s been an exercise in hype, fueled in part by an overzealous media. The Personalized Medicine Coalition—non-profi t advocacy group that “works to advance the understanding and adoption of personalized medicine for the ultimate benefi t of patients” and counts among its members several dozen biotech, consumer diagnostics, and genetic testing services companies (so you know where they’re coming from on this)&mdash;sounds the proper note of cautious optimism in its report “

,” written to “shed light” on the “demonstrated benefits and limitations” of personalized medicine. Another antidote to infl ated expectations can be found at the 

, written not by Mr. Eugene Sherpa, but by Yale University Clinical Genetics Fellow Steve Murphy, MD. Murphy, whose sensible optimism about this fi eld is tempered by an awareness of the challenges that lie ahead, likens the pursuit of personalized medicine to a “perilous path… Much like the route through the Himalayas, it has punished the naive and self-reliant.” Now that’s cutting through the hype.

Great Expectations: What happens when once-promising healthcare technologies and ideas don't deliver?

NJR Healthcare uses state-of-the-art technology and a non-traditional practice model to deliver high-quality care—including routine medical exams, comprehensive physical exams, continuity of care visits, and even “VIP services”&mdash;to a diverse patient population in a variety of settings.

1 What sets NJR Healthcare apart from a traditional medical practice?

We are a practice without walls. We provide healthcare to patients who are hospitalized or are in nursing homes and subacute rehabs, and we also make house calls. We provide services to patients who traditionally have had trouble getting healthcare—those that can’t easily leave their homes, or those whose insurance doesn’t pay well for office visits. We see everyone from indigent patients to patients with government-sponsored insurance to celebrities. It’s a great way to practice, particularly with the advanced technologies that enable our practice to be basically Internet-based and offer patients the ability to schedule appointments online and view their medical records anytime they wish.

2 What technologies do you use to support your practice? What are your staffing needs?

, a rather sophisticated, secure EMR system. I researched online and found there was really nothing out there that fit the needs of my practice and my patients, so I developed my own system. I have a full-time staffer who helps patients who have problems with the website, schedules appointments, etc. I have a full-time EMR support employee for troubleshooting, and a full-time office manager who coordinates everything. Our two nurse practitioners and I all travel with laptops that have broadband access, so we always can access medical records online with our “virtual office” and send information on lab results in real time. We use BlackBerries to communicate with each other through our secure e-mail site.

3 Do you have a Web portal that patients can access to check lab results and other information?

Absolutely. Our website has an administrative site and a patient access site. Patients get a password and username that allows them to log in and see the date of their last visit and check their prescriptions, allergies, latest lab results, last consultations, etc. I once had a patient who was on vacation in Hawaii who developed chest pain and ended up in the ER. She has a rather extensive history, so she went online, right there in the ER, and was able to access all of her information. The ER physicians claimed they hadn’t seen anything like that before.

4 What do your colleagues think about your practice?

Do they view the technology you are implementing as a barrier between you and your patients? I’ve met with probably 95% skepticism.  I’ve had to deal with specialists telling my patients they shouldn’t see me because I don’t have an office. But with the way my practice works, patients actually have more access to healthcare, not less. Doctors are very technically savvy when it comes to the latest tests and treatments, but unfortunately not so savvy with computers, the Internet, and other IT—I actually have colleagues who still don’t have a single computer in their office. They see me running around in the hospitals, talking to patients on my BlackBerry, and say, “What are you doing? You should be in front of them or you should be talking to them in your office.” It’s frustrating.  We cannot stop the progress of information technology. We should be giving patients more access to healthcare, not less. We need to make our practices more efficient, not less. I think patient demand will drive this. I had a colleague tell me that although he is skeptical of what I am doing, he can already see how NJR is changing the way medicine is perceived in our area.  His patients are saying, “The doctor who referred me to you has everything online. I can communicate with him online, so why do I have to wait two weeks to get information from you?” Virtual medicine is going to become a reality. Our local hospital system uses virtual neurologists to decide whether someone should get thrombolytic therapy. At fi rst I was skeptical, but when I saw it in action, I was completely amazed. It only gave me more motivation to do what I do. I have no doubt that this is the wave of the future in medicine.

. Contact Dr. Faustino with questions or comments at 

NJR Healthcare uses state-of-the-art technology and a non-traditional practice model to deliver high-quality careâ€"including routine medical exams, comprehensive physical exams, continuity of care visits, and even "VIP services"â€"to a diverse patient population in a variety of settings.

4 Questions... with Alan Faustino, MD, president of NJR Healthcare

Boris Rubinsky, professor of bioengineering and mechanical engineering at the University of California, Berkeley, explains his research using cell phone technology to reproduce medical imaging, which can then be transferred to a physician through his or her cell phone.

Why use cell phones to transmit medical images?  I’ve been working toward this goal for well over 10 years now and decided to focus on developing medical imaging for areas of the world with few resources. The particular application related to cell phones became obvious when I traveled to India, Th ailand, and China. People were speaking on their cellular phones and I realized that the phones were much more accessible than LAN lines, so I decided to look into something that was based on cellular phone technology, which led me to trying to fi gure what medical imaging technology would fi t developing countries. Understanding how medical imaging devices work, I began to think about the most essential and least expensive devices that need to be near the patient.  Medical devices have three major components: they are made of a data acquisition device that adjusts the fi xed ideas on the ultrasound and the ultrasound transducers that you put on the body of the ultrasound probe. Then the information is transferred to the processor of a computer that processes the data that produces the image, which is the second component.

The image is transferred to a display, which is the third component. These three components exist in all devices, and of course one has to understand how to separately handle them and all of these spare parts for all three components. It occurred to me that the cellular phone can serve as a replacement and can facilitate this entire design. The data acquisition device has to be in the vicinity of the patient, but that’s the only thing that needs to be in the vicinity of the patient. Our idea was that the data acquisition device plugs into the cell phone (a) and transfers only the raw data, which can be turned into a simple text message (b). Then, using a powerful computer at a central location ©, the raw data is processed and the image is developed and sent back through the cellular phone (d) the same way that a photo taken with a camera phone is sent. This new arrangement allows a physician to visit a remote area or be in the field and bring his cellular phone wherever he goes. The main issue is maintenance and the low number of resources worldwide. What this has done is taken an expensive machine that is broken into three parts and distributed it to different geographic locations that are connected by cellular phone technology, leading to a simple and inexpensive imaging technique.

Will this concept work for all medical specialties?  In terms of medical imaging, yes. The technology is very general and is used the same way as medical technology for every application. Th e most economical imaging applications would be electrical impedance tomography and ultrasound. Although it can be used with other technologies, the data acquisition part may be too expensive, but there is room to reduce costs.  How successful has the testing been?

We have not tested humans yet, but the tests we’ve done have been successful as reported in the paper published in the April 30, 2008 issue of 

. We didn’t have to develop new technology.  All we had to do was fi nd a way to use existing technology in a diff erent mode. Cellular phones exist, medical imaging exists, medical construction exists; we just rearranged the programs. We actually have a very interesting application in developed countries as well. We built a device that can be connected to the cellular phone that anyone in the United States could buy. It may be an interesting replacement for self examination. I think this technology will have a substantial aff ect on the cellular phone consumer market and on rural clinics. Underdeveloped countries aren’t the only ones that have these problems.  How long before the transmission of medical images via cell phones is a standard medical tool?

I think these things are driven by necessity. Cellular phones have become an indispensable tool for everything. In my opinion, this concept will probably become something that is used very widely in a couple of years.

July 2008