Joyce Frieden

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. So remember everything we build is affecting real workloads of real people.”

Disclosures: The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. So remember everything we build is affecting real workloads of real people.”

Disclosures: The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. So remember everything we build is affecting real workloads of real people.”

Disclosures: The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

10. Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

9. Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

8. Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI helps reconcile continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

7. Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” he said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped. …You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

6. Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

5. Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

4. Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

3. Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

2. Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate; it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

1. Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to fill out forms just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. “Everything we build is affecting real workloads of real people.”

The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

10. Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

9. Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

8. Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI helps reconcile continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

7. Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” he said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped. …You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

6. Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

5. Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

4. Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

3. Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

2. Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate; it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

1. Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to fill out forms just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. “Everything we build is affecting real workloads of real people.”

The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

10. Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

9. Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

8. Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI helps reconcile continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

7. Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” he said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped. …You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

6. Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

5. Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

4. Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

3. Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

2. Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate; it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

1. Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to fill out forms just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. “Everything we build is affecting real workloads of real people.”

The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — Although government health officials are hoping that most physicians will get on the “meaningful use” bandwagon, that's not likely to happen easily, according to Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.

“I don't think [health care] professionals have any idea what's coming,” Dr. Lichtenfeld said during a panel discussion at an eHealth Initiative conference. “I think [federal officials] are risking failure because doctors will say, 'Are you kidding? I don't want to have anything to do with this.' I hope that isn't what happens, but I tell you, be prepared.”

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of last year's federal stimulus law, physicians who treat Medicare patients can be awarded up to $44,000 over 5 years for the meaningful use of a certified health information system. For physicians whose patient populations are at least 30% Medicaid patients, the incentive is as much as $64,000.

But physicians who already have computers may find that they won't meet the requirements for the incentive, Dr. Lichtenfeld said. “Doctors have invested in these systems and now they're worthless. They don't have the time, they don't have the money, they don't have the expertise. And to have to get [a new system] up and running in 2-3 years—they won't do it. Something simpler would've gotten us to where we have to go.”

Despite a few patient-driven efforts (see box), no one has figured out how to use information technology as a way to get patients more involved in their care, Dr. Lichtenfeld contended. “A couple of years ago, personal health records… were the talk of the town. They were going to get everybody on board. Patients were going to run to various Web sites and fill out their health information. Health plans were going to get together and figure out how to bring their data so it would be downloadable and easily accessible.”

But none of that has yet come to pass, he said. “Personal health records landed with a thud. We need to figure out that sometimes we have to keep it simple.” For example, the cancer community should come up with a simple document to give to patients listing their diagnosis, their expected length of hospital stay, what kind of treatment they're getting, and what medications they need to take. “This is a good example of where we are not today.”

In the meantime, the Department Health and Human Services is trying to get physicians to meet some meaningful use criteria that aren't even written yet, said Dr. Steven Stack, an emergency physician and member of two workgroups of the department's HIT Policy Committee. He noted that two criteria “were supposed to be finished on Dec. 31, 2008, by statute. It's 2010 and they're not done, and it may be a year before we get something. A lot of these things aren't ready for prime time.”

Instead of requiring physicians to meet lots of criteria, “if we focus on the smallest of things, then doggedly persist until we knock down those barriers, and then require people to meet those [expectations]—with the proper incentives, we can make a really great step forward,” said Dr. Stack, who is a member of the American Medical Association board of trustees.

In contrast, Steven Findlay, senior health policy analyst at Consumers Union, expressed impatience with the process. “We ought to try to push as far as we possibly can with the 2011 meaningful use criteria,” he said. “We ought to be exquisitely sensitive to what's doable in 2011 … but shouldn't be running from time to push. We've been talking about this stuff for 10 years, and for the good of patients and consumers, we need to do this.”

The conference was sponsored by Ingenix, the AMA, and several other industry groups. The speakers reported that they had no conflicts of interest relevant to their presentations.

Patients Can Supply the Data

Patients can play a role in providing useful health information, Dr. Stack emphasized. As an example, he cited

www.patientslikeme.com

Visitors to the site can sign up for a free account and a screen name, which they use to post their comments and health statistics. “People voluntarily post their own health data. Some are very open about it—they post every pill they're on, the dose, the frequency, what's happening to them,” said Dr. Stack.

In the ALS community, members developed “a patient population and a data set that was so robust that if [community members] put in enough of their own variables, [the site] could predict when you'd be in a wheelchair within a week and when you'd be on a ventilator within a week. It was that precise. We could never replicate that in a prospective, double-blind randomized controlled trial. We could never get an institutional review board to [accept it] and never get people to do it.”

But for patients such as these, “the motivation of your own health and the fear of death through your own illness is a motivator we can't replicate with money or incentives,” he said.

WASHINGTON — Although government health officials are hoping that most physicians will get on the “meaningful use” bandwagon, that's not likely to happen easily, according to Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.

“I don't think [health care] professionals have any idea what's coming,” Dr. Lichtenfeld said during a panel discussion at an eHealth Initiative conference. “I think [federal officials] are risking failure because doctors will say, 'Are you kidding? I don't want to have anything to do with this.' I hope that isn't what happens, but I tell you, be prepared.”

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of last year's federal stimulus law, physicians who treat Medicare patients can be awarded up to $44,000 over 5 years for the meaningful use of a certified health information system. For physicians whose patient populations are at least 30% Medicaid patients, the incentive is as much as $64,000.

But physicians who already have computers may find that they won't meet the requirements for the incentive, Dr. Lichtenfeld said. “Doctors have invested in these systems and now they're worthless. They don't have the time, they don't have the money, they don't have the expertise. And to have to get [a new system] up and running in 2-3 years—they won't do it. Something simpler would've gotten us to where we have to go.”

Despite a few patient-driven efforts (see box), no one has figured out how to use information technology as a way to get patients more involved in their care, Dr. Lichtenfeld contended. “A couple of years ago, personal health records… were the talk of the town. They were going to get everybody on board. Patients were going to run to various Web sites and fill out their health information. Health plans were going to get together and figure out how to bring their data so it would be downloadable and easily accessible.”

But none of that has yet come to pass, he said. “Personal health records landed with a thud. We need to figure out that sometimes we have to keep it simple.” For example, the cancer community should come up with a simple document to give to patients listing their diagnosis, their expected length of hospital stay, what kind of treatment they're getting, and what medications they need to take. “This is a good example of where we are not today.”

In the meantime, the Department Health and Human Services is trying to get physicians to meet some meaningful use criteria that aren't even written yet, said Dr. Steven Stack, an emergency physician and member of two workgroups of the department's HIT Policy Committee. He noted that two criteria “were supposed to be finished on Dec. 31, 2008, by statute. It's 2010 and they're not done, and it may be a year before we get something. A lot of these things aren't ready for prime time.”

Instead of requiring physicians to meet lots of criteria, “if we focus on the smallest of things, then doggedly persist until we knock down those barriers, and then require people to meet those [expectations]—with the proper incentives, we can make a really great step forward,” said Dr. Stack, who is a member of the American Medical Association board of trustees.

In contrast, Steven Findlay, senior health policy analyst at Consumers Union, expressed impatience with the process. “We ought to try to push as far as we possibly can with the 2011 meaningful use criteria,” he said. “We ought to be exquisitely sensitive to what's doable in 2011 … but shouldn't be running from time to push. We've been talking about this stuff for 10 years, and for the good of patients and consumers, we need to do this.”

The conference was sponsored by Ingenix, the AMA, and several other industry groups. The speakers reported that they had no conflicts of interest relevant to their presentations.

Patients Can Supply the Data

Patients can play a role in providing useful health information, Dr. Stack emphasized. As an example, he cited

www.patientslikeme.com

Visitors to the site can sign up for a free account and a screen name, which they use to post their comments and health statistics. “People voluntarily post their own health data. Some are very open about it—they post every pill they're on, the dose, the frequency, what's happening to them,” said Dr. Stack.

In the ALS community, members developed “a patient population and a data set that was so robust that if [community members] put in enough of their own variables, [the site] could predict when you'd be in a wheelchair within a week and when you'd be on a ventilator within a week. It was that precise. We could never replicate that in a prospective, double-blind randomized controlled trial. We could never get an institutional review board to [accept it] and never get people to do it.”

But for patients such as these, “the motivation of your own health and the fear of death through your own illness is a motivator we can't replicate with money or incentives,” he said.

WASHINGTON — Although government health officials are hoping that most physicians will get on the “meaningful use” bandwagon, that's not likely to happen easily, according to Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.

“I don't think [health care] professionals have any idea what's coming,” Dr. Lichtenfeld said during a panel discussion at an eHealth Initiative conference. “I think [federal officials] are risking failure because doctors will say, 'Are you kidding? I don't want to have anything to do with this.' I hope that isn't what happens, but I tell you, be prepared.”

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of last year's federal stimulus law, physicians who treat Medicare patients can be awarded up to $44,000 over 5 years for the meaningful use of a certified health information system. For physicians whose patient populations are at least 30% Medicaid patients, the incentive is as much as $64,000.

But physicians who already have computers may find that they won't meet the requirements for the incentive, Dr. Lichtenfeld said. “Doctors have invested in these systems and now they're worthless. They don't have the time, they don't have the money, they don't have the expertise. And to have to get [a new system] up and running in 2-3 years—they won't do it. Something simpler would've gotten us to where we have to go.”

Despite a few patient-driven efforts (see box), no one has figured out how to use information technology as a way to get patients more involved in their care, Dr. Lichtenfeld contended. “A couple of years ago, personal health records… were the talk of the town. They were going to get everybody on board. Patients were going to run to various Web sites and fill out their health information. Health plans were going to get together and figure out how to bring their data so it would be downloadable and easily accessible.”

But none of that has yet come to pass, he said. “Personal health records landed with a thud. We need to figure out that sometimes we have to keep it simple.” For example, the cancer community should come up with a simple document to give to patients listing their diagnosis, their expected length of hospital stay, what kind of treatment they're getting, and what medications they need to take. “This is a good example of where we are not today.”

In the meantime, the Department Health and Human Services is trying to get physicians to meet some meaningful use criteria that aren't even written yet, said Dr. Steven Stack, an emergency physician and member of two workgroups of the department's HIT Policy Committee. He noted that two criteria “were supposed to be finished on Dec. 31, 2008, by statute. It's 2010 and they're not done, and it may be a year before we get something. A lot of these things aren't ready for prime time.”

Instead of requiring physicians to meet lots of criteria, “if we focus on the smallest of things, then doggedly persist until we knock down those barriers, and then require people to meet those [expectations]—with the proper incentives, we can make a really great step forward,” said Dr. Stack, who is a member of the American Medical Association board of trustees.

In contrast, Steven Findlay, senior health policy analyst at Consumers Union, expressed impatience with the process. “We ought to try to push as far as we possibly can with the 2011 meaningful use criteria,” he said. “We ought to be exquisitely sensitive to what's doable in 2011 … but shouldn't be running from time to push. We've been talking about this stuff for 10 years, and for the good of patients and consumers, we need to do this.”

The conference was sponsored by Ingenix, the AMA, and several other industry groups. The speakers reported that they had no conflicts of interest relevant to their presentations.

Patients Can Supply the Data

Patients can play a role in providing useful health information, Dr. Stack emphasized. As an example, he cited

www.patientslikeme.com

Visitors to the site can sign up for a free account and a screen name, which they use to post their comments and health statistics. “People voluntarily post their own health data. Some are very open about it—they post every pill they're on, the dose, the frequency, what's happening to them,” said Dr. Stack.

In the ALS community, members developed “a patient population and a data set that was so robust that if [community members] put in enough of their own variables, [the site] could predict when you'd be in a wheelchair within a week and when you'd be on a ventilator within a week. It was that precise. We could never replicate that in a prospective, double-blind randomized controlled trial. We could never get an institutional review board to [accept it] and never get people to do it.”

But for patients such as these, “the motivation of your own health and the fear of death through your own illness is a motivator we can't replicate with money or incentives,” he said.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person. The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give.

So remember everything we build is affecting real workloads of real people.”

Disclosures: The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person. The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give.

So remember everything we build is affecting real workloads of real people.”

Disclosures: The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person. The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder; they need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information; I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent; let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations; everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give.

So remember everything we build is affecting real workloads of real people.”

Disclosures: The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

Physicians in Montana may legally assist terminally ill patients in hastening death, according to a ruling by the Montana Supreme Court.

The decision in the case of Baxter v. State of Montana concerned Robert Baxter, a retired truck driver from Billings, Mont., who was terminally ill with lymphocytic leukemia with diffuse lymphadenopathy. As a result of the disease and its treatment, Mr. Baxter suffered from symptoms including “infections, chronic fatigue and weakness, anemia, night sweats, nausea, massively swollen glands, significant ongoing digestive problems, and generalized pain and discomfort,” according to the decision.

The court said further: “The symptoms were expected to increase in frequency and intensity as the chemotherapy lost its effectiveness. There was no cure for Mr. Baxter's disease and no prospect of recovery. Mr. Baxter wanted the option of ingesting a lethal dose of medication prescribed by his physician and self-administered at the time of Mr. Baxter's own choosing.”

Mr. Baxter, along with four physicians and Compassion & Choices, a pro–aid-in-dying group, filed suit in Montana's district court for the first judicial district, challenging the constitutionality of Montana homicide statutes being applied to physicians who provide aid in dying to mentally competent, terminally ill patients. Mr. Baxter's attorneys contended that the right to die with dignity was constitutional under Montana law.

The district court ruled in favor of Mr. Baxter, but the state appealed the ruling to the Montana Supreme Court. On Dec. 31, 2009, that court also ruled in favor of Mr. Baxter, by a vote of 5–2, although it declined to comment on whether aid in dying complied with the Montana constitution. Mr. Baxter had died in December 2008.

“This court is guided by the judicial principle that we should decline to rule on the constitutionality of a legislative act if we are able to decide the case without reaching constitutional questions,” wrote Justice W. William Leaphart. “We find nothing in Montana Supreme Court precedent or Montana statutes indicating that physician aid in dying is against public policy. … Furthermore, the Montana Rights of the Terminally Ill Act indicates legislative respect for a patient's autonomous right to decide if and how he will receive medical treatment at the end of his life. … We therefore hold that under [Montana law], a terminally ill patient's consent to physician aid in dying constitutes a statutory defense to a charge of homicide against the aiding physician when no other consent exceptions apply.”

Justice James Rice, one of the two dissenting judges, argued that under current Montana law, a physician can be prosecuted for helping a patient commit suicide–if the patient survives, the crime falls under the category of aiding suicide; if the patient dies, the crime is regarded as a homicide.

“Importantly, it is also very clear that a patient's consent to the physician's efforts is of no consequence whatsoever under these statutes,” he wrote. “[The majority] ignores expressed intent, parses statutes, and churns reasons to avoid the clear policy of the State and reach an untenable conclusion: that it is against public policy for a physician to assist in a suicide if the patient happens to live after taking the medication; but that the very same act, with the very same intent, is not against public policy if the patient dies. In my view, the Court's conclusion is without support, without clear reason, and without moral force.”

In the wake of the court ruling–which cannot be appealed–opinions vary as to whether more Montana physicians will now provide aid in dying to terminally ill patients. Chicago health care attorney Miles J. Zaremski, who wrote a “friend of the court” brief in support of Mr. Baxter in the Montana case, said that even though the decision came out in favor of their plaintiff, physicians in Montana will be reluctant to aid terminally ill patients in dying until legal protocols for the procedure have been established.

“In Montana, if the patient gives the doctor consent to provide aid in dying, the physician can escape homicide laws,” said Mr. Zaremski, who is also a former president of the American College of Legal Medicine. “Well, how was that consent given? Were there witnesses to it? Did you wait 10 days? I think you need protocols and standards in place.”

Oregon and Washington, the only states with aid-in-dying statutes, have protocols written into their laws, he noted. As to who would write the Montana protocols, “I think the legislature should, with input from the medical community,” he said.

Kathryn Tucker, legal director of Compassion & Choices, noted that another aid-in-dying case with which her group is involved is being litigated in Connecticut. Ms. Tucker disagreed with the idea that Montana physicians would not immediately feel freer to provide aid in dying to terminally ill patients in the wake of the state Supreme Court decision.

“Montana physicians can feel safe that in providing aid in dying they don't run risk of criminal prosecution,” she said “We know aid in dying happens in every state, even where the legality is unclear.” Ms. Tucker added that most medical care “is not governed by statute; it's governed by the standard of care and best practices. So most physicians will approach aid in dying in Montana as something regulated by the standard of care.”

Physicians in Montana may legally assist terminally ill patients in hastening death, according to a ruling by the Montana Supreme Court.

The decision in the case of Baxter v. State of Montana concerned Robert Baxter, a retired truck driver from Billings, Mont., who was terminally ill with lymphocytic leukemia with diffuse lymphadenopathy. As a result of the disease and its treatment, Mr. Baxter suffered from symptoms including “infections, chronic fatigue and weakness, anemia, night sweats, nausea, massively swollen glands, significant ongoing digestive problems, and generalized pain and discomfort,” according to the decision.

The court said further: “The symptoms were expected to increase in frequency and intensity as the chemotherapy lost its effectiveness. There was no cure for Mr. Baxter's disease and no prospect of recovery. Mr. Baxter wanted the option of ingesting a lethal dose of medication prescribed by his physician and self-administered at the time of Mr. Baxter's own choosing.”

Mr. Baxter, along with four physicians and Compassion & Choices, a pro–aid-in-dying group, filed suit in Montana's district court for the first judicial district, challenging the constitutionality of Montana homicide statutes being applied to physicians who provide aid in dying to mentally competent, terminally ill patients. Mr. Baxter's attorneys contended that the right to die with dignity was constitutional under Montana law.

The district court ruled in favor of Mr. Baxter, but the state appealed the ruling to the Montana Supreme Court. On Dec. 31, 2009, that court also ruled in favor of Mr. Baxter, by a vote of 5–2, although it declined to comment on whether aid in dying complied with the Montana constitution. Mr. Baxter had died in December 2008.

“This court is guided by the judicial principle that we should decline to rule on the constitutionality of a legislative act if we are able to decide the case without reaching constitutional questions,” wrote Justice W. William Leaphart. “We find nothing in Montana Supreme Court precedent or Montana statutes indicating that physician aid in dying is against public policy. … Furthermore, the Montana Rights of the Terminally Ill Act indicates legislative respect for a patient's autonomous right to decide if and how he will receive medical treatment at the end of his life. … We therefore hold that under [Montana law], a terminally ill patient's consent to physician aid in dying constitutes a statutory defense to a charge of homicide against the aiding physician when no other consent exceptions apply.”

Justice James Rice, one of the two dissenting judges, argued that under current Montana law, a physician can be prosecuted for helping a patient commit suicide–if the patient survives, the crime falls under the category of aiding suicide; if the patient dies, the crime is regarded as a homicide.

“Importantly, it is also very clear that a patient's consent to the physician's efforts is of no consequence whatsoever under these statutes,” he wrote. “[The majority] ignores expressed intent, parses statutes, and churns reasons to avoid the clear policy of the State and reach an untenable conclusion: that it is against public policy for a physician to assist in a suicide if the patient happens to live after taking the medication; but that the very same act, with the very same intent, is not against public policy if the patient dies. In my view, the Court's conclusion is without support, without clear reason, and without moral force.”

In the wake of the court ruling–which cannot be appealed–opinions vary as to whether more Montana physicians will now provide aid in dying to terminally ill patients. Chicago health care attorney Miles J. Zaremski, who wrote a “friend of the court” brief in support of Mr. Baxter in the Montana case, said that even though the decision came out in favor of their plaintiff, physicians in Montana will be reluctant to aid terminally ill patients in dying until legal protocols for the procedure have been established.

“In Montana, if the patient gives the doctor consent to provide aid in dying, the physician can escape homicide laws,” said Mr. Zaremski, who is also a former president of the American College of Legal Medicine. “Well, how was that consent given? Were there witnesses to it? Did you wait 10 days? I think you need protocols and standards in place.”

Oregon and Washington, the only states with aid-in-dying statutes, have protocols written into their laws, he noted. As to who would write the Montana protocols, “I think the legislature should, with input from the medical community,” he said.

Kathryn Tucker, legal director of Compassion & Choices, noted that another aid-in-dying case with which her group is involved is being litigated in Connecticut. Ms. Tucker disagreed with the idea that Montana physicians would not immediately feel freer to provide aid in dying to terminally ill patients in the wake of the state Supreme Court decision.

“Montana physicians can feel safe that in providing aid in dying they don't run risk of criminal prosecution,” she said “We know aid in dying happens in every state, even where the legality is unclear.” Ms. Tucker added that most medical care “is not governed by statute; it's governed by the standard of care and best practices. So most physicians will approach aid in dying in Montana as something regulated by the standard of care.”

Physicians in Montana may legally assist terminally ill patients in hastening death, according to a ruling by the Montana Supreme Court.

The decision in the case of Baxter v. State of Montana concerned Robert Baxter, a retired truck driver from Billings, Mont., who was terminally ill with lymphocytic leukemia with diffuse lymphadenopathy. As a result of the disease and its treatment, Mr. Baxter suffered from symptoms including “infections, chronic fatigue and weakness, anemia, night sweats, nausea, massively swollen glands, significant ongoing digestive problems, and generalized pain and discomfort,” according to the decision.

The court said further: “The symptoms were expected to increase in frequency and intensity as the chemotherapy lost its effectiveness. There was no cure for Mr. Baxter's disease and no prospect of recovery. Mr. Baxter wanted the option of ingesting a lethal dose of medication prescribed by his physician and self-administered at the time of Mr. Baxter's own choosing.”

Mr. Baxter, along with four physicians and Compassion & Choices, a pro–aid-in-dying group, filed suit in Montana's district court for the first judicial district, challenging the constitutionality of Montana homicide statutes being applied to physicians who provide aid in dying to mentally competent, terminally ill patients. Mr. Baxter's attorneys contended that the right to die with dignity was constitutional under Montana law.

The district court ruled in favor of Mr. Baxter, but the state appealed the ruling to the Montana Supreme Court. On Dec. 31, 2009, that court also ruled in favor of Mr. Baxter, by a vote of 5–2, although it declined to comment on whether aid in dying complied with the Montana constitution. Mr. Baxter had died in December 2008.

“This court is guided by the judicial principle that we should decline to rule on the constitutionality of a legislative act if we are able to decide the case without reaching constitutional questions,” wrote Justice W. William Leaphart. “We find nothing in Montana Supreme Court precedent or Montana statutes indicating that physician aid in dying is against public policy. … Furthermore, the Montana Rights of the Terminally Ill Act indicates legislative respect for a patient's autonomous right to decide if and how he will receive medical treatment at the end of his life. … We therefore hold that under [Montana law], a terminally ill patient's consent to physician aid in dying constitutes a statutory defense to a charge of homicide against the aiding physician when no other consent exceptions apply.”

Justice James Rice, one of the two dissenting judges, argued that under current Montana law, a physician can be prosecuted for helping a patient commit suicide–if the patient survives, the crime falls under the category of aiding suicide; if the patient dies, the crime is regarded as a homicide.

“Importantly, it is also very clear that a patient's consent to the physician's efforts is of no consequence whatsoever under these statutes,” he wrote. “[The majority] ignores expressed intent, parses statutes, and churns reasons to avoid the clear policy of the State and reach an untenable conclusion: that it is against public policy for a physician to assist in a suicide if the patient happens to live after taking the medication; but that the very same act, with the very same intent, is not against public policy if the patient dies. In my view, the Court's conclusion is without support, without clear reason, and without moral force.”

In the wake of the court ruling–which cannot be appealed–opinions vary as to whether more Montana physicians will now provide aid in dying to terminally ill patients. Chicago health care attorney Miles J. Zaremski, who wrote a “friend of the court” brief in support of Mr. Baxter in the Montana case, said that even though the decision came out in favor of their plaintiff, physicians in Montana will be reluctant to aid terminally ill patients in dying until legal protocols for the procedure have been established.

“In Montana, if the patient gives the doctor consent to provide aid in dying, the physician can escape homicide laws,” said Mr. Zaremski, who is also a former president of the American College of Legal Medicine. “Well, how was that consent given? Were there witnesses to it? Did you wait 10 days? I think you need protocols and standards in place.”

Oregon and Washington, the only states with aid-in-dying statutes, have protocols written into their laws, he noted. As to who would write the Montana protocols, “I think the legislature should, with input from the medical community,” he said.

Kathryn Tucker, legal director of Compassion & Choices, noted that another aid-in-dying case with which her group is involved is being litigated in Connecticut. Ms. Tucker disagreed with the idea that Montana physicians would not immediately feel freer to provide aid in dying to terminally ill patients in the wake of the state Supreme Court decision.

“Montana physicians can feel safe that in providing aid in dying they don't run risk of criminal prosecution,” she said “We know aid in dying happens in every state, even where the legality is unclear.” Ms. Tucker added that most medical care “is not governed by statute; it's governed by the standard of care and best practices. So most physicians will approach aid in dying in Montana as something regulated by the standard of care.”

Overall cancer incidence and mortality are declining in the United States, according to a report issued by the National Cancer Institute.

These reductions are attributed mostly to decreases in both incidence and mortality for lung, prostate, and co-lorectal cancer in men, and breast and co-lorectal cancer in women. For all types of cancers combined, new diagnoses dropped an average of almost 1% per year from 1999 to 2006, and deaths from cancer declined an average of 1.6% per year from 2001 to 2006.

In terms of gender, cancer rates overall are still higher for men than for women, although cancer incidence and mortality decreased more in men. In particular, for colorectal cancer–the second-leading cause of cancer deaths in the United States–overall rates are declining, but the rising incidence in men and women under age 50 years is worrisome, the report said.

The researchers also found that incidence rates in men have declined for cancers of the oral cavity, stomach, and brain, but rose for kidney/renal, liver, and esophageal cancers, as well as for leukemia, myeloma, and melanoma. In women, incidence rates decreased for uterine, ovarian, cervical, and oral-cavity cancers, but increased for lung, thyroid, pancreatic, bladder, and kidney cancers, as well as for non-Hodgkin's lymphoma, melanoma, and leukemia.

Among racial and ethnic groups, cancer mortality was highest in blacks and lowest among Asian/Pacific Islanders. In addition, death rates from pancreatic cancer increased among whites but decreased among blacks.

The authors modeled projections of colorectal cancer rates and found that by getting more patients to adopt lifestyle changes such as quitting smoking and by increasing the use of colonoscopy and other screening techniques, overall co-lorectal cancer mortality could be cut in half by 2020.

The report was written by researchers from the NCI, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries. (Cancer 2010;116:544-73).

Information on newly diagnosed invasive cancers was obtained from population-based cancer registries that participate in the NCI's Surveillance, Epidemiology, and End Results program and/or the CDC's National Program of Cancer Registries.

For most states, population estimates as of July 1 of each year were used to calculate annual incidence and death rates; these estimates are presumed to reflect the average population of a defined geographic area for a calendar year, the authors noted.

“The continued decline in overall cancer rates documents the success we have had with our aggressive efforts to reduce risk in large populations, to provide for early detection, and to develop new therapies that have been successfully applied in this past decade,” Dr. John E. Niederhuber, NCI director, said in a statement.

Overall cancer incidence and mortality are declining in the United States, according to a report issued by the National Cancer Institute.

These reductions are attributed mostly to decreases in both incidence and mortality for lung, prostate, and co-lorectal cancer in men, and breast and co-lorectal cancer in women. For all types of cancers combined, new diagnoses dropped an average of almost 1% per year from 1999 to 2006, and deaths from cancer declined an average of 1.6% per year from 2001 to 2006.

In terms of gender, cancer rates overall are still higher for men than for women, although cancer incidence and mortality decreased more in men. In particular, for colorectal cancer–the second-leading cause of cancer deaths in the United States–overall rates are declining, but the rising incidence in men and women under age 50 years is worrisome, the report said.

The researchers also found that incidence rates in men have declined for cancers of the oral cavity, stomach, and brain, but rose for kidney/renal, liver, and esophageal cancers, as well as for leukemia, myeloma, and melanoma. In women, incidence rates decreased for uterine, ovarian, cervical, and oral-cavity cancers, but increased for lung, thyroid, pancreatic, bladder, and kidney cancers, as well as for non-Hodgkin's lymphoma, melanoma, and leukemia.

Among racial and ethnic groups, cancer mortality was highest in blacks and lowest among Asian/Pacific Islanders. In addition, death rates from pancreatic cancer increased among whites but decreased among blacks.

The authors modeled projections of colorectal cancer rates and found that by getting more patients to adopt lifestyle changes such as quitting smoking and by increasing the use of colonoscopy and other screening techniques, overall co-lorectal cancer mortality could be cut in half by 2020.

The report was written by researchers from the NCI, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries. (Cancer 2010;116:544-73).

Information on newly diagnosed invasive cancers was obtained from population-based cancer registries that participate in the NCI's Surveillance, Epidemiology, and End Results program and/or the CDC's National Program of Cancer Registries.

For most states, population estimates as of July 1 of each year were used to calculate annual incidence and death rates; these estimates are presumed to reflect the average population of a defined geographic area for a calendar year, the authors noted.

“The continued decline in overall cancer rates documents the success we have had with our aggressive efforts to reduce risk in large populations, to provide for early detection, and to develop new therapies that have been successfully applied in this past decade,” Dr. John E. Niederhuber, NCI director, said in a statement.

Overall cancer incidence and mortality are declining in the United States, according to a report issued by the National Cancer Institute.

These reductions are attributed mostly to decreases in both incidence and mortality for lung, prostate, and co-lorectal cancer in men, and breast and co-lorectal cancer in women. For all types of cancers combined, new diagnoses dropped an average of almost 1% per year from 1999 to 2006, and deaths from cancer declined an average of 1.6% per year from 2001 to 2006.

In terms of gender, cancer rates overall are still higher for men than for women, although cancer incidence and mortality decreased more in men. In particular, for colorectal cancer–the second-leading cause of cancer deaths in the United States–overall rates are declining, but the rising incidence in men and women under age 50 years is worrisome, the report said.

The researchers also found that incidence rates in men have declined for cancers of the oral cavity, stomach, and brain, but rose for kidney/renal, liver, and esophageal cancers, as well as for leukemia, myeloma, and melanoma. In women, incidence rates decreased for uterine, ovarian, cervical, and oral-cavity cancers, but increased for lung, thyroid, pancreatic, bladder, and kidney cancers, as well as for non-Hodgkin's lymphoma, melanoma, and leukemia.

Among racial and ethnic groups, cancer mortality was highest in blacks and lowest among Asian/Pacific Islanders. In addition, death rates from pancreatic cancer increased among whites but decreased among blacks.

The authors modeled projections of colorectal cancer rates and found that by getting more patients to adopt lifestyle changes such as quitting smoking and by increasing the use of colonoscopy and other screening techniques, overall co-lorectal cancer mortality could be cut in half by 2020.

The report was written by researchers from the NCI, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries. (Cancer 2010;116:544-73).

Information on newly diagnosed invasive cancers was obtained from population-based cancer registries that participate in the NCI's Surveillance, Epidemiology, and End Results program and/or the CDC's National Program of Cancer Registries.

For most states, population estimates as of July 1 of each year were used to calculate annual incidence and death rates; these estimates are presumed to reflect the average population of a defined geographic area for a calendar year, the authors noted.

“The continued decline in overall cancer rates documents the success we have had with our aggressive efforts to reduce risk in large populations, to provide for early detection, and to develop new therapies that have been successfully applied in this past decade,” Dr. John E. Niederhuber, NCI director, said in a statement.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

10. Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

9. Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

8. Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

7. Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

6. Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

5. Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder. They need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

4. Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information. I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

3. Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

2. Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent. Let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

1. Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations. Everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. So remember everything we build is affecting real workloads of real people.”

The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

10. Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

9. Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

8. Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

7. Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

6. Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

5. Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder. They need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

4. Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information. I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

3. Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

2. Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent. Let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

1. Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations. Everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. So remember everything we build is affecting real workloads of real people.”

The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

WASHINGTON — If you're trying to develop a health information exchange to share electronic health record data with other providers in your area, Dr. Larry Garber has some advice for you.

Dr. Garber, an internist who is medical director for informatics at Fallon Clinic, in Worcester, Mass., outlined his 10 rules for developing a health information exchange (HIE) at the eHealth Initiative Conference:

10. Remember that patients are lousy historians. “It's up to our information technology infrastructures that we build to deliver the vast majority of health information to providers at the point of care,” rather than relying on patients to deliver the data, said Dr. Garber, who is also vice-chair of the Massachusetts eHealth Collaborative.

9. Don't let physicians and patients become a bottleneck to HIE. “It's hard enough to get emergency room physicians to look at something right under their noses, let alone to start thinking about a consent process,” he said. “And patients cannot be expected to use their personal health record as a way of controlling the flow of data.”

8. Create a statewide enterprise master person index (EMPI). Each state should have statewide universal consent forms that a patient can sign once and that apply throughout the system, Dr. Garber said. But to ensure that the consent form that John Smith signed applies to him whether he is in his primary care physician's office, a specialist's office, or the hospital, an EMPI is needed to make sure all the John Smiths are the same person.

The EMPI also helps with reconciling continuity of care documents. “What do I do when I get 20 medication lists and 20 allergy lists?” he said. “You can only [solve that problem] if you have an EMPI recognizing that these are all the same person.”

7. Don't promise to segregate specially protected information such as HIV status or mental health issues. “In order to make that work … the systems will have to err on the side of not sending information, and as a result we will have a true Swiss cheese of data being exchanged,” Dr. Garber said. In Massachusetts, health care organizations tried an HIE in which emergency departments filtered out potentially protected data. “It turned out that the resulting medication lists were useless and the project had to be stopped,” he said. “You're either all in or all out. It's dangerous [to withhold information], and patients don't understand the implications of not letting certain data flow.”

6. Keep the overhead low. The local HIE that Dr. Garber helped start had its software written internally in order to avoid paying licensing fees. The HIE also hosts its servers in its own data center, and the exchange members did not create a legal entity—such as a regional health information organization—in order to avoid paying attorneys' fees. As a result, the exchange's operating expenses are $7,000 annually, he said. “This may take a little more [money] in other communities, but the bottom line is that you have to lower operating fees if you want the HIE to be sustainable.”

5. Store the data based on the content, not on the source. “When the data is stored, you need to file it properly,” Dr. Garber said. “If you have outside electronic documents coming in, don't put them in an 'Outside Records' folder. They need to be integrated with the rest of the data. If I want to find the last MRI of the brain, I want to look in the imaging section and find the last MRI regardless of where it was done. File labs with labs and radiology with radiology.”

4. Make the electronic health record (EHR) “one-stop shopping.” “I only want to go look in one place for information. I don't want to have to go outside the EHR to a different portal to look for things,” he said. “I want one place with one common user interface.”

3. Re-use data. The beauty of an EHR is that you can take the data and repurpose it, according to Dr. Garber. For example, the clinic uses claims data to populate medication lists, past medical history, and past surgical history.

2. Don't require people to think. “If you want some process done consistently correctly, you have to kind of take the brain out of [it],” he said. For example, if a hospital needs to have patients sign consent forms for HIV testing, “when patients are checking in and being registered, don't ask the registration clerk to check if they have consented or need to consent. Let that process happen automatically—the consent form appears when it's appropriate, it doesn't appear when it's not appropriate.” The same should be true for ordering health maintenance and disease management tests.

1. Remember that this is the real world. “Don't forget that we're dealing with the real world and real people,” Dr. Garber said. “Our patients are our friends and ourselves. Everything we do affects real people and their health and their happiness. That also includes the physicians and nurses and staff that work in these organizations. Everything we do affects [them] as well.”

No one should expect physicians and staff to be filling out forms “just for the sake of collecting data so someone can do some analysis on the back end. Data collection should be a byproduct of the care that we give. So remember everything we build is affecting real workloads of real people.”

The conference was sponsored by Ingenix, the American Medical Association, and several other industry groups and trade associations. Dr. Garber did not disclose any conflicts of interest related to his presentation.

Overall cancer incidence and mortality rates are declining in the United States, according to a report issued by the National Cancer Institute.

These reductions are attributed mostly to decreases in both incidence and mortality for lung, prostate, and colorectal cancer in men, and breast and colorectal cancer in women. For all types of cancers combined, new diagnoses dropped an average of almost 1% per year from 1999 to 2006, and deaths from cancer declined an average of 1.6% per year from 2001 to 2006.

In terms of gender, cancer rates overall are still higher for men than for women, although cancer incidence and mortality decreased more in men. In particular, for colorectal cancer—the second-leading cause of U.S. cancer deaths—overall rates are declining, but the rising incidence in men and women under age 50 years is worrisome, the report said.

The researchers also found that incidence rates in men have declined for cancers of the oral cavity, stomach, and brain, but rose for kidney/renal, liver, and esophageal cancers, as well as for leukemia, myeloma, and melanoma. In women, incidence rates decreased for uterine, ovarian, cervical, and oral-cavity cancers, but increased for lung, thyroid, pancreatic, bladder, and kidney cancers, as well as for non–Hodgkin's lymphoma, melanoma, and leukemia.

Among racial and ethnic groups, cancer mortality rates were highest in blacks and lowest among Asian/Pacific Islanders. In addition, death rates from pancreatic cancer increased among whites but decreased among blacks.

The report also included a special section on colorectal cancer, with an emphasis on strategies to reduce its mortality rate. The authors modeled projections of colorectal cancer rates and found that by getting more patients to adopt lifestyle changes such as quitting smoking and by increasing the use of colonoscopy and other screening techniques, overall colorectal cancer mortality could be cut in half by 2020.

The report was written by researchers from the NCI, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries (Cancer 2010;116:544-73).

Information on newly diagnosed invasive cancers was obtained from population-based cancer registries that participate in the NCI's Surveillance, Epidemiology, and End Results program and/or the CDC's National Program of Cancer Registries. All participating cancer registries also belong to the NAACCR. The cause of death is based on death certificate information reported to state vital statistics offices.

For most states, population estimates as of July 1 of each year were used to calculate annual incidence and death rates; these estimates are presumed to reflect the average population of a defined geographic area for a calendar year, the authors noted.

“The continued decline in overall cancer rates documents the success we have had with our aggressive efforts to reduce risk in large populations, to provide for early detection, and to develop new therapies that have been successfully applied in this past decade,” Dr. John E. Niederhuber, NCI director, said in a statement. “Yet, we cannot be content with this steady reduction in incidence and mortality. We must, in fact, accelerate our efforts to get individualized diagnoses and treatments to all Americans.”

Overall cancer incidence and mortality rates are declining in the United States, according to a report issued by the National Cancer Institute.

These reductions are attributed mostly to decreases in both incidence and mortality for lung, prostate, and colorectal cancer in men, and breast and colorectal cancer in women. For all types of cancers combined, new diagnoses dropped an average of almost 1% per year from 1999 to 2006, and deaths from cancer declined an average of 1.6% per year from 2001 to 2006.

In terms of gender, cancer rates overall are still higher for men than for women, although cancer incidence and mortality decreased more in men. In particular, for colorectal cancer—the second-leading cause of U.S. cancer deaths—overall rates are declining, but the rising incidence in men and women under age 50 years is worrisome, the report said.

The researchers also found that incidence rates in men have declined for cancers of the oral cavity, stomach, and brain, but rose for kidney/renal, liver, and esophageal cancers, as well as for leukemia, myeloma, and melanoma. In women, incidence rates decreased for uterine, ovarian, cervical, and oral-cavity cancers, but increased for lung, thyroid, pancreatic, bladder, and kidney cancers, as well as for non–Hodgkin's lymphoma, melanoma, and leukemia.

Among racial and ethnic groups, cancer mortality rates were highest in blacks and lowest among Asian/Pacific Islanders. In addition, death rates from pancreatic cancer increased among whites but decreased among blacks.

The report also included a special section on colorectal cancer, with an emphasis on strategies to reduce its mortality rate. The authors modeled projections of colorectal cancer rates and found that by getting more patients to adopt lifestyle changes such as quitting smoking and by increasing the use of colonoscopy and other screening techniques, overall colorectal cancer mortality could be cut in half by 2020.

The report was written by researchers from the NCI, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries (Cancer 2010;116:544-73).

Information on newly diagnosed invasive cancers was obtained from population-based cancer registries that participate in the NCI's Surveillance, Epidemiology, and End Results program and/or the CDC's National Program of Cancer Registries. All participating cancer registries also belong to the NAACCR. The cause of death is based on death certificate information reported to state vital statistics offices.

For most states, population estimates as of July 1 of each year were used to calculate annual incidence and death rates; these estimates are presumed to reflect the average population of a defined geographic area for a calendar year, the authors noted.

“The continued decline in overall cancer rates documents the success we have had with our aggressive efforts to reduce risk in large populations, to provide for early detection, and to develop new therapies that have been successfully applied in this past decade,” Dr. John E. Niederhuber, NCI director, said in a statement. “Yet, we cannot be content with this steady reduction in incidence and mortality. We must, in fact, accelerate our efforts to get individualized diagnoses and treatments to all Americans.”

Overall cancer incidence and mortality rates are declining in the United States, according to a report issued by the National Cancer Institute.

These reductions are attributed mostly to decreases in both incidence and mortality for lung, prostate, and colorectal cancer in men, and breast and colorectal cancer in women. For all types of cancers combined, new diagnoses dropped an average of almost 1% per year from 1999 to 2006, and deaths from cancer declined an average of 1.6% per year from 2001 to 2006.

In terms of gender, cancer rates overall are still higher for men than for women, although cancer incidence and mortality decreased more in men. In particular, for colorectal cancer—the second-leading cause of U.S. cancer deaths—overall rates are declining, but the rising incidence in men and women under age 50 years is worrisome, the report said.

The researchers also found that incidence rates in men have declined for cancers of the oral cavity, stomach, and brain, but rose for kidney/renal, liver, and esophageal cancers, as well as for leukemia, myeloma, and melanoma. In women, incidence rates decreased for uterine, ovarian, cervical, and oral-cavity cancers, but increased for lung, thyroid, pancreatic, bladder, and kidney cancers, as well as for non–Hodgkin's lymphoma, melanoma, and leukemia.

Among racial and ethnic groups, cancer mortality rates were highest in blacks and lowest among Asian/Pacific Islanders. In addition, death rates from pancreatic cancer increased among whites but decreased among blacks.

The report also included a special section on colorectal cancer, with an emphasis on strategies to reduce its mortality rate. The authors modeled projections of colorectal cancer rates and found that by getting more patients to adopt lifestyle changes such as quitting smoking and by increasing the use of colonoscopy and other screening techniques, overall colorectal cancer mortality could be cut in half by 2020.

The report was written by researchers from the NCI, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries (Cancer 2010;116:544-73).

Information on newly diagnosed invasive cancers was obtained from population-based cancer registries that participate in the NCI's Surveillance, Epidemiology, and End Results program and/or the CDC's National Program of Cancer Registries. All participating cancer registries also belong to the NAACCR. The cause of death is based on death certificate information reported to state vital statistics offices.

For most states, population estimates as of July 1 of each year were used to calculate annual incidence and death rates; these estimates are presumed to reflect the average population of a defined geographic area for a calendar year, the authors noted.

“The continued decline in overall cancer rates documents the success we have had with our aggressive efforts to reduce risk in large populations, to provide for early detection, and to develop new therapies that have been successfully applied in this past decade,” Dr. John E. Niederhuber, NCI director, said in a statement. “Yet, we cannot be content with this steady reduction in incidence and mortality. We must, in fact, accelerate our efforts to get individualized diagnoses and treatments to all Americans.”

Viral illnesses, strain injuries, and lacerations—Dr. Kenneth V. Iserson treated common cases like this several times in a single week, just like many emergency physicians.

The only difference?

He was at the bottom of the world—and the outside temperature was −15°F.

Last month, Dr. Iserson finished up a 6-month tenure as lead physician at McMurdo Station in Antarctica, where he had been since late August.

When asked why he decided to take the post, Dr. Iserson's responded:

“Are you kidding? Who wouldn't want to go if they had the chance?”

“You are challenged to use everything you know and know how to do in medicine,” said Dr. Iserson in an e-mail interview. “The patients are all undifferentiated and supposedly healthy. Nevertheless, we see it all, and then some.”

Dr. Iserson's facilities included a small clinic/hospital with a staff of three physicians, a physician assistant, a physical therapist, a dentist, a medical technologist, an x-ray technician, three nurses, and a flight technician. The facility, which generally gets visits from 135–200 patients per week, has four outpatient beds and three inpatient beds. Dr. Iserson also guided treatment for the South Pole station, which has one physician and one physician assistant, as well as multiple field camps scattered across Antarctica.

Dr. Iserson's salary for his stint at the station was paid by Raytheon Polar Services Co., the main logistical contractor to the U.S. Antarctic Program, a government-funded project operated by the National Science Foundation.

The Sub-Zero ED

Despite the polar environment, Dr. Iserson saw only a few cases of frostbite and one moderate case of hypothermia. “We're all issued extreme-cold–weather gear, and everyone takes its use seriously,” he said.

Instead, the medical condition seen most often is “the crud,” which he defines as a series of viral illnesses that strikes each year. “This year appears to have been worse than most,” he added, “and reflects the large rotating population on station.”

The other common class of medical problem is overuse/sprain-strain, he continued. “Although there is a huge effort to reduce work-related injuries, this is an industrial park in the middle of a very unforgiving environment. Therefore, these injuries happen. That's one reason that we have a year-round physical therapist.”

When he had questions about a difficult case, Dr. Iserson consulted by e-mail with infectious disease specialists, “particularly about our H1N1 concerns and a couple of particular patients,” he said. “Of course, one of our flight surgeons—from the Delaware Air National Guard—is also a Stanford University professor in infectious disease, so that was a big help.”

Although the South Pole station is a full 800 miles away, Dr. Iserson went down there for his work. “The modern facility sits immediately adjacent to the ceremonial South Pole—a nice silver ball with lots of flags—and the actual geographic South Pole,” he said. “They are about 100 feet apart and about 100 yards from the nearest station doorway. At more than 9,000 feet, the physiological altitude can range up to 15,000 feet due to extreme low pressure caused by wind vortices and the Coriolis effect.”

Dr. Iserson was sent to the South Pole station to do gallbladder ultrasound exams required for people spending the winter at that location. “While I didn't know how to do that particular exam before I arrived at McMurdo, spending time with the ACEP ultrasound Web site allowed me to quickly learn and do these exams,” he said.

Because the weather prevented him from leaving for a few days, “I got to see the enormous 'Ice Cube' project to detect neutrinos, the AERO project to measure the cleanliness of the earth's air, and the amazing self-sustaining ice tunnels around the station that carry the water and sewage pipes. The tunnels are a constant −60°F.”

Psychiatry and Surgery

Dr. Iserson said he had a number of patients with panic attacks and depression. “A chronic problem here is sleep disorders.”

One treatment option Dr. Iserson tries to avoid is surgery.

“The most serious 'surgical' cases included a possible appendicitis we treated nonoperatively until we could fly him off the continent,” he recalled. Another challenging surgical case involved a second-degree burn of almost the entire hand. The medical team treated it successfully by incision and drainage of the huge blisters, frequent dressing changes, and immediate full range-of-motion in the bandage. “Not like the books say to do it,” he admitted.

One of the toughest aspects of the job, he said, was deciding when to send a patient off continent. It is often a complex and expensive option. “You must decide what you will have to treat on station, because medical evacuation may not be available due to visibility or weather conditions.”

Highs and Lows at the Bottom

Dr. Iserson's best day happened when the phone rang just as his office was closing.

“I picked it up. 'We've had a [snowmobile] accident with a hand injury,' the person said. 'We're at a field camp and have a helicopter coming.' After ascertaining that it didn't sound too bad, I suddenly thought to ask, 'Where are you located?'

The response: “On [Mount] Erebus.”

Dr. Iserson immediately got permission from the research manager to accompany the helicopter on an “amazing” trip to the Mount Erebus volcano.

“As billed, the patient had suffered only a minimal injury—while at an awesome location,” he said. “We landed at the scientific field camp on the active, snow-covered volcano only a few hundred yards from the summit. As it turns out, most long-time workers at McMurdo have never even been on Erebus. That was quite a treat!” The patient was able to return to Mount Erebus and her research 2 days later.

His worst day wasn't because of a clinical crisis—although it involved a challenge all too common to emergency physicians everywhere: overcrowding. The management told him they were planning to put a bunk in his room, “in case we need to put someone else in there with you.” Station management had already moved him to a very small room in the oldest dorm on station to guarantee that he would have a private room. “Eventually, they got so much push-back from the people in that dorm that they made other arrangements,” he added. “No bunk beds in that dorm.”

Expect the Unexpected

Then there have been the unexpected cases, like the heavy-equipment operator who had a very heavy pipe dropped on his finger and came strolling through the door with a gloved hand held high. “With our whole team watching, I removed the glove and immediately was wondering if we had a bone rongeur available.”

A small bit of tissue was all that connected his entire fingertip to his finger; the bone itself was completely exposed. “But since he could move it—and I had no way of moving him off the continent—I decided to replace the tissue over the bone and repair it,” Dr. Iserson recalled.

On another day, a friend of Dr. Iserson's came into his office and casually remarked that she had been unable to swallow anything—including water—since the night before. “After trying more benign options and without having any contrast I could safely use to image it, I opted to use the old push-it-through-with-the-NG-tube trick,” he said. “Not the most elegant solution, but it worked.”

More Than Medicine and Penguins

“Aside from the fascinating folks you meet everywhere you go, there are, intentionally, far more activities to do than time to do them,” he wrote. Along with a large library, the station hosts musicians who play often. Movies are shown every night in the coffee house, and there are lots of organized sports activities, periodic team trivia, bingo and other games, cross-country skiing on the Ice Shelf, a craft room, and even the Ross Island Yacht Club, which he added doesn't have any boats—“only interesting talks and good food.”

As for food, the staff has access to fresh fruits and vegetables, depending on what the supply planes bring. They also have eggs.

The continent also hosts periodic lectures by scientists and others who are sometimes among the most prominent experts in their field. Even the stars drop by for visits. Dr. Iserson had the chance to talk with Sir David Attenborough when he came to film for the BBC.

“This is a huge continent with amazing vistas over the Ross Sea Ice Shelf and of the Royal Geographic Society Mountain Range in the distance,” he said.

Unlike workers at the South Pole Station, Dr. Iserson said that they often spent a lot of time outdoors. “So what's a little −15°F temperature among friends?”

“You are challenged to use everything you know and know how to do in medicine,” said Dr. Iserson (left).

Source Courtesy Kenneth Stearns

In February, Dr. Kenneth V. Iserson finished up a 6-month tenure as lead physician at McMurdo Station.

Source Courtesy Dr. Kenneth V. Iserson

Viral illnesses, strain injuries, and lacerations—Dr. Kenneth V. Iserson treated common cases like this several times in a single week, just like many emergency physicians.

The only difference?

He was at the bottom of the world—and the outside temperature was −15°F.

Last month, Dr. Iserson finished up a 6-month tenure as lead physician at McMurdo Station in Antarctica, where he had been since late August.

When asked why he decided to take the post, Dr. Iserson's responded:

“Are you kidding? Who wouldn't want to go if they had the chance?”

“You are challenged to use everything you know and know how to do in medicine,” said Dr. Iserson in an e-mail interview. “The patients are all undifferentiated and supposedly healthy. Nevertheless, we see it all, and then some.”

Dr. Iserson's facilities included a small clinic/hospital with a staff of three physicians, a physician assistant, a physical therapist, a dentist, a medical technologist, an x-ray technician, three nurses, and a flight technician. The facility, which generally gets visits from 135–200 patients per week, has four outpatient beds and three inpatient beds. Dr. Iserson also guided treatment for the South Pole station, which has one physician and one physician assistant, as well as multiple field camps scattered across Antarctica.

Dr. Iserson's salary for his stint at the station was paid by Raytheon Polar Services Co., the main logistical contractor to the U.S. Antarctic Program, a government-funded project operated by the National Science Foundation.

The Sub-Zero ED

Despite the polar environment, Dr. Iserson saw only a few cases of frostbite and one moderate case of hypothermia. “We're all issued extreme-cold–weather gear, and everyone takes its use seriously,” he said.

Instead, the medical condition seen most often is “the crud,” which he defines as a series of viral illnesses that strikes each year. “This year appears to have been worse than most,” he added, “and reflects the large rotating population on station.”

The other common class of medical problem is overuse/sprain-strain, he continued. “Although there is a huge effort to reduce work-related injuries, this is an industrial park in the middle of a very unforgiving environment. Therefore, these injuries happen. That's one reason that we have a year-round physical therapist.”

When he had questions about a difficult case, Dr. Iserson consulted by e-mail with infectious disease specialists, “particularly about our H1N1 concerns and a couple of particular patients,” he said. “Of course, one of our flight surgeons—from the Delaware Air National Guard—is also a Stanford University professor in infectious disease, so that was a big help.”

Although the South Pole station is a full 800 miles away, Dr. Iserson went down there for his work. “The modern facility sits immediately adjacent to the ceremonial South Pole—a nice silver ball with lots of flags—and the actual geographic South Pole,” he said. “They are about 100 feet apart and about 100 yards from the nearest station doorway. At more than 9,000 feet, the physiological altitude can range up to 15,000 feet due to extreme low pressure caused by wind vortices and the Coriolis effect.”

Dr. Iserson was sent to the South Pole station to do gallbladder ultrasound exams required for people spending the winter at that location. “While I didn't know how to do that particular exam before I arrived at McMurdo, spending time with the ACEP ultrasound Web site allowed me to quickly learn and do these exams,” he said.

Because the weather prevented him from leaving for a few days, “I got to see the enormous 'Ice Cube' project to detect neutrinos, the AERO project to measure the cleanliness of the earth's air, and the amazing self-sustaining ice tunnels around the station that carry the water and sewage pipes. The tunnels are a constant −60°F.”

Psychiatry and Surgery

Dr. Iserson said he had a number of patients with panic attacks and depression. “A chronic problem here is sleep disorders.”

One treatment option Dr. Iserson tries to avoid is surgery.

“The most serious 'surgical' cases included a possible appendicitis we treated nonoperatively until we could fly him off the continent,” he recalled. Another challenging surgical case involved a second-degree burn of almost the entire hand. The medical team treated it successfully by incision and drainage of the huge blisters, frequent dressing changes, and immediate full range-of-motion in the bandage. “Not like the books say to do it,” he admitted.

One of the toughest aspects of the job, he said, was deciding when to send a patient off continent. It is often a complex and expensive option. “You must decide what you will have to treat on station, because medical evacuation may not be available due to visibility or weather conditions.”

Highs and Lows at the Bottom

Dr. Iserson's best day happened when the phone rang just as his office was closing.

“I picked it up. 'We've had a [snowmobile] accident with a hand injury,' the person said. 'We're at a field camp and have a helicopter coming.' After ascertaining that it didn't sound too bad, I suddenly thought to ask, 'Where are you located?'

The response: “On [Mount] Erebus.”

Dr. Iserson immediately got permission from the research manager to accompany the helicopter on an “amazing” trip to the Mount Erebus volcano.

“As billed, the patient had suffered only a minimal injury—while at an awesome location,” he said. “We landed at the scientific field camp on the active, snow-covered volcano only a few hundred yards from the summit. As it turns out, most long-time workers at McMurdo have never even been on Erebus. That was quite a treat!” The patient was able to return to Mount Erebus and her research 2 days later.

His worst day wasn't because of a clinical crisis—although it involved a challenge all too common to emergency physicians everywhere: overcrowding. The management told him they were planning to put a bunk in his room, “in case we need to put someone else in there with you.” Station management had already moved him to a very small room in the oldest dorm on station to guarantee that he would have a private room. “Eventually, they got so much push-back from the people in that dorm that they made other arrangements,” he added. “No bunk beds in that dorm.”

Expect the Unexpected

Then there have been the unexpected cases, like the heavy-equipment operator who had a very heavy pipe dropped on his finger and came strolling through the door with a gloved hand held high. “With our whole team watching, I removed the glove and immediately was wondering if we had a bone rongeur available.”

A small bit of tissue was all that connected his entire fingertip to his finger; the bone itself was completely exposed. “But since he could move it—and I had no way of moving him off the continent—I decided to replace the tissue over the bone and repair it,” Dr. Iserson recalled.

On another day, a friend of Dr. Iserson's came into his office and casually remarked that she had been unable to swallow anything—including water—since the night before. “After trying more benign options and without having any contrast I could safely use to image it, I opted to use the old push-it-through-with-the-NG-tube trick,” he said. “Not the most elegant solution, but it worked.”

More Than Medicine and Penguins

“Aside from the fascinating folks you meet everywhere you go, there are, intentionally, far more activities to do than time to do them,” he wrote. Along with a large library, the station hosts musicians who play often. Movies are shown every night in the coffee house, and there are lots of organized sports activities, periodic team trivia, bingo and other games, cross-country skiing on the Ice Shelf, a craft room, and even the Ross Island Yacht Club, which he added doesn't have any boats—“only interesting talks and good food.”

As for food, the staff has access to fresh fruits and vegetables, depending on what the supply planes bring. They also have eggs.

The continent also hosts periodic lectures by scientists and others who are sometimes among the most prominent experts in their field. Even the stars drop by for visits. Dr. Iserson had the chance to talk with Sir David Attenborough when he came to film for the BBC.

“This is a huge continent with amazing vistas over the Ross Sea Ice Shelf and of the Royal Geographic Society Mountain Range in the distance,” he said.

Unlike workers at the South Pole Station, Dr. Iserson said that they often spent a lot of time outdoors. “So what's a little −15°F temperature among friends?”

“You are challenged to use everything you know and know how to do in medicine,” said Dr. Iserson (left).

Source Courtesy Kenneth Stearns

In February, Dr. Kenneth V. Iserson finished up a 6-month tenure as lead physician at McMurdo Station.

Source Courtesy Dr. Kenneth V. Iserson

Viral illnesses, strain injuries, and lacerations—Dr. Kenneth V. Iserson treated common cases like this several times in a single week, just like many emergency physicians.

The only difference?

He was at the bottom of the world—and the outside temperature was −15°F.

Last month, Dr. Iserson finished up a 6-month tenure as lead physician at McMurdo Station in Antarctica, where he had been since late August.

When asked why he decided to take the post, Dr. Iserson's responded:

“Are you kidding? Who wouldn't want to go if they had the chance?”

“You are challenged to use everything you know and know how to do in medicine,” said Dr. Iserson in an e-mail interview. “The patients are all undifferentiated and supposedly healthy. Nevertheless, we see it all, and then some.”

Dr. Iserson's facilities included a small clinic/hospital with a staff of three physicians, a physician assistant, a physical therapist, a dentist, a medical technologist, an x-ray technician, three nurses, and a flight technician. The facility, which generally gets visits from 135–200 patients per week, has four outpatient beds and three inpatient beds. Dr. Iserson also guided treatment for the South Pole station, which has one physician and one physician assistant, as well as multiple field camps scattered across Antarctica.

Dr. Iserson's salary for his stint at the station was paid by Raytheon Polar Services Co., the main logistical contractor to the U.S. Antarctic Program, a government-funded project operated by the National Science Foundation.

The Sub-Zero ED

Despite the polar environment, Dr. Iserson saw only a few cases of frostbite and one moderate case of hypothermia. “We're all issued extreme-cold–weather gear, and everyone takes its use seriously,” he said.

Instead, the medical condition seen most often is “the crud,” which he defines as a series of viral illnesses that strikes each year. “This year appears to have been worse than most,” he added, “and reflects the large rotating population on station.”

The other common class of medical problem is overuse/sprain-strain, he continued. “Although there is a huge effort to reduce work-related injuries, this is an industrial park in the middle of a very unforgiving environment. Therefore, these injuries happen. That's one reason that we have a year-round physical therapist.”

When he had questions about a difficult case, Dr. Iserson consulted by e-mail with infectious disease specialists, “particularly about our H1N1 concerns and a couple of particular patients,” he said. “Of course, one of our flight surgeons—from the Delaware Air National Guard—is also a Stanford University professor in infectious disease, so that was a big help.”

Although the South Pole station is a full 800 miles away, Dr. Iserson went down there for his work. “The modern facility sits immediately adjacent to the ceremonial South Pole—a nice silver ball with lots of flags—and the actual geographic South Pole,” he said. “They are about 100 feet apart and about 100 yards from the nearest station doorway. At more than 9,000 feet, the physiological altitude can range up to 15,000 feet due to extreme low pressure caused by wind vortices and the Coriolis effect.”

Dr. Iserson was sent to the South Pole station to do gallbladder ultrasound exams required for people spending the winter at that location. “While I didn't know how to do that particular exam before I arrived at McMurdo, spending time with the ACEP ultrasound Web site allowed me to quickly learn and do these exams,” he said.

Because the weather prevented him from leaving for a few days, “I got to see the enormous 'Ice Cube' project to detect neutrinos, the AERO project to measure the cleanliness of the earth's air, and the amazing self-sustaining ice tunnels around the station that carry the water and sewage pipes. The tunnels are a constant −60°F.”

Psychiatry and Surgery

Dr. Iserson said he had a number of patients with panic attacks and depression. “A chronic problem here is sleep disorders.”

One treatment option Dr. Iserson tries to avoid is surgery.

“The most serious 'surgical' cases included a possible appendicitis we treated nonoperatively until we could fly him off the continent,” he recalled. Another challenging surgical case involved a second-degree burn of almost the entire hand. The medical team treated it successfully by incision and drainage of the huge blisters, frequent dressing changes, and immediate full range-of-motion in the bandage. “Not like the books say to do it,” he admitted.

One of the toughest aspects of the job, he said, was deciding when to send a patient off continent. It is often a complex and expensive option. “You must decide what you will have to treat on station, because medical evacuation may not be available due to visibility or weather conditions.”

Highs and Lows at the Bottom

Dr. Iserson's best day happened when the phone rang just as his office was closing.

“I picked it up. 'We've had a [snowmobile] accident with a hand injury,' the person said. 'We're at a field camp and have a helicopter coming.' After ascertaining that it didn't sound too bad, I suddenly thought to ask, 'Where are you located?'

The response: “On [Mount] Erebus.”

Dr. Iserson immediately got permission from the research manager to accompany the helicopter on an “amazing” trip to the Mount Erebus volcano.

“As billed, the patient had suffered only a minimal injury—while at an awesome location,” he said. “We landed at the scientific field camp on the active, snow-covered volcano only a few hundred yards from the summit. As it turns out, most long-time workers at McMurdo have never even been on Erebus. That was quite a treat!” The patient was able to return to Mount Erebus and her research 2 days later.

His worst day wasn't because of a clinical crisis—although it involved a challenge all too common to emergency physicians everywhere: overcrowding. The management told him they were planning to put a bunk in his room, “in case we need to put someone else in there with you.” Station management had already moved him to a very small room in the oldest dorm on station to guarantee that he would have a private room. “Eventually, they got so much push-back from the people in that dorm that they made other arrangements,” he added. “No bunk beds in that dorm.”

Expect the Unexpected

Then there have been the unexpected cases, like the heavy-equipment operator who had a very heavy pipe dropped on his finger and came strolling through the door with a gloved hand held high. “With our whole team watching, I removed the glove and immediately was wondering if we had a bone rongeur available.”

A small bit of tissue was all that connected his entire fingertip to his finger; the bone itself was completely exposed. “But since he could move it—and I had no way of moving him off the continent—I decided to replace the tissue over the bone and repair it,” Dr. Iserson recalled.

On another day, a friend of Dr. Iserson's came into his office and casually remarked that she had been unable to swallow anything—including water—since the night before. “After trying more benign options and without having any contrast I could safely use to image it, I opted to use the old push-it-through-with-the-NG-tube trick,” he said. “Not the most elegant solution, but it worked.”

More Than Medicine and Penguins

“Aside from the fascinating folks you meet everywhere you go, there are, intentionally, far more activities to do than time to do them,” he wrote. Along with a large library, the station hosts musicians who play often. Movies are shown every night in the coffee house, and there are lots of organized sports activities, periodic team trivia, bingo and other games, cross-country skiing on the Ice Shelf, a craft room, and even the Ross Island Yacht Club, which he added doesn't have any boats—“only interesting talks and good food.”

As for food, the staff has access to fresh fruits and vegetables, depending on what the supply planes bring. They also have eggs.

The continent also hosts periodic lectures by scientists and others who are sometimes among the most prominent experts in their field. Even the stars drop by for visits. Dr. Iserson had the chance to talk with Sir David Attenborough when he came to film for the BBC.

“This is a huge continent with amazing vistas over the Ross Sea Ice Shelf and of the Royal Geographic Society Mountain Range in the distance,” he said.

Unlike workers at the South Pole Station, Dr. Iserson said that they often spent a lot of time outdoors. “So what's a little −15°F temperature among friends?”

“You are challenged to use everything you know and know how to do in medicine,” said Dr. Iserson (left).

Source Courtesy Kenneth Stearns

In February, Dr. Kenneth V. Iserson finished up a 6-month tenure as lead physician at McMurdo Station.

Source Courtesy Dr. Kenneth V. Iserson

WASHINGTON — Government health officials are hoping that most physicians will get on the “meaningful use” bandwagon, but that's not likely to happen easily, according to Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.

“I don't think [health care] professionals have any idea what's coming,” Dr. Lichtenfeld said during a panel discussion at an eHealth Initiative conference. “I think [federal officials] are risking failure because doctors will say, 'Are you kidding? I don't want to have anything to do with this.' I hope that isn't what happens, but I tell you, be prepared.”

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of last year's federal stimulus law, physicians who treat Medicare patients can be awarded up to $44,000 over 5 years for the meaningful use of a certified health information system. For physicians whose patient populations are at least 30% Medicaid patients, the incentive is as much as $64,000.

But physicians who already have computers may find that they won't meet the requirements for the incentive, Dr. Lichtenfeld said. “Doctors have invested in these systems and now they're worthless. They don't have the time, they don't have the money, they don't have the expertise. And to have to get [a new system] up and running in 2–3 years—they won't do it. Something simpler would've gotten us to where we have to go.”

Despite a few patient-driven efforts (see box), no one has figured out how to use information technology as a way to get patients more involved in their care, Dr. Lichtenfeld contended. “A couple of years ago, personal health records … were the talk of the town. They were going to get everybody on board. Patients were going to run to various Web sites and fill out their health information. Health plans were going to get together and figure out how to bring their data so it would be downloadable and easily accessible.”

But none of that has yet come to pass, he said. “Personal health records landed with a thud. We need to figure out that sometimes we have to keep it simple.”

In the meantime, the Department Health and Human Services is trying to get physicians to meet some meaningful use criteria that aren't even written yet, said Dr. Steven Stack, an emergency physician and member of two workgroups of the department's HIT Policy Committee. He noted that two criteria “were supposed to be finished on Dec. 31, 2008, by statute. It's 2010 and they're not done, and it may be a year before we get something. A lot of these things aren't ready for prime time.”

Instead of requiring physicians to meet lots of criteria, “if we focus on the smallest of things, then doggedly persist until we knock down those barriers, and then require people to meet those [expectations]—with the proper incentives, we can make a really great step forward,” said Dr. Stack, who is a member of the American Medical Association board of trustees.

In contrast, Steven Findlay, senior health policy analyst at Consumers Union, expressed impatience with the process. “We ought to try to push as far as we possibly can with the 2011 meaningful use criteria,” he said. “We ought to be exquisitely sensitive to what's doable in 2011 … but shouldn't be running from time to push. We've been talking about this stuff for 10 years, and for the good of patients and consumers, we need to do this.”

The conference was sponsored by sponsored by Ingenix, the AMA, and other industry groups. The speakers reported that they had no conflicts of interest relevant to their presentations.

Site Collects Patient-Reported Data

Patients can play a role in providing useful health information, Dr. Stack emphasized. As an example, he cited

www.patientslikeme.com

Visitors to the site can sign up for a free account and a screen name, which they use to post their comments and health statistics. “People voluntarily post their own health data. Some are very open about it—they post every pill they're on, the dose, the frequency, what's happening to them,” said Dr. Stack. In the ALS community, members developed “a patient population and a data set that was so robust that if [community members] put in enough of their own variables, [the site] could predict when you'd be in a wheelchair within a week and when you'd be on a ventilator within a week. It was that precise. We could never replicate that in a prospective, double-blind randomized controlled trial. We could never get an institutional review board to [accept it] and never get people to do it.”

But for patients such as these, “the motivation of your own health and the fear of death through your own illness is a motivator we can't replicate with money or incentives,” he said. “When you are properly motivated, you'll seek out” available tools.

WASHINGTON — Government health officials are hoping that most physicians will get on the “meaningful use” bandwagon, but that's not likely to happen easily, according to Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.

“I don't think [health care] professionals have any idea what's coming,” Dr. Lichtenfeld said during a panel discussion at an eHealth Initiative conference. “I think [federal officials] are risking failure because doctors will say, 'Are you kidding? I don't want to have anything to do with this.' I hope that isn't what happens, but I tell you, be prepared.”

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of last year's federal stimulus law, physicians who treat Medicare patients can be awarded up to $44,000 over 5 years for the meaningful use of a certified health information system. For physicians whose patient populations are at least 30% Medicaid patients, the incentive is as much as $64,000.

But physicians who already have computers may find that they won't meet the requirements for the incentive, Dr. Lichtenfeld said. “Doctors have invested in these systems and now they're worthless. They don't have the time, they don't have the money, they don't have the expertise. And to have to get [a new system] up and running in 2–3 years—they won't do it. Something simpler would've gotten us to where we have to go.”

Despite a few patient-driven efforts (see box), no one has figured out how to use information technology as a way to get patients more involved in their care, Dr. Lichtenfeld contended. “A couple of years ago, personal health records … were the talk of the town. They were going to get everybody on board. Patients were going to run to various Web sites and fill out their health information. Health plans were going to get together and figure out how to bring their data so it would be downloadable and easily accessible.”

But none of that has yet come to pass, he said. “Personal health records landed with a thud. We need to figure out that sometimes we have to keep it simple.”

In the meantime, the Department Health and Human Services is trying to get physicians to meet some meaningful use criteria that aren't even written yet, said Dr. Steven Stack, an emergency physician and member of two workgroups of the department's HIT Policy Committee. He noted that two criteria “were supposed to be finished on Dec. 31, 2008, by statute. It's 2010 and they're not done, and it may be a year before we get something. A lot of these things aren't ready for prime time.”

Instead of requiring physicians to meet lots of criteria, “if we focus on the smallest of things, then doggedly persist until we knock down those barriers, and then require people to meet those [expectations]—with the proper incentives, we can make a really great step forward,” said Dr. Stack, who is a member of the American Medical Association board of trustees.

In contrast, Steven Findlay, senior health policy analyst at Consumers Union, expressed impatience with the process. “We ought to try to push as far as we possibly can with the 2011 meaningful use criteria,” he said. “We ought to be exquisitely sensitive to what's doable in 2011 … but shouldn't be running from time to push. We've been talking about this stuff for 10 years, and for the good of patients and consumers, we need to do this.”

The conference was sponsored by sponsored by Ingenix, the AMA, and other industry groups. The speakers reported that they had no conflicts of interest relevant to their presentations.

Site Collects Patient-Reported Data

Patients can play a role in providing useful health information, Dr. Stack emphasized. As an example, he cited

www.patientslikeme.com

Visitors to the site can sign up for a free account and a screen name, which they use to post their comments and health statistics. “People voluntarily post their own health data. Some are very open about it—they post every pill they're on, the dose, the frequency, what's happening to them,” said Dr. Stack. In the ALS community, members developed “a patient population and a data set that was so robust that if [community members] put in enough of their own variables, [the site] could predict when you'd be in a wheelchair within a week and when you'd be on a ventilator within a week. It was that precise. We could never replicate that in a prospective, double-blind randomized controlled trial. We could never get an institutional review board to [accept it] and never get people to do it.”

But for patients such as these, “the motivation of your own health and the fear of death through your own illness is a motivator we can't replicate with money or incentives,” he said. “When you are properly motivated, you'll seek out” available tools.

WASHINGTON — Government health officials are hoping that most physicians will get on the “meaningful use” bandwagon, but that's not likely to happen easily, according to Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.

“I don't think [health care] professionals have any idea what's coming,” Dr. Lichtenfeld said during a panel discussion at an eHealth Initiative conference. “I think [federal officials] are risking failure because doctors will say, 'Are you kidding? I don't want to have anything to do with this.' I hope that isn't what happens, but I tell you, be prepared.”

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of last year's federal stimulus law, physicians who treat Medicare patients can be awarded up to $44,000 over 5 years for the meaningful use of a certified health information system. For physicians whose patient populations are at least 30% Medicaid patients, the incentive is as much as $64,000.

But physicians who already have computers may find that they won't meet the requirements for the incentive, Dr. Lichtenfeld said. “Doctors have invested in these systems and now they're worthless. They don't have the time, they don't have the money, they don't have the expertise. And to have to get [a new system] up and running in 2–3 years—they won't do it. Something simpler would've gotten us to where we have to go.”

Despite a few patient-driven efforts (see box), no one has figured out how to use information technology as a way to get patients more involved in their care, Dr. Lichtenfeld contended. “A couple of years ago, personal health records … were the talk of the town. They were going to get everybody on board. Patients were going to run to various Web sites and fill out their health information. Health plans were going to get together and figure out how to bring their data so it would be downloadable and easily accessible.”

But none of that has yet come to pass, he said. “Personal health records landed with a thud. We need to figure out that sometimes we have to keep it simple.”

In the meantime, the Department Health and Human Services is trying to get physicians to meet some meaningful use criteria that aren't even written yet, said Dr. Steven Stack, an emergency physician and member of two workgroups of the department's HIT Policy Committee. He noted that two criteria “were supposed to be finished on Dec. 31, 2008, by statute. It's 2010 and they're not done, and it may be a year before we get something. A lot of these things aren't ready for prime time.”

Instead of requiring physicians to meet lots of criteria, “if we focus on the smallest of things, then doggedly persist until we knock down those barriers, and then require people to meet those [expectations]—with the proper incentives, we can make a really great step forward,” said Dr. Stack, who is a member of the American Medical Association board of trustees.

In contrast, Steven Findlay, senior health policy analyst at Consumers Union, expressed impatience with the process. “We ought to try to push as far as we possibly can with the 2011 meaningful use criteria,” he said. “We ought to be exquisitely sensitive to what's doable in 2011 … but shouldn't be running from time to push. We've been talking about this stuff for 10 years, and for the good of patients and consumers, we need to do this.”

The conference was sponsored by sponsored by Ingenix, the AMA, and other industry groups. The speakers reported that they had no conflicts of interest relevant to their presentations.

Site Collects Patient-Reported Data

Patients can play a role in providing useful health information, Dr. Stack emphasized. As an example, he cited

www.patientslikeme.com

Visitors to the site can sign up for a free account and a screen name, which they use to post their comments and health statistics. “People voluntarily post their own health data. Some are very open about it—they post every pill they're on, the dose, the frequency, what's happening to them,” said Dr. Stack. In the ALS community, members developed “a patient population and a data set that was so robust that if [community members] put in enough of their own variables, [the site] could predict when you'd be in a wheelchair within a week and when you'd be on a ventilator within a week. It was that precise. We could never replicate that in a prospective, double-blind randomized controlled trial. We could never get an institutional review board to [accept it] and never get people to do it.”

But for patients such as these, “the motivation of your own health and the fear of death through your own illness is a motivator we can't replicate with money or incentives,” he said. “When you are properly motivated, you'll seek out” available tools.