Conservative and libertarian writers, some with ties to the Reagan and Bush I administrations, have 

 that health insurance mandates—which may end up in a final federal health insurance reform law&mdash;are well beyond the constitutional authority of the federal government to tax, spend, and regulate interstate commerce. Others have picked up on these arguments and applied them to the EHR-implementation incentives under the HITECH Act as well. The bottom line is that these arguments fail, for four reasons:

there is no mandate to implement EHRs in the HITECH Act

. The EHR incentive provisions allow for reimbursement of certain costs, up to a stated maximum per provider, for the “meaningful use” of a “certified” EHR. Definitions of these key terms are being worked out by 

 and should be formally adopted by the end of December. Failure to begin meaningful use of a certified EHR system will result in a penalty, or discount, being applied to payments for services provided to enrollees in federal healthcare programs after the phase-in period is complete, in 2015.

As is the case with many other initiatives promoted by the federal government when it is acting as a third-party payor, incentives are provided for early adoption of new initiatives and/or penalties are imposed for failure to comply by the end of a phase-in period, with the financial incentives for compliance increasing over time. One example of this is the 

Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) system

 of “pay for reporting” of quality indicators by hospitals. It may feel like a mandate to some, but the existence of incentives and disincentives under a Medicare provider agreement do not a mandate make. No provider is required to participate in the Medicare program.

Second, even if the HITECH Act were a mandate for the use of EHRs, it would easily survive an attack based on the Commerce Clause of the US Constitution. Due to the limited powers granted by the states to the federal government, federal laws affecting economic activity may only be adopted if they regulate interstate commerce. Such a challenge to the HITECH Act, then, would have to be based on the contention that the federal government lacks the authority to regulate the delivery of healthcare services, because healthcare is neither “economic activity” nor an activity touching on interstate commerce. Given the development of Commerce Clause jurisprudence in the US Supreme Court, it is too late in the day to assert that healthcare services—even though they may be provided locally&mdash;do not involve interstate commerce. To suggest that healthcare  a $2.4 trillion sector of the US economy involves only local commerce and/or “non-economic activity” strains credulity.

Third, the argument has been made that Congress cannot tax what it cannot otherwise regulate, with the corollary being that a financial penalty associated with a decision not to adopt an EHR may not be imposed. While the basic proposition—that Congress may not tax what it cannot otherwise regulate&mdash;may have merit, the fact of the matter is that Congressional authority under the Commerce Clause is extremely broad; thus, there is indeed little that it cannot regulate and, therefore, tax. Many other sectors of the economy are constitutionally regulated and taxed; even if the HITECH Act’s disincentives were found to constitute a tax, they would be permissible under the US Supreme Court’s expansive reading of the Commerce Clause.

Finally, the HITECH Act may not be challenged as a bill of attainder, violating individual rights by imposing penalties without trial. Opponents of the law characterize the monetary penalty that may be imposed on Medicare providers that fail to make meaningful use of certified EHRs by 2015 as being similar to a government seizure of paychecks of Communists employed by the federal government in the 1940s—a legislative act that was overturned in the courts as a bill of attainder. The legitimate legislative purpose in the case of the HITECH Act is the anticipated improvement to the healthcare provided to Medicare beneficiaries served by providers adopting EHR systems, and the cost savings associated with anticipated system efficiencies; the class of persons being regulated is, appropriately, healthcare providers that participate in the Medicare program.

The promotion of meaningful use of certified EHRs by financial incentives and disincentives set forth in the HITECH Act pass constitutional muster as a rational set of rules designed to improve and streamline a significant sector of our economy.

, and is a healthcare lawyer and consultant based in Boston, MA. He helps healthcare providers and related businesses of all shapes and sizes realize their goals in an increasingly regulated environment. His blog, 

, is recognized as a leading healthcare law and policy blog. Follow him on Twitter: 

Articles

Columns

Arguments that the EHR-implementation incentives under the HITECH Act are unconstitutional fail for a variety of reasons.

The HITECH Act Is Constitutional

There has been much discussion about the HITECH Act and the effects it will have on healthcare in this country. The health IT industry, anticipating a ï¬ nancial windfall, has been vocal in its support, while the federal government claims that EHR use will lead to an increase in quality, a decrease in costs, and an overall improvement in patient care (cf, the answer to the question “Why health IT?” at 

). Skeptics like me disagree with these claims and feel that overall the push to adopt complex EHRs will be a bad deal for physicians, most of whom will bear large ï¬ nancial losses and have to markedly change the way that they interact with patients.

In the midst of this discussion, several opponents have questioned the constitutionality of the HITECH Act. Constitutional reviews of legislation usually rest on one of two claims: (1) lack of federal power; and (2) violation of individual rights protected by the Bill of Rights (

The US Constitution empowers each branch of government with a speciï¬ c set of duties, reserving all other powers for the states and for the people. The Commerce Clause allows for the regulation of economic activity across state lines that involve the production, distribution, or consumption of commodities. With the HITECH Act, the administration and Congress appear to be working under a distorted interpretation of the Commerce Clause that allows the feds to regulate and control just about everything, including the use of certiï¬ ed EHR systems (c-EHR).

The doctor—patient relationship and the use of c-EHR can hardly be regarded as commercial activities. A stricter interpretation of the Commerce Clause would hold that the government does not have the authority to force doctors to spend their money on technology. There would appear to be some precedent for this view of things. In a Washington Post editorial, David B. Rivkin Jr. and Lee A. Casey noted that, “In two key cases, 

 (2000), the Supreme Court speciï¬ cally rejected the proposition that the commerce clause allowed Congress to regulate noneconomic activities merely because, through a chain of causal effects, they might have an economic impact” (

Article I, Section 8 of the US Constitution gives Congress the power to tax, borrow, and spend money; raise and support armies; declare war; establish post ofï¬ ces; and regulate commerce. However, it is politically unpalatable for Congress to tax physicians for not meeting the qualiï¬ cations for “meaningful use” of a c-EHR, so they decided to impose penalties to legally force physicians to adopt health IT. The legal deï¬ nition of “penalty” is: “1) in criminal law, a money ï¬ ne or forfeiture of property ordered by the judge after conviction for a crime; 2) an amount agreed in advance if payment or performance is not made on time, such as a “late payment” on a promissory note or lease, or a ï¬ nancial penalty for each day a building contractor fails to complete a job” (

http://legal-dictionary.thefreedictionary.com/Penalty

). Thus, the “penalty” for non-meaningful use is really a ï¬ ne levied for the “crime” of not purchasing and using a c-EHR system.

Let’s take this a bit further: a bill of attainder is an act of the legislature declaring a person or group guilty of a crime and punishing them without a trial. Article 1, Section 9 of the US Constitution speciï¬ cally forbids the federal and state governments to enact bills of attainder (

). Very few acts of Congress have been overturned due to a court subsequently determining them to be an unconstitutional bill of attainder. In one such ruling, Cummings v. Missouri, the court stated that “A bill of attainder, is a legislative act which inï¬‚ icts punishment without judicial trial and includes any legislative act which takes away the life, liberty or property of a particular named or easily ascertainable person or group of persons because the legislature thinks them guilty of conduct which deserves punishment” (

, the court stated that “Legislative acts, no matter what their form, that apply either to named individuals or to easily ascertainable members of a group in such a way as to inï¬‚ ict punishment on them without a trial, are ‘bills of attainder’” (

Based on these precedents, I think the legality of the HITECH Act is murky at best. It fails not only because Congress lacks the power to regulate this activity (per the Commerce Clause), but also because the Act appears to function as a prohibited bill of attainder that violates the individual rights of physicians.

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 reï¬‚ect those of

Skeptics like Borges disagree with claims that HIT adoption will improve quality of care and cut costs, and feel that overall the push to adopt complex EHRs will be a bad deal for physicians.

The HIT Realist: Is the HITECH Act Constitutional?

Patient/Provider Connectivity: Leading the Transformation of Healthcare Delivery 

Presented by David Nace, MD, RelayHealth 

Nace began his presentation with a review of the current challenges facing medical practices. He noted that healthcare cost pressures and the economic downturn have caused a need for administrative efï¬ ciencies and reimbursement management at the point of care. Healthcare reform and the HITECH stimulus also present challenges in trying to achieve meaningful use and interoperability for care collaboration. 

Nace cited the results of the RelayHealth survey on point-of- service (POS) reimbursement challenges, which found that practices want better visibility into payment at the POS, patient collections are a signiï¬ cant challenge for physicians, and practices are willing to collect payment at the POS based on credible estimates. 

Returning to the topic of administrative efï¬ ciencies, Nace noted that the total cost of medical practice interaction with insurers is $21-$31 billion per year. The total practice impact is more than $68,000 per physician each year. 

When discussing laying the foundation for interoperability, Nace explained that health information exchange (HIE) is moving faster than EHRs, with HIE funding beginning in 2010, typically received as up-front grants via the states, and EHR funding beginning in 2011, paid directly to providers AFTER proving meaningful use. Options for those who adopt are a “connected” EHR, going with a modular approach, or starting out with the basics and then adding advanced applications, explained Nace. 

Focusing on HIE, Nace stated that the evolving world of Web services (SaaS)—through Web applications, clinical data distribution, interoperability services, and network identity management&mdash;allows for the avoidance of costly, complex, locally installed software; the avoidance of infrastructure needs (just access to the Internet); rapid deployment and adoption; no need of local or practice IT staff, and predictable costs. Further, HIE use can help reduce staff time that would be spent on handling lab and radiology results and clerical administration and ï¬ling; decrease what is spent on redundant testing; decrease costs of care for chronic care patients; and reduce medication errors, according to Nace. 

What the Economic Stimulus Package Means for Physician Practices: Optimizing the Opportunity 

Presented by Justin T. Barnes, Chairman, EHR Association, VP, Greenway Medical Technologies 

Barnes, who has presented to Congress and actually worked on the stimulus package, began his 20-minute session with an overview of the HIT stimulus, which provides more than $30 billion of direct adoption incentives ($17.7 billion for Medicare and $12.4 billion for Medicaid). 

Breaking it down further, $2 billion is for the Ofï¬ ce of the National Coordinator for Health Information Technology, the National Institute of Standards and Technology, and health information exchange infrastructure; $2 billion is for distance learning, telemedicine, and broadband program account loan guarantees and grants; $1.5 billion for the Health Resources and Services Administration, $1.1 billion for the Agency for Health Research and Quality, $500 million for the Social Security Administration, and $85 million for Indian Health Services.

“Conservative Congressional Budget Ofï¬ce estimates show that American Recovery and Reinvestment Act (ARRA) funding will save over $15 billion in government spending throughout the health sector through improved quality and care coordination, reduced medication errors, and duplicative care,” continued Barnes.

Key milestones for ARRA, according to Barnes, include

• Sec 3003: HIT policy committee — announced April 3, 2009 

• Sec 3003: HIT standards committee — announced May 8, 2009 

• Sec 3004: Adopt an initial set of standards, implementation speciï¬ cations, and certiï¬ cation criteria — set for December 31, 2009 

• Sec 4101: Medicare incentives for eligible professionals pay out year begins — starts January 1, 2012 

• Sec 4201: Medicaid incentives for eligible professionals pay out year begins — starts as early as 2010, but bulk comes in 2012 

When looking at Medicare-eligible professional incentives for meaningful use of a certiï¬ ed EHR, Barnes says the breakdown will be as follows: install in 2009-2010, receive $18,000 in 2011, $12,000 in 2012, $8,000 in 2013, $4,000 in 2014, and $2,000 in 2015, up to $44,000 per provider. For those who don’t meet meaningful use criteria, they can expect a 1% penalty in 2015. Then, a study will be conducted, and if more than 70% of practices don’t have a certiï¬ ed EHR, reductions will continue for two years, up to 5%. 

The breakdown for Medicaid, says Barnes, looks like this: install in 2009-2010, receive $25,000 in 2011, $10,000 per year through 2014, and then $8,000-$10,000 for 2015, up to $63,750 per provider of uninsured, rural, FQHC, and low-income providers/eligible professionals who have a 30% Medicaid population. Pediatricians must have a 20% Medicaid population to receive incentives, but must have over 30% to receive the full $63,750. No penalty reductions will be handed out to those who don’t adopt. 

One interesting fact that Barnes mentioned: for certain eligible professionals who predominantly furnish services in an area that is designated by the secretary as a health professional shortage area, the amount of incentives they receive is increased by 10%. 

“Seize the opportunity today,” said Barnes. Begin fostering the EHR discussion, understand the goals for adoption, review the process, and get leadership set in ï¬ nancial, quality, patient satisfaction, clinical research, and community areas, he advised, adding that practitioners need to make sure the EHR meets their practice needs, keeping in mind that no product is perfect and that one may need to meet the system “in the middle.” Properly deploying an EHR system takes time. 

Barnes said to begin the move to an EHR by learning all you can at sites such as 

. He noted that although CCHIT won’t be THE certifying body, it will be one of them and that physicians should ask their vendor if they are not only 2008-certiï¬ ed, but 2009-certiï¬ ed as well. He added that “companies that are CCHIT-certiï¬ ed are committed to success just like you.” 

Things to look for in an EHR, according to Barnes, include: 

• References from practitioners in your specialty and practice size 

• Product workï¬‚ ow that is consistent with your practice requirements 

• A product that can be “meaningfully used” at the point of care 

• Product certiï¬cation (he notes that many see the new certiï¬cation process building from the current CCHIT framework and efforts) 

• 2008 CCHIT certiï¬cation & meaningful use 

“So, what does meaningful use call for?” asked Barnes. It includes the following: 

• Reporting of usage and clinical quality measures using the EHR 

Finally, Barnes recommended that physicians reach out to their senators and congressmen and educate them on the challenges 

Leveraging a Software-Enabled-Service (SeS) Platform to Improve Clinical and Administrative Outcomes for a Practice 

Presented by Jeremy Delinsky, athenahealth, Inc. 

Healthcare should be about taking care of patients, began Delinsky; this simple thought certainly makes sense, but it can easily be forgotten when trying to keep a practice aï¬‚ oat these days. Healthcare is a challenging business to operate, with physicians (and patients) feeling the pressure from all sides, including: 

• Government regulations (HIPAA, NPI, ICD10) 

• Payers (Lower reimbursement, more hurdles to getting paid, increased “self pay” balances) 

• Industry (Consumer-directed healthcare, retail clinicians, P4P reporting requirements) 

In order to make it all work, extensive connectivity is needed, explained Delinsky. So, what plays a role in that? For starters, groundbreaking legislation was passed with the ARRA and the HITECH Act, the latter tying $17.2 billion to “meaningful use” of an EHR. Meaningful use, the presenter noted, is focused on improving quality, safety, and efï¬ ciency; engaging patients and families; improving care coordination; improving population health; and ensuring privacy and security. Adoption and use are key, he added. 

Proposed health reform is tied to payment reform, said Delinsky, calling attention to a quote from the April 21, 2006 issue of Modern Healthcare that reads “9 out of 10 health care leaders back a ‘complete transformation’ of the U.S. health care system.” Adding to the argument that health reform is tied to payment reform, Delinsky presented a quote from President Barack Obama on paying for results rather than utilization: Obama said on March 24, 2009, “How are we going to reduce health costs?...Let’s invest in mechanisms that look at who’s doing a better job controlling costs while producing good quality outcomes…and let’s reimburse on the basis of improved quality, as opposed to simply how many procedures you’re doing.” Delinsky also quoted Dr. David Blumenthal from the NCHIT, on changing the payment system: “Realizing the full potential of HIT depends in no small measure on changing the healthcare system’s overall payment incentives so that providers beneï¬ t from improving the quality and efï¬ ciency of the services they provide.” 

Currently, it’s too hard for physicians to get paid, said Delinsky, adding that there is “a mess of complex, analog-based requirements” and that “controlling the clinical workï¬‚ ow requires mastering a similar mess.” So, what’s a physician to do? Buy new software? Outsource billing? Delinsky said that doctors need a partner. 

And that partner needs to be focused on results, not products; have aligned incentives (they only get paid when you do); be ï¬‚ exible by quickly adapting to the ever-changing healthcare landscape; and apply collective knowledge for the beneï¬ t of everyone. This partner, Delinsky feels, can come in the way of a software-enabled service that can help physicians get paid more, faster, and with less hassle. 

Leah Cohen, a Government Affairs Representative for MGMA, led off her presentation by announcing to the large crowd that she is “only the messenger.” It was a great way to break the ice, and her comment got many laughs from the physicians in the audience who were looking to her to sort out some of the legislation that affects them. However, they may not have gotten the closure they wanted from this meeting, because Cohen rightfully informed them that much of the information she had on her slides changes daily. 

Her presentation touched on a number of key issues that physicians hear about all the time — PQRI, Medicare, reimbursement, employer requirements, and so on. She did a nice job explaining complicated issues and spoke at length about what the House and Senate Finance Committees are trying to accomplish in the next few years. There were enough pie charts, graphs, and numbers to make anyone’s head spin, but aside from all the talk about government legislation, Cohen also provided some interesting resources. There are two in particular that all physicians should familiarize themselves with: 

Cohen continually encouraged the audience to get involved by sending letters to legislators regarding healthcare reform. She also said to send them often and to keep them updated. However, because this can be tedious, she referred listeners to 

, where visitors can input their information and generate a pre-written letter. 

Project SwipeIT is “an industry wide initiative launched by the Medical Group Management Association (MGMA) in January 2009 to advance the adoption of standardized patient health-insurance identiï¬ cation (ID) cards containing machine-readable information. MGMA estimates that the healthcare industry wastes as much as $2.2 billion annually as a result of nonstandardized cards.” Want to learn more about this initiative? Visit 

MGMA Saves the Best for Last: A Panel Discussion with Three Wise Men 

One of the conference’s ï¬nal sessions was a panel discussion on improving the quality of care through quality, innovation, and service. If this panel were a baseball team they’d be the Yankees. We’re talking about some big names: Dr. Delos M. Cosgrove, president and chief executive ofï¬ cer of Cleveland Clinic; Dr. William Wright, Executive Medical Director Colorado Permanente Medical Group; and Dr. Gary S. Kaplan, Chairman and CEO of the Virginia Mason Health System. Each panel member made an opening statement, introduced themselves, mentioned what roles they have in their respective organizations, and spoke on a few different issues. 

Are solo practitioners an endangered species? Moderator William F. Jesse, MD, astutely noted that many of the members at MGMA likely came from much smaller practices and organizations than the panel members, and asked them how their experiences would translate to the audience. Dr. Cosgrove was the ï¬rst to respond, noting that, in reality, only 10% of physicians are either in a solo practice or are with one other physician, and that this statistic speaks to a trend that seems to be growing each year. He mentioned that there are many reasons for this: an exploding body of knowledge; the ï¬ nancial aspect (ie, the complexity of contracting, measuring quality, EHRs, etc); and a huge change in generations - no longer do physicians want to be on call 24/7. They want a better work/life balance. Dr. Cosgrove used cardiac surgeons and cardiologists as an example, as these two medical specialties have been teaming up all over the country. 

In order for healthcare reform to be successful, incentives must change — and soon. This was the most popular topic of the discussion, and it seemed that every answer came back to incentives. All three panel members felt very strongly about this issue, and were all in agreement. Part of the problem with the healthcare system right now is that 75% of the cost of care is a result of patients with chronic conditions. In addition, there’s relatively little focus on prevention of these conditions. The panel stressed the importance of making patients a facilitator in their own care. The members stated that the incentives are in the healthcare system are all wrong: hospitals and practices create more care, and insurance companies only care about money. Truly positive healthcare reform will consist of two major changes: caregivers must cut out unnecessary tests, and patients must be incented to be active in preventative health. 

To the ï¬rst change, Dr. Kaplan mentioned a Virginia Mason program that involved a collaboration with both Starbucks and Aetna. Starbucks believes its baristas should have health insurance, but is concerned about the cost. Through some research, Virginia Mason discovered that back problems were very common among the baristas, and that many times they were recommended an MRI. Unfortunately, an MRI in this situation is rarely beneï¬ cial in determining a cause of the pain, and Virginia Mason made sure that these referrals stopped. So, by cutting out this costly test, they may have taken a hit in their bottom line due to the cost of the MRIs, but in the end they were helping to provide care in a much more cost-effective way, and changed the model in which care was delivered, beneï¬ tting everyone involved. The focus was shifted to the patient instead of proï¬ t margins. 

To the second change, Dr. Wright mentioned that Safeway had recently put a program in place that he hopes will lead to a chain reaction. He encouraged the audience to ï¬ nd more information about it online. Safeway introduced a plan in which “preventative care was covered completely, and included a health saving account of $1,000 per person that Safeway funded. Health care costs above that are covered by employees.” Read more about this program at 

. The bottom line is that patients who are living an unhealthy lifestyle and are subsequently causing a strain on the cost of healthcare in this country should be hit hard where it hurts them the most — their wallet. 

This discussion was a very interesting session to sit in on, and it involved some physicians who are at the forefront of enacting change in a broken healthcare system. On second thought, maybe these presenters are more like hockey players. Dr. Kosgrove answered an attendee’s question about health reform with a reference to Wayne Gretzky, who is known as “The Great One.” 

“One day a reporter asked Gretzky what made him so great. Do you know how he responded?” After it was apparent that there were no hockey enthusiasts in the audience, he continued. “He told the reporter that he always had a sense of where the puck was going to be. So not only did he always know where it was, but he knew what to expect next. That’s the type of leader we need in healthcare reform.” 

Feature Articles

Couldn't make it to Denver, CO for the Medical Group Management Association 2009 Annual Conference in October? Don't worry, our editors have summarized some of the best presentations from the 2009 MGMA Conference.

MGMA Meeting Highlights

Picking the best smartphone hinges on several key factors. First is the network on which the device runs. Second is the mobile operating system used by the device. Third is what types of applications are available for that device. Let’s quickly look at why these are important criteria. 

Although some of the smaller, regional network operators offer attractive pricing plans and some good devices, your best bet is to stick with the four national network operators. That means choosing between AT&T, Sprint, T-Mobile, or Verizon Wireless. The beneï¬ ts that these carriers offer are country-wide footprints, roaming agreements with other operators in other countries, and ready access to speedy 3G wireless broadband networks. They also offer a wide range of voice, messaging, and data plans to ï¬ t most budgets. 

The mobile operating system is probably what matters most when it comes to smartphones. For the busy professional, that system should be easy to use, speedy, and capable of running a wide range of applications. Other factors to consider are support for enterprise-grade e-mail and security. The short list includes Android, BlackBerry OS, iPhone OS, and Windows Mobile. 

Without applications, a smartphone isn’t more than a regular cell phone. If a smartphone doesn’t have a large number of applications standing behind it, there’s less chance that it will be able to support the advanced functions that users actually need. Access to apps is key. 

It was with these criteria in mind that we selected the eight best smartphones for physicians. 

AT&T offers nearly every smartphone platform that exists. The company’s philosophy is to make the widest selection available to customers so that all its bases are covered. AT&T also has a bevy of smartphone plans that stand up to the competition. Although sizable, the company’s 3G footprint is not as large as several of its competitors. On the plus side, AT&T holds roaming agreements in pretty much every country around the world. 

: The darling device on the AT&T network is surely the iPhone (

). The latest version, the iPhone 3GS, comes in two models with the only difference being the size of the internal memory (16GB or 32GB). The iPhone is well priced at $200 and $300, respectively, and voice and data plans start at a reasonable $80 per month. Why is this a good pick? 

First, the iPhone has a staggering 85,000 applications available from the easy-to-use iPhone App Store. What’s more impressive is that software companies have taken the iPhone very seriously and offer an incredible selection of health- and medicine-related applications that can help with the daily duties of any physician. 

The iPhone also offers a good feature set, which includes 3G, Wi-Fi, GPS, Bluetooth, a 3.2-megapixel camera, and the ability to shoot video. It also features the best mobile browser available on a smartphone. On the downside, battery life is a bit lacking, and it’s easy to reach critically low levels before the end of the work day, depending on use. The iPhone also suffers from poor voice call quality and doesn’t work very well as a speakerphone. Also, many users may not like using the device’s on-screen keyboard. 

) is the newest smartphone to come from Research In Motion (RIM), and it makes some serious strides when compared to its predecessors. It has a high-resolution display and a great (and real) QWERTY keyboard for typing out e-mails and other messages. 

The Bold is truly best-in-class when it comes to BlackBerries. It runs the newest operating system from RIM, which features numerous updates system-wide. Because it is a BlackBerry, it offers the best mobile e-mail experience hands-down. It is also secure and can be conï¬ gured and locked down by IT to protect information. The BlackBerry App World (

) isn’t quite as large as the iPhone App Store, but it still offers users thousands of applications from which to choose; many are made for business users and medical professionals in particular. The Bold 9700’s specs match its competitors well. It carries 3G, Wi-Fi, GPS, and Bluetooth radios. It also has a 3.2-megapixel camera with autofocus, ï¬‚ ash, and video capture. Battery life has always been a strong point for BlackBerries, and the Bold offers six hours of talk time and more than two weeks of standby time. It also replaced the trackball that’s been used on BlackBerries for years and substitutes in an optical mouse. It takes a bit of getting used to, but is a very good method for interacting with the Bold. 

Negatives would include the browser, which is lagging behind the competition, and its smaller screen size. Pricing hasn’t been announced yet for this phone. 

Sprint offers many of the best smartphone platforms (but not all of them), and a very good 3G network, but uses a technology for its phones that is not used by most European and Asian countries (with the exception of South Korea). This means users will need to pick wisely if they need to travel abroad. On the plus side, Sprint offers the most aggressive pricing when it comes to voice and data plans. 

) is a smartphone that runs the Android operating system from Google. HTC has taken the base Android OS and pasted its own, custom-made Sense user interface on top. These two combined make for a very easy-to-use and customizable handset. 

The Hero has access to more than 10,000 applications in Google’s Android market. That makes it a winner for medical professionals who need to be able to run productivity software. Buying applications from the Android Market isn’t as easy as it is from the iPhone App Store, but anyone with a credit card has access, and many of the apps are free. 

The HTC Hero offers excellent support for Google’s e-mail platform, Gmail, though the included Exchange e-mail client is not the most robust on the market. It also has a browser that is second only to the iPhones in terms of HTML support and the ability to interact with websites. The hardware features 3G, Wi-Fi, GPS, and Bluetooth, and the device is tightly integrated with Google services, such as Maps for Mobile, Voice Search, and YouTube. It boasts a 5-megapixel camera, besting much of the competition. 

On the downside, there is no physical keyboard, battery life will only get most users through one day, advanced Bluetooth proï¬ les aren’t supported, and it is limited to use in the US. The Hero costs $180. 

: If Microsoft is more your thing, the new Intrepid (

) from Samsung offers the latest version of Windows Mobile in a compact and stylish package. It looks similar to the BlackBerry Bold, but combines a physical QWERTY keyboard with touchscreen capabilities. 

The Intrepid can access the brand-new Microsoft Marketplace for Mobile (

). The new storefront from Microsoft has fewer than 1,000 applications at writing, but that will surely grow quickly. The Intrepid runs Windows Mobile 6.5, which is the newest version of smartphone software from Microsoft. The platform itself is capable, and much easier to use than previous versions of the operating system. It supports all the enterprise applications you could ever hope to run. 

The Intrepid runs on Sprint’s 3G network in the US but can also access 3G networks in Europe and Asia. It also features Wi-Fi, Bluetooth, and GPS. The Intrepid has a 3-megapixel camera with video capture. On the downside, the screen is on the small side, and it still becomes necessary to break out the stylus to use some menus and applications. The Intrepid costs $150. 

T-Mobile offers most smartphone platforms that are out there, along with very competitive voice and data plans. The biggest drawback for T-Mobile is that its 3G network isn’t nearly as large as its competitors. Be sure to check a coverage map to make sure 3G is available where you work and live before choosing T-Mobile. On the plus side, phones from T-Mobile automatically work in Europe and Asia. 

: This beast of a phone combines Windows Mobile 6.5 with HTC’s TouchFLO 3D user interface and has both a large, beautiful touchscreen and large physical QWERTY keyboard. This phone means business. 

) offers nearly every feature that a business or medical professional might hope to have. On top of access to applications within Microsoft Marketplace for Mobile, it has 3G for the US and abroad, Wi-Fi, GPS, Bluetooth, and a 3.2-megapixel camera. Because it runs the Microsoft platform, it has built-in support for Microsoft Exchange mobile e-mail, calendar, and contact syncing. 

The touchscreen is simply huge and tilts up to make for easier viewing while typing out e-mails on a user-friendly keyboard. The TP2 runs HTC’s custom-built TouchFLO 3D user interface, making it much easier to use when compared to the native Windows Mobile user interface. 

On the downside, the TP2 is large and heavy; the device is not for the weak. Battery life is also a bit less than some of the others listed here. The device will set you back a whopping $350. 

: This less-expensive alternative to the Bold 9700 offers a smaller, lighter footprint with many of the same beneï¬ ts of its bigger brother. The 8520 (

) is perfect for those with smaller hands and is less tiring to carry around and use due to its reduced size. Despite being small, it can still download and run all the applications that are available from BlackBerry App World, and it features the same enterprise-worthy security and IT policy control that a medical professional might need. 

Perhaps its biggest strength is support for T-Mobile’s Wi-Fi- based calling service. The Curve 8520 can seamlessly transition voice calls from the cellular network to a Wi-Fi network—where calls are free; this gives it a major leg up over its rivals. The Curve 8520 also features the same optical mouse pad as the Bold 9700. 

On the downside, the 8520 does not feature 3G, though Wi-Fi, GPS and Bluetooth are included. It also has a screen resolution that isn’t up to par with the competition. The Curve costs $130. 

Likely the biggest strength for Verizon Wireless is its 3G coverage, which the company claims is ï¬ ve times that of AT&T’s. The company’s site currently has 20 Smartphone options from which to choose, mostly from Motorola, BlackBerry, HTC, and Samsung. Check out ratings for each at 

) succeeds where the original Storm failed; it is a true touchscreen BlackBerry that offers a premium experience and feature set, making it the cream of the BlackBerry crop. 

The Storm2 is the ï¬‚agship device from RIM and for Verizon Wireless. It runs the newest operating system from RIM, and has a very good mobile e-mail experience. It is also extremely secure and can be conï¬ gured and locked down by IT to protect information. The number of apps in the BlackBerry App World doesn’t match that of other BlackBerries, but it’s still respectable, with access to plenty of medical applications. 

The Storm2 features a generous touchscreen and nearly every feature a smartphone can possibly cram inside. That means 3G in the US, Europe, and Asia; Wi-Fi (a much-needed upgrade); and a typing experience that has been vastly improved. After a short learning curve, users can type e-mails very quickly. Battery life is excellent. 

What might concern some users is the Storm2’s heavier-than- average weight. The device goes for $180. 

www.phones.verizonwireless.com/motorola/droid

) is the newest device from Motorola and the best effort from the Chicago-based company in years. The Droid runs the Android 2.0 operating system from Google, which is a major leap forward for the Android platform. It brings in a bevy of new features and truly is a more enterprise-grade operating system. Of course, support for the Android Market (

) and its 10,000 apps is included, and it has both a large touch screen and full QWERTY keyboard for typing messages. It is slimmer than many of the other phones, and has a large, high-deï¬ nition screen. Android 2.0 also means the Droid has built-in support for Microsoft Exchange. As far as specs go, the Droid lands near the top. It has 3G, Wi-Fi, Bluetooth GPS, and a 5-megapixel camera with ï¬‚ ash, autofocus, and image stabilization. What’s really interesting is that the Droid can shoot DVD-quality video (720 x 480 pixels at 24 frames per second), which is far and away better than the competition. 

Reasons to reconsider would include sub-par battery life, a mushy keyboard, and a larger footprint. Pricing hasn’t been announced yet for this device. 

Mr. Zeman is an editor, writer, and manager with more than 10 years’ experience in the publishing industry. During the last ï¬ve years, he has managed the editorial content and direction of magazines, websites, weblogs, e-newsletters, customer marketing programs, industry events, webinars/webcasts, and more. 

MoBlog (Mobile Web Blog): Check out Eric Zeman’s MoBlog on 

 for more on the latest smartphone news and use in medical practice. 

Now is a great time to buy a smartphone. Powerful devices, better plans, and advanced applications boost productivity and let the busy physician stay more in tune with his or her practice. Here are eight highly recommended smartphones for the enterprising physician.

8 Best Smartphones for MDs

What a year. Despite procuring highly coveted press credentials, I sat out the famous Consumer Electronics Show (CES) in 2009, mainly because the event had been reduced in size, as Seagate, Logitech, Cisco, Yahoo, Sanyo, Phillips Electronics, and other major gadget makers opted not to incur the expense of a Las Vegas exhibition in light of the global economic crisis. Yet, life goes on. Some great new gadgets have come out this year. I thought hard about whether austerity was in order for this year’s guide, given the thrashing many of our 401(k)s have taken and the dismal job market faced by many of our new graduating physicians. However, we need good gadgets now more than ever, both to help us maintain or increase our productivity as physicians, and of course to also keep us engaged and enthralled as we seek the next greatest thing. CES 2010 is just around the corner and is marked prominently on my “to-do” list for next year. Unlike past CES shows, rooms in Vegas are plentiful and inexpensive right now. There will also be some attractive bargains this holiday season for vigilant gearheads. That might help ring in a happier and more prosperous 2010! 

These compact, durable, and easy-to-use video cameras by Flip are so popular and inexpensive you may wish to buy more than one. Cisco loved them so much, they bought the entire company! The primary advantage of these cameras is their attractive price and small form factor. These cameras allow you to shoot high-quality (Flip Ultra) and HD (Mino HD) video in settings you may never have thought possible. I find them extremely useful for filming instructional videos for our residents at Stanford. Flip makes it easy to edit and share your videos using free software that comes with the camera. Best of all, there are no cords to lose: the USB connector that you plug into your computer is built into the device! I even took the camera to a recent vacation in Cancun. I was able to film underwater sea turtles and coral using an inexpensive underwater case I purchased as an accessory. 

Anyone who knows anything about filmmaking knows that it’s all about the sound! Unfortunately, the Flip cameras, and most consumer video cameras, suffer from poor sound due to cheap, built-in microphones and fixed microphones that can’t be properly placed for optimal recording. Luckily, the folks at Zoom have created a super easy device that will let you record amazing, high-quality stereo sound to make your videos “pop.” The Zoom H4N has two microphones that can be manipulated for narrow or wide field of sound recording, and writes the audio files directly to an SD fl ash card. It even comes with a foam wind sock so you can maintain great sound even when outside on windy days. You can then reunite the audio file with your video using a video-editing program, such as 

 for PC. The editing is not that hard, really. Although it might be overkill for baby’s first steps, your friends and family will think you are the next Scorsese, and you can take all the credit. 

I have been searching for a new, high-quality SLR for the past year, but not because I want to take photographs. My work in medical education informatics has led me to quite a few educational films. Yet, I have always desired to take my work to the next level with a better video camera. It turns out that the best video camera value you can buy isn’t a video camera at all. It is the Canon Eos 7D. 

The Canon Eos 7D is a revolutionary new camera that takes motion picture-quality video. It has an 18 MP APS-C sensor and can record in 1080p HD with native 24 and 30 frames per minute. What makes this camera unique is the large APS-C sensor that allows you to create motion images with shallow depth of field so that your subject remains sharp, but the background can be blurred out. The Canon Eos 7D is also compatible with Canon’s large collection of interchangeable, high-quality camera lenses. These are features that until now have only been available on very expensive digital motion picture cameras or still cameras in the $5,000 range. Of course, the 7D is also a marvelous professional-quality still photography camera. 

Some examples of films taken with the Canon Eos 7D include the opening title sequence for Saturday Night Live and a recent Frontline documentary in Afghanistan shot by embedded photojournalist Danfung Dennis called 

. You may also wish to check out Pulitzer Prize-winning photographer Vincent Laforet’s film 

, which uses a similar Canon camera. Take a look at the films, and you will be seduced by the potential. 

$1,699.00 Body only; $1,899.00 with EF 28-135mm f3.5-5.6 IS USM Zoom Lens

I’ve advocated the potential of ePaper and electronic readers for years, and Amazon’s Kindle made my 2008 gadget guide list. However, I’m going to go against the conventional wisdom and point out the Barnes & Noble Nook eReader for your holiday gadget buying consideration. Like the Kindle, you can purchase new books via wifi and AT&T’s 3G wireless connection. However, the Nook also allows you to view PDF files, which the Kindle does not. This is really important for those of us who have large collections of PDF documents, such as scientific articles from the medical literature and custom-created PDF documents that we generate for our own use. The Nook also lets you browse an entire ebook when you are connected to wifi in Barnes & Noble stores, enabling you to do some pleasure reading while sipping a latte on a Sunday morning. You can checkout and read local library ebooks for free and even lend your own ebooks to other people for two weeks at a time. A nice additional feature is the color touch screen at the bottom that let’s you browse ebook titles. 

I admit not everyone will care to purchase a Magic Mouse from Apple. The Cupertino, California-based computer company is perceived by some folks to be over-priced and focused more on form than function, if you believe the many Microsoft-funded advertisements featuring everyday people claiming “I’m not cool enough to own a Mac.” However, Apple’s Magic Mouse is, in my opinion, where form not only meets function, but enhances it. The new Bluetooth wireless mouse by Apple is the first “multitouch” mouse on the market, and it allows you to replicate the “two-finger swipe” that advances through Web pages and flies through photo albums in a snap, as well true two-finger clicking (PC users, think “left” and “right” mouse buttons). Less often-used features include the 360 scroll (move the window with one finger on the mouse) and the very cool screen zoom to get close to the action, especially when viewing small photos or text. 

 two years ago, I complained that Palm computing had lost its footing in the medical computing world due to lack of innovation. I bemoaned how it hadn’t updated its operating system in years and that its leadership in mobile computing was being taken by the likes of Apple’s iPhone. That all changed in 2009. Palm computing finally released its brand new incarnation of the Palm OS and a new phone/ communications platform and user experience. The Palm Pre really needs an entire review of its own, so I will not provide an elaborate one here. However, I will point out that it has an appealing form factor that innovates on the best of what we loved about the Palm computing experience. It is definitely worth a look for those considering a smartphone purchase. 

The first time I heard the Bose SoundDock Portable was in a loft apartment with 20-foot ceilings in Buenos Aires, Argentina, where my brother is studying to become a tango master. The device holds a simple proposition: fantastic sound filled with rich trebles and deep bass coupled with convenient portability. The SoundDock Portable is designed to work with many audio sources, but excels with iPhones and iPods because it has a built-in dock for these devices. The sound generated by the Bose unit completely fills even large spaces like my brother’s loft but is portable enough to take on trips to the beach or park for impromptu tango lessons. The iPod dock rotates and stores for travel. The device comes with a remote control and built-in carrying handle and works on A/C power or a rechargeable built-in lithium ion battery. 

Apple’s iPods always seem to make it on my gadget list, and for good reason: they work well and come in models with price points that appeal to every level of consumer. I’m a particular fan of the new iPod Nanos, because they pair well with the Cinemin pico projector (see below), and this latest generation includes FM radio to keep me updated on the latest news. Best of all, the built-in camera that takes video clips seals the deal. 

Though not technically a gadget, Moo cards definitely appeal to the gadget-inclined. I recently attended the Medicine 2.0 conference in Toronto, an annual gathering of physicians, medical students, and researchers from over 20 countries who use the Internet and Web 2.0 technologies to advance the practice of medicine. Many of our younger European colleagues have adopted the use of small “mini” cards (about half the size of a normal business card, split lengthwise) that they use for their e-mail and social media account addresses (eg, Twitter, Facebook, MySpace). The cards can be highly customized in many visually engaging ways, and a pack of 100 cards can be printed with many different individual themes. I love the concept of separating business from social media, while also customizing cards for people whom you would like to see your Tweets, but not necessarily play a round of golf or be “Facebook” friends with. 

The folks at Wow Wee are known for their robotic toys and general playful approach to technology. Their Cinemin Swivel could have just as easily been named Cinemin Swirl, as it is a very tasty gearhead treat, indeed. The first of a series of planned pico projector devices, the Swivel uses Texas Instruments’ DLP technology to project crisp images using a small, handheld form factor. The Swivel is the only pico projector on the market that has a projection head that swivels up to 90 degrees, allowing you to project movies and slides on a wall without propping the projector on a stand. The Swivel projects images up to five feet wide from eight feet away. A built-in speaker and easy iPhone connectivity make spur-of-the- moment film screenings easy. A rechargeable, 2-hour battery let’s you enjoy it with a picnic and a good bottle of wine if you wanted to have an outdoor screening. One slight drawback of the Swivel is the lack of internal storage or fl ash drive, essentially tethering it to an iPod or similar media device. Those of you wanting the storage option will have to wait for the Cinemin Stick, which has yet to be released. 

$299.00 available for pre-order online from Wow Wee

I always check these websites for potential gadget bargains, and suggest you do the same this holiday season: 

editorial board member and assistant professor of anesthesia, Department of Anesthesia and Pain Management, Stanford University School of Medicine.

Editor's Note

A brief guide to the must-have gadgets for you and your loved ones this holiday season.

The Third Annual Gearhead's Holiday Gadget Buying Guide

 a while back about the frustrations of trying to find out how much his son’s tympanostomy was going to cost. After getting the runaround for a while from the front desk, he was finally able to get them to divulge the facility fee, but not the physician fees. After asking “why they don’t bundle everything into one price” so healthcare consumers would be able to “compare across various combinations of facilities and providers,” he was told he would have to take it up with the physician’s office. Another phone call (this one to the physician’s office) procured the CPT code and procedure charge (actually, the insurancedictated reimbursement amount). Finally, after a third call (to the anesthesiologist) and some more jousting, he was able to find out the cost of that portion of the total bill.

It took all of that time and effort, by someone who “knows the ins and outs, all the secret handshakes and covert codes, and most aspects of healthcare financing,” just to figure out how much a medical procedure actually cost. As healthcare consumers are taking a more active role in managing their health and looking to drive their interactions with the healthcare system by comparing hospitals and providers, the issue of price transparency (or rather, the lack of price transparency) is fast becoming a hot topic. In his blog post, by way of analogy, Shreeve notes that diners do not get “separate receipts for tomatoes, buns, and burger--[they] get a single price for the thing [they] want: the complete hamburger.”

Now, it’s certainly true that it is often difficult to say for certain how much a procedure or visit will cost ahead of time, due to the number of unknown variables (What other complications will be uncovered during the exam? What other tests will be required?). It is also true that the actual cost of healthcare is obscured by insurance deductibles, co-pays, and other factors. And yet, how are consumers to make a truly informed choice about the healthcare services they wish to engage when so much important information is unavailable to them? As Shreeve noted, although he was able to finally learn the cost of his son’s procedure, in the end he had no information about “outcomes achieved, safety rates, customer satisfaction, or other metrics” that would potentially influence one’s decision about whether to engage the services of a particular provider.

More than ever, patients are seeking answers to these questions and are creating and using Health 2.0 tools that will enable them to compile and compare information on pricing and outcome. In closing, let me add a question of my own: How do MDNG readers handle requests for information about the cost of treatments and procedures? What do you say to patients when they ask, “How much is this going to cost me, doc?”

November 2009

The HITECH Act Is Constitutional

The HIT Realist: Is the HITECH Act Constitutional?

MGMA Meeting Highlights

8 Best Smartphones for MDs

The Third Annual Gearhead's Holiday Gadget Buying Guide

Is there really such a thing as "the healthcare marketplace"?