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Hate the wait to ask a simple medical question of your doctor in this age of Internet email? This week, Dr. Ron Risley looks at the implications of online medical correspondence from doctors' and patients' viewpoints. We also sort out the facts about Apple's recent firmware upgrades and shift our focus away from Mac OS X with a review of The Mac OS 9 Bible. In the news, check out the releases of Netscape Communicator 4.77 and Toast 5 Titanium.


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Netscape Releases Communicator 4.77 -- Netscape has released Communicator 4.77, a maintenance update that provides a few minor fixes to the company's older Web browser for the Mac (most of Netscape's development efforts are focused on Netscape 6 - see "Netscape 6 Arrives on Wobbly Legs" in TidBITS-556). The new version corrects a problem with bookmarks added to the Personal Toolbar, plus two JavaScript related issues: Command-clicking some JavaScript URLs wasn't always properly handled, and Communicator now always handles JavaScript URLs internally. The new version is a 14.7 MB download. [JLC]


Toast 5 Titanium Adds Video CD Support -- When Apple announced the CD and DVD burning capabilities of its new Macs, we wondered what it mean for Roxio's Toast, the current standard in media burning. Now, Roxio has released Toast 5 Titanium, a new version that can burn Video CDs which can be played on most DVD Video players. The new version also improves its MP3 Disc, Data CD, Audio CD, and CD Copy formats, includes background burning and a new interface, and adds support for Apple's iMovie and iTunes. Toast 5 Titanium is now shipping for $90. [JLC]


UpdateAgent Correction -- After reading last week's article on installing Mac OS X (see "Out of the Box: Installing Mac OS X" in TidBITS-574), the folks at Insider Software pointed out that the TidBITS copy editing team might want to spend some time back in the box. We incorrectly listed UpdateAgent as "UpgradeAgent," and priced it at $70 instead of the actual $50 amount, which covers one year of service. Insider Software also noted that UpdateAgent is available on CD, which is handy for consultants or people with more than one Mac. Our stash of wet noodles has thankfully been drying in a closet for several weeks, but rest assured they've been re-moistened in preparation for a good flogging. [JLC]


Poll Results: When Will X Mark the Spot? Two weeks ago, we asked when you planned to install Mac OS X to gauge the level of interest among TidBITS readers. Of the nearly 900 respondents, a third said they'd install the new operating system immediately, another 16 percent said they'd be getting to installation between now and July 2001 (when Apple plans to start putting Mac OS X on new Macs by default), and 46 percent said they'd wait until some time after that July. Two aggregate conclusions: 95 percent of respondents plan to install Mac OS X eventually, and roughly half of those people plan to do so by July. [ACE]


Apple Firmware Update Problems Clarified and Solved

by Adam C. Engst <>

Last week, we wrote about firmware updates for recent Macs which Apple issued shortly after the release of Mac OS X, and which were causing updated Macs to stop seeing some third-party memory modules. (See "Avoid Current Firmware Updates" in TidBITS-574.) Apple has now provided a statement to MacInTouch in which they say that the 4.1.7 and 4.1.8 firmware updates incorporate a new check that validates whether installed RAM is compatible to address random crashes and overall stability issues. The firmware update causes the Mac to ignore DIMMs that either don't meet Apple's specifications or that the update can't identify as compatible. Of course, this raises the question of why Apple initially didn't provide some warning about the possible consequences (which they've now done in the descriptions of these files on the Apple Software Downloads site), or why the firmware update itself doesn't test the DIMMs before installation.


Glenn Anderson, author of Qualcomm's Eudora Internet Mail Server, has stepped up to the challenge with DIMM First Aid (previously called DIMMCheck), a free utility you can run in Mac OS 9 to see if your DIMMs are likely to fail Apple's newly enforced specifications. If the test fails, DIMM First Aid can reprogram the offending DIMMs' Serial Presence Detect EEPROMs so they won't later be disabled by the firmware updater. DIMM First Aid is a 6K download.


So, before running the 4.1.7 or 4.1.8 firmware updates (which Apple says "dramatically improve system stability and performance"), be sure to check your Mac's memory with DIMM First Aid. If your DIMMs fail, use DIMM First Aid to fix them. If your DIMMs pass, it's almost certainly safe to update your firmware. You can download the firmware updates from Apple's Software Downloads Web site (search for "firmware update") or get them via the Software Update control panel, but note that the firmware updates on the Mac OS 9.1 CD-ROM that comes with Mac OS X are much older versions. We said in "Out of the Box: Installing Mac OS X" in TidBITS-574 that you shouldn't run these firmware updates; that's a mistake, and we'd encourage anyone installing Mac OS X to run at least the older firmware updates on the Mac OS 9.1 CD-ROM beforehand.


If you're in the nerve-wracking position of having the firmware updates already disable one or more DIMMs, first run DIMM First Aid, which should be able to fix the problem even after the DIMMs have been disabled. If, for some reason, that doesn't work, contact the vendor from whom you purchased the RAM. Most of them, according to a Ramseeker survey, are accepting returned DIMMs. They either replace the DIMMs or reprogram the EEPROMs for you.

In the end, Glenn Anderson deserves the highest accolades for his work in creating DIMM First Aid, in contrast with Apple, whose release of an update that could disable hardware without warning was negligent in the extreme.


BookBITS: The Mac OS 9 Bible

by Kirk McElhearn <>

Computer books can be big, because computers - as well as the applications and operating systems they use - are far more complex than their makers would often like to admit. Although size isn't always important, it is true that a huge tome often contains information left out of other books.

The Mac OS 9 Bible, by Lon Poole and Todd Stauffer (Hungry Minds, $40) is one such book. It does not offer an introduction to the Mac OS 9 or a tutorial approach to using it, but tries to present the whole shebang - and at over 900 pages, there is little missing. You might ask why it would be worth buying a Mac OS 9 book at the dawn of Apple's release of Mac OS X, but, aside from the fact that not all Macs are able to run Mac OS X, I strongly suspect that many Macintosh users are taking a wait-and-see attitude toward Mac OS X. And if you're planning to stick with Mac OS 9 for another year, or, if you're planning to run older applications in the Classic environment (which uses Mac OS 9.1), there's no reason not to make the most of it in that time.


You get a sense of the depth of this book in the first few pages - the table of contents alone is 22 pages long. Poole and Stauffer have compiled seemingly as much information as possible on the Mac OS, and they present it in a clear and easy-to-understand manner.

However, the Mac OS 9 Bible is not a book for Macintosh beginners, as the authors specify in the introduction. It won't tell you how to point and click or how to select menu items. Instead, it's for those who want to know how everything works, or who want a reference book at their side when a question arises.

The first 100 pages or so deal with the basics of using the desktop and the Finder, as well as what's new and cool in Mac OS 9. (Note that it does not cover the recent Mac OS 9.1 update; I doubt there will be a new edition taking new features such as the Finder's new Window menu into account, but Mac OS 9.1's visible changes are mostly minimal.) This material is geared toward inexperienced users, but the sheer quantity of information presented will probably turn off such users. In short, don't give the Mac OS 9 Bible to someone to get them up and running with a new iMac (TidBITS will publish a comparative review of some iMac-oriented books in the near future).

The Mac OS 9 Bible was not written to be read cover-to-cover, but it includes everything, in well thought-out chapters, and contains excellent explanations of some of the key aspects of the Mac OS. Just a few examples: the section on fonts gives an overview of the different types of fonts and how they work; the two comprehensive chapters on printing tell more than you will ever need to know about the subject; and the chapter titled "Adjust Controls and Preferences" tells you how to tweak every tweakable part of your system.

The Mac OS 9 Bible also includes a good chapter on Apple's system-level scripting technology, AppleScript - something that many Mac OS books mention merely in passing. Power users have long appreciated the automation possibilities presented by AppleScript, such as mounting network volumes, changing file attributes, integrating applications, or applying folder actions (scripts that watch over folders and act when files are added or removed). It can be hard to get started with AppleScript, but with a good introduction like this, even novices can start writing scripts that work wonders.

For those interested in setting up a network (home or home-office networks are becoming increasingly common), three chapters tell all about networking and file sharing. I did notice one significant omission, though: Apple's AirPort wireless networking technology warrants only a brief mention that covers less than one page. AirPort deserves significantly more attention, since being able to set up a network without running cables through your home is quite empowering. (See "Going to the AirPort" in TidBITS-567 for more on setting up and using AirPort networks.)


I was pleased to see a chapter on shareware - there are many excellent applications available for the Mac that are not sold through traditional channels, and, in more than 20 pages, the Mac OS 9 Bible presents dozens of the best shareware programs, along with the URLs to find their latest versions. Many people are unaware of these gems, and some of the best enhancements to the Mac OS come from shareware sources.

Another hefty chapter on tips and secrets goes beyond the basics, but I was a bit disappointed by the troubleshooting chapter. The Mac OS may be powerful and generally easier to use than Windows, but Mac users have their share of problems as well. Though the pages on preventive measures are excellent, I would have preferred to see a more thorough explanation of some of the most common problems and their solutions. If you're looking for Macintosh troubleshooting information, pick up a copy of the 4th edition of Ted Landau's long-standing Sad Macs, Bombs, and Other Disasters (Peachpit Press, $35).


Compared to David Pogue's Mac OS 9: The Missing Manual, which I reviewed recently, the Mac OS 9 Bible offers roughly twice the number of pages, and presents information differently. Where Pogue takes a didactic approach aimed at teaching you how to use Mac OS 9, Poole and Stauffer are more exhaustive, digging into every nook and cranny of the Mac OS. The former is a great book for general users who want to get a handle on their Macs, but the Mac OS 9 Bible fills in all the missing details that are inevitably lost when trying to present a coherent lesson.


All in all, the Mac OS 9 Bible is excellent, even though I found it lacking in a few areas. I consider myself a power user, yet I've referred to it many times and, in most cases, found the answers to my questions (an first-class index and glossary of key terms also help find the answers inside). It's a bit pricey at $40, but when you think of the time the Mac OS 9 Bible can save you, it is definitely worth the cost. Well-written, clear, and with an excellent layout, this is one of the best and most complete books on Mac OS 9.

[Kirk McElhearn is a freelance translator and technical writer living in a village in the French Alps.]

What's Up, eDoc? Emailing Your Doctor, Part 1

by Ron Risley <>

It's a frustration I'm sure everyone has experienced: you have a medical question. You want to follow the advice in those pharmaceutical commercials and "ask your doctor," but the next clinic appointment is three months away and it seems silly (and expensive) to schedule an appointment just to ask a simple question. You try calling, but you end up on hold, or talking to a receptionist, or maybe you even get your doctor's voice mail but you have trouble explaining the problem to a recording.

Wouldn't it be great if you could just email your physician? You could compose your thoughts carefully and at leisure, then send the correspondence immediately without listening to hold music or explaining personal problems to a secretary or a recording machine. Using email to communicate with our doctors mirrors the vision many of us have of using information technology to recapture some of the personal experience that mass-market commercialization has taken away.

The Doctors' Side -- Using email is a tempting proposition for the physician as well. Patients might be surprised at the conditions under which many doctors practice in our high-pressure, managed care world. For example, you might think your doctor has a plush office with a large desk, telephone, computer, and a clerical staff to handle filing, correspondence, and the like. Reality can be far different. My family practice clinic - at a prestigious university medical center - has a single large workroom (euphemistically called the "doctor's lounge") that serves as an office for nearly the entire practice. About forty doctors share three telephones and four small desks (no drawers, lockers, or other space for personal files or supplies). We have no clerical staff - I personally handle every phone call, letter, prescription refill, fax, or government form for my patients. There are a few Windows 95 computers in the lounge, but they are maintained by the university's Information Services Department and have a downtime approaching an astonishing 80 percent. Worse, all medical records are kept on paper in a central warehouse. Reviewing a record requires that you request that it be delivered to the clinic, where it often gets lost long before it finds you in the crowded workroom.

Time is another constraint. Our salaries are based on a forty hour workweek, but to meet minimum productivity requirements and other mandatory commitments while providing a decent level of patient care often requires over seventy hours per week. Our schedules have no time allotted for "non-reimbursed patient contact," which generally means answering telephone calls.

Physicians in the clinic use various strategies to cope with these primitive conditions. The most common is to limit patient contact to a scheduled office visit, when records are available and some time (often ten minutes or so) is specifically allocated for patient contact. This approach ensures some resources are available, but I feel as though it places a burden on patients, who cannot even ask "Should I take this daily medication in the morning or at night?" without scheduling a visit, waiting weeks their appointment, waiting hours in the germ-infested waiting room, and handling the costs of parking and a copayment.

Several of us have tried addressing these shortcomings with handheld computers. I was an early adopter of Newton technology, and migrated to Psion machines running the EPOC operating system when Apple killed the Newton.


With a computer in my pocket, I could have some basic information about my patients with me at all times. I could log voice mail and calls so I have a record of what was said, and I could receive and send email practically anyplace using my Psion and GSM mobile phone (except, as luck would have it, from the family practice clinic, which has very poor GSM reception).

The Benefits of Email -- If all my patients would communicate by email, I could handle much of my patient correspondence from my home office. I could quickly triage messages and concentrate on the more urgent ones, as opposed to voice mail where I might waste an entire break listening to a few messages (more likely than not, long-winded administrative ones) without leaving time to return calls. I cannot return calls from home because it is generally late by the time I get there, and it is disruptive to my family for me to carry on medical and psychiatric conversations at home. Returning calls from work is difficult, as there is no place to sit and speak privately.

Even more important, email gives me a written record of exactly what a patient told me and what steps I took in reply. I can refer back to that at a later date if we're trying to figure out when a symptom first occurred and whether it's worsening or improving. The patient, too, benefits from written instructions that can be referred to, and has an open pipeline for clarification if my instructions aren't clear.

It sounds great, and it can work well, but there are some characteristics of email which might not be obvious to the average patient and which deserve some extra attention.

Privacy -- Medical records privacy is far, far more important than the average person realizes. It didn't take long after I started medical practice for me to become profoundly uncomfortable with the cavalier way both providers and patients treat private medical information. When most people are sick, they just want to get better. They aren't fully aware of how their treatment records might, on some future day, affect their ability to hold certain jobs, obtain insurance, get credit, or even drive a car.

As health care institutions slowly and reluctantly move away from 19th century style record keeping, privacy advocates have raised the banner of medical privacy to delay the implementation of physician support systems that could improve the quality of care. Never mind that no such hue and cry was heard when billing systems - with equally privileged medical information - were automated back in the last century. Now that technology is being proposed for the benefit of the patient instead of the billing office, extreme caution is being urged.

And it's about time. As frustrating as it is to have to tolerate a double standard - electronic record keeping systems are being held to much stricter controls than paper-based records ever have been - the recent attention to privacy is a good thing. Medical records have become largely the property of insurers, billers, and attorneys instead of a tool maintained by and for the patient to assist the doctor in rendering care. If we truly restore privacy to the records, they will necessarily revert to that latter, more important role.

So what constitutes a private record? Most people are comfortable with the privacy of a telephone call. That's pretty reasonable. Wiretaps exist, legal and otherwise, but phone calls - even digitally switched as they all are now - are ephemeral. Someone pretty much has to operate the tap in real time, and pretty much has to have a human being doing the listening (or reviewing the recording). We have a long tradition, in the United States at least, of not randomly monitoring telephone conversations on a large scale. Unless you're a terrorist, organized criminal, or large-scale street drug importer, chances are your telephone calls aren't monitored.

Next on the list is the fax. Medical records are routinely faxed around the country, from doctors' offices to insurers to government agencies to hospitals and back. The fax has become, far and away, the most common mode of transport for medical information. Though faxes are carried on standard telephone lines, they are less secure than phone conversations. First, it is relatively easy to monitor telephone lines for fax (and modem) signals and record the results. Also, if someone dials a single digit incorrectly, your fax could appear on any random fax machine in the country; this happens on my personal fax machine with amusing frequency. Most importantly, fax machines at the receiving end often dump your private records into a wire basket or onto the floor where they are picked up and (if we're lucky) filed by a clerk with virtually no incentive to keep the information private. Even the building maintenance crew has probably seen your faxed medical records at one time or another.

Opposing editorials in the Psychiatric News a few years back debated the question of email confidentiality (psychiatrists are notoriously picky about confidentiality, such that it is common practice to keep two sets of books: a simple record of visits and treatments for the bean counters and attorneys, and a set of private process notes detailing what patients actually say in therapy). One position was that email was as private as a telephone call. The other was that one might as well publish one's correspondence in the New York Times. As much as I wanted to believe the former position, my experience as a data security consultant forced me to embrace the latter reluctantly. Email is carried by organizations which lack the regulatory and historical incentives to ensure privacy. Email, because of its electronic nature, is very easy to monitor and can be recorded and preserved indefinitely at a very low cost. Unlike either telephone calls or faxes, email is recorded by your ISP (and possibly others) while in transit and awaiting retrieval. That recorded data often makes its way onto backup media where it might be indefinitely archived. In other words, even if no one has any interest in your records now, they could conceivably go digging through archive tapes from AOL or EarthLink ten years from now and find private information.

Another factor in email privacy is that using email seems to create an illusion of privacy. Studies have shown patients are much more willing to divulge information when corresponding by email than when writing a letter or leaving a telephone message. Under current guidelines, though, email correspondence with your physician may become a part of the medical record. Even if email were perfectly private, the result is still only as secure as current medical records. Not reassuring.

What's a Patient to Do? Caveats aside, the benefits of email for most patients will still outweigh the risks. If your doctor is willing to communicate by email, make sure you both have a basic understanding of the limits of confidentiality of email. Doctors who use email should have written policies available for patients to review.

First, don't send your doctor an email message saying "I have crushing chest, arm, and jaw pain and I'm short of breath; I've taken six nitroglycerine pills and it hasn't gone away, it feels just like my last heart attack; should I call 9-1-1?" Make sure you understand how long it might be before you get a response. If it's important enough that you're worried about response time, consider a more immediate mode of communication. Remember, too, that email can get lost or routed incorrectly in both directions.

Second, put some care into composing your message. As we all know, too often email is overly brief, confusing, or missing relevant details. Don't assume that your doctor will automatically know what you're talking about just because you've been dealing with the pain or illness for a few days. Clarity of communication is paramount if your doctor is to provide a useful response.

Third, the $26 your insurance company paid for your office visit two years ago does not entitle you to a lifetime of free Internet medical advice. Simple questions with uncomplicated consequences are okay, but don't expect your doctor to retrieve your records, call the Center for Disease Control and your insurance company, and read half a dozen journal articles just to assuage you and your friends' medical curiosity. If you ask a question and your doctor tells you to come in rather than answering in depth, consider that it might just be a way of making sure that you get appropriate attention paid to your problem.

In the next installment, we will explore policy and regulations affecting use of doctor-patient email, and discuss some practical strategies doctors and patients can use for improving the privacy of electronic correspondence.

[Ron Risley is a family doctor, psychiatrist, former communications engineer, and inveterate hacker plying his trades in Sacramento, California.]

Non-profit, non-commercial publications and Web sites may reprint or link to articles if full credit is given. Others please contact us. We do not guarantee accuracy of articles. Caveat lector. Publication, product, and company names may be registered trademarks of their companies. TidBITS ISSN 1090-7017.

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