text:
Patient-Centered Cancer Treatment Planning: Improving the Quality of Oncology Care
A National Coalition for Cancer Survivorship and Institute of Medicine Workshop
Each year about 1.5 million people are diagnosed with cancer in the United States (ACS, 2010), and must then decide on a course of care. Cancer treatment often involves multiple options and specialties; it can be toxic, costly, intense, and protracted and may involve serious long-term complications. In addition, responses to cancer treatments are quite variable, so predicting the potential risks and benefits of various treatment options for individual patients is often difficult. Because of the complexity of treatment choices, coupled with the life-threatening nature of cancer and its emotional repercussions, it is often difficult for people with cancer to make decisions about their care. The fragmented nature of the cancer care system (IOM, 1999) also presents challenges that may impede coordinated care and the development of comprehensive treatment plans.
Recognizing these challenges, the National Coalition for Cancer Survivorship (NCCS)and the National Cancer Policy Forum (NCPF) of the Institute of Medicine hosted a public workshop in Washington, DC, on February 28 and March 1, 2011, titled Patient-Centered Cancer Treatment Planning: Improving the Quality of Oncology Care. The workshop agenda, which includes speakers and their affiliations, can be found in the appendix. This document is a summary of the workshop. The views expressed in this summary are those of the speakers and discussants, as attributed to them,
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 1
Cancer Treatment Planning:
Improving the Quality of Oncology Care
A National Coalition for Cancer Survivorship and
Institute of Medicine Workshop
Each year about 1.5 million people are diagnosed with cancer in the
United States (ACS, 2010), and must then decide on a course of care. Can-
cer treatment often involves multiple options and specialties; it can be toxic,
costly, intense, and protracted and may involve serious long-term compli-
cations. In addition, responses to cancer treatments are quite variable, so
predicting the potential risks and benefits of various treatment options for
individual patients is often difficult. Because of the complexity of treatment
choices, coupled with the life-threatening nature of cancer and its emotional
repercussions, it is often difficult for people with cancer to make decisions
about their care. The fragmented nature of the cancer care system (IOM,
1999) also presents challenges that may impede coordinated care and the
development of comprehensive treatment plans.
Recognizing these challenges, the National Coalition for Cancer Sur-
vivorship (NCCS) and the National Cancer Policy Forum (NCPF) of the
Institute of Medicine hosted a public workshop in Washington, DC, on
February 28 and March 1, 2011, titled Patient-Centered Cancer Treatment
Planning: Improving the Quality of Oncology Care. The workshop agenda,
which includes speakers and their affiliations, can be found in the appendix.
This document is a summary of the workshop. The views expressed in this
summary are those of the speakers and discussants, as attributed to them,
OCR for page 1
and are not the consensus views of the workshop participants or members
of the National Cancer Policy Forum.
The workshop included an overview of patient-centered care and
cancer treatment planning, as well as sessions on shared decision making,
communication in the cancer care setting, and patient experiences with
cancer treatment. Best practices, models of treatment planning, and tools
to facilitate their use were also discussed, as well as policy changes that
may promote patient-centeredness by enhancing patients' understanding
of and commitment to the goals of treatment through a shared decision-
making process with their healthcare team from the moment of diagnosis
onward. While previous Institute of Medicine (IOM) work has focused on
the challenges of cancer care planning for individuals who have completed
their treatment (sometimes referred to as follow-up or survivorship care
planning), this workshop focused on treatment planning for patients with
cancer at the time of diagnosis.
Patient-centered care has been defined as "providing care that is respect-
ful of and responsive to individual patient preferences, needs, and values,
and ensuring that patient values guide all clinical decisions" (IOM, 2001).
A primary goal of patient-centered treatment planning is to engage patients
and their families in meaningful and thorough interactions with their
healthcare providers to develop an accurate, well-conceived treatment plan,
using all available medical information appropriately while also considering
the medical, social, and cultural needs and desires of the patient and family.
A treatment plan may entail a prognostic and therapeutic plan at the time
of initial diagnosis, which can be updated with changes during the course of
treatment, as well as a prognostic and palliative care plan near the end of life.
Participants at the workshop identified numerous obstacles to achiev-
ing patient-centered care planning in practice, including variable and often
suboptimal communication between the patient and healthcare provider
that may not be culturally or personally appropriate, and information over-
load for the patient and family, without appropriate written documentation
of treatment plans, options, and expectations that the patient and family
might refer to after a visit. Many participants also lamented the frequent
lack of involvement of primary care physicians and provider teams who
might know patient and family better. Numerous factors that might con-
tribute to that lack of involvement were noted, including poor coordination
of care or inappropriate exclusion by the oncology team, the inability of
primary care physicians to devote the time needed to keep up with myriad
complex and rapidly changing cancer treatment regimens, and the lack of
OCR for page 1
availability of primary care physicians due to workforce shortages. Other
obstacles to care planning identified by workshop participants included
the increasingly complex medical data that healthcare providers need to
consider when making treatment decisions, and a lack of decision support
for healthcare providers (for example, in electronic health records) to aid in
managing the complexity of medical information. In addition, the current
reimbursement system for health care does not compensate providers for the
time it takes to develop, discuss, and document a treatment plan.
Workshop participants also suggested a variety of mitigation strategies
to address these many obstacles, including improved training of physicians,
nurses, and other healthcare providers in the components of optimal com-
munication with patients and families, and improved education of patients
and families about how to be more proactive and assertive to optimize
interactions with healthcare providers. Many participants advocated for
greater use of support services, such as mental health services, social work,
and nutrition counseling, as well as greater involvement of patient naviga-
tors who can help coordinate cancer care and foster communication among
providers. However, others argued that the need for patient navigators is a
symptom of a broken system, and strongly advocated for more structural,
systemic reforms in cancer care. For example, many participants emphasized
a need to change the reimbursement and financial incentives in the system
to encourage and support more patient-centered care. They also stressed
that greater use of quality improvement programs and accountable care
systems could have a positive impact on the care provided to patients with
cancer. A variety of tools and online resources were also cited as potential
means to improve care planning, such as electronic health records that can
organize all important medical information, share it with all members of the
healthcare team, utilize decision support to better ensure optimal treatment
recommendations for patients, and facilitate electronic input from patients
into their healthcare records.
Cancer takes patients on a journey most have never taken before, whose
outcomes are unknown. This creates uncertainty and anxiety, especially
given the potential life-threatening nature of the disease, as several patients
and providers noted at the workshop. Mr. Richard Boyajian, a cancer
survivor and clinical director and primary nurse practitioner of the Adult
Survivorship Program at Dana-Farber Cancer Institute, said that fear of the
OCR for page 1
unknown was a major issue for him when he was a leukemia patient and
that a cancer treatment plan helped alleviate that fear. "The idea of having
some sense of the roadmap, of where this journey is going to take you, is
really important," added Mr. Mark Gorman, a cancer survivor and director
of Survivorship Policy at NCCS. "It's critical to manage uncertainty."
A cancer treatment plan can provide that roadmap, even in the final
stages of cancer when treatment might only be palliative (to address symp-
toms), stressed Dr. Patricia Ganz, professor of health services and medicine
at the University of California, Los Angeles, and director of the Division
of Cancer Prevention and Control Research at the Jonsson Comprehensive
Cancer Center. "Patients want to know what's going to happen to them.
That's why we have to do this," she said. Ms. Alison Smith, vice president
for strategic initiatives at C-Change, added that "pilots don't take off with-
out a flight pattern, and architects don't break ground without a blueprint.
Patients diagnosed with cancer are taking the journey of their life, literally,
so the role of the cancer treatment plan in starting a conversation, in pro-
moting comprehension and retention, in managing expectations and anxi-
ety, and providing continuity across settings and episodes is so important."
Cancer care also has a number of unique attributes that make treatment
planning vital. Dr. Ganz noted that cancer treatments can be complex,
toxic, intense, expensive, disruptive, life-threatening, and protracted, with
the possibility of cancer recurrence or late complications, and thus requiring
lifelong surveillance. In addition, patients often have to choose between sev-
eral treatment options, each with its own set of potential risks and benefits.
Cancer care also usually involves multiple practitioners and can occur in
isolation from primary healthcare delivery, with physicians whom patients
usually have not known for long.
Given the complexity of cancer care, a written cancer treatment plan
is critical, noted Dr. Karen Sepucha, director of the Health Decision Sci-
ences Center at Massachusetts General Hospital and assistant professor
of medicine at Harvard Medical School. "It is unfathomable the lack of
documentation and what's supposed to be kept in your head versus the
limits of cognition. There is an approach in human factors engineering
in which you design your system so that humans can work in it and not
fail. We haven't really translated that well into health care, so we're setting
ourselves up for failure all the time, for missing the handoffs," she said. Dr.
Lawrence Shulman, chief medical officer, senior vice president for medi-
cal affairs, and chief of the Division of General Oncology at Dana-Farber
Cancer Institute, added that cancer treatment plans are likely to become
OCR for page 1
increasingly important as the growing complexity of cancer care becomes a
challenge for providers.
Cancer treatment planning is especially important because a patient's
survival can hinge on making the correct treatment decision. "When you are
making these important decisions, if [a doctor makes] the wrong decision,
the next day the doctor gets to try again with a new patient," said Ms. Anne
Willis, cancer survivor and director of Survivorship Programs for NCCS.
"The patient doesn't have that option. [Patients] only have one chance to
get it right."
The 2001 IOM consensus report Crossing the Quality Chasm: A New
Health System for the 21st Century defines patient-centered care as "providing
care that is respectful of and responsive to individual patient preferences,
needs, and values, and ensuring that patient values guide all clinical deci-
sions" (IOM, 2001). Most speakers at the workshop indicated that when
patient-centered care is given, there is a partnership between a patient and
his or her providers. To enable this partnership, communication must be
sensitive to the needs and capabilities of the patient so that the patient is
informed about his or her treatment options and encouraged to share in the
decision making about care.
Patient-centered care may also involve patient navigators, social work-
ers, or other personnel to help patients coordinate their care and relieve
their health-related burdens, including psychosocial issues such as anxiety
or financial stress. As one patient who spoke at the workshop summarized
it, patient-centered care is having the health system organized around the
patient rather than the patient having to organize his or her life around the
The key components of patient-centered care stressed at the workshop
were the following:
• atient education and empowerment
• atient-centered communication, involving the patient, family, and
friends, that explains treatment options and includes patients in
treatment decisions to reflect patients' values, preferences, and needs
• oordination and integration of care
• rovision of emotional support as needed, such as relieving fear and
anxiety and addressing mental health issues
OCR for page 1
Patient Education
Oncologists and other cancer healthcare providers typically provide
some information to their patients about their diagnosis, stage, and treat-
ment options. Yet, as several speakers at the workshop noted, patients
also want to know the likely outcomes and side effects of each potential
treatment, including long-term outcomes and risks of cancer recurrence, if
known. They also want to know the signs of recurrence so that they don't
worry unnecessarily. Many cancer treatments may also reduce fertility; thus,
ways to preserve fertility should also be discussed with patients in advance
of treatment when appropriate, several speakers said.
Research on breast and colon cancer patients and survivors by
Dr. Deborah Mayer, associate professor at the University of North Carolina
School of Nursing, suggested that patients want both print- and Web-based
information, and they want information about their diagnosis at the time
they are diagnosed and a treatment plan when they first start their treat-
ment. Examples of Web-based tools that can help patients learn more about
their diagnosis and treatments options are described in the section on Tools
and Resources (p. 29). Cancer patients also would like information on local
resources, including support groups, dieticians, physical and mental health
therapists, and exercise and health promotion programs.
There is variability in the amount of information that patients want to
receive about their cancer, several speakers noted. Because of the stress of
being diagnosed with cancer, patients may have difficulty processing exces-
sive amounts of information, especially complex technical information.
Mr. Boyajian suggested providing patients with just the "Cliff Notes"—a
concise summary of the most important pieces of information about diag-
nosis and treatment—and then referring them to other sources if they want
additional information. However, Dr. Ganz stressed the importance of dis-
cussing all care options and having both verbal and written communication
of those options and of the treatment plan. Several participants suggested
recording the consultation a patient has with his or her oncologist in which
this information is discussed, so that it can be reviewed later by the patient
and family members. Some patients also find it helpful to have a companion
present who can take notes during this discussion and help with post-visit
translation of care plans and rationale for treatment.
It is also helpful if providers put the potential risks and benefits of vari-
ous treatment options in a context that patients can understand, pointed
out Dr. Sherrie Kaplan, Assistant Vice Chancellor for Healthcare Measure-
OCR for page 1
ment and Evaluation and professor of medicine at the University of Cali-
fornia, Irvine. For example, the risk of a rare complication can be given as
equivalent to the likelihood of other rare events occurring, such as being
struck by lightning, hit by a car, or winning the state lottery.
Patient Empowerment
Both patients and providers at the workshop noted that people with
cancer are expected to take an active role in their care and share in decision
making, but few people have experience and training in what Dr. Kaplan
termed "planned patienthood." Although we are much more likely to be
patients at some point during our lifetimes than to be in a fire, she pointed
out, we are trained for the latter and not the former. Consequently, the aver-
age patient asks five or fewer questions during a 15-minute doctor's office
visit, with a high proportion asking no questions (reviewed by IOM, 2008),
suggesting that patients generally are not taking an active role in their care.
According to the IOM consensus report Cancer Care for the Whole Patient:
Meeting Psychosocial Health Needs (2008), poor communication and lack
of patient involvement are particularly worrisome because a substantial
literature has linked effective patient-clinician communication to positive
health outcomes. Thus, Dr. Kaplan stressed that "we need to prepare people
on how to be patients."
Patient advocate Mr. Robert Erwin, president of the Marti Nelson
Cancer Foundation, concurred that patients often need to be encouraged
to take a more active role in their care. He suggested patients learn to see
themselves more as clients, which has more active connotations than the
term patients. Along those lines, Dr. Ganz added that patients should be
aware that they can always "fire" their doctors if they are not doing a good
job of taking care of them. Dr. Elizabeth Clark, executive director of the
National Association of Social Workers, added that patients' self-advocacy
gives them a better sense of being in control over their own lives, which
is important after being given a life-threatening diagnosis, such as cancer.
"Self-advocacy can improve quality of life, and it may be the difference that
turns feeling hopeless and helpless into feeling hopeful," she said.
Dr. Kaplan noted that effective patient skills include asking focused
questions, understanding that options exist, and eliciting all options and
their potential risks and benefits. Dr. Kaplan stressed that patients should
also be assertive about stating personal preferences and relevant life circum-
stances that affect treatment options and should negotiate conflicts with the
OCR for page 1
preferences of their physicians when these arise. Empowered patients can
actively participate in shared decision making, an important component of
patient-centered care. She defined shared decision making as "the process
of negotiation by which physicians and patients arrive at a specific course
of action, based on a common understanding of the goals of treatment, the
risks and benefits of the chosen treatment versus reasonable alternatives, and
each other's values and preferences" (adapted from Sheridan et al., 2004).
Dr. Jessie Gruman, cancer survivor and president of the Center for
Advancing Health, pointed out that the National Cancer Institute (NCI)
has a monograph that specifies six functions of patient-centered communi-
cation (Epstein and Street, 2007):
1. Fostering healing relationships
2. Exchanging information
3. Responding to emotions
4. Managing uncertainty
5. Making decisions
6. Enabling patient self-empowerment
Other participants added that patient-centered communication should
be sensitive to patients'
• ulnerability;
• egree of education and ability to understand medical terms, con-
cepts, risks, and benefits;
• ossible reluctance to assert preferences and ask questions;
• references related to treatment; and
• ultural and spiritual outlook.
Several speakers stressed that provider communication should be
simple, concise, and free of acronyms and jargon, which one participant
called "oncobabble." Such communication should be specific to avoid
medication errors or inattention to symptoms. For example, Dr. Linda
Burhansstipanov, grants director and founder of the Native American
Cancer Research Corporation and president of Native American Cancer
Initiatives, Inc., pointed out that many patients are told to contact their
OCR for page 1
doctors when they experience excessive bleeding, but they do not know how
much is considered excessive. Dr. Carolyn Clancy, director of the Agency
for Healthcare Research and Quality (AHRQ), added that patients may
overdose on their medications if their doctor tells them to take two a day,
without specifying if it is two pills or 2 milligrams they should be taking
daily. "You need to translate across different levels of education and literacy,
cultural context, age, gender, and many other individual differences," said
Dr. Jeffrey Peppercorn, associate professor of medicine at Duke University
and faculty associate of the Trent Center for Bioethics.
To ensure that patients understand the information given to them,
several participants suggested that they be asked to repeat what they heard,
rather than just be asked if they understand. Dr. Clancy recalled an evalua-
tion of a diabetes education program led by nurses at an academic medical
center primary care clinic that found that although patients would nod
politely to indicate they understood the information, questions asked of
them a few days later revealed there was little retention of such informa-
tion. Dr. Burhansstipanov also suggested repeating the key points of the
treatment plan to improve patient retention of the information. Those key
points could be repeated in different ways, or given in different formats,
she suggested.
It is important for providers to solicit patient preferences and not
make assumptions about which treatment option and associated side effects
patients are more likely to prefer or feel is best for them. Dr. Sepucha
pointed out that many providers assume that women with early-stage
breast cancer, for whom mastectomy or lumpectomy followed by radiation
is equally effective, would prefer not to lose their breast. Yet in a study of
breast cancer patients who were provided with comprehensive information
about the risks and benefits of mastectomy and lumpectomy, one-third
of these informed women chose mastectomy (Collins et al., 2009). "We
can't make assumptions that everybody is going to feel the way that we
do, so you have to ask the patient," she said. Dr. Clancy added that some
patients with laryngeal cancer likely prefer having radiation therapy over
surgery because although they will not live as long with this treatment, it
will preserve their ability to speak and that is more important to them than
the length of their life.
Providers also have to be sensitive to what patients are saying. "You
need to have competencies on both sides," said Willis. "It's not enough for
me to go to my doctor and communicate my needs. My doctor needs to be
able to listen to what I'm saying." Dr. Anthony Back, professor of medicine
OCR for page 1
at the University of Washington and director of the Program in Cancer
Communication at the Seattle Cancer Care Alliance and Fred Hutchinson
Cancer Research Center, noted that one meta-analysis (Venetis et al., 2009)
found that when patients are encouraged to participate in conversations
with providers and these providers show empathy, the patients are more
likely to report being satisfied with their care than when there is more
"instrumental talk," in which the providers merely indicated the tests and
treatments they would be having. Dr. Nancy Keating, associate professor
of medicine and healthcare policy at Harvard Medical School and general
internist at Brigham and Women's Hospital, conducted a study that found
patients with breast cancer who received the degree of input they wanted
into decision making about their treatment were more likely to report being
satisfied with their treatment choice than those who did not (Keating et
al., 2002).
Dr. Burhansstipanov, who is part Cherokee and advocates for Native
Americans, stressed the importance of being culturally sensitive when
communicating with patients of differing ethnicities and cultures. She said
misunderstandings often occur when doctors inform their Native American
patients that their biopsy is "positive" because the patient often assumes this
is good news, otherwise the doctor would not consider it to be positive. Gay
and lesbian couples, she added, should not be asked if they have a spouse,
but rather if they have a lifetime partner who should be informed of the
patient's medical condition.
She also noted that many Native Americans view spirituality as
being intertwined with healing and seek traditional healers or spiritual
advisers while being treated medically. Physicians need to be sensitive
to other religious traditions, as well as the role spirituality plays in heal-
ing, Dr. Burhansstipanov said. She added that doctors also have to be
cognizant that in some Native American tribes, the mother is the decision
maker for her children, even grown children, and thus must be consulted
when devising cancer treatment plans.
Other speakers stressed the importance of communication with the
family or caregivers of the patient as well as with the patient, and recogni-
tion that their informational needs are different. For example, family mem-
bers need to know how to care for a patient during cancer treatment, how
to plan for practical and financial concerns, and how to talk with children
about a parent with cancer, Dr. Marie Bakitas, associate professor of anes-
thesiology at Dartmouth Medical School, pointed out. Studies show it is
also helpful to have family members or other companions with patients at
OCR for page 1
doctor visits to make sure that patient needs, preferences, and questions are
conveyed and that the information is being understood. As Dr. Ganz noted,
because of the stress of a cancer diagnosis and treatment, a patient may not
be able to ask questions and take in what the doctor is saying and a family
member or a companion may be more able to do so. One study found that
when a companion was present with a patient, significantly more questions
were asked than when the patient was alone (Eggly et al., 2006). Dr. Back
suggested that physicians should endorse having patients be accompanied
by someone other than a family member or friend. This person could take
notes, ask questions, and hopefully retain more of what is said than would
a family member or friend who is emotionally attached to the patient.
Communication with Patients with Advanced Cancer
Communication about advanced cancer can be especially challeng-
ing. Dr. Peppercorn referred to a statement from the American Society of
Clinical Oncology (ASCO) on care for patients who have advanced cancer,
and thus a poor prognosis (Peppercorn et al., 2011), specifying that when
discussing cancer treatment options with patients, they should be told the
relevant pessimistic information as well as optimistic information to best
inform their decision making. The policy statement also argues that patients
should be told not just the likelihood of a response, but the nature of that
response (i.e., whether it will improve symptoms, shrink the cancer, or slow
its progression), as well as its costs and toxicity.
Although it can be difficult to convey a poor prognosis, some speak-
ers stressed the importance of being honest when communicating with
patients. Dr. Thomas Smith, professor of medicine and palliative care at the
Virginia Commonwealth University Massey Cancer Center, said his stud-
ies show that patients expect their physicians to be honest with them and
informing patients that they have a fatal illness does not quash their hope
or make them depressed. However, Mr. Erwin noted that patients like to
hear, and physicians like to give, hopeful information, even when it is false
hope. This often leads to an overpromotion of various types of treatments
that are not likely to be effective in late-stage cancer. "It's almost as though
we no longer give people permission to die," he said, "so the end-of-life
aspect of cancer care can get lost."
Dr. Smith stressed the importance of conveying to patients in the final
stages of cancer that although there may no longer be any effective treat-
ment against their cancer, there are still treatments that can improve their
OCR for page 1
Dr. Mayer added that until information technology issues such as pri-
vacy and compatibility are addressed, the creation of survivorship care plans
will require a laborious effort. "We need to take advantage of the health
information technology efforts that are going on in healthcare reform now
to create these interfaces that will make doing these things a bit easier," she
said. To ensure the value of survivorship care plans before they are fully
implemented, Dr. Mayer suggested identifying and measuring outcomes
when the plans are put into practice. "While this is not an evidence-based
intervention currently, there is no reason why it can't be over time," she said.
Participants suggested several policy options to promote patient-cen-
tered cancer treatment planning, including standards for training, licensure,
and practice of providers, financial incentives, research, and healthcare
Standards for Training, Licensure, and Practice
Several speakers suggested setting standards of care for oncology that
include patient-centered treatment planning and communication, and mak-
ing these standards part of physician training and licensure. Mr. Boyajian
also suggested that standard cancer treatment plan templates be developed
on a national level and made freely available to institutions and practices.
Dr. Ganz suggested that one standard of care for the initial cancer
treatment planning process should be for a multidisciplinary team that uses
the best available evidence. The treatment planning process should include
the patient and family in decision making, encourage second opinions to
validate the initial provider's recommendations and diagnosis, and organize
treatment decisions with a written treatment plan that is communicated to
all parties, she added.
Dr. Bakitas suggested developing cancer treatment planning guide-
lines that make oncology nurse education sessions about cancer treatment
explicit and mandatory. Attending to patients' psychosocial concerns should
also be made a standard of patient-centered care, and there should be poli-
cies, funding, and training that supports this, stressed Drs. Clark, Partridge,
and Hoverman and Ms. Esparza. Currently social workers are not reim-
bursed for many of their services to cancer patients, Dr. Smith pointed out.
OCR for page 1
Mr. Gorman added that viewing good physician communication with
patients as a skill that can be learned, rather than a trait that is inherited, has
led some state medical licensing boards to start to require adequate physi-
cian communication in their certification process, especially for internal
medicine and its subspecialties.
Financial Incentives
Financial incentives are also needed to spur implementation of patient-
centered cancer treatment planning, according Dr. Ganz. As Dr. Keating
noted, "The visit-based reimbursement system that we have in health care
doesn't help us at all because doctors' schedules are packed, and they don't
have a lot of time."
Dr. Ganz suggested that insurers could incentivize patient-centered
care by reimbursing physicians only if they provide the documentation
that is involved in creating a patient-centered cancer treatment plan. As she
pointed out, insurers already require documentation on a number of items
for reimbursement. Dr. Shulman added that one of Massachusetts Blue
Cross's pay-for-performance metrics is the creation of treatment plans. The
reasoning for this, he said, is that encouraging more documentation of care
can ensure that proper care is being given (for example, obtaining KRAS11
status before administering cetuximab to colon cancer patients). The docu-
mentation also enables insurers to be proactive, such as providing nurse
navigators when needed to reduce emergency room visits and hospital stays.
In an initiative led by the NCCS, patient advocates have lobbied for
legislation that would require the Centers for Medicare and Medicaid Ser-
vices (CMS) to cover cancer care planning as part of its Medicare program,
Ms. Elizabeth Goss, partner at Turner & Goss, LLP, reported. She said
there were plans to reintroduce the legislation, called the Comprehensive
Cancer Care Improvement Act, to Congress again in 2011. Mr. Erwin also
suggested that CMS could pay for a patient-centered care program as part
of its coverage with evidence development program.12
11 Kirsten ras, a type of oncogene in which activating mutations play a key role in the
progression of some cancers, such as colon cancer.
12 On July 12, 2006, CMS released a guidance document titled National Coverage
Determinations with Data Collection as a Condition of Coverage: Coverage with Evidence
Development (CED); see https://www.cms.gov/CoverageGenInfo/03_CED.asp (accessed
May 12, 2011).
OCR for page 1
Many participants said that an integral component to providing more
patient-centered cancer treatment planning is the collection of more data
on patient-centered outcomes such as how various cancer treatments affect
patients' quality of life and daily functioning. "If we are going to have
good decisions, we have to have good evidence," said Dr. Sharon Murphy.
Dr. Mayer added, "We need to create the evidence as we go along and
think about the evidence we want to collect." Dr. Greenfield also stressed
the need to do more comparative effectiveness research to provide infor-
mation that patients and their doctors need when deciding on the most
appropriate care.
To facilitate patient-centered care, AHRQ has conducted surveys
through the Consumer Assessment of Healthcare Providers and Systems
(CAHPS) program. These surveys are designed to bring the patient's voice
into assessments of healthcare quality and the results will be used for qual-
ity improvement and consumer choice. AHRQ is currently working with
the NCI to develop a cancer-focused CAHPS, Dr. Clancy said. The agency
also conducts research aimed at addressing questions that are particularly
important to cancer patients, such as what the long-term consequences of
various cancer treatment options are.
Dr. Claire Snyder, associate professor of medicine at Johns Hopkins
University, pointed out the usefulness of the Patient Reported Outcomes
Measurement Information System (PROMIS) developed by the National
Institutes of Health (NIH). This system is designed to collect a wide array
of outcomes, not just those relevant to cancer, and provides short forms
as well as computer-adaptive tests to ensure that the questions asked are
relevant to the patients in a specific population. It also enables compari-
sons across studies. She added that cancer patients can log on and enter
information about their quality of life at patientviewpoint.org, which is
then fed into the patients' electronic medical record. Dr. Glasgow noted
that PROMIS could also advance performance measurement by creating
a common core set of patient reported measures that can be widely used
in patient care.
Other tools are also available to measure patients' quality of life,
including the Memorial Symptom Assessment Scale, Dr. Mayer reported,
as well as the PACIC (Patient Assessment of Chronic Illness Care) that
was developed by Dr. Glasgow and measures patient experiences with a
chronic disease. Dr. John Ayanian developed a survey instrument based on
OCR for page 1
the Picker patient-centered principles,13 Dr. Wagner reported, and he has
found it useful in measuring problems that patients are experiencing in their
cancer care. Dr. Wagner cautioned against using generic patient satisfaction
surveys because he said they lull providers and organizations into thinking
they are measuring patient experience when they are not doing so effec-
tively. Dr. Smith also stressed the need to verify patient-reported outcomes,
because some may be based on false hopes or other misconceptions of what
can be achieved with treatment.
Supporting the endeavor to conduct research whose findings will
aid cancer treatment planning are the millions of dollars AHRQ recently
received via the American Recovery and Reinvestment Act of 2009 to sup-
port patient-centered outcomes research, as well as the establishment of
the Patient-Centered Outcomes Research Institute (PCORI), which was
called for in the Patient Protection and Affordable Care Act of 2010. This
institute is supported by federal funds, including taxes on insurers that
will amount to about $600 million a year, Dr. Clancy reported. PCORI
is governed by stakeholders and has a 21-member board that includes the
directors of AHRQ and NIH, industry representatives, clinicians, insurers,
and consumers. She said that PCORI will be unique in giving researchers
the capacity to do long-term follow-up of cancer patients and to acquire
patients' perspectives on the care they received and how it affected them.
"The only way you can find out if care is patient-centered is to ask the
patients themselves. Clinical aspirations to get to patient-centered care
aren't enough. We are going to need to get there by constantly checking to
see how we're doing," Dr. Clancy said.
Healthcare Reform
Several participants suggested policies to enhance systematic healthcare
reform that promotes patient-centered cancer treatment, including more
accountable care organizations that coordinate care under a single institu-
tion and have quality metrics and incentives to ensure that patient-centered
care is being provided. Dr. Wagner noted that "cancer patients need a clini-
cal home that takes responsibility and is accountable for the quality of care
through all the handoffs." Dr. Wagner emphasized this need in his figure of
the chronic care model, adapted specifically for oncology (Figure 3).
Dr. Hoverman added that such model cancer treatment centers will
13 See http://pickerinstitute.org/about/picker-principles/.
OCR for page 1
Figure 3
vector editable
scaled forATIENT-CENTERED CANCER TREATMENT PLANNING
P landscape above, portrait below
Health System
Resources and Policies
Resources and Policies Collabora ng Health Care Organiza ons
Decision Support and Clinical Informa on
Psychosocial and
Mul disciplinary
Self-Management Systems and Performance
Care Planning
Support Measurement
Phase of Care
Account- O
Informed, R
Prac ce
Care Plan and D
Ac vated Team I
Pa ents and N
and/or Adjuvant Rx
Interactions A
Families Care T
Manager/ I
Improved N
Pallia on
FIGURE 3 The model of quality cancer care developed by Dr. Ed Wagner emphasizes
the need for an accountable practice team or navigator to ensure that cancer care is
coordinated among the different phases and modalities of care.
SOURCE: Wagner presentation (March 1, 2011). Reprinted, with permission, from
Ed Wagner.
work only if they can be shown to save money, and he encouraged an
exploration of how resources can be redirected within the healthcare system.
Dr. Ganz suggested addressing the inefficiency and waste in the current
healthcare system and said that the resources saved in this effort could be
put to use providing better, more comprehensive, and more coordinated
care to patients. Dr. Smith noted that abundant resources can be saved
by providing cancer patients with appropriate end-of-life care. Mr. Smith
suggested involving health economists in healthcare reform efforts and
conducting studies that address the financial concerns of the Congressional
Budget Office.
Other powerful tools for change are videos of patients telling their own
stories, several participants suggested. Mr. Erwin added, "You ultimately
have to have the facts to have good legislation, but if you don't have the
story and the emotion and the sound bite, the facts themselves don't sell
very easily." He noted that having people convey their personal experiences
with breast cancer was instrumental in getting state cigarette taxes allocated
to breast cancer research in California. Ms. Smith added that "engaging
OCR for page 1
patients in solving the barriers is really important," and Mr. Gorman sug-
gested that patients be taught advocacy skills so they can tell their stories
powerfully and succinctly.
According to many workshop speakers, cancer patients often are not
receiving patient-centered cancer treatment planning, and many speakers
suggested that there needs to be more promotion of such planning via
accreditation standards, guidelines, financial incentives, training, and pol-
icy. Speakers also suggested that research on patient-centered cancer treat-
ment outcomes and the value of cancer treatment plans is needed. However,
several people also pleaded to avoid letting "the great be the enemy of the
good" but rather to take concrete steps now, based on existing knowledge
and evidence, to foster patient-centered cancer treatment planning. "We
have enough trends to show that this is going in a very positive direction,"
noted Ms. Esparza. "Don't use evidence-based practice as an excuse not to
do anything." Mr. Boyajian added, "Develop some consensus, go forward
from that, and look for the evidence afterwards. I don't want to be a patient
that is left behind while you are waiting for the gold standard. I want you
to give us your best guess, and we'll start looking at that."
ACS (American Cancer Society). 2010. Cancer facts and figures 2010. Atlanta, GA: American
Cancer Society.
Alexander, S. C., A. M. Sullivan, A. L. Back, J. A. Tulsky, R. E. Goldman, S. D. Block, S. K.
Stewart, M. Wilson-Genderson, and S. L. Lee. 2011. Information giving and receiving
in hematological malignancy consultations. Psycho-Oncology 20(5):10.
ASCO (American Society of Clinical Oncology). 2011. Advanced care planning. http://
(accessed May 12, 2011).
Ayanian, J. Z., A. M. Zalavsky, E. Guadagnoli, C. S. Fuchs, K. J. Yost, C. M. Creech, R. D.
Cress, L. C. O'Connor, D. W. West, and W. E. Wright. 2005. Patients' perceptions of
quality care for colorectal cancer by race, ethnicity, and language. Journal of Clinical
Oncology 23(27):6576-6586.
Bakitas, M., K. D. Lyons, M. T. Hegel, S. Balan, F. C. Brokaw, J. Seville, J. G. Hull, Z.
Li, T. D. Tosteson, I. R. Byock, and T. A. Ahles. 2009. Effects of a palliative care
intervention on clinical outcomes in patients with advanced cancer: The Project
ENABLE II randomized controlled trial. Journal of the American Medical Association
OCR for page 1
Bayard, J. M., C. Calianno, and C. L. Mee. 1997. Care coordinator-blending roles to improve
patient outcomes. Nursing Management 28(8):49-51.
Belkora, J. K., A. Teng, S. Volz, M. K. Loth, and L. J. Esserman. 2011. Expanding the reach
of decision and communication aids in a breast care center: A quality improvement
study. Patient Education and Counseling 83(2):234-239.
Berry, D. L., B. A. Blumenstein, B. Halpenny, S. Wolpin, J. R. Fann, M. Austin-Seymour, N.
Bush, B. T. Karras, W. B. Lober, and R. McCorkle. 2011. Enhancing patient-provider
communication with the electronic self-report assessment for cancer: A randomized
trial. Journal of Clinical Oncology 29(8):1029-1035.
Blayney, D. W., K. McNiff, D. Hanauer, G. Meila, D. Markstrom, and M. Neuss.
2009. Implementation of the Quality Oncology Practice Initiative at a university
comprehensive cancer center. Journal of Clinical Oncology 27(23):3802-3807.
C-Change. 2005. Cancer patient navigation. http://www.cancerpatientnavigation.org/
resources.html (accessed April 24, 2011).
Chung, H. M., L. Lyckholm, and T. J. Smith. 2009. Palliative care in BMT. Bone Marrow
Transplantation 43(4):265-273.
Clayton, J. M., P. N. Butow, M. H. Tattersall, R. J. Devine, J. M. Simpson, G. Aggarwal,
K. J. Clark, D. C. Currow, L. M. Elliott, J. Lacey, P. G. Lee, and M. A. Noel. 2007.
Randomized controlled trial of a prompt list to help advanced cancer patients and their
caregivers to ask questions about prognosis and end-of-life care. Journal of Clinical
Oncology 25(6):715-723.
Collins, E. D., C. P. Moore, K. F. Clay, S. A. Kearing, A. M. O'Connor, H. A. Llewellyn-
Thomas, R. J. Barth, Jr., and K. R. Sepucha. 2009. Can women with early-stage
breast cancer make an informed decision for mastectomy? Journal of Clinical Oncology
Connor, S. R. 2007. U.S. hospice benefits. Journal of Pain Symptom Management 33(3):238-
De Raad, J., K. van Gool, M. Haas, P. Haywood, M. Faedo, G. Gallego, S. Pearson, and
R. Ward. 2010. Nursing takes time: Workload associated with administering cancer
protocols. Clinical Journal of Oncology Nursing 14(6):735-741.
Del Giudice, M. E., E. Grunfeld, B. J. Harvey, E. Piliotis, and S. Verma. 2009. Primary
care physicians' views of routine follow-up care of cancer survivors. Journal of Clinical
Oncology 10;27(20):3338-3345.
Dow, L., L. Kuhn, V. Vramakrishnan, R. Matsuyama, E. Lamont, and T. J. Smith. 2010.
Paradoxes in advance care planning: The complex relationship of oncology patients,
their physicians, and advance medical directives. Journal of Clinical Oncology 28(2):299-
Eggly, S., L. A. Penner, M. Greene, F. W. K. Harper, J. C. Ruckdeschel, and T. L. Albrecht.
2006. Information seeking during "bad news" oncology interactions: Question asking
by patients and their companions. Social Science & Medicine 63(11):2974-2985.
El-Jawahr, A., L. M. Podgurski, A. F. Eichler, S. R. Plotkin, J. S. Temel, S. L. Mitchell, Y.
Chang, M. J. Barry, and A. E. Volandes. 2010. Use of video to facilitate end-of-life
discussions with patients with cancer: A randomized controlled trial. Journal of Clinical
Oncology 28(2):301-310.
Epstein, R. M., and R. L. Street, Jr. 2007. Patient-centered communication in cancer care:
Promoting healing and reducing suffering. Bethesda, MD: National Cancer Institute.
OCR for page 1
Fagerlin, A., I. Lakhani, P. M. Lantz, N. K. Janz, M. Morrow, K. Schwartz, D. Deapen, B.
Salem, L. Liu, and S. J. Katz. 2006. An informed decision? Breast cancer patients and
their knowledge about treatment. Patient Education and Counseling 64(1-3):303-312.
Gabram, S. G., M. J. Lund, J. Gardner, N. Hatchett, H. L. Bumpers, J. Okoli, M Rizzo,
B. J. Johnson, G. B. Kirkpatrick, and O.W. Brawley. 2008. Effects of an outreach and
internal navigation program on breast cancer diagnosis in an urban cancer center with
a large African-American population. Cancer 113(3):602-607.
Gallup. 2010. Nurses top honesty and ethics for 11th year. http://www.gallup.com/poll/145043/
Nurses-Top-Honesty-Ethics-List-11-Year.aspx (accessed April 24, 2011).
Ganti, A. K., S. J. Lee, J. M. Vose, M. P. Devetten, R. G. Bociek, J. O. Armitage, P. J.
Bierman, L. J. Maness, E. C. Reed, and F. R. Loberiza, Jr. 2007. Outcomes after
hematopoietic stem-cell transplantation for hematologic malignancies in patients with
or without advance care planning. Journal of Clinical Oncology 25(35):5643-5648.
Gittell, J. H., K. M. Fairfield, B. Bierbaum, W. Head, R. Jackson, M. Kelly, R. Laskin,
S. Lipson, J. Siliski, T. Thornhill, and J. Zuckerman. 2000. Impact of relational
coordination on quality of care, postoperative pain and functioning, and length of stay:
A nine-hospital study of surgical patients. Medical Care 38(8):807-819.
Given, C. W., A. Sikorskii, D. Tamkus, B. Given, M. You, R. McCorkle, V. Champion,
and D. Decker. 2008. Managing symptoms among patients with breast cancer during
chemotherapy: Results of a two-arm behavioral trial. Journal of Clinical Oncology
Greenfield S., S. H. Kaplan, J. E. Ware Jr., E. M. Yano, H. J. Frank. 1988. Patients'
participation in medical care: Effects on blood sugar control and quality of life in
diabetes. Journal of General Internal Medicine 3(5):448-457.
Heiman, H., D. W. Bates, D. Fairchild, S. Shaykevich, and L. S. Lehmann. 2004. Improving
completion of advance directives in the primary care setting: A randomized controlled
trial. American Journal of Medicine 117(5):318-324.
Huskamp, H. A., N. L. Keating, J. L. Malin, A. M. Zaslavsky, J. C. Weeks, C. C. Earle,
J. M. Teno, B. A. Virnig, K. L. Kahn, Y. He, and J. Z. Ayanian. 2009. Discussions
with physicians about hospice among patients with metastatic lung cancer. Archives of
Internal Medicine 169(10):954-962.
IOM (Institute of Medicine). 1999. Ensuring quality cancer care. Washington, DC: National
Academy Press.
IOM. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington,
DC: National Academy Press.
IOM. 2008. Cancer care for the whole patient: Meeting psychosocial health needs. Washington,
DC: The National Academies Press.
IOM. 2010. The future of nursing: Leading change, advancing health. Washington, DC: The
National Academies Press.
Keating, N. L., E. Guadagnoli, M. B. Landrum, C. Borbas, and J. C. Weeks. 2002. Treatment
decision making in early-stage breast cancer: Should surgeons match patients' desired
level of involvement? Journal of Clinical Oncology 20(6):1473-1479.
Keating, N. L., J. C. Weeks, C. Borbas, and E. Guadagnoli. 2003. Treatment of early stage
breast cancer: Do surgeons and patients agree regarding whether treatment alternatives
were discussed? Breast Cancer Research and Treatment 79(2):225-231.
OCR for page 1
Keating, N. L., M. B. Landrum, N. K. Arora, J. L. Malin, P. A. Ganz, M. van Ryn, and J. C.
Weeks. 2010a. Cancer patients' roles in treatment decisions: Do characteristics of the
decision influence roles? Journal of Clinical Oncology 28(28):4364-4370.
Keating, N. L., M. B. Landrum, S. O. Rogers, Jr., S. K. Baum, B. A. Virnig, H. A. Huskamp,
C. C. Earle, and K. L. Kahn. 2010b. Physician factors associated with discussions about
end-of-life care. Cancer 116(4):998-1006.
Koutsopoulous, S., E. D. Papthanassoglou, M. C. Katapodi, and E. I. Patiraki. 2010. A
critical review of the evidence for nurses as information providers to cancer patients.
Journal of Clinical Nursing 19(5-6):749-765.
Lasser, K. E., J. Murillo, E. Medlin , S. Lisboa, L. Valley-Shah, R. H. Fletcher, K. M.
Emmons, and J. Z. Ayanian. 2009. A multilevel intervention to promote colorectal
cancer screening among community health center patients: Results of a pilot study.
BMC Family Practice, 2009 May 29;10:37.
Lee, C., J. K. Belkora, Y. Chang, C. Cosenza, C. A. Levin, B. Moy, A. Partridge, and K. R.
Sepucha. 2009a. The quality of decisions about breast cancer surgery. Presented at the
31st Annual Meeting of the Society for Medical Decision Making, October 2009,
Hollywood, CA.
Lee, C., J. Belkora, M. Wetschler, Y. Chang, S. Feibelmann, B. Moy, A. Partridge, and K.
Sepucha. 2009b. The quality of decisions about adjuvant chemotherapy for early stage
breast cancer. Presented at the San Antonio Breast Cancer Symposium, December 2009,
San Antonio, TX.
Lee, C. N., R. Dominik, C. A. Levin, M.J. Barry, C. Cosenza, A. M. O'Connor, A. G. Mulley
Jr., K. R. Sepucha. 2010. Development of instruments to measure the quality of breast
cancer treatment decisions. Health Expectations (3):258-72.
Matsuyama, R., S. Reddy, and T. J. Smith. 2006. Why do patients choose chemotherapy near
the end of life? A review of the perspective of those facing death from cancer. Journal of
Clinical Oncology 24(21):3490-3496.
McCorkle, R., N. E. Strumpf, I. F. Nuamah, D. C. Adler, M. E. Cooley, C. Jepson, E. J.
Lusk, and M. Torosian. 2000. A specialized home care intervention improves survival
among older post-surgical cancer patients. Journal of the American Geriatric Society
Morrow, M., M. Mujahid, P. M. Lantz, N. K. Janz, A. Fagerlin, K. Schwartz, L. Liu, D.
Deapen, B. Salem, I. Lakhani, and S. J. Katz. 2005. Correlates of breast reconstruction:
Results from a population-based study. Cancer 104(11):2340-2346.
NCCN (National Comprehensive Cancer Network). 2005. Practice guidelines in oncology.
Palliative care. Pittsburgh, PA: National Comprehensive Cancer Network.
NCCS (National Coalition for Cancer Survivorship). 1996. Imperatives for quality cancer
care: Access, advocacy, action, and accountability. Washington, DC: National Coalition
for Cancer Survivorship.
Northouse, L. L., M. C. Katapodi, L. Song, L. Zhang, and D. W. Mood. 2010. Interventions
with family caregivers of cancer patients: Meta-analysis of randomized trials. CA: A
Cancer Journal for Clinicians 60(5):317-339.
Oluwole, S. F., A. O. Ali, A. Adu, B. P. Blane, B. Barlow, R. Oropeza, and H. P. Freeman
2003. Impact of a cancer screening program on breast cancer stage at diagnosis in
a medically underserved urban community. Journal of the American College Surgery.
OCR for page 1
Panagopoulou, E., G. Mintziori, A. Montgomery, D. Kapoukranidou, and A. Benos. 2008.
Concealment of information in clinical practice: Is lying less stressful than telling the
truth? Journal of Clinical Oncology 26(7):1175-1177.
Peppercorn, J. M., T. J. Smith, P. R. Helft, D. J. DeBono, S. R. Berry, D. S. Wollins, D. M.
Hayes, J. H. von Roenn, and L. E. Schnipper. 2011. American Society of Clinical
Oncology statement: Toward individualized care for patients with advanced cancer.
Journal of Clinical Oncology 29(6):755-760.
Pollak, K. I., R. M. Arnold, A. S. Jeffreys, S. C. Alexander, M. K. Olsen, A. P. Abernethy,
C. Sugg Skinner, K. L. Rodriguez, and J. A. Tulsky. 2007. Oncologist communication
about emotion during visits with patients with advanced cancer. Journal of Clinical
Oncology 25(36):5748-5752.
Rakovitch, E., E. Franssen, J. Kim, I. Ackerman, J. P. Pignol, L. Paszat, K. I. Pritchard, C.
Ho, and D. A. Redelmeier. 2003. A comparison of risk perception and psychological
morbidity in women with ductal carcinoma in situ and early invasive breast cancer.
Breast Cancer Research and Treatment 77(3):285-293.
Ravdin, P. M., I. A. Siminoff, and J. A. Harvey. 1998. Survey of breast cancer patients
concerning their knowledge and expectations of adjuvant therapy. Journal of Clinical
Oncology 16(2):515-521.
Sheridan, S. L., R. P. Harris, and S. H. Woolf. 2004. Shared decision making about screening
and chemoprevention: A suggested approach from the U.S. Preventive Services Task
Force. American Journal of Preventive Medicine 26(1):56-66.
Skalla, K. A., M. Bakitas, C. T. Furstenberg, T. Ahles, and J. V. Henderson. 2004. Patients'
need for information about cancer therapy. Oncology Nursing Forum 31(2):313-319.
Smith, T. J., L. A. Dow, E. Virago, J. Khatcheressian, L. Lyckholm, and R. Matsuyama. 2010.
Giving honest information to patients with advanced cancer maintains hope. Oncology
Smith, T. J., L. A. Dow, E. A. Virago, J. Khatcheressian, R. Matsuyama, and L. J. Lyckholm.
2011. A pilot trial of decision aids to give truthful prognostic and treatment information
to chemotherapy patients with advanced cancer. Journal of Supportive Oncology 9(2):
Spettell, C. M., W. S. Rawlins, R. Krakauer, J. Fernandes, M. E. Breton, W. Gowdy, S.
Brodeur, M. MacCoy, and T. A. Brennan. 2009. A comprehensive case management
program to improve palliative care. Journal of Palliative Medicine 12(9):827-832.
Stille, C. J., A. Jerant, D. Bell, D. Meltzer, and J. G. Elmore. 2005. Coordinating care across
diseases, settings, and clinicians: A key role for the generalist in practice. Annals of
Internal Medicine 142(8):700-708.
Tariman, J. D., D. L. Berry, B. Cochrane, A. Doorenbos, and K. Schepp. 2010. Preferred and
actual participation roles during health care decision making in persons with cancer: A
systematic review. Annals of Oncology 21(6):1145-1151.
Temel, J. S., J. A. Greer, A. Muzikansky, E. R. Gallagher, S. Admane, V. A. Jackson, C. M.
Dahlin, C. D. Blinderman, J. Jacobsen, W. F. Pirl, J. A. Billings, and T. J. Lynch. 2010.
Early palliative care for patients with metastatic nonsmall-cell lung cancer. New England
Journal of Medicine 363(8):733-742.
OCR for page 1
Venetis, M. K., J. D. Robinson, K. L. Turkiewiczc, and M. Allen. 2009. An evidence base
for patient-centered cancer care: A meta-analysis of studies of observed communication
between cancer specialists and their patients. Patient Education and Counseling
Weeks, J. C., E. F. Cook, S. J. O'Day, L. M. Peterson, N. Wenger, D. Reding, F. E. Harrell, P.
Kussin, N. V. Dawson, A. F. Connors, Jr., J. Lynn, and R. S. Phillips. 1998. Relationship
between cancer patients' predictions of prognosis and their treatment preferences.
Journal of the American Medical Association 279(21):1709-1714.
Wright, A. A., B. Zhang, A. Ray, J. W. Mack, E. Trice, T. Balboni, S. L. Mitchell, V. A.
Jackson, S. D. Block, P. K. Maciejewski, and H. G. Prigerson. 2008. Associations
between end-of-life discussions, patient mental health, medical care near death,
and caregiver bereavement adjustment. Journal of the American Medical Association
Zhang, B., A. A. Wright, H. A. Huskamp, M. E. Nilsson, M. L. Maciejewski, C. C. Earle,
S. D. Block, P. K. Maciejewski, and H. G. Prigerson. 2009. Health care costs in the last
week of life: Associations with end-of-life conversations. Archives of Internal Medicine
169(5): 480-488.


text:
UpSkill Houston
The Partnership's UpSkill Houston initiative is the nation's first business-led, community-wide, integrated workforce effort. The initiative focuses on closing the skills gap in Houston by increasing the number of Houstonians trained for great careers across the region. The Partnership forecasts nearly 75,000 annual jobs openings in these "middle skills" careers that require more than a high school education but less than a four-year college degree.
UpSkill Houston has three key objectives:
- Attract individuals to skilled jobs and professions in seven critical sectors
- Train individuals on the basic employability and technical skills necessary
- Place and retain individuals in critical skills jobs and professions
Career Connections:
- Petrochemical job-seekers: www.energizehouston.org offers information about training and career opportunities and training in petrochemical careers.
- Construction professions like welding, pipefitting, electricians: Go to www.constructioncitizen.com and click on the Craft Careers section, which describes available careers, where you can get training, and lists available jobs.
- Health Care professions: Your local community college has information about available careers at www.gulfcoastcc.org/healthcare This site features skills required for each career along with wage information.
Other Resources
- United Way of Greater Houston: United Way operates 2-1-1 Texas/United Way HELPLINE. You can dial 211 on your phone and ask to get connected with a THRIVE specialist who can help you build a stronger financial future by acquiring skills and education, obtaining better jobs, developing good financial habits and building savings. Call 211 on your phone.
- Workforce Solutions: Provides resources, intelligence and the tools you need to succeed in your career search. Check out: www.wrksolutions.com/upskillhouston.
UpSkill Houston Workforce Development Summit
On November 12, GHP held the UpSkill Houston Workforce Summit which brought together industry, education and community leaders to discuss the middle skills workforce challenges and solutions for Houston and the nation, and provided an update on UpSkill Houston's progress and 2015 agenda.
The event featured a number of expert panels and a luncheon keynote from Joe Fuller of Harvard Business School, who discussed the U.S. Competitiveness Project and the role companies can play in creating supply-demand alignment. The U.S. Competitiveness Project is a research-led effort by Harvard Business School to identify practical steps to strengthen the nation's economy, with recent emphasis on beefing up job skills, K-12 education, transportation and infrastructure.
In addition, JPMorgan Chase released an important report, "Preparing Houston to Skill Up, Addressing the Skills Mismatch to Meet Employer Demand in High-Growth Industries."

subset: commoncrawl


text:
Jason Borger
Join Us on Our Next LIVE Broadcast!
Just fill out the form below and we'll notify you of our next information packed interview.
They're FREE and you can listen over the Internet or by phone.
After you send your name and email address check your email for a message that explains how to get your Bonus!
Privacy Policy
By D. Roger Maves
The challenge of fly fishing can increase dramatically when conditions become difficult. Whether it be due to weather, water, cover, hatches, distance, or a combination of those factors, when the angling gets tough, it pays to have a few tricks up your sleeve. Learn from Jason about ways to make difficult angling situations easier and more productive.
Skinny Water Trout
Angling Approaches for Streams
Casting and Presentation Strategies for Trout
A Systematic Approach to Nymphing - Duane Redford
Fly Fishing - Art of War - Chad Schiel
Improving Your Casting Fundamentals to Catch More Fish - Dusty Wissmath
Moving Water: A Fly Fisher's Guide to Current - Jason Randall
Reading Waters - Gary Borger
Single-Handed Spey Casting - Simon Gawesworth
Specialty Casts - Getting Your Fly to the Fish - Mac Brown
Tips and Tricks That Will Make You A Better Fly Fisher - Kirk Deeter
Trout Sense - Jason Randall


text:
Expand your
Research: |
Journals And Magazines |
The Web's Best Sites |
Additional Readings |
(ND), an influenza-like viral infection of birds that causes epidemics in domestic poultry, and which can spread to humans. The disease was first seen in the English city of Newcastle. It is caused by a single-stranded RNA virus belonging to the viral family Paramyxoviridae. The ND virus is quite stable and can remain infectious for long periods even at low temperature.


text:
Caliber yachts ?
View Single Post
Junior Member
Join Date: Jan 2012
Posts: 2
Thanks: 0
Thanked 0 Times in 0 Posts
Rep Power:
The engine is in but not aligned -
The main reason for considering to modify the shaft tube is to prevent the future wear on the shaft.
Even at the current offset alignment, the shaft does not make it past the skeg -
The other reason to move it, because of the angle, it is very hard to access the left side of the engine (oil stick) and there is very little play between the engine and the seafrost compressor (which is attached to the bulkhead and not the engine, I purchased the boat that way and because of the engine angle, I can see very little options other then the way it is).
That being said, you make a great point regarding the prop walk....
Any other thoughts? Should I not be concerned about the potential wear on the shaft?
Have you witnessed the engine angle I am talking about within a similar Caliber boat?
View Public Profile
Send a private message to wiltsan
Find all posts by wiltsan


text:
Free Dream Dictionary | Meaning of Dream Numbers | Meaning of Dream Colors | Dream Psychology | eBooks Psychic Phone Advisor | iPod's | Tea Deals
Index: Darby English Bible Micah 7[1] [2] [3] [4] [5] [6] [7]7:1 Woe is me! for I am as when they have gathered the summer-fruits, as the grape-gleanings of the vintage. There is no cluster to eat; there is no early fruit [which] my soul desired. |


text:
2011 Comedy/Childrens Not Rated 83 Minutes
In Theaters | Made for TV | |||
On Blu-ray | Not Available | Alert Me | Remind Me | ? |
On DVD | February 7, 2012 | Now Available | ? | |
When Announced | When Released |
Fred Figglehorn (Lucas Cruikshank) is back in an all-new movie adventure, and his life has gone from kooky to spooky. Fred's beloved music teacher, Mrs. Felson, has mysteriously disappeared, and Fred is convinced that her replacement, Mr. Devlin, has a secret life – as a vampire! And to make matters worse, Mr. Devlin is dating Fred's mom! With the help of his awesome dad (WWE Superstar John Cena) and his friends Bertha (Daniella Monet from "Victorious") and Talia (Ariel Winter from "Modern Family"), Fred begins a weird and wildly comic quest to expose Mr. Devlin's true identity – before he turns Fred's cul-de-sac into a community of bloodsuckers!
Not Rated.
Copyright © 1999-2015 VideoETA, Inc. All Rights Reserved.
Version 5.5.8


text:
Chapel Street,
Tel: 01733 703257
Fax: 01733 703225
Email Us
Welcome to Stanground St John's
Welcome to Stanground St John's C of E Primary School
Founded in 1900, our school has been at the heart of Stanground Village for over a century, enjoying close links with our local church and our community. In 2013, we became part of the Diocese of Ely Multi Academy Trust.
I feel privileged to lead such a friendly and caring school. Our pupils are well-behaved and enthusiastic. As a staff, we are dedicated to the success of every child, fostering a love for learning, through a rich curriculum, in a welcoming and stimulating environment.
I hope you enjoy exploring our website and that it provides the information that you need to best support your child at school.
If you are a prospective parent, I hope that it offers you a flavour of what our school is like. To see us in action, please make an appointment by contacting the school office.
I look forward to working in partnership with you to ensure that our pupils have the best possible education, during this vital part of their lives.
Sally Williams
Head Teacher


text:
Similar images
View allKeywords
THIS IMAGE WAS PRODUCED USING A LENS BABY SELECTIVE FOCUS LENS.)... News PhotoAmerica's Cup,Catamaran,General View,Horizontal,Italy,Luna Rossa,Naples - Italy,Sailing,Sport,Water Sport,YachtingPhotographer Jacopo RauleCollection: Getty Images Sport 2013 Jacopo RauleNAPLES, ITALY - APRIL 19: (EDITORS NOTE: THIS IMAGE WAS PRODUCED USING A LENS BABY SELECTIVE FOCUS LENS.) General view of ac45 catamaran of Team Luna Rossa Swordfish during America's cup World Series Naples on April 19, 2013 in Naples, Italy. (Photo by Jacopo Raule/Getty Images)


text:
10-14-2008, 01:16 AM | #12 (permalink) | |
Join Date: Feb 2008
Posts: 51
For all those concerned about danger its just as safe if not more safe than a longboard. With a freebord you have much more control over your speed can can even stop like a snowboard. Yes u can catch and edge but once you get used to it you barely ever will. If your really concerned you could wear a lot of protective gear. Another video for you, this just won best video contest. Warning BSV'08 on Vimeo |
10-14-2008, 09:44 AM | #14 (permalink) |
Posts: n/a
Hey, I have been lurking, cheking these out and listening to what you cats are saying about these bad boys.. I think I want one!! do they have a website?? can you refer me to the link... I am interested in learning more>??? Hey perp 3?? have you ridden the freeboard?? do they have a website>>> I suppose I could do a search myself.. any info would be helpful... thanks fellas.. cheers..
10-14-2008, 09:48 AM | #15 (permalink) |
Veteran Member
Join Date: Nov 2007
Location: Ottawa
Posts: 1,212
Yeah sure planka, here's their website:
Sport Technology
"This comment brought to you by Bombay Gin" |
10-14-2008, 11:57 AM | #18 (permalink) |
Join Date: Feb 2008
Posts: 51
haha ok think what u want bro. I'll tell you right now flowboards SUCK!! You can't do anything you can do on a snowboard on a flowboard. I'm trying to tell you guys about an awesome new sport and your all just hating. Sorry bro but ANYONE who knows anything about flowboards and freebords will tell you which is legit and which sucks. I hate to say it but if you think a flowboard is better than a freebord(or more like snowboarding i should say) you are sadly mistaken. Good luck riding an $80 board from walmart down a 25% slope hill. You can't even stop on a flowboard, I have one and trust me they BLOW.
10-14-2008, 12:05 PM | #19 (permalink) | |
Join Date: Feb 2008
Posts: 51
Dude i'm telling your flowboards are garbage! I'm not just hating on it for no reason trust me I've ridden them. Freebording does take some practice to learn but once you do it feels very similar to snowboarding, you can move the board in any direction at any speed, control you slides, spin 360, float into switch, anything. On a flowboard you can carve if thats what you want to call it. yes it's cheaper but the price reflects the product. Heres a video of a flowboard and a freebord so you can see the difference flowboard YouTube - flow board freebord YouTube - meds |
Thread Tools | |
Display Modes | |


text:
Cut Flowers and Floral Design: BLOSSOMBUDDY picture (May 2009 in the Garden)
Communities > Forums
Image Copyright BLOSSOMBUDDY
In reply to: May 2009 in the Garden
Forum: Cut Flowers and Floral Design
Back to post |
BLOSSOMBUDDY wrote: Thanks Haighr! Here is a coreopsis. I keep trying with that pathetic camera.. been switching with my hubs periodically too so if you are seeing larger shots, those are his camera now and my camera are the little frames. I have simmered down to a low roar over my frustration with it.. So been sooo trying to adapt. (I hate change!!) |
[ Home |
About |
Advertise |
Media Kit |
Mission |
Featured Companies |
Submit an Article |
Terms of Use |
Tour |
Rules |
Privacy Policy |
Contact Us ]


text:
Top-quality leather, construction and hardware make this a rugged, long-lasting work belt
This classic western "ranger" belt is embossed with a traditional basketweave pattern. Belt is handcrafted from premium-grade saddle leather, and built for the working man. Rugged stitching and heavy-duty buckle stands up to daily wear in the field and is capable of supporting the weight of tool holsters and other accessories. Solid brass buckle. Unlined. 1-3/4" wide. USA made. Specify Men's even waist size (order one size larger than waist) from the selection box above. See drop down box for sizes currently available.
NOTE: Add $2 for sizes 46-52.
2015 Master Catalog: Page 186
(based on 17 reviews)
Ratings Distribution
5 Stars
4 Stars
3 Stars
2 Stars
1 Stars
of respondents would recommend this to a friend.
Best Uses
Most Liked Positive Review
Full thickness harness leather--no fluff
No kidding, I bought a "Triple K" ranger belt over twenty five years ago and have worn it nearly every day since. I've tried others, but they simply don't hold...Read complete review
No kidding, I bought a "Triple K" ranger belt over twenty five years ago and have worn it nearly every day since. I've tried others, but they simply don't hold up. Dollar for dollar, one of the best values for the money. You won't be disappointed.
Most Liked Negative Review
Beautiful Leather Work
I bought this Ranger Belt for my conceal carry weapon. While the belt is stout... it won't hold my weapon close enough to my body for total concealment with just wearing a...Read complete review
I bought this Ranger Belt for my conceal carry weapon. While the belt is stout... it won't hold my weapon close enough to my body for total concealment with just wearing a shirt. I would recommand this for pure good looks and doing what it was designed for... but not for CCW.
Reviewed by 17 customers
Sort by
Displaying reviews 1-5
Back to top
Previous | Next »
Finally found the belt he was looking fo
By LaLaof2
from Birmingham AL
About Me Casual Dresser
Comments about Classic Ranger Leather Work Belt:
After searching for a while, I finally found the belt my husband was looking for. Boy, was I every happy! Unfortunately, I ordered the wrong size but that's okay, he will just have to lose a pound or two :)
Top notch & American made
By JfromPO
from Port Orford, Oregon
About Me Classic Dresser
I was shopping for a wide durable belt that doesn't weigh to much and can distribute the pocket weight and fill the loops of cargo style pants. Gemplers catalog had the one right product at a good price. Grand slam!
Classic Ranger Belt
By Larry
from Nashville TN
I play Country Music in the studio,on TV and on the radio in front of a live audience. I wear "Western" style clothing and this Ranger Belt is perfect. The price and quality are great. My fellow musicians asked where I got it and the Gemplers catalog is being circulated around at work.
Belt great in looks & Quality fantastic!
By Bobby
from Tampa.fl
Build quality great...Delivery time fantastic......This companies unbeatableRMV Tampa fl
(1 of 1 customers found this review helpful)
One of the best built belt I have owned
By Byron
from Allen. Texas
See all my reviews
I use this belt for every day use in certain pants. The width is GREAT but it will not work with many of my dress clothes.


text:
This entry was posted on Friday, January 25th, 2013 at 5:16 pm and is filed under . You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.
Fields marked with a * are required.
Name *
E-mail address *


text:
Byebyesnow's Traveler Profile
Recent Entries by Byebyesnow
January 1, 2014 - Jan 1, 2014
We hope you all had a fabulous year in 2013 and that 2014 will be even better! As I sit down this morning to write this, I am looking through photos of the past 6 or 9 months… and realize wha...
Happy 2014 - Dec 31, 2013
So… here is the shortest blog entry in history… simply because we want to wish you all a very happy and prosperous 2014! All is well here in Ojochal, Costa Rica:-) It's been a lovel...
We've Arrived! - Oct 18, 2013
Just a really quick note tonight to reassure family and friends that we arrived safe in Costa Rica around 12:30 today. Great flights and care via WestJet (as usual)... we also had amazing flying we...


text:
The Indianapolis Colts' Northwestside complex is under construction, expanding to meet its needs.
At the risk of disrespecting the Pro Football Hall of Fame, Colts owner Jim Irsay believes similar expansion is required there after Peyton Manning was named the NFL's Most Valuable Player for a record-tying third time.
"Whenever I talk about Canton, Ohio, I always talk about maybe (there should be) an extra level at the place . . . a room upstairs,'' Irsay said. "Everyone there is in the Hall of Fame, but then there's certain guys, just a very rare few that seem to transcend a little higher within the hallowed grounds.''
Manning, the Colts' quarterback and cornerstone since being selected with the first pick in the 1998 draft, joins Brett Favre as the league's only three-time MVPs. Manning received 32 votes from The Associated Press' national panel of 50 sportswriters and broadcasters, easily outdistancing Miami quarterback Chad Pennington and Atlanta running back Michael Turner, who tied for second with four votes apiece.
Manning shared the 2003 award with Tennessee quarterback Steve McNair and won it outright in 2004.
Combined with the Colts' Super Bowl victory after the 2006 season, in which Manning also was named MVP, Irsay said Manning's ticket to that "room upstairs'' at the Hall of Fame should be punched.
"He's gone into that rare class of guys,'' Irsay said, adding that Colts receiver Marvin Harrison should end up there as well. "He has measured up to every single criteria you could use.''
Manning was quick to share the award with his teammates.
"I really feel like it's a team award with what our team went through this year,'' he said Friday from the team complex, shortly before the Colts departed for tonight's game in San Diego. "Just the way we responded to a little bit of football adversity at the beginning of the season, being 3-4.
"I just can't tell you how much I appreciate the opportunity to play with great football players and teammates.''
The latest honor comes in what has been Manning's most challenging season. He missed the preseason after undergoing two operations on his left knee, then had to fight through an erratic start as his rehabilitation spilled into the regular season. He dropped about 10 pounds, to 220. He lost strength in his left leg. He had to recapture his timing with his receivers, running backs and offensive linemen. Injuries to the latter further complicated matters.
Yet after the 3-4 start, Manning was the driving force as the Colts secured a seventh consecutive playoff berth. They closed the season with a nine-game winning streak, during which Manning directed four game-winning drives in the fourth quarter.
He compiled a 109.7 passer rating during the streak, including a gaudy 130.8 during Indy's 4-0 December.
In Irsay's eyes, one of Manning's most valuable traits has been his ability to play every game of every season. Manning extended his streak of consecutive regular-season starts to 178, second only to Favre's 269 among quarterbacks in NFL history.
"I've always said one of the most important things about greatness in this league is being able to stay on the field,'' Irsay said. "If you can't stay on the field, it's hard to achieve that super level of greatness.
"The things he's done this year, the way he's fought back from adversity, the way we struggled in several areas -- stopping the run, not being able to run the ball; those usually are the two foundations of your team -- has been impressive.''
Irsay paused, then added, "It always seems to mean more when you fight through the adversity. You lose a lot of battles, but still win the war. There's something very satisfying about that.''
Call Star reporter Mike Chappell at (317) 444-6830.
Kyle Neddenriep contributed to this story.


text:
US 7364087 B2 Abstract A method of copying virtual firmware smart card code from a first secured memory in a system and loading the virtual firmware smart card code into a second secured memory in the system so that the code may be run on a microprocessor to provide smart card services to the system.
Claims(26) 1. A method comprising:
copying virtual firmware smart card code from a first secured memory in a system;
loading the virtual firmware smart card code into a second secured memory in the system;
running the virtual firmware smart card code on a microprocessor to provide smart card services to the system; and
programming a chipset in the system to provide input/output (I/O) traps for hardware emulation prior to running the virtual firmware smart card code on the microprocessor.
2. The method of
3. The method of
4. The method of
5. The method of
6. The method of
7. The method of
8. The method of
9. The method of
10. The method of
11. The method of
12. An article comprising a machine-accessible medium having stored thereon instructions that, when executed by a machine, cause the machine to provide smartcard services to a system by:
copying virtual firmware smart card code from a first secured memory in a system;
loading the virtual firmware smart card code into a second secured memory in the system;
running the virtual firmware smart card code on a microprocessor to provide smart card services to the system; and
programming a chipset in the system to provide input/output (I/O) traps for hardware emulation prior to running the virtual firmware smart card code on the microprocessor.
13. The article of
14. The article of
15. The article of
16. The article of
17. The article of
18. The article of
19. A system, comprising:
a processor;
a network interface device coupled to the processor; and
memory coupled to the processor, the memory adapted for storing instructions, which upon execution by the processor, cause virtual firmware smart card code to be copied from a first secured memory in a system, virtual firmware smart card code to be loaded into a second secured memory in the system, virtual firmware smart card code on a microprocessor to be run to provide smart card services to the system, and program a chipset in the system to provide input/output (I/O) traps for hardware emulation prior to running the virtual firmware smart card code on the microprocessor.
20. The system of
21. The system of
22. The system of
23. The system of
24. The system of
25. The system of
26. The system of
Description A smart card is typically a plastic card embedded with a computer chip that stores and transacts data between users. This data may be associated with secret information and is stored and processed within the card's chip, generally a low performance 8-bit microprocessor with a small amount of memory. The card data is transacted via a reader that may be part of a computing system. Smart card systems are in use today in many industries, including healthcare, banking, entertainment and transportation. On a computer platform today, no capabilities exist for secure, isolated storage and execution, such as that provided by a smart card, in both the pre-boot and the runtime environments. A better understanding of the present invention can be obtained from the following detailed description in conjunction with the following drawings, in which: Embodiments of a method to provide virtual firmware smart card functionality for a computer system are disclosed. The computer system may be any system which includes at least a processor (CPU) and memory, including, but not limited to, a personal computer (PC), a mobile computer, a server, or a handheld device. These systems may include various types of software, firmware, and hardware. Reference throughout this specification to �one embodiment� or �an embodiment� indicate that a particular feature, structure, or characteristic described in connection with the embodiment is included in at least one embodiment. Thus, the appearances of the phrases �in one embodiment� or �in an embodiment� in various places throughout this specification are not necessarily all referring to the same embodiment. Furthermore, the particular features, structures, or characteristics may be combined in any suitable manner in one or more embodiments. Tamper-proof system techniques may be used to provide the same integrity and functionality as provided in hardware smart cards by storing smart card code in a secure memory location on a system. The secure stored smart card code shall be referred to as a virtual firmware smart card (VFSC), or may alternately be referred to as virtual firmware smart card code. Next, it is determined whether hardware emulation is desired (block 112). If hardware emulation is desired, then an I/O trap is programmed (block 114). In one embodiment, for hardware emulation, an O/S driver may send specific smart card commands to an I/O port. The I/O Controller Hub (ICH) is programmed to trap on access to specific addresses. When these addresses are accessed, an interrupt is generated, which causes firmware in SMM to execute. The firmware stored in SMRAM (the VFSC) emulates the smartcard command, returning the result to the I/O port address of the ICH for the host software to read. If software emulation is desired (block 116), a programmatic interface may be published (block 118). In one embodiment using software emulation, the host O/S driver will look for an EFI interface. EFI is a public industry specification that describes an abstract programmatic interface between platform firmware and shrink-wrap operating systems or other custom application environments. The EFI framework standard includes provisions for extending basic input output system (�BIOS�) code functionality beyond that provided by the BIOS code stored in a platform's boot firmware device. The EFI interface is named via a GUID, or globally unique identifier. The host O/S driver will then invoke the software interface. After the VFSC has been loaded into either SMRAM or system memory and the desired type of emulation has been chosen, VFSC services may be provided to the system (block 120). VFSC services may be provided to the system in the pre-boot environment. Examples of VFSC services which may be provided to the system include key exchange, authentication, signing, and other services that could typically be provided by a hardware smart card. Finally, as shown in block 122, the target O/S is booted. VFSC services may be provided to the system in the runtime environment after the O/S has booted as well. In embodiments of the present invention the VFCS may provide emulation for an ISO7816 Smart Card Interface, hardware emulation of a TCPA Platform Module (TPM), Security System Processor (SSP), IBM 4758 PCI-attached cryptographic coprocessor module, or a software interface into a TPM ore other aforementioned hardware entity. Access mechanisms may include Legacy BIOS, or EFI protocol. Initially, the VFSC is stored in secure flash memory, 252. Upon system initialization, the VFSC is either loaded into SMRAM, 211, for an IA-32 architecture based system, or it is locked into system memory 210. The VFSC is then accessible either through an I/O trap which is programmed on the ICH for hardware emulation, or it may be accessed via a programmatic interface for software emulation. The host CPU, processor 212, is used for all VFSC computation, such as cryptography. The use of a host processor for VFSC computation provides a great increase in performance as compared to a typical hardware smart card. In one embodiment, the VFSC may be retrofitted on a computer system that presently has no smart card functionality. A firmware update may add the desired VFSC functionality. In another embodiment, the system implementing the VFSC may be a cellular telephone or handheld communications device. For a cellular telephone, the VFSC may be implemented instead of a SIM (subscriber identity module) card. This implementation would be cost saving and would also allow for higher levels of integration. The VFSC functional blocks may include functions that would typically be found on a hardware smart card. These functional blocks may include a hash (306), a random number generator, or RNG (308), an asymmetric key generator (310), a monotonic counter (312), a VFSC kernel/dispatcher (314), signing and encryption (316), power detection (318), non-volatile memory (320), and I/O (322). VFSC functions are provided to the system via I/O interface 324. As described above, the I/O interface 324 may be implemented as an I/O trap for hardware emulation, or may be a programmatic or protocol interface for software emulation. New cryptographic support modules or other functional blocks or smart card upgrades may be added to the VFSC through a firmware update. Thus, a method and apparatus for a virtual firmware smart card (VFSC) has been disclosed. These methods may be implemented in software or firmware, among other implementations. Program instructions may be used to cause a general-purpose or special-purpose processing system that is programmed with the instructions to perform the operations described herein. Alternatively, the operations may be performed by specific hardware components that contain hardwired logic for performing the operations, or by any combination of programmed computer components and custom hardware components. The methods described herein may be provided as a computer program product that may include a machine readable medium having stored thereon instructions that may be used to program a processing system or other electronic device to perform the methods. The term �machine readable medium� used herein shall include any medium that is capable of storing or encoding a sequence of instructions for execution by the machine and that cause the machine to perform any one of the methods described herein. The term �machine readable medium� shall accordingly include, but not be limited to, solid-state memories, optical and magnetic disks, and a carrier wave that encodes a data signal. Furthermore, it is common in the art to speak of software, in one form or another (e.g., program, procedure, process, application, module, logic, and so on) as taking an action or causing a result. Such expressions are merely a shorthand way of stating the execution of the software by a processing system cause the processor to perform an action of produce a result. In the above description, numerous specific details are set forth. However, it is understood that embodiments may be practiced without these specific details. In other instances, well-known circuits, structures and techniques have not been shown in detail in order not to obscure the understanding of this description. Embodiments have been described with reference to specific exemplary embodiments thereof. It will, however, be evident to persons having the benefit of this disclosure that various modifications and changes may be made to these embodiments without departing from the broader spirit and scope of the embodiments described herein. The specification and drawings are, accordingly, to be regarded in an illustrative rather than a restrictive sense. Patent Citations
Non-Patent Citations
Referenced by
Legal Events
Rotate |