	In last month’s column, I talked about Microsoft’s newest desktop operating system, 

, and outlined several reasons why you might want to purchase it when it comes out this year. Windows 7 will include some really cool features—like multi-touch technology and usability improvements&mdash;that can benefit medical practitioners and their office staff. Because it is in Microsoft’s best interest to make the process of upgrading to Windows 7 simple and straightforward, you would think the software giant would put great effort into streamlining the experience. Unfortunately, it seems to me that Microsoft is hell-bent on driving its customers straight into the arms of its chief competitor, Apple, Inc. Microsoft engineers do this by making the software upgrade process excessively difficult for the average non-techie user.

	Even if you decide to purchase a new computer that comes with Windows 7 pre-installed, you’ll still have to select which version of Windows 7 to get. Once again, Microsoft makes this overly complicated by selling a multitude of editions. There are six flavors of Windows 7. One is for emerging-market countries, so unless you practice in Bulgaria or Uganda, that one is probably a bad choice. Another version is for people who work in large corporations, again a bad choice for most doctors. There is a stripped-down version called Starter that is available only on new machines. That version will likely be too minimal for the needs of most 

	Most tech-savvy physicians will choose either Windows 7 Home Premium, which has all the important Windows 7 features, or Professional, which adds special networking capabilities and the capacity to run some older, specialized programs. Windows 7 Professional enables you to connect remotely to a network using a system called “domain joining,” which I doubt would be used by many practices with fewer than 100 physicians. But the ability to run older programs is important for those of us who haven’t yet upgraded our legacy practice management software. One last version, called Windows 7 Ultimate, combines all the features of the other versions.

	There is one more complication. There are 32-bit and 64- bit editions of each of the three main consumer versions of Windows 7 (ie, Home Premium, Professional, and Ultimate). The 32-bit editions are for computers with standard 32-bit processors, typically found in most medical offices. The 32- bit versions cannot recognize more than three gigabytes of RAM memory, which should be more than enough for the average user. The 64-bit editions for PCs with souped-up 64-bit processors can use much more memory, making the machine run faster when multiple applications are open or when doing CPU-intensive tasks like hi-def video playback.

	For those who want to upgrade existing machines to Windows 7, there is good news and bad, depending on what operating system you use today. Vista users face a relatively easy, direct upgrade process that preserves personal files, settings, and programs, although there are some restrictions on which versions of Vista can be upgraded to which versions of Windows 7. For the most part, you can only directly upgrade comparable versions of Vista and Windows 7—Vista Home Premium to Windows 7 Home Premium, Vista Business to Windows 7 Professional, etc. There are exceptions, and you can go to Microsoft’s Website to learn more.

	For Windows XP users, the news is far worse. You will have to upgrade manually, which means that you have to reinstall and reconfigure all of your applications, settings, and personal files, assuming you kept and can fi nd the original discs, download files, and software keys. I recently read about a third-party utility from Laplink Software (

) that can handle the manual process of moving from Windows XP to Windows 7. A new version of its popular PCmover utility (

) will be able to perform automated, in-place upgrades to Windows 7 on an existing Windows XP machine and preserve existing programs. I have not used the software and cannot attest to its efficacy, but the fact that Microsoft consistently produces complicated and difficult-to-adopt software remains great news for those companies that build user-friendly utilities that are designed to remedy these headaches.

Dr Bertman is Physician Editor-in-Chief of MDNG: Primary Care/Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer Website focusing on personal medical topics. He is in private practice in Hope Valley, RI. 

Articles

In last month's column, I talked about Microsoft's newest desktop operating system, Windows 7, and outlined several reasons why you might want to purchase it when it comes out this year. Windows 7 will include some really cool features-like multi-touch technology and usability improvements-that can benefit medical practitioners and their office staff. Because it is in Microsoft's best interest to make the process of upgrading to Windows 7 simple and straightforward, you would think the software giant would put great effort into streamlining the experience.

Nothing Is Ever Simple with Windows

The recently enacted American Recovery & Reinvestment Act (ARRA), commonly referred to as the “stimulus plan,” includes more than $19 billion in incentives for physicians to adopt electronic health record (EHR) technology. This part of the ARRA legislation is known as the Health Information Technology for Economic and Clinical Health Act (HITECH). In essence, HITECH calls for physicians to earn up to $44,000 over five years if they use an EHR in such a way as to comply with yet-to-be-finalized criteria. So, if you are one of the 83% of doctors who have not yet implemented an EHR system, now may seem like the perfect time to do so. But not so fast… 

Now, I’m probably the last person you’d expect to be saying this, but as I investigated the actual details of this law, I came to a startling realization: none of the details have been worked out, and running out to get an expensive EHR system in hopes of recouping the cost through the incentive programs is nowhere near a sure thing.

Let’s start with what is known. Beginning in 2011, physicians can receive extra Medicare payments for the “meaningful use” of a certified EHR. These payments can total as much as $18,000 in the first year for practitioners who adopt in 2011 or 2012, with slightly lower amounts for those who do so in 2013 and 2014; incentives are gradually reduced and then end in 2016. For physicians with high volumes of Medicaid patients (30% or higher), the law provides subsidies through the Medicaid program as well. Doctors must choose whether to participate in the Medicaid or Medicare bonus program; they cannot receive bonus payments from both.

Thus, eligible professionals demonstrating meaningful use of a certified EHR starting in 2011 could collect $44,000 over five years. Waiting until 2013 would result in a maximum bonus of $27,000 over three years. HITECH also imposes financial penalties to spur adoption. Physicians who are not using EHRs meaningfully by 2015 will lose 1% of their Medicare fees, then 2% in 2016, and 3% in 2017. The bottom line is that 2011 is still 18 months away, so there is plenty of time to wait to make a decision about your EHR, even if you want to collect the maximum $44,000 benefit.

What qualifies as meaningful use of a certified EHR? 

The law states that only “eligible professionals” who “meaningfully use” a “certified” EHR will able to collect the stimulus money. Yet none of these terms have been authoritatively or legally defined. There is much analysis and information about this legislation from various sources floating around the Internet, but none of it has the official seal of government approval. Like most new laws, it will probably take years of regulation, test cases, and interpretations by lawyers and courts before we have definitive answers to many of our questions. We can, however, make some logical assumptions based on the goals of the government.

The biggest issue is America’s high level of healthcare expenditures (compared to the rest of the world). Thus, we can assume that meaningful EHR use will promote the functions that can reduce this cost, such as prescribing generics, sharing lab and radiology findings among physicians rather than reordering tests when the results aren’t readily available, and ensuring that standards of care for community health are followed.

Using e-prescribing, computerized ordering/reviewing of tests, and health information exchange networks all seem to be part of what would be defined as meaningful use; unfortunately, it seems unlikely that tort reform will make it into this discussion to any significant degree, and thus we will continue to practice defensive (and expensive) medicine, ordering questionable tests, procedures, and consults just to reduce our risk of lawsuits.

In terms of a “certified” EHR, it seems reasonable—and it is assumed by many observers&mdash;that CCHIT (Certification Commission for Health Information Technology) certification will suffice in lieu of a formal government certifying body. So, even though CCHIT charges tens of thousands of dollars to apply&mdash;and requires not only the “meaningful” features above, but also hundreds of other “bell and whistle” features that make EHRs less usable&mdash;it looks like that is the future of our EHR choices (Amazing Charts is currently going through the onerous process of getting CCHIT-certified, so watch for a future article describing this experience).

The most important question for physicians is how to get the promised money (before future budget cuts remove it). I reviewed the HITECH legislation and couldn’t find any real details on how the money was to be distributed. I went to the Healthcare Information and Management Systems Society (HIMSS) conference, where everyone was buzzing about the HITECH legislation. I had two basic questions, assuming I used a certified EHR in a meaningful way by 2011:

• Who is an “eligible professional?” An eligible professional appears to be a physician, but does a nurse practitioner or physician assistant count? What if this mid-level practitioner owns his or her own practice?

• How does a physician actually get the money? It appears that you are allowed up to 75% of Medicare payments per physician, but will the payments come in a lump sum, or over time, or piecemeal with each Medicare payment? 

Amazingly, nobody I spoke with—including a number of EHR vendors who were advertising the $44,000 stimulus funds to entice folks to purchase their overpriced systems&mdash;knew the answers. Eventually, I found a booth for the agency tasked with overseeing HITECH, the Office of the National Coordinator for Health Information Technology (ONCHIT). There, I spoke with two representatives (who requested not to be identified). One said they just didn’t know; the other said she “couldn’t answer.” When asked if she couldn’t because she didn’t know, or wouldn’t because she wasn’t allowed, she replied, “A little of both.”

Frankly, I have no idea what that means. It certainly sounds cryptic, but the fact that even an ONCHIT representative couldn’t (or wouldn’t) provide the answers to simple questions is astounding, especially given the way in which this money is being advertised by vendors and agencies with an interest in accelerating EHR adoption.

While it is disappointing that there is, as of yet, no clear interpretation of several fundamental parts of the HITECH legislation, it is unconscionable that vendors and other groups are hyping this money knowing that the details have yet to be defined. I suspect we’ll find, as we did with the promise of P4P, that the actual money delivered is far less than what was implied. A further risk is that the next administration or congress may choose to cut funding for this incentive program due to fiscal constraints. In the end, it is the underpaid and overworked primary care physicians who will be cajoled, enticed, and ultimately forced into spending tens of thousands of dollars for unproven technology.

I will continue to closely follow and report on how these critical issues play out over the coming months. Until then, slow down and try to ignore all the background noise from vendors and other groups with their various agendas, pushing you into an EHR solution before you’re ready.

Dr. Bertman is Physician Editor-in-Chief of 

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

The recently enacted American Recovery & Reinvestment Act, commonly referred to as the "stimulus plan," includes more than $19 billion in incentives for physicians to adopt EHR technology.

I will get $44,000 to Use an EHR? Where do I Sign Up?

Does it seem like everyone in the world has suddenly created a profile on Facebook and wants to become your “friend?” If you already use social networking sites like Facebook, MySpace, Friendster, and Twitter, then read no further. But if you think a Twitter produces the high notes in your stereo speakers and a Facebook is your old high school yearbook, this column is for you.    

For most of our lives, “socializing” meant attending a function or event in person, meeting people, and making small talk. “Networking” meant meeting someone through a common bond with a third person. Today, thanks to the Internet, social networking has an entirely different meaning. In place of face-to-face meetings, social networking now occurs online, mediated through a “profile” or some other form of Web page that represents you to the rest of the world. People frequently use these pages to express themselves, share their interests, and post updates about their personal and professional lives. People become “friends” or “colleagues” by linking their pages together. 

The 800-pound gorilla of the social networking space right now is 

. Started by a college student who wanted to create the online equivalent of the “facebook” typically given to freshman at college orientation, Facebook today has tens of millions of members. When you join Facebook, you select a user name and password and then create a profile page. You can add pictures, videos, and as much information about yourself as you want. If you enter your school and work affiliations, Facebook will automatically seek out and find people you may know based on those associations. 

Something strange will happen not long after you set up a Facebook page: old friends and colleagues you haven’t heard from or thought about in years will invite you to become their “friends.” Unless you accept their invitations, these people cannot see your page or any of your personal information. Once you do accept, you can view the other person’s page and be added to their network and vice-versa. Facebook pages can also be created for companies, organizations, and groups. So, your Facebook page might have connections with your college alumni page, medical school alumni page, and a Grateful Dead fan page. 

If you’re part of the Gen-X or baby boomer generations, this decade’s earlier social networking phenomenon, MySpace, almost certainly passed by you unnoticed. MySpace seemed to be tailor-made for hormone-crazed pre-teens, teenagers, and adults obsessed with acting youthful. MySpace offers much less privacy than Facebook; anyone can see your MySpace page (Check out my attempt at 

Twitter deserves special mention, not only because it is currently all the rage, but also because I believe it represents one of the worst aspects of social networking—the narcissistic need some people have to update everyone in their network on exactly what they are doing at that very moment. In all seriousness, people use Twitter to broadcast things like: “I just ate an apple” or “I’m stuck in traffic.” To be fair, I have seen it used for slightly more productive purposes, including providing live, near-instant updates from meetings and conferences. 

There are also several professional social networking sites for physicians and other healthcare providers. Probably the most popular of these is Sermo.com, but others include DoctorsHangout.com, DoctorNetworking.com, and PhysicianOnline.com. I don’t use these sites, but they offer a highly focused forum for professional and social exchange between medical practitioners. 

Whether you want to locate an old boyfriend or girlfriend from college, or just network with other pediatricians practicing in Chicago, there is probably a social networking site for you. Don’t be afraid to try social networking, but don’t be foolhardy in how you approach it. Try to minimize the amount of financial or personal identity information you give out online, and don’t download software or files from anyone you don’t trust. And remember: the information you post is now public information that will be online forever, so don’t brag about anything that could derail your chances to become the next Surgeon General. 

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

Does it seem like everyone in the world has suddenly created a profile on Facebook and wants to become your "friend?" If you already use social networking sites like Facebook, MySpace, Friendster, and Twitter, then read no further.

Social Networking Comes of Age

The hottest trend right now in mobile communications is location-based services (LBS) on smartphones. Packed with numerous features such as touch-screen interfaces or full QWERTY keyboards, along with speedier Web browsing, smartphones represented 23% of all handset purchases in the fourth quarter of 2008, compared to just 12% for the same period in 2007, according to NPD Market Research (http://tinyurl.com/bee3mz). 

More and more of these mobile devices are being sold with built-in global positioning system (GPS) modules, so chances are that the next mobile phone you buy will already have GPS. Network operators like Sprint and Verizon require a small monthly fee for GPS service, or it is bundled into your regular monthly fees, depending on the package you choose.

Although GPS use is most closely identified within-car or pedestrian navigation, a growing number of people are using LBS applications for information and entertainment. Here’s how it works: the GPS receiver knows where you are based on signals from satellites circling the earth. The accuracy of a position determined with GPS depends on the type of receiver. Most handheld GPS units have an accuracy of about 10-20 meters. With knowledge of your physical vicinity, the application can locate other things nearby. In GPS-speak, these are generally known as points of interest (POI) and include everything from hotels, museums, and hospitals to restaurants, banks, and retailers. A GPS system linked to a social network like Twitter will tell you the location of the friends and colleagues who are part of the network.

Suppose you’re driving or walking in an unfamiliar neighborhood and you want to know where the nearest ATM is located. Simply pull out your cell phone and look up the closest bank. I was in midtown Manhattan not too long ago when I had a sudden craving for sushi. I used my Blackberry to pull up the Zagat restaurant guide online. Based on my location, the service was able to show me all the Japanese restaurants within a few blocks of where I was standing. I could even adjust the search parameters to look for restaurants inside a quarter-mile radius. How cool is that? My service provider, Sprint, charges $4 per month for this Zagat mobile service.

Another great service when you’re driving is the ability to find cheap gas. Of course, you can use a free website to do this, but the main advantage of lBS is that mobile users don’t have to manually specify ZIP codes or other location identifiers—the system already knows where you are. Other location-based content services that make sense for drivers provide real-time information about traffic jams, locations of cameras designed to catch speeders, parking reservations, and concierge services.

Mobile commerce is another growing application, taking the form of coupons or advertising directed at customers based on their current location. Say you’re driving or walking past a Starbucks, your phone rings and you see a coupon for $1 off a latte. Consider this an invasion of privacy? I might, too, which is why this particular service hasn’t caught fire with consumers yet. But I can imagine that many people will be happy to get discounts for products and services they already want, so look for this kind of “push” marketing to proliferate in the near future.

How can doctors use LBS in their practice? Just like for most busy professionals with not enough hours in the day, location-based services can be a real time saver, whether you’re avoiding traffic as you drive to the hospital to round, or using the service to find the closest ice cream parlor as you’re walking around town with the family on the weekend. Depending on the kind of practice you run, it might make sense to have your medical office listed as a point of interest in the directories published by GPS device companies like Garmin, Tom-Tom, and others. You never know, your next patient may be driving or walking by your office right now.

Do you use location-based services on your cell phone or PDA? Do you foresee this technology being applied in meaningful ways in healthcare? Do you have concerns over security and privacy issues associated with LBS technology?

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

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

, a leading developer of EHR software. He is also the founder and president of 

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

The hottest trend right now in mobile communications is location-based services on smartphones.

The ABCs of Location-based Services

As anyone who has lugged a notebook computer through an airport can attest, even today’s sleekest machines feel heavy after a few hours. Add in chargers, backup batteries, a peripheral or two, and a carrying case, and you could be hauling around an extra 10 or 15 pounds.  

But do you really need all this gear if you only want to do a few basic things, like check and respond to e-mails and surf the Internet, but want a better user experience than smartphones provide? A few years ago, a small company called Asus pioneered the so-called “netbook” category with its line of Eee PCs. Sometimes called an ultra-portable notebook, this new device category falls somewhere between a smartphone or PDA and a laptop computer. 

Many industry pundits now say that netbooks are the next big thing in small computers. In fact, analyst firm IDC predicts netbook sales will grow 300% in 2009 compared to 2008. Although I have not yet purchased a netbook, I believe there is some merit to the basic premise behind these products: people want simple, fast, and highly portable computers. At the same time, there are some drawbacks that you should consider before purchasing one. 

First, let’s consider what these pint-sized devices do well. If you use a desktop computer at home or the office, and carry a simple cell phone instead of a smartphone with Internet connectivity, a netbook makes a lot of sense. You can easily slip it into your jacket pocket, bring it anywhere, and connect to the Internet via built-in WiFi wireless networking. 

According to a quick survey of product reviews in PC periodicals, netbooks boast fast boot-up and connection times. Some of them are capable of connecting to the Internet in as little as 45 seconds from power on. For anyone who has waited the seemingly interminable five minutes or more it can take a Windows Vista computer to boot up and connect to the Internet, that kind of speediness sounds like a minor miracle. Part of the reason for the fast boot up and connect times may be due to the fact that some of these machines run the Linux OS and open source applications, which are a good deal less “bloated” than the code coming out of Redmond, WA these days. 

Needless to say, these machines are lightweight. For example, the Sony VAIO P Series, introduced at this year’s Consumer Electronics Show, weighs just 1.3 pounds. Low cost is another attractive feature, as most netbooks sell for under $600. Basic models of the well-reviewed Acer Aspire One start at around $350, making it an ideal solution for students, the budget-minded, or professionals who already have a primary laptop or desktop but want something more portable. 

So, what are the downsides? Let’s start with screen size. If you are accustomed to the large, high-resolution screen of your Dell laptop or Apple MacBook, your eyeballs will be underwhelmed with the seven to 10-inch screen on most netbook models. Nearly all of the netbooks have screens with resolutions smaller than 1024x768, which renders some sites and applications unusable, including many EHRs and other practice management applications. 

Cramped keyboards are another issue with netbooks. While having a full keyboard is a distinct advantage over using your thumbs to type into a PDA or smartphone, the truth is that a keyboard can be made too small for practical use. Some netbooks do have small, poorly designed keyboards, so I would test drive a netbook before buying one. 

Netbooks are definitely not for everyone, but they fill a useful niche in the marketplace. Is there a netbook in your future? I suggest you take a trip down to your local electronics store to see for yourself. 

Would you use one of these devices in your practice? Or does the small screen size and potential difficulty interfacing with EHRs make a netbook less than ideal for a practicing physician? 

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

Would you use one of these devices in your practice? Or does the small screen size and potential difficulty interfacing with EHRs make a netbook less than ideal for a practicing physician?

As anyone who has lugged a notebook computer through an airport can attest, even today’s sleekest machines feel heavy after a few hours.

Jonathan Bertman, MD

Articles

Nothing Is Ever Simple with Windows

I will get $44,000 to Use an EHR? Where do I Sign Up?

Social Networking Comes of Age

The ABCs of Location-based Services

The Incredible Shrinking Notebook