Erik Goldman

WASHINGTON — Both the search engine giant Google and the software colossus Microsoft are attempting to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Acting on their view of individual patients, not health care systems, as the primary locus of change for health care information technology, both companies provide individuals with secure, user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record keeping.

Executives at both HealthVault and Google Health said that they believe digitally enabled patients will help push more doctors to implement electronic health records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses his or her PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a lot of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic health records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing, Mr. Scriban said.

Both Google and Microsoft are actively engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system. “Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to reevaluate the pilot later in the year before expanding it to Kaiser members.

HealthVault and Google Health aim to make consumers agents of change. ©2008 Microsoft Corp./Google Health

WASHINGTON — Both the search engine giant Google and the software colossus Microsoft are attempting to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Acting on their view of individual patients, not health care systems, as the primary locus of change for health care information technology, both companies provide individuals with secure, user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record keeping.

Executives at both HealthVault and Google Health said that they believe digitally enabled patients will help push more doctors to implement electronic health records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses his or her PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a lot of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic health records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing, Mr. Scriban said.

Both Google and Microsoft are actively engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system. “Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to reevaluate the pilot later in the year before expanding it to Kaiser members.

HealthVault and Google Health aim to make consumers agents of change. ©2008 Microsoft Corp./Google Health

WASHINGTON — Both the search engine giant Google and the software colossus Microsoft are attempting to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Acting on their view of individual patients, not health care systems, as the primary locus of change for health care information technology, both companies provide individuals with secure, user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record keeping.

Executives at both HealthVault and Google Health said that they believe digitally enabled patients will help push more doctors to implement electronic health records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses his or her PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a lot of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic health records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing, Mr. Scriban said.

Both Google and Microsoft are actively engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system. “Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to reevaluate the pilot later in the year before expanding it to Kaiser members.

HealthVault and Google Health aim to make consumers agents of change. ©2008 Microsoft Corp./Google Health

WASHINGTON — Search engine giant Google has joined software giant Microsoft in an attempt to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Acting on their view of individual patients, not health care systems, as the primary locus of change for health care information technology, both companies provide individuals with secure, user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record keeping.

Executives at both HealthVault and Google Health said that they believe digitally enabled patients will help push more doctors to implement electronic health records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses his or her PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a lot of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic health records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing, Mr. Scriban said.

Both Google and Microsoft are actively engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system. “Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to re-evaluate the pilot later in the year before expanding it to Kaiser members.

HealthVault and Google Health aim to make consumers agents of change. ©2008 Microsoft Corporation/Google Health

WASHINGTON — Search engine giant Google has joined software giant Microsoft in an attempt to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Acting on their view of individual patients, not health care systems, as the primary locus of change for health care information technology, both companies provide individuals with secure, user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record keeping.

Executives at both HealthVault and Google Health said that they believe digitally enabled patients will help push more doctors to implement electronic health records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses his or her PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a lot of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic health records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing, Mr. Scriban said.

Both Google and Microsoft are actively engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system. “Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to re-evaluate the pilot later in the year before expanding it to Kaiser members.

HealthVault and Google Health aim to make consumers agents of change. ©2008 Microsoft Corporation/Google Health

WASHINGTON — Search engine giant Google has joined software giant Microsoft in an attempt to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Acting on their view of individual patients, not health care systems, as the primary locus of change for health care information technology, both companies provide individuals with secure, user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record keeping.

Executives at both HealthVault and Google Health said that they believe digitally enabled patients will help push more doctors to implement electronic health records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses his or her PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a lot of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic health records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing, Mr. Scriban said.

Both Google and Microsoft are actively engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system. “Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to re-evaluate the pilot later in the year before expanding it to Kaiser members.

HealthVault and Google Health aim to make consumers agents of change. ©2008 Microsoft Corporation/Google Health

WASHINGTON – Search engine giant Google has joined software giant Microsoft in an attempt to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Both companies see individual patients, not health care systems, as the primary locus of change for health care information technology, and both provide individuals with secure but user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record-keeping.

Executives at both HealthVault and Google Health said they believe digitally enabled patients will help push more doctors to implement electronic medical records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health will allow people across the country to store their PHRs and allow them to make their own determinations about who may have access to those records. Users also will be able to store medical contacts and other relevant information.

“Users should have easy access to their medical records, and should be able to act on their data. Medical records should follow the patient and exist in an environment of interoperability, portability, privacy, and security,” Mr. Wiseman said. “We don't hold our users' data hostage.”

The system can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said. Google Health's PHR function also will be enriched with specialized health-oriented search functions, clinical trial matching, and a host of other health management tools, all of which can be integrated with a user's Gmail e-mail account.

Google Health will not charge people to store PHRs; likewise, doctors will be able to access their patients' PHRs–with patient permission, of course–at no cost.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses their PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a LOT of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information, presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic medical records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

HealthVault and Google Health are similar in many respects.

“Both are backed by large companies with a lot of resources; [both companies] have looked at the same problem and arrived at similar conclusions. One conclusion is that you cannot revolutionize health care in one big step. The other is that the consumer is really the agent of change in all of this,” Mr. Scriban said.

Still, there are some differences. He stressed that Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing.

Although it is natural to view the current landscape as a clash of the IT titans, Mr. Scriban thinks that view is overstated. “In the end, we're really glad that Google has joined us in attempting to deal with the problems of personal health information management. I don't think it's really a Google vs. Microsoft scenario. It's more like Google, Microsoft, and all of us who are involved in PHRs and EHRs versus paper!”

Google and Microsoft are engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system.

“Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to reevaluate the pilot later in the year before expanding it to Kaiser members.

Google's Mr. Wiseman said it is particularly important to create alliances with health plans. “A lot of people won't use Google Health unless their health plans support it.” Google's other major focus is on consumer decision support tools.

Among Google Health's new partners is HealthGrades, the private company that has quietly emerged as the leader in online physician and hospital ratings. HealthGrades uses publicly available data on quality outcomes based on 32 standardized procedures and health conditions to grade physician and hospital performance. The ratings parameters are based on work done by the National Quality Forum.

“HealthGrades' mission is to guide Americans to better health care,” said Dr. Samantha Collier, chief medical officer of HealthGrades. “There are enormous gaps between what we know we could do and should do, and what actually happens in health care. There are vast gaps between the best and worst hospitals and clinics.”

Currently, Web users seeking HealthGrades ratings for a doctor or hospital must pay a fee. Under the partnership agreement, Google Health users would have free access to the ratings.

The specifics have not yet been worked out, but the idea is that Google Health users searching for doctors or clinics would obtain a listing of the top 10 appropriate practitioners locally. Each listing would contain basic contact information, as well as a “more” button, clicking on which would allow the user to see the full HealthGrades profile for that physician or hospital–including any disciplinary actions or malpractice cases, past or pending.

At issue is how Google and HealthGrades will determine which practitioners or facilities show up on the top 10 list for a particular search. Dr. Collier and Mr. Wiseman said that initially, the order of rank would be based on Google's standard model, which lists the most trafficked sites highest. The rankings would not be based on the HealthGrade scores.

One thing is certain: With major IT players like Google and Microsoft entering the arena, PHRs and electronically empowered patients are going to play a signicant role in reshaping health care over the next decade.

Google Health and HealthVault aim to help patients make informed decisions. © 2008 Microsoft Corporation/Google Health

WASHINGTON – Search engine giant Google has joined software giant Microsoft in an attempt to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Both companies see individual patients, not health care systems, as the primary locus of change for health care information technology, and both provide individuals with secure but user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record-keeping.

Executives at both HealthVault and Google Health said they believe digitally enabled patients will help push more doctors to implement electronic medical records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health will allow people across the country to store their PHRs and allow them to make their own determinations about who may have access to those records. Users also will be able to store medical contacts and other relevant information.

“Users should have easy access to their medical records, and should be able to act on their data. Medical records should follow the patient and exist in an environment of interoperability, portability, privacy, and security,” Mr. Wiseman said. “We don't hold our users' data hostage.”

The system can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said. Google Health's PHR function also will be enriched with specialized health-oriented search functions, clinical trial matching, and a host of other health management tools, all of which can be integrated with a user's Gmail e-mail account.

Google Health will not charge people to store PHRs; likewise, doctors will be able to access their patients' PHRs–with patient permission, of course–at no cost.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses their PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a LOT of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information, presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic medical records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

HealthVault and Google Health are similar in many respects.

“Both are backed by large companies with a lot of resources; [both companies] have looked at the same problem and arrived at similar conclusions. One conclusion is that you cannot revolutionize health care in one big step. The other is that the consumer is really the agent of change in all of this,” Mr. Scriban said.

Still, there are some differences. He stressed that Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing.

Although it is natural to view the current landscape as a clash of the IT titans, Mr. Scriban thinks that view is overstated. “In the end, we're really glad that Google has joined us in attempting to deal with the problems of personal health information management. I don't think it's really a Google vs. Microsoft scenario. It's more like Google, Microsoft, and all of us who are involved in PHRs and EHRs versus paper!”

Google and Microsoft are engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system.

“Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to reevaluate the pilot later in the year before expanding it to Kaiser members.

Google's Mr. Wiseman said it is particularly important to create alliances with health plans. “A lot of people won't use Google Health unless their health plans support it.” Google's other major focus is on consumer decision support tools.

Among Google Health's new partners is HealthGrades, the private company that has quietly emerged as the leader in online physician and hospital ratings. HealthGrades uses publicly available data on quality outcomes based on 32 standardized procedures and health conditions to grade physician and hospital performance. The ratings parameters are based on work done by the National Quality Forum.

“HealthGrades' mission is to guide Americans to better health care,” said Dr. Samantha Collier, chief medical officer of HealthGrades. “There are enormous gaps between what we know we could do and should do, and what actually happens in health care. There are vast gaps between the best and worst hospitals and clinics.”

Currently, Web users seeking HealthGrades ratings for a doctor or hospital must pay a fee. Under the partnership agreement, Google Health users would have free access to the ratings.

The specifics have not yet been worked out, but the idea is that Google Health users searching for doctors or clinics would obtain a listing of the top 10 appropriate practitioners locally. Each listing would contain basic contact information, as well as a “more” button, clicking on which would allow the user to see the full HealthGrades profile for that physician or hospital–including any disciplinary actions or malpractice cases, past or pending.

At issue is how Google and HealthGrades will determine which practitioners or facilities show up on the top 10 list for a particular search. Dr. Collier and Mr. Wiseman said that initially, the order of rank would be based on Google's standard model, which lists the most trafficked sites highest. The rankings would not be based on the HealthGrade scores.

One thing is certain: With major IT players like Google and Microsoft entering the arena, PHRs and electronically empowered patients are going to play a signicant role in reshaping health care over the next decade.

Google Health and HealthVault aim to help patients make informed decisions. © 2008 Microsoft Corporation/Google Health

WASHINGTON – Search engine giant Google has joined software giant Microsoft in an attempt to revolutionize health care information technology, one patient at a time.

Google launched Google Health this spring with an aim of establishing itself as the leading repository of personal health records (PHR). Google is also positioning itself as a primary clearinghouse for clinical information, self-care tools, and provider ratings to help patients make educated health care decisions.

Google Health emerged just as the smoke began to clear from Microsoft's launch of its own HealthVault PHR platform last fall.

Both companies see individual patients, not health care systems, as the primary locus of change for health care information technology, and both provide individuals with secure but user-friendly systems for aggregating all of their health care records, data, diagnostic images, laboratory results, and medical histories. They hope to put an end to the fragmentation, duplication, and lack of portability that characterize paper-based health record-keeping.

Executives at both HealthVault and Google Health said they believe digitally enabled patients will help push more doctors to implement electronic medical records systems in their offices.

Todd Wiseman, head of Google's Federal Enterprise Team, says the creation of Google Health was a natural move. “We now have more than 1 billion people worldwide using Google every day. Google is the No. 1 search engine for health information, and health topics are a top search category for Google,” he said at the fifth annual World Health Care Congress.

Google Health will allow people across the country to store their PHRs and allow them to make their own determinations about who may have access to those records. Users also will be able to store medical contacts and other relevant information.

“Users should have easy access to their medical records, and should be able to act on their data. Medical records should follow the patient and exist in an environment of interoperability, portability, privacy, and security,” Mr. Wiseman said. “We don't hold our users' data hostage.”

The system can automatically import physician reports, prescription history, and lab results. Eventually, it will enable people to schedule appointments, refill prescriptions, and employ personal health and wellness tools, Mr. Wiseman said. Google Health's PHR function also will be enriched with specialized health-oriented search functions, clinical trial matching, and a host of other health management tools, all of which can be integrated with a user's Gmail e-mail account.

Google Health will not charge people to store PHRs; likewise, doctors will be able to access their patients' PHRs–with patient permission, of course–at no cost.

“We don't have any plans for ads within the Google Health product,” Mr. Wiseman said. “We see it as a way to drive more Google search traffic.” The search returns, of course, will arrive with ads and sponsored placements (just like every Google search), but he stressed that the PHR side of things will remain free of commercials.

Google is currently running a pilot field test of the Google Health system in partnership with the Cleveland Clinic. “We're 2 months into that, and we have 1,600 Cleveland Clinic patients storing their PHRs right now. This will go up to about 10,000. We're testing the process of data sharing in a live clinical-care delivery setting, with real patients and real doctors. The goal is simply proof of concept.”

Mr. Wiseman pointed out that Google has significant advantages over other companies vying for a piece of the evolving PHR market. For one, the company is wholly independent and not tethered to any health care plan or provider system, so a Google Health PHR is completely portable. Users would be able to access their records even if they change health plans, jobs, or even countries.

Mr. Wiseman stressed that, as a company, Google is a neutral stakeholder as far as how someone uses their PHR, which is different from PHR systems tied to specific health plans. “We stand by the user and the user only.”

Google has one more major advantage: massive data storage capacity.

“We can store and manage a LOT of data,” Mr. Wiseman said, noting that Google already gives its Gmail users six gigabytes of e-mail storage capacity. “That's a lot. And when you think about storing x-rays, MRIs, and other things like that, there will be a big need for memory.”

Google Health essentially is head-on competition for Microsoft's HealthVault, which has been up and running since last fall. While Microsoft has been involved in health care IT solutions for hospitals and health plans for more than a decade, its PHR efforts are fairly new, said George Scriban, senior product manager for HealthVault.

In an interview, Mr. Scriban said HealthVault, which is also free to consumers, tries to solve one of the most frustrating health issues for ordinary people: fragmentation. “Fragmentation of delivery of care has a lot to do with fragmentation of someone's health care identity. Everybody's health care identity is spread around in little slices in different sectors. The employer has some information, various doctors have others, hospitals and payers and pharmacies have still others. The ideal is to have all one's information, presentable and portable and useful to any and all providers,” Mr. Scriban said.

Essentially, HealthVault is a consumer-controlled hub for gathering and controlling information from various sectors of a person's “health care ecosystem.”

Mr. Scriban said that he understands that some physicians get nervous at the thought of patients in control of their own medical records. But he believes that systems like HealthVault and Google Health are really just systematizing what already happens informally.

“When a patient gets a referral from one doctor to another, it is really that patient who acts as an information transporter, telling the new doctor his or her medical history, medication use, and in some cases actually transferring paper records,” he said.

HealthVault tries to standardize, stabilize, and formalize that process, and Mr. Scriban contends that this will reduce errors, prevent loss of important information, eliminate redundancy, and give physicians a fuller picture of their patients' health. He added that HealthVault is being designed to interface with many different electronic medical records systems. He said that he hopes that as more patients create PHRs, more doctors will see the ultimate value in interconnectivity.

HealthVault and Google Health are similar in many respects.

“Both are backed by large companies with a lot of resources; [both companies] have looked at the same problem and arrived at similar conclusions. One conclusion is that you cannot revolutionize health care in one big step. The other is that the consumer is really the agent of change in all of this,” Mr. Scriban said.

Still, there are some differences. He stressed that Microsoft is primarily focused on enabling people to manage their health information, and less engaged in providing self-care tools, something that Google is pursuing.

Although it is natural to view the current landscape as a clash of the IT titans, Mr. Scriban thinks that view is overstated. “In the end, we're really glad that Google has joined us in attempting to deal with the problems of personal health information management. I don't think it's really a Google vs. Microsoft scenario. It's more like Google, Microsoft, and all of us who are involved in PHRs and EHRs versus paper!”

Google and Microsoft are engaged in lining up partners across the health care landscape, including insurers and managed care plans, information service providers, medical organizations, and patient advocacy groups.

Microsoft recently partnered with Kaiser Permanente, an integrated health plan with more than 8 million members, to test the transfer of data from Kaiser's personal health record into HealthVault. The pilot project, launched last month, is open to Kaiser's 159,000 employees. The idea is to combine the clinical data entered by Kaiser physicians, which are available in the Kaiser personal health record, with patient-entered health information and clinical information from providers outside of the Kaiser system.

“Providing new ways to manage their health online is one more way we can engage consumers in their care,” Anna-Lisa Silvestre, vice president of online services at Kaiser Permanente, said in a statement. “We believe that Microsoft HealthVault will be a valuable supplement to our expanding set of online features.”

Kaiser officials plan to reevaluate the pilot later in the year before expanding it to Kaiser members.

Google's Mr. Wiseman said it is particularly important to create alliances with health plans. “A lot of people won't use Google Health unless their health plans support it.” Google's other major focus is on consumer decision support tools.

Among Google Health's new partners is HealthGrades, the private company that has quietly emerged as the leader in online physician and hospital ratings. HealthGrades uses publicly available data on quality outcomes based on 32 standardized procedures and health conditions to grade physician and hospital performance. The ratings parameters are based on work done by the National Quality Forum.

“HealthGrades' mission is to guide Americans to better health care,” said Dr. Samantha Collier, chief medical officer of HealthGrades. “There are enormous gaps between what we know we could do and should do, and what actually happens in health care. There are vast gaps between the best and worst hospitals and clinics.”

Currently, Web users seeking HealthGrades ratings for a doctor or hospital must pay a fee. Under the partnership agreement, Google Health users would have free access to the ratings.

The specifics have not yet been worked out, but the idea is that Google Health users searching for doctors or clinics would obtain a listing of the top 10 appropriate practitioners locally. Each listing would contain basic contact information, as well as a “more” button, clicking on which would allow the user to see the full HealthGrades profile for that physician or hospital–including any disciplinary actions or malpractice cases, past or pending.

At issue is how Google and HealthGrades will determine which practitioners or facilities show up on the top 10 list for a particular search. Dr. Collier and Mr. Wiseman said that initially, the order of rank would be based on Google's standard model, which lists the most trafficked sites highest. The rankings would not be based on the HealthGrade scores.

One thing is certain: With major IT players like Google and Microsoft entering the arena, PHRs and electronically empowered patients are going to play a signicant role in reshaping health care over the next decade.

Google Health and HealthVault aim to help patients make informed decisions. © 2008 Microsoft Corporation/Google Health

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: you're not alone. Many of the pay-for-performance movement's leaders share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

"Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy," said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

"P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives." Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. "We may end up teaching to the test, while ignoring the bigger picture."

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily-chosen individual physician "accountability" measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

"You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care."

Dr. James defines systems transparency as meaning that, "you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability."

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones, and may end up rewarding "performance" on tasks that do not really lead to better patient care. Secondly, financial incentives can skew care delivery. "As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others."

Finally, financial incentives create the wrong sort of motivations. "One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you," he said.

An effective P4P program motivates physicians by stressing improved patient care. "Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement," said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. "Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril."

"The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable," said Robert Burney, director of Quality Improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. "The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical."

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through "a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, "Your data stinks, it's all BS," through one of, "Your data are meaningful but don't really apply to me," through, "The reasons my data are bad is because everyone's data are bad," to finally accepting there's a need for improvement. But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference.

On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as "lower quality." This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. "You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5' of their Medicare revenue, they close their doors. They can't take that kind of hit."

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

"I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them," said Dr. Jack Lewin, who is CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

"Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement." Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

ACC is currently studying "door to balloon" time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. "How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes."

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

"We can tell the medical staff how they are doing compared to their peers," Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. "We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data."

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: you're not alone. Many of the pay-for-performance movement's leaders share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

"Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy," said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

"P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives." Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. "We may end up teaching to the test, while ignoring the bigger picture."

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily-chosen individual physician "accountability" measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

"You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care."

Dr. James defines systems transparency as meaning that, "you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability."

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones, and may end up rewarding "performance" on tasks that do not really lead to better patient care. Secondly, financial incentives can skew care delivery. "As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others."

Finally, financial incentives create the wrong sort of motivations. "One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you," he said.

An effective P4P program motivates physicians by stressing improved patient care. "Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement," said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. "Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril."

"The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable," said Robert Burney, director of Quality Improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. "The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical."

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through "a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, "Your data stinks, it's all BS," through one of, "Your data are meaningful but don't really apply to me," through, "The reasons my data are bad is because everyone's data are bad," to finally accepting there's a need for improvement. But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference.

On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as "lower quality." This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. "You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5' of their Medicare revenue, they close their doors. They can't take that kind of hit."

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

"I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them," said Dr. Jack Lewin, who is CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

"Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement." Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

ACC is currently studying "door to balloon" time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. "How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes."

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

"We can tell the medical staff how they are doing compared to their peers," Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. "We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data."

WASHINGTON — If you're of the mind that the pay-for-performance plans instituted by federal as well as private payers are questionable at best and potentially dangerous at worst, don't worry: you're not alone. Many of the pay-for-performance movement's leaders share your concerns.

Speaking at the fourth World Health Care Congress, advocates of pay-for-performance (P4P) acknowledged that if not designed carefully, these plans can create perverse incentives, warp physician behavior, and ultimately fail in their primary objective of improving health care quality.

P4P leaders admit that in many cases, they're not sure they're tracking the right measures. Even if they do get it right, there is little evidence that the measures are truly meaningful to ordinary people needing to make medical decisions.

This doesn't mean P4P is going away any time soon. In fact, P4P plans will only become more widespread in the coming years, spurred on by Medicare's embrace of the concept. But P4P advocates are rapidly finding out they need to assess the impact of their systems as closely as they monitor physician and hospital performance.

"Everything we do must be monitored for unintended consequences. P4P plans are no different. The movement is in its infancy," said Dr. Tom Valuck, director of value-based purchasing for the Centers for Medicare and Medicaid Services. He cited a recent Institute of Medicine report concluding that while P4P has potential to improve health care systems, experience is still very limited, close monitoring is essential, and plan developers need to build in provisions for rapid redesign and correction.

"P4P may lead to focus on wrong priorities. For example, we can end up focusing on individual accountability instead of system performance. This raises a lot of questions about rewards and incentives." Wrongly focused P4P could exacerbate health care disparities, leading to cherry-picking and cream-skimming, and detracting clinical attention from other priorities, he added. "We may end up teaching to the test, while ignoring the bigger picture."

Dr. Brent James is executive director of the Institute for Healthcare Delivery Research at Intermountain Healthcare, a health system with one of the most proactive quality improvement and performance measurement systems in the nation. An early advocate of P4P, Dr. James said he has learned some important lessons over several attempts at establishing P4P programs.

Where most P4P plans go awry is by being overly focused on arbitrarily-chosen individual physician "accountability" measures and not being focused enough on overall systems process measures that tie back to meaningful clinical outcomes, said Dr. James.

"You have to show end-of-day improvement in care. If everyone is doing 'perfect score' medicine, but there's no improvement in outcomes, it means either people are gaming the system or the measures are irrelevant. If you build for system improvement, you'll get accountability data along the way. Build from the bottom up, so as not to damage care."

Dr. James defines systems transparency as meaning that, "you have sufficient information to make a whole series of decisions, and this holds for patients and practitioners alike. It is not as if any one single piece of information tells the whole story or allows one to make a definitive decision. Transparency is a much broader, a much more profound concept than accountability."

Dr. James said that he is wary of plans that attach heavy financial rewards or penalties to individual physician measures. First, the measures may not be clinically important ones, and may end up rewarding "performance" on tasks that do not really lead to better patient care. Secondly, financial incentives can skew care delivery. "As you attach greater rewards or punishments to achieving a number, you get increasing propensity for suboptimization; you make one area look good at the expense of the others."

Finally, financial incentives create the wrong sort of motivations. "One of the worst things you can do to physicians is tell them that money is more important than their professional judgment. They will end up believing you," he said.

An effective P4P program motivates physicians by stressing improved patient care. "Extrinsic awards destroy intrinsic motivation for improvement. Get the professional incentives right and you get system improvement," said Dr. James.

Tom Sackville, chief executive of International Federation of Health Plans, and former Minister of Health in Britain, strongly agreed. "Doctors are highly trained, independent-minded, intelligent professionals. They know what they have to do. If they perceive distant bureaucrats throwing bits of fish, they'll start behaving like … performing sea lions. Our doctors pride themselves on having a true vocation. We spoil that at our peril."

"The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable," said Robert Burney, director of Quality Improvement for the U.S. Department of State.

Dr. James questioned the extent to which P4P data has any relevance to patients at all. "The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical."

If patients tend not to respond to data, physicians will … eventually.

Dr. Varga said doctors tend to go through "a sort of 'Kübler-Ross acceptance process' when it comes to P4P, going from a denial attitude of, "Your data stinks, it's all BS," through one of, "Your data are meaningful but don't really apply to me," through, "The reasons my data are bad is because everyone's data are bad," to finally accepting there's a need for improvement. But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.

Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference.

On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as "lower quality." This can make it hard for younger doctors to build practices.

There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. "You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5' of their Medicare revenue, they close their doors. They can't take that kind of hit."

At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.

"I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them," said Dr. Jack Lewin, who is CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.

"Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement." Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.

ACC is currently studying "door to balloon" time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. "How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes."

The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.

"We can tell the medical staff how they are doing compared to their peers," Dr. Lewin said at the conference sponsored by the Wall Street Journal and CNBC. "We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data."

NEW YORK — End-on dermoscopy is an invaluable tool in making an accurate diagnosis in patients who present with dark streaks in the nails of their fingers or toes, Dr. Nathaniel Jellinek said at the American Academy of Dermatology's Academy 2007 meeting.

Because the dorsal nail plate is produced by the proximal nail matrix, and the ventral plate is produced by the distal matrix, an end-on dermoscopic view of the patient's nails can provide something of a map of the nail, indicating the points from which the pigment is emanating (J. Am. Acad. Dermatol. 2006;55:512–3). This can be a helpful guide as to where and when to biopsy, said Dr. Jellinek of the department of dermatology, Brown University, Providence, R.I.

The real value of end-on dermoscopy is not so much that it leads to a definite diagnosis in and of itself, but that it can tell you where you need to look when taking a biopsy, he said. It helps you zero in on the lesion location.

Dorsal pigmentation points to a proximal matrix lesion, whereas pigmentation of the ventral aspect of the nail plate points to distal lesions. "You still have to biopsy if you are not sure what you're looking at," Dr. Jellinek said.

Nail biopsies, however, are tricky. Small biopsies in the setting of a large lesion run the risk of missing something important, but larger full-thickness biopsies (greater than 3 mm) increase the risk of permanent dystrophy, particularly of the proximal matrix. This can lead to permanent split nails.

Dr. Jellinek outlined his published algorithmic approach for assessing and evaluating longitudinal melanonychia. If the lesion seems to be in the distal nail matrix and measures 3 mm or less, a 3-mm punch biopsy is adequate and safe. If the lesion is larger than 3 mm, however, a newer technique—the matrix shave biopsy—may be a better option (J. Amer. Acad. Dermatol. 2007;56:803–10).

Any proximal matrix lesion can be handled elegantly by the matrix shave biopsy. "Done right, there's minimal risk of nail dystrophy," he said of the shave technique. Any lesion of the lateral aspects of the nail unit should be handled by lateral longitudinal excision.

Longitudinal brown or black streaks on a nail present a diagnostic challenge. In most cases, the underlying etiology is benign, but in some, these streaks can signal the presence of nail melanoma.

The first diagnostic step is to consider the patient's age and overall cutaneous appearance, according to Dr. Jellinek. Melanomas are extremely rare in children and younger adolescents; this is reassuring but certainly not an absolute finding, and each patient must be evaluated on a case-by-case basis. Furthermore, "always look at the patient's whole skin. It can provide a lot of clues," Dr. Jellinek added. Then, go to dermoscopy and end-on dermoscopy, preferably using a water-soluble medium.

The observable diagnostic features of melanocytic nevi on dermoscopy include brown, longitudinal pigmentation with smooth, parallel lines and consistent thickness. Brown pigmentation overlaid by longitudinal lines showing irregularity of thickness, spacing, or alignment are suggestive of melanoma (Dermatol. Ther. 2007;20:3–10).

Grayish bands without any brown stripes are suggestive of lentigines or other types of melanocytic activation, and are much less suggestive of melanoma. Round-shaped black spots are generally blood spots under the nail plate, indicative of injury but not neoplasia. It is important to note that the presence of blood does not rule out an underlying neoplasm (J. Am. Acad. Dermatol. 2007;57:176).

Although most physicians notice brown streaks on a patient's nails, and quickly jump into a work-up to rule out malignant melanoma, many overlook cases of erythronychia, or red streaks in the nail plate. "It's underrecognized in our clinics. I'm seeing red bands in the nails at least once a week," Dr. Jellinek said.

These lesions almost always involve the distal nail matrix, and although they are usually innocuous, this is not always the case.

The real worry is squamous cell carcinoma, which is, fortunately, rare in the nail bed, he noted. If the red streak is on only one nail and is long standing, then it is probably stable and not neoplastic.

Dermoscopy of the left great toenail (left) shows a longitudinal band with parallel brown lines. With end-on dermoscopy, the pigment maps to the ventral surface of the nail plate's free edge (arrow). PHOTOS COURTESY DR. NATHANIEL JELLINEK

NEW YORK — End-on dermoscopy is an invaluable tool in making an accurate diagnosis in patients who present with dark streaks in the nails of their fingers or toes, Dr. Nathaniel Jellinek said at the American Academy of Dermatology's Academy 2007 meeting.

Because the dorsal nail plate is produced by the proximal nail matrix, and the ventral plate is produced by the distal matrix, an end-on dermoscopic view of the patient's nails can provide something of a map of the nail, indicating the points from which the pigment is emanating (J. Am. Acad. Dermatol. 2006;55:512–3). This can be a helpful guide as to where and when to biopsy, said Dr. Jellinek of the department of dermatology, Brown University, Providence, R.I.

The real value of end-on dermoscopy is not so much that it leads to a definite diagnosis in and of itself, but that it can tell you where you need to look when taking a biopsy, he said. It helps you zero in on the lesion location.

Dorsal pigmentation points to a proximal matrix lesion, whereas pigmentation of the ventral aspect of the nail plate points to distal lesions. "You still have to biopsy if you are not sure what you're looking at," Dr. Jellinek said.

Nail biopsies, however, are tricky. Small biopsies in the setting of a large lesion run the risk of missing something important, but larger full-thickness biopsies (greater than 3 mm) increase the risk of permanent dystrophy, particularly of the proximal matrix. This can lead to permanent split nails.

Dr. Jellinek outlined his published algorithmic approach for assessing and evaluating longitudinal melanonychia. If the lesion seems to be in the distal nail matrix and measures 3 mm or less, a 3-mm punch biopsy is adequate and safe. If the lesion is larger than 3 mm, however, a newer technique—the matrix shave biopsy—may be a better option (J. Amer. Acad. Dermatol. 2007;56:803–10).

Any proximal matrix lesion can be handled elegantly by the matrix shave biopsy. "Done right, there's minimal risk of nail dystrophy," he said of the shave technique. Any lesion of the lateral aspects of the nail unit should be handled by lateral longitudinal excision.

Longitudinal brown or black streaks on a nail present a diagnostic challenge. In most cases, the underlying etiology is benign, but in some, these streaks can signal the presence of nail melanoma.

The first diagnostic step is to consider the patient's age and overall cutaneous appearance, according to Dr. Jellinek. Melanomas are extremely rare in children and younger adolescents; this is reassuring but certainly not an absolute finding, and each patient must be evaluated on a case-by-case basis. Furthermore, "always look at the patient's whole skin. It can provide a lot of clues," Dr. Jellinek added. Then, go to dermoscopy and end-on dermoscopy, preferably using a water-soluble medium.

The observable diagnostic features of melanocytic nevi on dermoscopy include brown, longitudinal pigmentation with smooth, parallel lines and consistent thickness. Brown pigmentation overlaid by longitudinal lines showing irregularity of thickness, spacing, or alignment are suggestive of melanoma (Dermatol. Ther. 2007;20:3–10).

Grayish bands without any brown stripes are suggestive of lentigines or other types of melanocytic activation, and are much less suggestive of melanoma. Round-shaped black spots are generally blood spots under the nail plate, indicative of injury but not neoplasia. It is important to note that the presence of blood does not rule out an underlying neoplasm (J. Am. Acad. Dermatol. 2007;57:176).

Although most physicians notice brown streaks on a patient's nails, and quickly jump into a work-up to rule out malignant melanoma, many overlook cases of erythronychia, or red streaks in the nail plate. "It's underrecognized in our clinics. I'm seeing red bands in the nails at least once a week," Dr. Jellinek said.

These lesions almost always involve the distal nail matrix, and although they are usually innocuous, this is not always the case.

The real worry is squamous cell carcinoma, which is, fortunately, rare in the nail bed, he noted. If the red streak is on only one nail and is long standing, then it is probably stable and not neoplastic.

Dermoscopy of the left great toenail (left) shows a longitudinal band with parallel brown lines. With end-on dermoscopy, the pigment maps to the ventral surface of the nail plate's free edge (arrow). PHOTOS COURTESY DR. NATHANIEL JELLINEK

NEW YORK — End-on dermoscopy is an invaluable tool in making an accurate diagnosis in patients who present with dark streaks in the nails of their fingers or toes, Dr. Nathaniel Jellinek said at the American Academy of Dermatology's Academy 2007 meeting.

Because the dorsal nail plate is produced by the proximal nail matrix, and the ventral plate is produced by the distal matrix, an end-on dermoscopic view of the patient's nails can provide something of a map of the nail, indicating the points from which the pigment is emanating (J. Am. Acad. Dermatol. 2006;55:512–3). This can be a helpful guide as to where and when to biopsy, said Dr. Jellinek of the department of dermatology, Brown University, Providence, R.I.

The real value of end-on dermoscopy is not so much that it leads to a definite diagnosis in and of itself, but that it can tell you where you need to look when taking a biopsy, he said. It helps you zero in on the lesion location.

Dorsal pigmentation points to a proximal matrix lesion, whereas pigmentation of the ventral aspect of the nail plate points to distal lesions. "You still have to biopsy if you are not sure what you're looking at," Dr. Jellinek said.

Nail biopsies, however, are tricky. Small biopsies in the setting of a large lesion run the risk of missing something important, but larger full-thickness biopsies (greater than 3 mm) increase the risk of permanent dystrophy, particularly of the proximal matrix. This can lead to permanent split nails.

Dr. Jellinek outlined his published algorithmic approach for assessing and evaluating longitudinal melanonychia. If the lesion seems to be in the distal nail matrix and measures 3 mm or less, a 3-mm punch biopsy is adequate and safe. If the lesion is larger than 3 mm, however, a newer technique—the matrix shave biopsy—may be a better option (J. Amer. Acad. Dermatol. 2007;56:803–10).

Any proximal matrix lesion can be handled elegantly by the matrix shave biopsy. "Done right, there's minimal risk of nail dystrophy," he said of the shave technique. Any lesion of the lateral aspects of the nail unit should be handled by lateral longitudinal excision.

Longitudinal brown or black streaks on a nail present a diagnostic challenge. In most cases, the underlying etiology is benign, but in some, these streaks can signal the presence of nail melanoma.

The first diagnostic step is to consider the patient's age and overall cutaneous appearance, according to Dr. Jellinek. Melanomas are extremely rare in children and younger adolescents; this is reassuring but certainly not an absolute finding, and each patient must be evaluated on a case-by-case basis. Furthermore, "always look at the patient's whole skin. It can provide a lot of clues," Dr. Jellinek added. Then, go to dermoscopy and end-on dermoscopy, preferably using a water-soluble medium.

The observable diagnostic features of melanocytic nevi on dermoscopy include brown, longitudinal pigmentation with smooth, parallel lines and consistent thickness. Brown pigmentation overlaid by longitudinal lines showing irregularity of thickness, spacing, or alignment are suggestive of melanoma (Dermatol. Ther. 2007;20:3–10).

Grayish bands without any brown stripes are suggestive of lentigines or other types of melanocytic activation, and are much less suggestive of melanoma. Round-shaped black spots are generally blood spots under the nail plate, indicative of injury but not neoplasia. It is important to note that the presence of blood does not rule out an underlying neoplasm (J. Am. Acad. Dermatol. 2007;57:176).

Although most physicians notice brown streaks on a patient's nails, and quickly jump into a work-up to rule out malignant melanoma, many overlook cases of erythronychia, or red streaks in the nail plate. "It's underrecognized in our clinics. I'm seeing red bands in the nails at least once a week," Dr. Jellinek said.

These lesions almost always involve the distal nail matrix, and although they are usually innocuous, this is not always the case.

The real worry is squamous cell carcinoma, which is, fortunately, rare in the nail bed, he noted. If the red streak is on only one nail and is long standing, then it is probably stable and not neoplastic.

Dermoscopy of the left great toenail (left) shows a longitudinal band with parallel brown lines. With end-on dermoscopy, the pigment maps to the ventral surface of the nail plate's free edge (arrow). PHOTOS COURTESY DR. NATHANIEL JELLINEK

BARCELONA — It is clinically feasible to measure breast tumor cells in a patient's circulation, according to the findings of an observational study.

The next step is to determine whether the presence of these cells is truly predictive of impending recurrence or metastasis.

Breast cancer kills only if it metastasizes, so it is important to identify the earliest signs of metastasis. Measuring circulating tumor cells (CTCs) may be a key step in this direction, said Dr. Julia Jueckstock of the department of obstetrics and gynecology, Ludwig-Maximilians University, Munich, where the technique is being pioneered.

Earlier findings showing that CTCs can be measured in bone marrow samples suggest that the presence of tumor cells outside the primary tumor site are indeed predictive of metastasis and poor prognosis. But the difficulty of obtaining bone marrow makes this approach impractical for routine clinical use. Analysis of peripheral blood is potentially much more useful.

Dr. Jueckstock and her colleagues' work is part of the ongoing SUCCESS (Simultaneous Study of Docetaxel-Gemcitabine Combination Adjuvant Treatment With Extended Bisphosphonate and Surveillance) trial. The investigators collected blood from 852 women with high-risk, node-negative breast tumors immediately following surgery but before chemotherapy, then at the end of chemo, and again after 2 years and 5 years.

“These were women with large tumors of unfavorable grade,” Dr. Jueckstock said at the 14th European Cancer Conference.

In all, 94 (11%) had CTCs present after surgery but before chemotherapy. Of these, only nine patients (10%) remained CTC-positive after treatment with either docetaxel or gemcitabine, suggesting that these drugs are effective in reducing the risk of metastasis in most patients.

Of the women who were CTC-negative after surgery, only 7% became positive at some point during the postchemo follow-up. At some stage, 10% of the total patient cohort showed CTCs, measured as number of tumor cells per 20 mL blood. There were no CTCs detected in samples from 24 healthy controls.

Dr. Jueckstock noted that the presence of CTCs did not correlate with any known risk factor for metastasis or progression, other than lymph node status. Circulating CTCs tend to accompany lymphatic invasion.

“Screening blood for CTCs is practical and can be done during chemotherapy and at any time during the follow-up period,” said Dr. Jueckstock. It is clearly more patient-friendly than bone marrow sampling, the only other current method for attempting to predict metastasis.

Does the presence of CTCs mean imminent metastasis? “We know this technology works. The big question is, what does it really tell us?” asked Dr. John Smyth, chair of medical oncology at the University of Edinburgh, commenting on Dr. Jueckstock's presentation. “We don't yet know whether detecting those CTCs has any real clinical significance.”

That question will be answered further down the road as the Munich investigators follow the patients. “We think it will predict the likelihood of recurrence and metastasis, but we don't have the data yet,” Dr. Jueckstock said.

If the CTCs do prove prognostic, this testing method could have major clinical importance. It would provide a relatively simple way of determining which patients need closer and more thorough radiologic examination to seek out potential metastases at their earliest, potentially treatable stages.

“We will have the final results within 5 years. If the study goes as expected, and CTCs have independent prognostic value, we really think this could improve patient care by identifying who needs very aggressive therapy, and by helping us to not over-treat the low-risk patients,” she said at the meeting, which was sponsored by the Federation of European Cancer Societies.

BARCELONA — It is clinically feasible to measure breast tumor cells in a patient's circulation, according to the findings of an observational study.

The next step is to determine whether the presence of these cells is truly predictive of impending recurrence or metastasis.

Breast cancer kills only if it metastasizes, so it is important to identify the earliest signs of metastasis. Measuring circulating tumor cells (CTCs) may be a key step in this direction, said Dr. Julia Jueckstock of the department of obstetrics and gynecology, Ludwig-Maximilians University, Munich, where the technique is being pioneered.

Earlier findings showing that CTCs can be measured in bone marrow samples suggest that the presence of tumor cells outside the primary tumor site are indeed predictive of metastasis and poor prognosis. But the difficulty of obtaining bone marrow makes this approach impractical for routine clinical use. Analysis of peripheral blood is potentially much more useful.

Dr. Jueckstock and her colleagues' work is part of the ongoing SUCCESS (Simultaneous Study of Docetaxel-Gemcitabine Combination Adjuvant Treatment With Extended Bisphosphonate and Surveillance) trial. The investigators collected blood from 852 women with high-risk, node-negative breast tumors immediately following surgery but before chemotherapy, then at the end of chemo, and again after 2 years and 5 years.

“These were women with large tumors of unfavorable grade,” Dr. Jueckstock said at the 14th European Cancer Conference.

In all, 94 (11%) had CTCs present after surgery but before chemotherapy. Of these, only nine patients (10%) remained CTC-positive after treatment with either docetaxel or gemcitabine, suggesting that these drugs are effective in reducing the risk of metastasis in most patients.

Of the women who were CTC-negative after surgery, only 7% became positive at some point during the postchemo follow-up. At some stage, 10% of the total patient cohort showed CTCs, measured as number of tumor cells per 20 mL blood. There were no CTCs detected in samples from 24 healthy controls.

Dr. Jueckstock noted that the presence of CTCs did not correlate with any known risk factor for metastasis or progression, other than lymph node status. Circulating CTCs tend to accompany lymphatic invasion.

“Screening blood for CTCs is practical and can be done during chemotherapy and at any time during the follow-up period,” said Dr. Jueckstock. It is clearly more patient-friendly than bone marrow sampling, the only other current method for attempting to predict metastasis.

Does the presence of CTCs mean imminent metastasis? “We know this technology works. The big question is, what does it really tell us?” asked Dr. John Smyth, chair of medical oncology at the University of Edinburgh, commenting on Dr. Jueckstock's presentation. “We don't yet know whether detecting those CTCs has any real clinical significance.”

That question will be answered further down the road as the Munich investigators follow the patients. “We think it will predict the likelihood of recurrence and metastasis, but we don't have the data yet,” Dr. Jueckstock said.

If the CTCs do prove prognostic, this testing method could have major clinical importance. It would provide a relatively simple way of determining which patients need closer and more thorough radiologic examination to seek out potential metastases at their earliest, potentially treatable stages.

“We will have the final results within 5 years. If the study goes as expected, and CTCs have independent prognostic value, we really think this could improve patient care by identifying who needs very aggressive therapy, and by helping us to not over-treat the low-risk patients,” she said at the meeting, which was sponsored by the Federation of European Cancer Societies.

BARCELONA — It is clinically feasible to measure breast tumor cells in a patient's circulation, according to the findings of an observational study.

The next step is to determine whether the presence of these cells is truly predictive of impending recurrence or metastasis.

Breast cancer kills only if it metastasizes, so it is important to identify the earliest signs of metastasis. Measuring circulating tumor cells (CTCs) may be a key step in this direction, said Dr. Julia Jueckstock of the department of obstetrics and gynecology, Ludwig-Maximilians University, Munich, where the technique is being pioneered.

Earlier findings showing that CTCs can be measured in bone marrow samples suggest that the presence of tumor cells outside the primary tumor site are indeed predictive of metastasis and poor prognosis. But the difficulty of obtaining bone marrow makes this approach impractical for routine clinical use. Analysis of peripheral blood is potentially much more useful.

Dr. Jueckstock and her colleagues' work is part of the ongoing SUCCESS (Simultaneous Study of Docetaxel-Gemcitabine Combination Adjuvant Treatment With Extended Bisphosphonate and Surveillance) trial. The investigators collected blood from 852 women with high-risk, node-negative breast tumors immediately following surgery but before chemotherapy, then at the end of chemo, and again after 2 years and 5 years.

“These were women with large tumors of unfavorable grade,” Dr. Jueckstock said at the 14th European Cancer Conference.

In all, 94 (11%) had CTCs present after surgery but before chemotherapy. Of these, only nine patients (10%) remained CTC-positive after treatment with either docetaxel or gemcitabine, suggesting that these drugs are effective in reducing the risk of metastasis in most patients.

Of the women who were CTC-negative after surgery, only 7% became positive at some point during the postchemo follow-up. At some stage, 10% of the total patient cohort showed CTCs, measured as number of tumor cells per 20 mL blood. There were no CTCs detected in samples from 24 healthy controls.

Dr. Jueckstock noted that the presence of CTCs did not correlate with any known risk factor for metastasis or progression, other than lymph node status. Circulating CTCs tend to accompany lymphatic invasion.

“Screening blood for CTCs is practical and can be done during chemotherapy and at any time during the follow-up period,” said Dr. Jueckstock. It is clearly more patient-friendly than bone marrow sampling, the only other current method for attempting to predict metastasis.

Does the presence of CTCs mean imminent metastasis? “We know this technology works. The big question is, what does it really tell us?” asked Dr. John Smyth, chair of medical oncology at the University of Edinburgh, commenting on Dr. Jueckstock's presentation. “We don't yet know whether detecting those CTCs has any real clinical significance.”

That question will be answered further down the road as the Munich investigators follow the patients. “We think it will predict the likelihood of recurrence and metastasis, but we don't have the data yet,” Dr. Jueckstock said.

If the CTCs do prove prognostic, this testing method could have major clinical importance. It would provide a relatively simple way of determining which patients need closer and more thorough radiologic examination to seek out potential metastases at their earliest, potentially treatable stages.

“We will have the final results within 5 years. If the study goes as expected, and CTCs have independent prognostic value, we really think this could improve patient care by identifying who needs very aggressive therapy, and by helping us to not over-treat the low-risk patients,” she said at the meeting, which was sponsored by the Federation of European Cancer Societies.

BARCELONA — The long-awaited 5-year survival analysis from the Clinical Outcomes of Surgical Therapy trial indicate that laparoscopic colectomy is clinically equivalent to open abdominal surgery as a treatment for colon cancer and has advantages for quality of life, Dr. Heidi Nelson said at the 14th European Cancer Conference.

The National Cancer Institute-funded Clinical Outcomes of Surgical Therapy (COST) study began in the mid-1990s, largely in response to a 1994 statement by the American Society of Colorectal Surgeons that “absence of 5-year data makes it premature to endorse this procedure [laparoscopic colectomy].”

The numbers are now in, and “we can now say that Level 1 evidence supports the practice of laparoscopic colectomy,” said Dr. Nelson, a colorectal surgeon at the Mayo Clinic, Rochester, Minn.

The trial protocol randomized 872 people with stage I-III colon cancer to either open surgery or laparoscopic colectomy, performed by well-credentialed laparoscopic surgeons at major U.S. cancer hospitals. All procedures were videotaped and archived, as were histologic samples of tumor tissue.

Initial survival data were first published in 2004, and showed no difference in clinical outcomes between the two procedures (N. Engl. J. Med. 2004;350:2050–9). However, in terms of quality of life, length of hospital stay, and pain, the scope-based procedures were clearly superior.

The 5-year survival data echo those earlier findings, Dr. Nelson said at the conference, sponsored by the Federation of European Cancer Societies. “The curves are completely overlapping. There is no significant difference in terms of overall survival or disease-free survival. The cumulative incidence of recurrence was low in both treatment arms. There is no real evidence of a clinical advantage of one procedure over the other.”

After a median of 7 years' follow-up, 75% of the laparoscopic surgery patients and 77% of the open surgery patients were still alive. Disease-free survival was equal, at 69%, and local recurrence rates were very low at 2.6% in the laparoscopic group and 2.3% in the open surgery group.

Dr. Nelson noted that there seemed to be a slight statistical advantage of open procedures for overall survival of stage I patients. But this finding is difficult to interpret because most of the deaths in patients with stage I tumors were not cancer related.

The procedures were equivalent in terms of treatment-related morbidity and complication rates, which were low in both groups.

Laparoscopic colectomy had clear advantages in terms of quality of life; for example, the total mean incision lengths were 60 mm for laparoscopic surgery and 180 mm for open surgery.

Mean length of stay was 5 days for the laparoscopically treated patients vs. 6 days for open surgery patients, a 20% decrease with significant fiscal implications given the high cost of hospitalization. Laparoscopically treated patients also used fewer painkillers.

ELSEVIER GLOBAL MEDICAL NEWS

BARCELONA — The long-awaited 5-year survival analysis from the Clinical Outcomes of Surgical Therapy trial indicate that laparoscopic colectomy is clinically equivalent to open abdominal surgery as a treatment for colon cancer and has advantages for quality of life, Dr. Heidi Nelson said at the 14th European Cancer Conference.

The National Cancer Institute-funded Clinical Outcomes of Surgical Therapy (COST) study began in the mid-1990s, largely in response to a 1994 statement by the American Society of Colorectal Surgeons that “absence of 5-year data makes it premature to endorse this procedure [laparoscopic colectomy].”

The numbers are now in, and “we can now say that Level 1 evidence supports the practice of laparoscopic colectomy,” said Dr. Nelson, a colorectal surgeon at the Mayo Clinic, Rochester, Minn.

The trial protocol randomized 872 people with stage I-III colon cancer to either open surgery or laparoscopic colectomy, performed by well-credentialed laparoscopic surgeons at major U.S. cancer hospitals. All procedures were videotaped and archived, as were histologic samples of tumor tissue.

Initial survival data were first published in 2004, and showed no difference in clinical outcomes between the two procedures (N. Engl. J. Med. 2004;350:2050–9). However, in terms of quality of life, length of hospital stay, and pain, the scope-based procedures were clearly superior.

The 5-year survival data echo those earlier findings, Dr. Nelson said at the conference, sponsored by the Federation of European Cancer Societies. “The curves are completely overlapping. There is no significant difference in terms of overall survival or disease-free survival. The cumulative incidence of recurrence was low in both treatment arms. There is no real evidence of a clinical advantage of one procedure over the other.”

After a median of 7 years' follow-up, 75% of the laparoscopic surgery patients and 77% of the open surgery patients were still alive. Disease-free survival was equal, at 69%, and local recurrence rates were very low at 2.6% in the laparoscopic group and 2.3% in the open surgery group.

Dr. Nelson noted that there seemed to be a slight statistical advantage of open procedures for overall survival of stage I patients. But this finding is difficult to interpret because most of the deaths in patients with stage I tumors were not cancer related.

The procedures were equivalent in terms of treatment-related morbidity and complication rates, which were low in both groups.

Laparoscopic colectomy had clear advantages in terms of quality of life; for example, the total mean incision lengths were 60 mm for laparoscopic surgery and 180 mm for open surgery.

Mean length of stay was 5 days for the laparoscopically treated patients vs. 6 days for open surgery patients, a 20% decrease with significant fiscal implications given the high cost of hospitalization. Laparoscopically treated patients also used fewer painkillers.

ELSEVIER GLOBAL MEDICAL NEWS

BARCELONA — The long-awaited 5-year survival analysis from the Clinical Outcomes of Surgical Therapy trial indicate that laparoscopic colectomy is clinically equivalent to open abdominal surgery as a treatment for colon cancer and has advantages for quality of life, Dr. Heidi Nelson said at the 14th European Cancer Conference.

The National Cancer Institute-funded Clinical Outcomes of Surgical Therapy (COST) study began in the mid-1990s, largely in response to a 1994 statement by the American Society of Colorectal Surgeons that “absence of 5-year data makes it premature to endorse this procedure [laparoscopic colectomy].”

The numbers are now in, and “we can now say that Level 1 evidence supports the practice of laparoscopic colectomy,” said Dr. Nelson, a colorectal surgeon at the Mayo Clinic, Rochester, Minn.

The trial protocol randomized 872 people with stage I-III colon cancer to either open surgery or laparoscopic colectomy, performed by well-credentialed laparoscopic surgeons at major U.S. cancer hospitals. All procedures were videotaped and archived, as were histologic samples of tumor tissue.

Initial survival data were first published in 2004, and showed no difference in clinical outcomes between the two procedures (N. Engl. J. Med. 2004;350:2050–9). However, in terms of quality of life, length of hospital stay, and pain, the scope-based procedures were clearly superior.

The 5-year survival data echo those earlier findings, Dr. Nelson said at the conference, sponsored by the Federation of European Cancer Societies. “The curves are completely overlapping. There is no significant difference in terms of overall survival or disease-free survival. The cumulative incidence of recurrence was low in both treatment arms. There is no real evidence of a clinical advantage of one procedure over the other.”

After a median of 7 years' follow-up, 75% of the laparoscopic surgery patients and 77% of the open surgery patients were still alive. Disease-free survival was equal, at 69%, and local recurrence rates were very low at 2.6% in the laparoscopic group and 2.3% in the open surgery group.

Dr. Nelson noted that there seemed to be a slight statistical advantage of open procedures for overall survival of stage I patients. But this finding is difficult to interpret because most of the deaths in patients with stage I tumors were not cancer related.

The procedures were equivalent in terms of treatment-related morbidity and complication rates, which were low in both groups.

Laparoscopic colectomy had clear advantages in terms of quality of life; for example, the total mean incision lengths were 60 mm for laparoscopic surgery and 180 mm for open surgery.

Mean length of stay was 5 days for the laparoscopically treated patients vs. 6 days for open surgery patients, a 20% decrease with significant fiscal implications given the high cost of hospitalization. Laparoscopically treated patients also used fewer painkillers.

ELSEVIER GLOBAL MEDICAL NEWS

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

“If you're getting cultures, you're seeing this, because it is definitely there,” said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. “Where's it coming from? Everywhere!”

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309–17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he noted.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. “Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant,” he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in Atlanta, Minnesota, and Baltimore are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted. Trimethoprim-sulfamethoxazole (Bactrim) still works almost everywhere, although in Baltimore, 17% of MRSA strains have been found resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences whatsoever between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123–7).

Dr. Lebwohl cautioned against such antibiotic nihilism. “If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are treating the whole community.”

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections (Curr. Med. Res. Opin. 2005;21:1923–6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: a recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024–32). Unfortunately, it is very expensive.

Generally, one should stay clear of quinolones and macrolides, as they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance develops very quickly.

Dr. Lebwohl advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373–406). He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Dr. Lebwohl has been a consultant for Galderma (clindamycin) and Pfizer (doxycycline).

'If you're getting cultures, you're seeing this, because it is definitely there.' DR. LEBWOHL

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

“If you're getting cultures, you're seeing this, because it is definitely there,” said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. “Where's it coming from? Everywhere!”

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309–17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he noted.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. “Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant,” he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in Atlanta, Minnesota, and Baltimore are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted. Trimethoprim-sulfamethoxazole (Bactrim) still works almost everywhere, although in Baltimore, 17% of MRSA strains have been found resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences whatsoever between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123–7).

Dr. Lebwohl cautioned against such antibiotic nihilism. “If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are treating the whole community.”

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections (Curr. Med. Res. Opin. 2005;21:1923–6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: a recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024–32). Unfortunately, it is very expensive.

Generally, one should stay clear of quinolones and macrolides, as they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance develops very quickly.

Dr. Lebwohl advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373–406). He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Dr. Lebwohl has been a consultant for Galderma (clindamycin) and Pfizer (doxycycline).

'If you're getting cultures, you're seeing this, because it is definitely there.' DR. LEBWOHL

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

“If you're getting cultures, you're seeing this, because it is definitely there,” said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. “Where's it coming from? Everywhere!”

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309–17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he noted.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. “Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant,” he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in Atlanta, Minnesota, and Baltimore are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted. Trimethoprim-sulfamethoxazole (Bactrim) still works almost everywhere, although in Baltimore, 17% of MRSA strains have been found resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences whatsoever between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123–7).

Dr. Lebwohl cautioned against such antibiotic nihilism. “If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are treating the whole community.”

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections (Curr. Med. Res. Opin. 2005;21:1923–6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: a recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024–32). Unfortunately, it is very expensive.

Generally, one should stay clear of quinolones and macrolides, as they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance develops very quickly.

Dr. Lebwohl advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373–406). He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Dr. Lebwohl has been a consultant for Galderma (clindamycin) and Pfizer (doxycycline).

'If you're getting cultures, you're seeing this, because it is definitely there.' DR. LEBWOHL

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

“If you're getting cultures, you're seeing this, because it is definitely there,” said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. “Where's it coming from? Everywhere!”

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309-17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he stressed.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. “Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant,” he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in the cities of Atlanta and Baltimore and the state of Minnesota are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted.

Fortunately, trimethoprim-sulfamethoxazole (Bactrim) still works almost everywhere. In Baltimore, though, 17% of MRSA strains have been found to be resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123-7).

Dr. Lebwohl cautioned against such antibiotic nihilism. “If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family members, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are also treating the whole community.”

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections, especially in the bones and joints (Curr. Med. Res. Opin. 2005;21:1923-6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: A recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024-32). Unfortunately, it is very expensive.

Generally, one should stay clear of quinolones and macrolides, as they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance develops very quickly.

Dr. Lebwohl strongly advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373-406). He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Over the past year, Dr. Lebwohl has been a consultant for a number of drug companies, including Galderma (clindamycin) and Pfizer (doxycycline).

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

“If you're getting cultures, you're seeing this, because it is definitely there,” said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. “Where's it coming from? Everywhere!”

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309-17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he stressed.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. “Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant,” he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in the cities of Atlanta and Baltimore and the state of Minnesota are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted.

Fortunately, trimethoprim-sulfamethoxazole (Bactrim) still works almost everywhere. In Baltimore, though, 17% of MRSA strains have been found to be resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123-7).

Dr. Lebwohl cautioned against such antibiotic nihilism. “If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family members, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are also treating the whole community.”

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections, especially in the bones and joints (Curr. Med. Res. Opin. 2005;21:1923-6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: A recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024-32). Unfortunately, it is very expensive.

Generally, one should stay clear of quinolones and macrolides, as they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance develops very quickly.

Dr. Lebwohl strongly advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373-406). He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Over the past year, Dr. Lebwohl has been a consultant for a number of drug companies, including Galderma (clindamycin) and Pfizer (doxycycline).

NEW YORK — Methicillin-resistant Staphylococcus aureus is now the most common cause of serious skin and soft-tissue infections in many communities throughout the United States, Dr. Mark Lebwohl said at the American Academy of Dermatology's annual Academy 2007 meeting.

“If you're getting cultures, you're seeing this, because it is definitely there,” said Dr. Lebwohl of the department of dermatology at Mount Sinai Medical Center, New York. “Where's it coming from? Everywhere!”

In one study he cited, methicillin-resistant Staphylococcus aureus (MRSA) accounted for 72% of all skin and soft-tissue infections seen at a major medical center and affiliated outpatient clinics in Atlanta (Ann. Intern. Med. 2006;144:309-17). MRSA is particularly common among athletes, military personnel, homeless people, and intravenous drug users, but in reality, everyone is at risk, he stressed.

The bad news is that MRSA isn't just resistant to methicillin. It seems to be increasingly resistant to most antibiotics these days. “Unfortunately, vancomycin resistance is emerging in MRSA organisms. Erythromycin borders on worthless, as almost all MRSA strains are erythromycin-resistant,” he said.

Clindamycin is still effective in most communities around the country, but resistance to this drug also is starting to show up. Between 10% and 15% of all MRSA strains identified in the cities of Atlanta and Baltimore and the state of Minnesota are resistant to clindamycin. In Chicago, the number is over 50% for infected adults, Dr. Lebwohl noted.

Fortunately, trimethoprim-sulfamethoxazole (Bactrim) still works almost everywhere. In Baltimore, though, 17% of MRSA strains have been found to be resistant to this drug as well.

All of this bad news might lead one to conclude that antibiotic therapy for MRSA is ultimately futile. A study published several years ago suggested that, when treating MRSA-infected skin and soft-tissue abscesses, there were no significant differences between allegedly effective and ineffective antibiotics, and that the key to treatment was incision and drainage (Pediatr. Infect. Dis. J. 2004;23:123-7).

Dr. Lebwohl cautioned against such antibiotic nihilism. “If there's no difference between the antibiotics, it's reasonable to ask: Why treat? But the point is, it is not the patient you are seeing that you worry about. It is the person you are not seeing: the patient's family members, neighbors, colleagues. MRSA can cause sepsis, coagulopathy, osteomyelitis. It can kill people. It is very serious. You need to use the right antibiotics, because in treating your patient properly you are also treating the whole community.”

Clindamycin and Bactrim are still good options, as are doxycycline and minocycline, although they are not recommended for children. For adults, doxycycline and minocycline are the top choices, he said. Daptomycin (Cubicin) is also a good choice for deep-tissue infections, especially in the bones and joints (Curr. Med. Res. Opin. 2005;21:1923-6).

Dr. Lebwohl also had high praise for linezolid (Zyvox), a newcomer to the antibiotic front lines. MRSA seems to be very sensitive to this drug: A recent in vitro study of almost 3,400 MRSA isolates showed that all were sensitive to linezolid (Antimicrob. Agents Chemother. 2005;49:5024-32). Unfortunately, it is very expensive.

Generally, one should stay clear of quinolones and macrolides, as they are ineffective against MRSA at this point. Rifampin may seem to work at first, but resistance develops very quickly.

Dr. Lebwohl strongly advised colleagues to read and practice according to the Infectious Diseases Society of America's 2005 guidelines for the management of skin and soft-tissue infections (Clin. Infect. Dis. 2005;41:1373-406). He also advocated routine culture and sensitivity testing. The more information physicians can gather about the infections they are confronting, the more intelligently they can choose the antibiotic therapy.

Over the past year, Dr. Lebwohl has been a consultant for a number of drug companies, including Galderma (clindamycin) and Pfizer (doxycycline).

NEW YORK — Scalp nevi in young children almost always are benign and seldom warrant excision, Dr. Jean Bolognia said at the American Academy of Dermatology's Academy 2007 meeting.

Despite the absence of medical necessity, many dermatologists routinely remove these lesions. In part, they are responding to parental pressures but also to a misperception that scalp nevi are somehow harbingers of future problems. "They've never been proven to be bad, yet everyone thinks they are bad," said Dr. Bolognia of the department of dermatology at Yale University, New Haven, Conn.

Several decades ago, researchers at the National Cancer Institute were studying malignant melanoma clusters in families. They found that children who had scalp nevi were predisposed to having large numbers of moles later in life, though there was no evidence that these nevi became melanoma. Nonetheless, the NCI report suggested that scalp nevi be removed, and it has become almost customary in dermatology to do so.

Dr. Bolognia believes it is time to question that practice. She acknowledged that scalp nevi often are seen in "moley" children, and that, in some cases, the nevi have a detrimental effect on the child's appearance and self-image. The nevi may be disturbing to look at, but so are hypertrophic scars, she pointed out. Self-conscious children with many nevi probably will end up having numerous surgeries and that means many scars. This is not necessarily a great trade-off, Dr. Bolognia suggested.

She urged caution in jumping to excision if there's no medical necessity or strong cosmetic consideration. "Once you get on the 'excision train' with a family, it is very difficult to get off. The parents will be bringing the kid in very frequently," Dr. Bolognia said. A child with several nevi on the scalp and 10 or more on his or her body will probably need close dermatologic attention for life, but the lesions should not be construed as red flags for melanoma, she stressed.

Many moley children and adolescents have fairly large "fried egg" lesions on their trunks. These have a deeply pigmented central area, akin to the yolk of a fried egg, surrounded by a broader, lightly pigmented field. Dr. Bolognia said these are the "Paris Hiltons" of nevi: They are sensational and attract a lot of attention, much of it negative. In reality, though, they are harmless. "Unless there's a superimposed change, these lesions are symmetrical and are not precursors of malignant melanoma," she said. Because they are conspicuous, they are easy to follow over time, especially compared with the multiple, tiny black nevi that some patients have.

If these "fried eggs" are left alone, the darker central area will gradually become intradermal nevus tissue, and the lightly pigmented field will gradually fade.

Eclipse nevi (lesions with pale centers and darkened, often stellate rims) also get negative attention, and many dermatologists are inclined to remove them. But again, unless there are worrisome changes, these nevi are completely benign and will usually disappear over time. "You often see these on the scalps of children. They are completely benign, so just follow them closely. There's no need to excise them," Dr. Bolognia said.

Many people with large numbers of moles develop halo nevi, which are completely benign in most cases. The central pigmented spot usually fades and disappears, leaving the hypopigmented halo behind. These can be disconcerting to patients and their families, especially if there are many such halos. Reassure patients that 95% of these halos will repigment, though it may take years. At any rate, unless there are strong indicators of melanoma, halo nevi do not warrant excision.

If excision of a nevus truly is necessary, or if parents are relentless in demanding it, saucerization is Dr. Bolognia's procedure of choice. "It leaves a better scar," she noted. Some might argue that excision of nevi, even if they are benign, essentially is harmless, so long as scarring doesn't become a problem. Insurers, however, may not see it that way.

In a separate presentation at the conference, Dr. Clay J. Cockerell, a dermatopathologist at the University of Texas at Dallas, and a past president of the American Academy of Dermatology, said that he expects third-party payers to start clamping down on unnecessary surgeries in the near future.

NEW YORK — Scalp nevi in young children almost always are benign and seldom warrant excision, Dr. Jean Bolognia said at the American Academy of Dermatology's Academy 2007 meeting.

Despite the absence of medical necessity, many dermatologists routinely remove these lesions. In part, they are responding to parental pressures but also to a misperception that scalp nevi are somehow harbingers of future problems. "They've never been proven to be bad, yet everyone thinks they are bad," said Dr. Bolognia of the department of dermatology at Yale University, New Haven, Conn.

Several decades ago, researchers at the National Cancer Institute were studying malignant melanoma clusters in families. They found that children who had scalp nevi were predisposed to having large numbers of moles later in life, though there was no evidence that these nevi became melanoma. Nonetheless, the NCI report suggested that scalp nevi be removed, and it has become almost customary in dermatology to do so.

Dr. Bolognia believes it is time to question that practice. She acknowledged that scalp nevi often are seen in "moley" children, and that, in some cases, the nevi have a detrimental effect on the child's appearance and self-image. The nevi may be disturbing to look at, but so are hypertrophic scars, she pointed out. Self-conscious children with many nevi probably will end up having numerous surgeries and that means many scars. This is not necessarily a great trade-off, Dr. Bolognia suggested.

She urged caution in jumping to excision if there's no medical necessity or strong cosmetic consideration. "Once you get on the 'excision train' with a family, it is very difficult to get off. The parents will be bringing the kid in very frequently," Dr. Bolognia said. A child with several nevi on the scalp and 10 or more on his or her body will probably need close dermatologic attention for life, but the lesions should not be construed as red flags for melanoma, she stressed.

Many moley children and adolescents have fairly large "fried egg" lesions on their trunks. These have a deeply pigmented central area, akin to the yolk of a fried egg, surrounded by a broader, lightly pigmented field. Dr. Bolognia said these are the "Paris Hiltons" of nevi: They are sensational and attract a lot of attention, much of it negative. In reality, though, they are harmless. "Unless there's a superimposed change, these lesions are symmetrical and are not precursors of malignant melanoma," she said. Because they are conspicuous, they are easy to follow over time, especially compared with the multiple, tiny black nevi that some patients have.

If these "fried eggs" are left alone, the darker central area will gradually become intradermal nevus tissue, and the lightly pigmented field will gradually fade.

Eclipse nevi (lesions with pale centers and darkened, often stellate rims) also get negative attention, and many dermatologists are inclined to remove them. But again, unless there are worrisome changes, these nevi are completely benign and will usually disappear over time. "You often see these on the scalps of children. They are completely benign, so just follow them closely. There's no need to excise them," Dr. Bolognia said.

Many people with large numbers of moles develop halo nevi, which are completely benign in most cases. The central pigmented spot usually fades and disappears, leaving the hypopigmented halo behind. These can be disconcerting to patients and their families, especially if there are many such halos. Reassure patients that 95% of these halos will repigment, though it may take years. At any rate, unless there are strong indicators of melanoma, halo nevi do not warrant excision.

If excision of a nevus truly is necessary, or if parents are relentless in demanding it, saucerization is Dr. Bolognia's procedure of choice. "It leaves a better scar," she noted. Some might argue that excision of nevi, even if they are benign, essentially is harmless, so long as scarring doesn't become a problem. Insurers, however, may not see it that way.

In a separate presentation at the conference, Dr. Clay J. Cockerell, a dermatopathologist at the University of Texas at Dallas, and a past president of the American Academy of Dermatology, said that he expects third-party payers to start clamping down on unnecessary surgeries in the near future.

NEW YORK — Scalp nevi in young children almost always are benign and seldom warrant excision, Dr. Jean Bolognia said at the American Academy of Dermatology's Academy 2007 meeting.

Despite the absence of medical necessity, many dermatologists routinely remove these lesions. In part, they are responding to parental pressures but also to a misperception that scalp nevi are somehow harbingers of future problems. "They've never been proven to be bad, yet everyone thinks they are bad," said Dr. Bolognia of the department of dermatology at Yale University, New Haven, Conn.

Several decades ago, researchers at the National Cancer Institute were studying malignant melanoma clusters in families. They found that children who had scalp nevi were predisposed to having large numbers of moles later in life, though there was no evidence that these nevi became melanoma. Nonetheless, the NCI report suggested that scalp nevi be removed, and it has become almost customary in dermatology to do so.

Dr. Bolognia believes it is time to question that practice. She acknowledged that scalp nevi often are seen in "moley" children, and that, in some cases, the nevi have a detrimental effect on the child's appearance and self-image. The nevi may be disturbing to look at, but so are hypertrophic scars, she pointed out. Self-conscious children with many nevi probably will end up having numerous surgeries and that means many scars. This is not necessarily a great trade-off, Dr. Bolognia suggested.

She urged caution in jumping to excision if there's no medical necessity or strong cosmetic consideration. "Once you get on the 'excision train' with a family, it is very difficult to get off. The parents will be bringing the kid in very frequently," Dr. Bolognia said. A child with several nevi on the scalp and 10 or more on his or her body will probably need close dermatologic attention for life, but the lesions should not be construed as red flags for melanoma, she stressed.

Many moley children and adolescents have fairly large "fried egg" lesions on their trunks. These have a deeply pigmented central area, akin to the yolk of a fried egg, surrounded by a broader, lightly pigmented field. Dr. Bolognia said these are the "Paris Hiltons" of nevi: They are sensational and attract a lot of attention, much of it negative. In reality, though, they are harmless. "Unless there's a superimposed change, these lesions are symmetrical and are not precursors of malignant melanoma," she said. Because they are conspicuous, they are easy to follow over time, especially compared with the multiple, tiny black nevi that some patients have.

If these "fried eggs" are left alone, the darker central area will gradually become intradermal nevus tissue, and the lightly pigmented field will gradually fade.

Eclipse nevi (lesions with pale centers and darkened, often stellate rims) also get negative attention, and many dermatologists are inclined to remove them. But again, unless there are worrisome changes, these nevi are completely benign and will usually disappear over time. "You often see these on the scalps of children. They are completely benign, so just follow them closely. There's no need to excise them," Dr. Bolognia said.

Many people with large numbers of moles develop halo nevi, which are completely benign in most cases. The central pigmented spot usually fades and disappears, leaving the hypopigmented halo behind. These can be disconcerting to patients and their families, especially if there are many such halos. Reassure patients that 95% of these halos will repigment, though it may take years. At any rate, unless there are strong indicators of melanoma, halo nevi do not warrant excision.

If excision of a nevus truly is necessary, or if parents are relentless in demanding it, saucerization is Dr. Bolognia's procedure of choice. "It leaves a better scar," she noted. Some might argue that excision of nevi, even if they are benign, essentially is harmless, so long as scarring doesn't become a problem. Insurers, however, may not see it that way.

In a separate presentation at the conference, Dr. Clay J. Cockerell, a dermatopathologist at the University of Texas at Dallas, and a past president of the American Academy of Dermatology, said that he expects third-party payers to start clamping down on unnecessary surgeries in the near future.