With all the recent talk about federal stimulus money, healthcare reform, hospital payments, Medicare funding, and other healthcare finance topics, it can be easy to lose sight of just how much money is involved. To help you see the big (and we mean really big) picture, we’ve created this handy graphic. (Click on the image labled "KEY" to view larger images)

Articles

Pulse

How much money does it take to pay for healthcare?

Piles of Cash

On July 14, 2009, HCPLive.com blogger and author of the MDNG column “The HIT Realist,” Alberto Borges, MD, participated in a live debate with Joseph Kvedar, MD, director of the 

As experts in the area of health IT (HIT) adoption and use, Drs. Borges and Kvedar discussed how physicians can find answers to their questions about the HITECH Act, the meaning of “meaningful use,” and the connection between reimbursement and the adoption and use of health IT. 

Specifically, the participants addressed the following: 

• The meaning of “connected health” and how it relates to the application of communications technologies to improve patient care 

 • The good, the bad, and the ugly of the HITECH Act 

 • A recent lawsuit filed against three officials in the Obama administration, claiming that the ARRA HIT provisions unconstitutionally violate the HIPAA privacy rule, Privacy Act, and Federal Common Law 

 • The draft recommendations for “meaningful use” from the Office of the National Coordinator for Health Information Technology 

 • The connection between HIT adoption and quality improvements, decreased errors, and decreased costs in healthcare 

 • The latest certification approaches from the Certification Commission for Healthcare Information Technology (CCHIT) 

 • Interoperability of electronic records 

 to download an audio recording of the entire event! 

What’s the Center for Connected Health?

A division of Partners Health- Care in Boston, MA, the Center for Connected Health “develops innovative and effective solutions for delivering quality patient care outside of the traditional medical setting. The Center engages in pioneering research in a wide range of connected health-related areas and works to advance the field through its convening and publishing activities.” 

Programs, focusing on cardiac care, dermatology, diabetes, e-visits, medication adherence, remote consultations, and more, “use a combination of remote-monitoring, online communications and intelligence, and technology applications to improve patient adherence, engagement and clinical outcomes. Participants in our programs are patients and providers at Partners-affiliated practices and hospitals throughout New England. Our programs are also being offered by large self-insured employers who wish to help employees better manage their health, to contain healthcare spending and to improve productivity and satisfaction.” 

CHECK OUT ARCHIVES OF DR. BORGES’ “THE HIT REALIST” COLUMN AND BLOG 

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

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

www.hcplive.com/mdnglive/The_HIT_Realist/GE_healthymagination

The Kibbe/Leavitt Rumble in the High-tech Jungle!

Since CCHIT first came onto the scene back in 2006, we’ve read numerous partisan rants about the issues of HIT/CCHIT/ HIMSS, with an occasional major clash among those of us mere mortals with a strong interest in the matter. Not often do we hear of a heated personal exchange involving two of the best-known experts in the field. 

www.hcplive.com/mdnglive/The_HIT_Realist/Kibbe_Leavitt

A Pragmatic View of the GE Healthymagination Initiative

On 5/7/2009 General Electric (GE) announced that it was launching a $6 billion healthcare initiative called Healthymagination, $3 billion of which will be spent over the next six years for research and development of HIT and other tools that could “lower costs and boost quality.” GE officials pledged to increase the speed and productivity of HIT by “improving the use and capacity of certified electronic health record (c-EHR) systems and related technology.” 

Feature Articles

Did You Miss Our Live Webinar? The Great Debate 

If existing case law and legislation is clear and well-developed, then an asset protection plan that falls within the pre-set boundaries should have favorable and predictable results. 

The OJ Simpson civil case demonstrates this principle in dramatic fashion. The families of the victims have vigorously pursued collection of a $33 million civil judgment against Simpson for more than 10 years, but they have been largely unsuccessful because a large portion of Simpson’s assets is held in retirement plans that are exempt from judgments. The law specifically protects from collection of the total amount in such plans, as well as any proceeds that are distributed. Published reports are that Simpson had approximately $4.1 million in his retirement plans and draws a benefit of $25,000 per month, completely shielded from the judgment. 

Although we’ve seen many similar results in less notorious cases, the asset protection in the Simpson case was well supported by law and withstood persistent and sophisticated attacks from the victim’s families, clearly demonstrating that a protected retirement plan can shelter substantial assets from liabilities and judgments even in the most egregious circumstances. In order to take advantage of the asset protection features of a protected retirement plan, the plan itself must be developed and designed so that it qualifies under the law as an exempt asset, free from potential judgment claims. Because the law varies from state to state and federal law may apply in some circumstances, I’ll provide some general rules and guidelines to which you can refer when discussing the specific details of your case with your attorney. 

One group of retirement plans that is exempt from judgments are the well-known ERISA-qualified plans, such as defined-benefit, profit-sharing, and 401(k) plans. Federal and state law clearly protects the amounts in these plans and any distributions that are made. There may be exceptions for some court-ordered family-support obligations and possibly federal or state taxes, but as a general rule these plans are well-protected from lawsuits and judgments. 

One drawback of these plans is that if you have several employees in your practice you may have to make contributions for them also--you can’t just cover yourself in a qualified plan. As a result, the expenses of covering all employees, preparing the necessary filings, and paying for annual administration may exceed the tax- and asset-protection benefits. You should carefully evaluate all aspects of these plans to measure the costs and potential advantages. 

If you are self-employed and your plan covers only yourself (IRAs and solo 401(k)s), the amount exempt from a judgment varies significantly from state to state. Some states protect the entire amount in these plans while others shield only the amount necessary for “reasonable retirement needs,” a vague and subjective standard that you probably wouldn’t want to rely on. If a big part of your savings is or will be in an IRA, determine with your attorney whether it is exempt from judgments in your state. Also, consider whether the amount of your contribution limits to your IRA is sufficient to shelter a significant portion of your savings. 

In some states (such as California), the law allows for the creation of a private retirement plan that is entirely exempt from judgments. These 

 are highly flexible in design, need not cover other employees, and allow for annual contributions that can substantially exceed those available under the qualified plans or IRAs. Although no tax deduction is available for these contributions, the complete exemption for amounts in these plans may be highly valuable in a wide variety of circumstances and should be considered as a stand-alone asset-protection plan or in conjunction with a tax-deferred account. 

Consult with your attorney and tax advisor to learn more about the legal and tax consequences of these retirement plans and which provides the best asset protection value for you.

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 

Columns

If existing case law and legislation is clear and well-developed, then an asset protection plan that falls within the pre-set boundaries should have favorable and predictable results.

Saving for a Rainy Day: What is the Best Asset Protection Plan for Physicians?

 for a decade now, and healthcare technology has changed in so many ways in those years. In the early days, our goal was to be a kind of “TV Guide to the Internet” for physicians, many of whom were just becoming aware of the resources and information available online. We catalogued the best websites for physicians and patients, interviewed the visionaries who were imagining new and exciting ways that the connective powers of the Internet could be applied to healthcare, and profiled other information technologies. As the Internet and health IT became more sophisticated, so too did our readers, incorporating these tools into daily practice. As readers’ information needs and professional interests evolved over the years, 

 kept pace, expanding our Internet-centric coverage to include now-indispensible gadgets such as PDAs and smartphones, EHRs, e-prescribing, and other applications. Change is in the air once again. From pending healthcare reform on an as-yet-unknown scale to the explosion of “Health 2.0” and social media technologies, the healthcare landscape is in flux, and 

 is adapting with the times. In this issue, you will notice several changes in both form and content. We’ve freshened up the look and style of our layouts and incorporated new graphical elements and flourishes. I think you’ll agree that our designers have really outdone themselves. Taking cues from some of our favorite design and technology journals, we’re going to explore how graphic design can not just complement text, but reinforce and transform it. 

We’ve done more than just change our style sheets—we have also reimagined the editorial content in 

. The most noticeable change is that we’ve improved our famous Net Guide section. Previously, it was organized according to resource type—online CME programs, patient education resources, clinical trial listings, medical websites designed specifically for physicians, abstracts of studies published online, etc. Although such an arrangement has its uses, it doesn’t match with how most clinicians search for and interact with the information they find online. Narrowly focused search is the name of the game nowadays, and our redesigned Net Guides reflect that. Now, readers will find specialty-specific clinical information, tools, and other resources organized by disease and condition. Each Net Guide section is further organized by resource type (the familiar categories I previously mentioned), allowing readers to access disease-specific information in a variety of formats. As part of this redesign, we have also refreshed the front-of-book section formerly known as “The Pulse,” rechristening it as “The Check Up” and devoting that space to profiling useful technology applications and other tools and online resources for physicians. 

Our feature articles and cover stories will put less emphasis on comprehensive, full-featured EHRs, and instead pay more attention to Health 2.0/Web 2.0 collaborative technologies, the applications that David Kibbe and others refer to as “clinical groupware,” and other technologies and tools that have unexpected relevance and utility for practicing physicians. We will explore the use of social media applications and other online resources to promote physician—physician and physician–patient communication and collaboration, and the ways in which new technology tools and gadgets can be adapted to help physicians improve productivity and efficiency in their professional and personal lives, deliver better care, and just get more done. Finally, MDNG will also leverage the power of the HCPLive network, connecting to our dynamic online portal and incorporating feedback and commentary on the content in MDNG from our growing community of engaged online physician readers. We will create a self-sustaining and ongoing dialogue that enables us to tap into the collective intelligence of our readers, using that insight to inform and shape the content in 

, creating a seamless publishing environment that provides cutting-edge content that helps readers stay abreast of the news and issues that matter most to them. It promises to be a fascinating journey, and we’re glad you’re coming along for the ride. 

Cover Story

We have been publishing MDNG for a decade now, and healthcare technology has changed in so many ways in those years.

Already in progress

Sermo.com CEO Daniel Palestrant recently proclaimed that the AMA no longer speaks for US physicians, and that now is the time to “turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession.” We posted an 

 about this on HCPLive.com and also sent out a “Hot Topic” eDigest that asked readers to complete a survey and share their thoughts and opinions on the AMA, Sermo, and whether physicians’ interests and concerns are being adequately represented in the debate over healthcare reform. Several responses from readers are reprinted below. 

It is my opinion that the AMA does not effectively represent the interests of surgical specialists whose voices are often overwhelmed by the primary care predominance of the AMA’s membership. 

Physicians need someone to represent them and it is not the AMA, which is just another tool being used to manipulate the lives of American doctors. No one ever includes real practicing medical professionals in policy-making; rather they go to the AMA for the “pulse” of the medical community. Sites [like Sermo] that allow physicians to voice their opinions and truly poll their current feelings are relevant and more valid than the AMA. The system has taken away most of our rights and abilities to control our own destinies, and the AMA has been a willing participant from the beginning of the anti-doctor revolution. If Sermo is a viable forum and tool for physicians to fight back, we should and will support it. 

The AMA when first established represented the views of the doctors in the “trenches,” but now they have capitulated to our government and are not interested in the needs of practicing physicians. The AMA is only interested in self-advancement and maintaining its position. 

The AMA has a 162-year history of open dialogue in a democratically elected House of Delegates representing each state and specialty society. Reference committee sessions take place twice yearly where any member physician, not just delegates, can speak his or her mind about policy. Non-members may also petition to speak, and usually are granted the privilege! There is transparency in revenues and expenditures, including compensation of officers. Consensus creates policy; policy drives action. Sermo has a two-year history of dependency on the AMA. There is nothing democratic about its function; nothing transparent about its operation and financing. Just a naive entrepreneur who thinks he is the Phoenix about to arise from the ashes. 

—Dave Hannan, MD, president of the Medical Society of the State of New York 

I share the view that the AMA is too conservative and obstructionist to be useful, but I am not sure there is any organization that is able to take its place. I tell myself I should become more active in the AMA so as to have a chance to change its policies and politics, but, like most physicians, those good intentions get swept away by the demands of my everyday clinical and academic work. It is not enough for us to want change, we must find ways to make it happen--and I admit I have not been able to do this. 

The AMA makes money from its CPT and ICD-9 coding, which it reworks every few years. I have often wondered why the whole system cannot be replaced by... English? Why use numeric codes that must be translated into English? Why not just establish a unified English diagnostic lexicon? Because then it could not be licensed and would not require expensive training courses, meaning it would not be controlled by the AMA. Yes Sermo, no AMA! 

The discussion on Sermo was huge and interesting. It essentially involved two groups: the majority of Sermo users, who are conservative, some rabidly so, decrying the AMA for being too liberal and giving away the store, and the rest of us, decrying the AMA as too conservative and obstructionist on healthcare reform. The conservatives urged membership in the American Association of Physicians and Surgeons, a fringe group in my mind, but perhaps it will become the new home of some of the AMA’s disaffected conservatives. Liberals urged joining Doctors for America, Physicians for a National Health Plan, or the American College of Physicians (I’m in all three). The bottom line is that the AMA counts less than 20% of physicians as members. Older conservatives think it’s because they’ve gone soft and liberal. I think it is very clearly the opposite: Older, whiter, more conservative and more highly paid procedure-based specialists hold too much sway and have alienated the progressives, particularly in primary care specialties such as family practice, internal medicine, and pediatrics. 

Do you agree with Sermo CEO Daniel Palestrant’s claim that the AMA no longer speaks for the majority of US physicians and does a poor job of representing the interests of physicians? 

Sermo.com CEO Daniel Palestrant recently proclaimed that the AMA no longer speaks for US physicians, and that now is the time to “turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession.”

Hot Topic: The AMA vs. Sermo

You may have seen advertisements, or may already have been contacted by people who’ve promised to help you figure it all out so you can get your share of the stimulus money. Be wary. The truth is that the Obama administration is still defining many essential elements of the Health Information Technology for Economic and Clinical Health Act (HITECH), and full details about the exact reimbursement process will not be known until the fourth quarter of this year, at the earliest. 

Nonetheless, there is a growing field of people who call themselves “EHR consultants.” They promise to advise you on which system to purchase for your needs, help set up and integrate the necessary hardware and software, and perhaps even troubleshoot any on-going problems you may have. Sounds tempting, right? 

Let me stress that many EHR consultants are legitimate and can provide valuable services at a reasonable price. But there are some pitfalls to avoid. First, let’s define the difference between a consultant and a reseller. A consultant should be completely independent and have no relationship, financial or otherwise, with the vendors they recommend or refer to you. Conversely, a reseller receives payments from an EHR vendor for providing leads or getting a practice to purchase that specific EHR. An ethical consultant (ie, a reseller) will let you know upfront that they have a fiduciary relationship with one or more vendors, and then you can make an informed decision on the advice they provide. Many consultants and EHR/technology “experts,” however, quietly arrange kick-backs with various EHR vendors and fail to disclose this conflict of interest to their perspective clients. 

There is one quick way to tell if you’re dealing with a consultant or a reseller. A reseller’s services should be free to you because the vendor is picking up the tab by paying the reseller a percentage of the sale, or some other pre-arranged fee. You know in advance that a reseller is going to steer you toward a particular product, and you can thus take what they say with the same healthy dose of skepticism that we apply to information we receive from drug reps. 

On the other hand, if you are paying for services and recommendations, then you are dealing with a consultant who should be giving you unbiased advice. Unfortunately, a good number of consultants accept fees from doctors but then also receive referral fees from vendors for sending them potential clients. These payments may be in the form of cash, discounted hardware and software, or anything else of value. 

The EHR industry is relatively young and appears to be one of the exciting growth areas in an otherwise slumping economy. But this has resulted in a Wild West-like frontier where the various players (eg, vendors, consultants, resellers, state and local groups, and other agencies) can say just about anything without disclosing anything. And many IT companies and other consultants (even physicians seeking to earn some extra money) have agreements with software companies to receive payment for steering potential clients toward a specific vendor. Surprisingly, many of these otherwise honest people feel that if they aren’t specifically asked if they receive compensation from vendors (whether it be for directing leads, providing a recommendation, reselling, or even providing consultant services to the EHR vendor), they don’t need to share this information with their client or colleague. 

You need to ensure that the information you receive from these “experts” is unbiased and based on the reasonable approach of matching your practice’s needs with the available solutions. A few key steps could save you tens of thousands of dollars in hardware and software expenses, not to mention the frustration of being cajoled into purchasing an overpriced and unusable EHR that you’ll regret later: 

• When considering an EHR consultant, ask them pointblank if they have any relationship with one or more vendors, and ask exactly how those relationships work. 

• Ask the consultant how many practices of similar size and specialty they have helped in the past, and get at least three different practice names and contact information to confirm that they were pleased with the consultant, would recommend their services, and would use them again. 

• For smaller practices, be especially wary of consultants who also sell IT hardware and/or technical support. In my experience, IT consultants tend to recommend significantly more complex (and expensive) hardware and software than is necessary for the average small medical practice. 

The third point deserves a bit more discussion, since many of the consultants in the EHR space also provide IT services and sell computers, servers, and other hardware. The main problem with hiring an IT consultant for guidance is that all too often these technologically -minded people push equipment and policies that are significantly more expensive and complex than is reasonable to run a small practice. 

In my experience as an EHR vendor, all too frequently when an IT consultant is used, the practice ends up not only spending much more on hardware than my non-IT-consultant practices, but they have much less of an understanding of their system and thus an inability to troubleshoot issues that arise from time to time. In fact, Amazing Charts (my EHR company) recently raised prices for additional providers because we found that larger practices tend to have overly complex technology infrastructures based on the recommendations of their IT consultants. These systems take more time and energy to troubleshoot, and much more frequently, hardware and network issues are the source of the difficulties that lead to downtime. 

Even big companies can be guilty of up-selling unnecessary equipment to small practices. For example, Amazing Charts used to recommend our users contact Dell to get advice and affordable systems. While Dell certainly makes good and affordable hardware, many of our clients called Dell and ended up directed to Dell telesales representatives who regularly scared them into purchasing big servers, tape backup systems, and other equipment because they were a “medical practice.” Most of the up-selling of robust servers and other equipment is completely unnecessary if you perform regular data backups and follow basic networking guidance. 

When a consultant does recommend a specific product, whether an EHR system or anything else, do some online research to find out what others have to say. The American Association of Family Physicians (www.aafp.com) has a good site for researching EHR software (ie, the Center for Health IT). Message boards can be another useful research resource, if you have time to sort through all the garble. 

The most important take-away from this month’s column is to make sure that your independent EHR consultant is not actually shilling for someone else. Get it in writing so you have some legal recourse if you make a purchase and have buyer’s regret a few months later.

Editor-in-Chief of MDNG: Primary Care/Cardiology Edition

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

You may have seen advertisements, or may already have been contacted by people who’ve promised to help you figure it all out so you can get your share of the stimulus money. Be wary.

Don't Get Fooled Again: Insider's Tips on How to Tell the Difference between EHR Consultants and Resellers

Unexpected technology applications are transforming daily practice—everything from how you search for clinical information to how you share and store your data. As usual, Google is at the center of it all. But nowadays, the Web giant is about so much more than just search. Search is so 2007. Now, it’s all about the apps. 

“The Internet is fundamentally changing the way doctors practice medicine by enabling greater access to medical information, easier collaboration with patients and colleagues, and economic opportunities for entrepreneurs in Health IT,” says Roni Zeiger, product manager, Google Health. “Many Google services have powerful applications for a physician’s daily work. For example, Google Alerts and Google Reader are great ways for physicians to keep up to date with new research and news in their practice areas.” 

“We focus our coverage on apps that aren’t necessarily geared toward medicine but that, with a little bit of thought, could be well used in your dayto- day practice. “We are always looking for better ways to serve patients and physicians,” adds Zeiger. You might be surprised at what Google can help you achieve.

app to quickly and easily create customizable websites. How can you use this app? Let us count the ways: 

• Use it to create a website for your practice. 

• Organize a centralized online location for you and your project team (see an example at 

https://sites.google.com/a/altostrat.com/projecteggplant/Home

• Create an intranet for your office or practice to disseminate news and announcements, update schedules, post messages and reminders, track projects and paperwork, and more (see an example at 

http://sites.google.com/a/organic-city.com/intranet/Home

• Maintain communications and relationships with important vendors and other clients. 

• Publish patient education resources so you can guide the content that your patients see and read. 

The list is literally endless. To learn more about Google Sites and get started on your own projects, visit  

www.google.com/sites/help/intl/en/overview.html

Google says that it’s “a playground where our more adventurous users can play around with prototypes of some of our wild and crazy ideas and offer feedback directly to the engineers who developed them. Please note that Labs is the first phase in a lengthy product development process and none of this stuff is guaranteed to make it onto Google. com. While some of our crazy ideas might grow into the next Gmail or iGoogle, others might turn out to be, well, just plain crazy.” 

Before you get too carried away experimenting with the great apps and tools at Google Labs, a word of caution: The projects in Labs are intended to “showcase cool and wacky ideas but are not intended to be full-blown Google products. Labs experiments may be unavailable or be even removed without notice and you may not be able to access any of your data.” Google recommends that you not use sensitive information in a Labs experiment. 

Having said that, what will curious physicians currently find in Google Labs? 

Use this app to manage large collections (up to 100MB) of tabular data “in the cloud.” You can share the data with whomever you like. Apply filters, aggregate and visualize your data on maps and charts, merge from various tables, export, and hold discussions regarding the info based on row, column, or cell all, right in Fusion Tables. Learn more at http://tables.googlelabs.com/public/tour/tour1.html. 

Google Squared is an experimental tool that takes a category (like “hypertension treatments”) and creates a matrix, or “square” of information, automatically “fetching and organizing facts from across the Web.” You can modify your square by “removing rows and columns you don’t like—or by adding new rows and columns and having Google Squared attempt to fetch the relevant facts.” Google Squared “does the grunt work for you, making research fast and easy,” and is excellent for compiling educational supplements for your patients. 

Use this tool to manage your news and other data chronologically “on a zoomable, graphical timeline.” Set the timeline to weeks, months, years, or decades, or use a timeframe in a given query, and navigate through the information by dragging the timeline. Sample queries using “EMR,” “autism vaccine,” and “Kathleen Sebelius” quickly produced an enormous amount of well-organized and timely information. 

One of our favorite apps we’ve seen yet in Google Labs, Similar Images allows you to search for images using pictures rather than words. With the similar images feature, “most images have a link below them that lets you find other images like them. There’s no need for you to refine the text of your query. Your new results will be tailored based on whatever image you select.” So, if you’ve found a picture or graphic, but can’t figure out how to describe it, just click the similar images link to see “more like this.” Use it to find the perfect image for your next presentation, to illustrate patient education materials, and for a variety of other research purposes. 

Personalized health records are the future for portable, aggregated personal medical information. 

 already allows your patients to store and manage all of their health information in one central place. How does this benefit you? It allows them to keep you up to date with the latest changes to their health and information, eliminates the need for new patients to fill out the same paperwork over and over, prevents you from ordering redundant or already performed lab tests, and more. 

More companies and vendors are partnering with Google Health in order to integrate patients’ records and information into their systems. The list already includes Allscripts ePrescribe, Beth Israel Deaconess Medical Center, the Cleveland Clinic, CVS, Medco, Quest Diagnostics, and others. 

EHR vendors are starting to take notice, and many of them are working with Google to develop functionality that will enable them to interface, with Google Health, allowing physicians’ EHRs to populate key data into patients’ Google Health records. 

“Our hope is that as patients become more engaged in their healthcare and begin using the web to organize and manage their health information, more consumers will start asking their hospitals and doctors’ offices to use electronic medical records and integrate with consumer platforms like Google Health,” says Zeiger. 

Forget your local medical library and PubMed and use 

 to search for scholarly literature published in the form of peer-reviewed pieces, theses, books, and abstracts from any number of scholarly organizations, including professional societies, universities, and academic publishers. Search results are ranked by weight of the article’s full text, author(s), publication, and number of times it has been cited by other scholarly literature. 

Collaborating on an article with colleagues at multiple locations? Don’t run the risk of losing valuable work and time by e-mailing documents back and forth—get out of the past and into the cloud! 

 to upload text, spreadsheets, graphics, and more from your desktop. Control user access and edit your documents anytime, from anywhere. Share changes in real time in a secure virtual environment. Plus, “Google Docs has built-in capabilities to send an e-mail form, which could be a great way to gather feedback from patients,” says Zeiger. 

What’s new at Google Docs? How about more than 70 new “themes” and templates for creating forms and documents; new functionality that lets you view your projects with all formatting intact on your favorite mobile device; improved footnote capabilities; analytics tracking; custom colors and fonts; a brand new interface for creating slide presentations; and more. 

www.google.com/google-d-s/intl/en/tour1.html

Got a tip, trick, or suggestion for making Google Docs even better? Share it at 

www.google.com/support/forum/p/Google+Docs/label?lid=2040927159da752f&hl=en

Be sure to check out these additional noteworthy apps, both in released and “Google Labs” states. 

Get one phone number for your office, mobile, home, BlackBerry, hospital, or other phones; assign which one(s) ring(s) based on who’s calling you; get all voicemails transcribed; and call anyone in the US, all for free. 

This Google Labs offering allows physicians to host staff meetings, discussions with colleagues, and even potentially grand rounds with participants who can be anywhere that Internet access is available. Offering collaborative Q&A for group events, the app helps “keep things on track by allowing users to both suggest questions and vote on others’ questions.” 

Provide resources to patients in any of more than 40 languages through your website, translate patient pamphlets in any of these languages, or offer patients prescription information in their own language using this instant translator. “Take 2 with water” becomes “tomar 2 con el agua” in less than a second. 

Currently in beta stage, Knol enables anybody to share what they know with the world, specify the level of collaboration with the community, connect with other experts with similar interests, and see their great content become visible on popular search engines. 

Don’t want to sit through an entire presentation from the latest annual conference of your society of choice? Use the speech technology of this app, from Google Labs, to jump right to the good stuff based on your search terms. 

Enter a few items from any given set (eg, EMR, HITECH, technology) and this Google Labs app will provide a large or small—you decide&mdash;set of related items to be searched for using Google Search. 

Keep track of the latest news in your field or monitor the developing acetaminophen story with Google Alerts, sent right to the e-mail inbox of your choosing. The app allows users to search just about any topic, choose from various types of sources (eg. blogs, news, video), and determine how often the alerts arrive. 

Going beyond the traditional news aggregator, Google News displays similar stories in groups, with each only appearing after having been ranked based on how often and on what sites it appears. You personalize the news to only cover the topics of most interest.

Unexpected technology applications are transforming daily practice&mdash;everything from how you search for clinical information to how you share and store your data.

5 Ways Google Can Make You a Better Doctor

Since the HITECH Act was signed into law, physicians have had more questions than answers for the Office of the National Coordinator for Health Information Technology, the branch of the Department of Health and Human Services tasked, along with The Centers for Medicare & Medicaid, with overseeing the implementation of the incentive program outlined in the HITECH Act. The two biggest questions have been what constitutes a certified EHR under the rules of the program, and what exactly does “meaningful use” mean when it comes to qualifying for the incentive payments? 

A preliminary answer to the meaningful use question was released by the HIT Policy Committee on June 16. The 

 to the “meaningful use matrix” stated in part that the HIT Policy Committee recommends that:

“...the ultimate goal of meaningful use of an Electronic Health Record is to enable significant and measurable improvements in population health through a transformed health care delivery system. The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities. This “north star” must guide our key policy objectives, the advanced care processes needed to achieve them, and lastly, the specific use of information technology that will enable the desired outcomes, and our ability to monitor them...”

The Committee went on to note that “the recommended definition of meaningful use will depend on the healthcare setting in which it is employed. Thus, some features and capabilities will be recommended as required in an ambulatory setting before similar functions are expected to be widely used in the hospital. This reflects both the availability of the technology in these different settings as well as the potential impact of these features on the health of the population served. Although some recommended measures used to assess meaningful use in 2011 may apply to specific chronic diseases, the recommended 2011 objectives are meant to establish a foundation for effecting a more comprehensive set of health outcomes in the future. Many of the current proposed EHR-generated quality measures apply to primary care providers and are derived from NQF-endorsed measures. New measures under development, by NQF, and other recognized organizations will also address the work of specialists. The Workgroup anticipates that future recommended meaningful use objectives and measures will reflect emerging national priorities.” 

Finally the Committee pointed out that “in identifying potential criteria for meaningful use of an electronic health record, it became apparent that there are considerable gaps in EHR-generated measures available to monitor key desired policy outcomes, (eg, efficiency, patient safety, care coordination). While these measures will not be required for Medicare and Medicaid incentive payments until 2013, the Workgroup is seeking feedback on how to best frame these measures including measurement of key public health conditions, measuring health care efficiency, and measuring the avoidance of certain adverse events. These comments will be used to help revise the recommended measurement strategy to include more extensive and refined outcome measures for “meaningful use” in 2013 and beyond.” 

The first working definition of meaningful use is laid out in a meaningful use matrix, a document that matches specific “care goals” with health outcomes policy priorities and explains the year-to-year objectives for achieving these through the use of EHRs. The complete document can be accessed at 

The Office of the National Coordinator for Health Information Technology (ONC) is seeking comments, questions, and suggestions from physicians, vendors, payers, patients, and other healthcare stakeholders on the preliminary definition of “meaningful use.” The American Health Information Management Association was first to chime in, with recommendations offered on 

 to access a schedule of upcoming Health IT Policy Committee meetings, as well as transcripts and other materials from previous meetings. The public is invited to submit comments at the conclusion of each meeting.

 readers had a lot to say about all of this. And they’ve never had so many ways of making their voices heard before. Between Twitter tweets, comments on HCPLive.com, responses to our “Hot Topic” eDigests, e-mails to our editors, blog posts, and messages on discussion forums, 

 readers had ample opportunity to share their thoughts. We’ve compiled the best of the best ideas and opinions: 

“The bar has been set too high and the recommendations put forth will be virtually impossible to implement within the aggressive time schedule of the HITECH Act. Simply put, it appears that not enough attention was paid to the processes/workflow changes that are required as part of a successful HIT roll-out to meet these MU recommendations. For example, recommendations call for CPOE use in 2011. CPOE is extremely challenging to implement and the technology piece is actually a pretty small component of the overall implementation. The real challenge with CPOE is its direct impact on physician workflow and practices. Thus, CPOE requires significant forethought, process mapping, implementation and training. Getting all that done and to demonstrate meaningful CPOE use by 2011? Don’t bet on it.” 

“This is just the beginning of a long conversation. Today, the HIT Policy Committee met and highlighted some of the essential components that outlines this mysterious phrase, ‘meaningful use.’ We won’t see physicians meaningfully using an EHR overnight. This will happen in three stages (although many things will also be happening simultaneously): Data capture and sharing by 2011; advanced clinical processes by 2013; and improved outcomes by 2015.” 

— From HCPLive Network member Joseph Kim, MD, on his blog 

, a website dedicated to “unbiased independent EMR discussions”: 

“I am a tad confused. I have an EMR. Other physician groups have other brands of EMR. The hospital has no formal electronic record, but the nurses document electronically, and labs and rads are accessed through a portal (no CPOE or physician electronic charting). Who is supposed to create the features that will meet the “meaningful use” guidelines in this situation?” 

www.emrupdate.com/forums/p/20003/98803.aspx

I am sure that someone will come up in future with perfect system but at present it will cost at least $44,000 or more to implement the EHR/ EMR for every practice. The subsidy from government will help but in the end physicians will end up paying the difference. Hopefully this will be worthwhile in the longer run due to ease of finding charts in the practice and other EHR/EMR benefits. 

EMR no doubt will save doctors money in the long run, especially in reducing staff salary. I think in a busy practice, it takes at least one person who has to search, file, copy, reshelf, etc. paper charts. Some of the EMR systems, however, are so complex and costly that whatever the amount the government will ACTUALLY give out might not be enough. 

You do not install an EMR system on Monday and become “meaningful use” compliant by Tuesday; this is a social integration process that can take months to smoothly function! You MUST allow sufficient time and money for training. Plus, the number of QUALIFIED health IT personnel to help with hardware upgrades and software installation and coaches to help with the implementation is finite and they will be avalanched in 2010 & 2011 (read: more scarce and more expensive than today). 

Comments taken from “I’ll Get $44,000 to use an EHR? Where Do I Sign Up?” a recent column written by 

 Physician Editor-in-Chief Jonathan Bertman, MD. To respond to these commenters or Dr. Bertman, visit 

www.hcplive.com/mdnglive/articles/PC_use_an_EHR

The $787 Billion American Recovery and Reinvestment Act (ARRA) of 2009 (aka “the Stimulus Bill”) was signed into law on February 17, 2009. Included in this law is $19.2 billion which is intended to be used “to increase the use of electronic health records (EHR) by physicians and hospitals; this portion of the bill is called, the Health Information Technology for Economic and Clinical Health Act, or HITECH Act.” 

Technology for the Future of Health and Care

“ARRA authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “meaningful users” of an electronic health record (EHR). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing an EHR in compliance with the meaningful use definition or they will be subject to financial penalties under Medicare.”

Twitter is buzzing with physicians, CMIOs, HIT vendors, and other healthcare stakeholders commenting on the latest about the HITECH Act, meaningful use, CCHIT, the nuances of “certified,” and everything else related to the use of EHRs and other information technology in medical practice. Here’s just a sample. 

Ftvelasco - My take is that #CCHIT is addressing the structural component of ARRA. Other #HITPol criteria need to be satisfied to qualify for ARRA bonus 

Dirkstanley - confused by the uneven correlation between goals and objectives in the HIT Meaningful Use Matrix. 

BeckersASC - ASCs in Danger of Being Excluded from HITECH Incentive Funds 

EMR_Advocate - #CCHIT #HITpol All vendors will need to certify/re-certify for ARRA including 2008 CCHIT vendors (“delta process”) 

Pamorin - Numerous EHRs officially dead as won’t meet the min 2011 criteria w/out massive development. #hitpol (via @john_chilmark) 

Perryholz - “Meaningful use” turned out not so meaningful. Do over. 

Cascadia - “meaningful use” is ultimately linked to achieving measurable outcomes in patient engagement, care coordination, & population health 

CanadianEMR - Meaningful use in the US. Bar set too high with too little attention to process/ workflow changes. 

What do physicians really think about the HITECH act, health IT stimulus incentives, and the government’s new role in their lives? Using the power of social media, we did a little research and asked MDNG readers to share their opinions, concerns, and advice.

Bonus or Bogus? Are federal funds for health IT a true stimulus, or merely a stopgap?

Many states are seeing the HITECH money as an opportunity to aggressively 

 to improve healthcare through adoption of EHRs and health information exchanges. 

The four states discussed below have vastly different plans for health IT, from the aggressive to the sublime. 

 Since 2004, MA has become a national leader in implementing health IT. The most recent health IT bill, 

, which set the groundwork for further state-led health IT initiatives and large-scale health IT adoption among providers. This bill established the Massachusetts eHealth Collaborative, which is meant to oversee state health IT activities and promote adoption of health IT across the state, including the deployment of EHR systems networked through a statewide HIE. 

 questioned 18,282 physicians in order to test how much health IT uptake has been affected after four years of massive funding for health IT in MA. Of 519 who responded, roughly 36% use all “basic” EHR capabilities, which is about twice what is seen nationally. Unfortunately, only 5% of MA physicians “significantly use” advanced capabilities, which is just 1% higher than found nationally. In MA, 20% of 

 The uptake of EMR technology throughout Arizona has been credited to a 2005 executive order by then-Gov. Janet Napolitano, which required that all healthcare providers install EHRs by 2010. A 

 has stated that there is a marked increase in physicians who are canceling their EHR contracts and deinstalling their expensive c-EHR software systems. This is especially prevalent among smaller physician groups. Deinstallations and failed installations will be among the biggest factors that will keep a national HIE from becoming a reality. 

 that made it the first state to mandate a move toward EHRs. On May 11, 2009, 

 was proposed that would make it illegal to sell or otherwise distribute a non-CCHIT c-EMR in the state of NJ, applying penalties of up to $5,000 for multiple violations. 

It seems that its main sponsor had numerous financial ties with lobbying groups, including HIMSS, the “State Alliance for e-Health,” and the “Healthcare Information Management Society,” as documented in his 

. The idea of manipulating competition as a quid pro quo by making the sale of a non-c-EHR system illegal is bad policy. 

 was signed into law, mandating that all state-regulated health insurance payers (not just Medicare/Medicaid) need to provide monetary incentives to healthcare providers to adopt an EHR and use it in a “meaningful manner.” This law is meant to bolster the state’s efforts to create an HIE by October 2009. 

With this bill, the state is trying to cut off all physician choice concerning HIT by making a licensed practitioner subject to a host of grants/penalties depending on the degree of 

Several states are trying to aggressively 

 health IT /HIEs/EHRs, even though c-EHR systems have only been adopted by 17% of physicians, with only 4% of physicians “significantly using” them. 

Those legislators who are rushing HIT bills need to go slow, need to show due diligence in learning the nature and history of EHRs, and should consider the overall impact of health IT programs within the fiscal constraints of a recession. They should stay clear of improper lobbyist influence and associations with companies that may ultimately benefit from this health IT push. 

The growth of health IT will evolve slowly; it can’t be rushed with poorly written laws.

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 

Many states are seeing the HITECH money as an opportunity to aggressively promote health IT to improve healthcare through adoption of EHRs and health information exchanges.

States to Obama: Give Us that HITECH Grant Money!

Complete information transparency and the protection of intellectual property do not make friendly neighbors, and this reality has historically been a stumbling block to disclosure of results from clinical trials. Managing the competing needs of sponsors, pharmaceutical companies, investigators, and the public interest can be tricky, and it would seem that mandating the deposit of trial design information into an accepted clinical trials registry would lead to more secrecy and a decrease in trial disclosures. 

International Committee of Medical Journal Editors

 (ICMJE) provided the impetus for change regarding trial information disclosure when it announced 

 journals would no longer publish results from trials that were not registered in a public trials registry. Many other publications adopted their guidelines. Accordingly, ClinicalTrials.gov, the largest trials registry at the time with a 13,153-trial database, saw a 

That figure has since risen to more than 71,000, according to Deborah Zarin, assistant director for clinical research projects at the National Library of Medicine (NLM), spurred by the ICMJE, as well as provisions in the 

Food and Drug Administration Amendments Act of 2007

“Since FDAAA went into effect on the registration side, we’ve been getting between 300 and 350 new trials registered per week from around the world. This is up from about 250 prior to this law being passed,” said Zarin, during an April 20, 2009 public meeting on expanding the registry. 

NLM, which has primary responsibility for clinicaltrials.gov, has also received nearly 700 records of basic study results from the drug industry and other contributors, Zarin said. She said that about 40 

 records are submitted to NLM each month. 

Although FDAAA 2007 expanded the registration mandate to include all Phase II-IV controlled clinical trials of FDA-regulated drugs, biologics, and devices (previously only trials involving serious or life-threatening conditions were required to be registered), many industry observers—including William Vaughan, health policy analyst for Consumers Union&mdash;argue for widening the scope further to include Phase I trials and trials of non- FDA approved medical materials. 

“Information gained from all trials involving human subjects should be part of the world’s scientific database,” wrote Vaughan in a public comment on the registry expansion. “Knowing what doesn’t work is in many ways as important as knowing what does.” Vaughan especially believes that there is much to learn from Phase I trials in the way of efficacy and safety. (

Rules mandating that researchers report results of the “doesn’t work” type take effect in September 2009. All adverse events—major, minor, and unexpected&mdash;must be presented in tabular format, listing organ type and number and frequency for each arm of the trial; 

The story of how journal editors, the clinical research community, and Big Pharma managed to work together to protect the public health, ensure the continued advance of medical science, and safeguard vital intellectual property.

July 2009