Lab Soft News

Comparing the ASP with the SaaS Computer Management Model

I was very intrigued when Mr. HIStalk revealed that Baylor Healthcare System’s The Heart Hospital in Plano, Texas, will be first to go live on Centricity Enterprise  using an ASP model. Here is the link to the HIStalk reference and here is the link to the press release.  Below is an excerpt from the article:

GE Healthcare... announced the launch of Centricity Enterprise Remote Services, which will facilitate the adoption of integrated electronic medical records (EMRs) by mid-size healthcare organizations....Remote hosting puts sophisticated health information technology within reach of many more hospitals, not just academic medical centers and large integrated delivery networks....Hospitals using Centricity Enterprise Remote Services will have access to enterprise-wide clinical and financial applications, without the initial outlay required to purchase hardware and software, and without dedicating resources to implementing, maintaining and upgrading the software....Under the ASP arrangement, the Centricity Enterprise system will run on HP... servers owned by GE and located at its hosting center in Chicago. GE will be responsible for all technical support of Centricity Enterprise software versions, including installation of new release software and maintenance of the ... servers.

The application service provider model (ASP) is analogous to the remote hosting or remote services models. Here is a definition for ASP (link here):

An Application Service Provider (ASP) hosts a variety of applications on a central server. For a fee, customers can access the applications that interest them over secure Internet connections or a private network. This means that they do not need to purchase, install and maintain the software themselves; instead they rent the applications they need from their ASP. Even new releases, i.e., software upgrades, are generally included in the price.

Although offering the Centricity software using a remote services model is relatively innovative in the context of healthcare IT, it is important to point out that this approach is now being overshadowed by a new computer management model that is often referred to as software as a service (SaaS). Here is a definition for SaaS (link here):

Software as a Service (SaaS) is a model of software delivery where the software company provides maintenance, daily technical operation, and support for the software provided to their client. SaaS is a model of software delivery rather than a market segment....The reason for moving away from the term ASP or application service provider is that the ASP generation was merely traditional client-server applications with HTML frontends added as an afterthought. ....Because the applications were not written as net-native applications, performance was poor and application updates were no better than self managed applications. By comparison, current net-native SaaS applications or independent portions are updated regularly, many daily.

I don't know whether the SaaS architecture will be deployed soon in the healthcare IT domain but it is based on very compelling logic. Most, if not all, of the ASP models being offered in healthcare are, as noted above, retooled client-server systems with PCs functioning as the client and a secure Internet-based VPN connection to the backend server hosted by the vendor.

Such an architecture can offer a hospital client a number of advantages such as those listed in quote above. However, in the long run, the most efficient web-services model will require the development of "net-native SaaS applications" with only a front-end browser required by a user to interact with the system. As noted above, enhancements to such a system can be added rapidly by the SaaS provider without any changes required of the system users.

Bayer Sells Lab Diagnostics Unit to Siemens

Some breaking news about the Bayer Diagnostics purchase by Siemens today. Here is a link to the article and below is an excerpt from the it:

German drug maker Bayer AG said Thursday it was selling its diagnostics operations to Siemens AG for 4.2 billion euros ($5.26 billion). The sale, which is subject to regulatory approval, is expected to close in the first half of 2007....Munich-based Siemens said the purchase is part of its continued expansion of its health care equipment and services business. The deal will also help partly finance Bayer’s pending takeover of domestic rival Schering AG. Bayer said that sales of the divested unit, which employs 5,000 workers, rose in 2005 by 8.4 percent to 1.4 billion euros. Siemens, Germany’s largest engineering and technology conglomerate by sales, added in a separate statement that the unit achieved double-digit earnings before interest, taxes, depreciation and amortization margin in 2005.

Apparently the recent purchase of DPC by Siemens (links here and here) did not satisfy the company's appetite for a position in the IVD industry and greater integration across healthcare. Look for some roughly equivalent response from GE Healthcare which I think is predisposed to match Siemens tit for tat (link here).

A Guidebook for Medical Tourists

I have written a number of previous notes about medical tourism and offshoring of healthcare services (examples can be found here and here and here). In the first of these notes, I made the following comment:

Here's a business idea -- someone should start the equivalent of a "Frommer's guide" to evaluate the quality of the various medical tourism offerings by country. The opinions of a "medical tourism broker" like MedSolution might be questioned as not being impartial.

Well, it turns out that such a guidebook already exists. Here is the link to an article describing such a book and its author and below is an excerpt from the story:

As the phenomenon of medical tourism grows exponentially, only one book teaches readers how to find the best plastic surgeons at the lowest prices. Author JoAnn Roselli has recently released the latest update of her warmly embraced overseas plastic surgery guide, "How to Get High-Quality Plastic Surgery... cheap." As in earlier editions, JoAnn has included her own story of discovering affordable plastic surgery performed by Board Certified skillful plastic surgeons in the Dominican Republic....The guide instructs readers on personal care and hygiene methods to help guard against post-surgical wound infection, as well as important factors to take into consideration when deciding if an overseas surgical trip is the best option.

 It came as no surprise to me that the first medical tourism book on the market focuses on plastic surgery. Here are some of the reasons why I think that plastic surgery will be the first major medical tourism success story, but with others to follow in rapid succession:

• Such procedures are not reimbursed by healthcare insurance plans so that some shoppers undoubtedly will be seeking cut-rate options
• Such procedures are generally performed on an outpatient basis so there is no requirement for a large capital investment in inpatient facilities
• Post-operative care is important but not very complex -- note the reference to post-operative surgical wound care above suggesting the need for the patient to take some ownership for this process
• The success of the surgery is almost totally dependent on the skill of the surgeon, as opposed to the quality, say, of nursing personnel and the successful outcome of the procedure can be assessed by the patients and their friends
• There is a large and growing demand for such services in the U.S. even by consumers of only modest incomes

I suspect that many more books addressing other types of surgical procedures will follow. I would also suggest that there is a need for web sites about the topic other than those created by the brokers of medical tourism services. In fact, I would turn to a very success travel site, TripAdvisor that you can link to here, as an excellent model for a potential medical tourism web site. Publishing  user-generated comments about the successes or failures of various plastic surgeons abroad would provide a major service absent U.S.-based independent evaluation & accreditation bodies.

I know, I know. There are many risks associated with user-generated content. For one, shills working for the hospitals and physicians abroad can plant favorable reviews on such web site. However, just point your browser to TripAdvisor. You will instantly understand that authentic reviews have a ring of truth about them that can't be faked. Also, at least for hotels, one should always cross-check any review using multiple references.

Meconium and Fetal Alcohol Expposure

Fetal alcohol exposure is usually determined through self-reported maternal consumption. Self-reported drinking, however, is often an unreliable measure for any patient. Researchers have found that the presence of certain fatty acid ethyl esters (FAEEs) in meconium (a baby's first stool) may provide a dependable biomarker of fetal alcohol exposure (July 2006 issue of Alcoholism: Clinical & Experimental Research). Here is the link to the news story and below an excerpt from it:

There are only a few biomarkers that indicate if an infant has been exposed to alcohol during pregnancy, and most of them are not strictly associated with alcohol use....When people drink alcohol, it combines with certain fats in the body known as fatty acids, and FAEEs are formed. These "markers" are either deposited in tissues or, in the case of a growing fetus, in fetal urine or meconium.

Dr. Michael Laposata reacted to this article in the following way: "....the test is only able to identify about one quarter of the mothers who ingest alcohol during pregnancy." He suggested that testing expectant mothers for alcohol intake prior to delivery would have more merit than testing meconium after birth because an objective identification of alcohol intake during pregnancy could lead to intervention, possible cessation of drinking, and a better outcome for the fetus.

Below is an excerpt from a web page (link here) where the prevalence and diagnosis of fetal alcohol spectrum disorders is discussed plus the social and economic impact of the problem. Below is a quote from it:

Fetal alcohol spectrum disorders are estimated to occur in approximately 0.5-3 children per 1,000 live births in the United States each year, rivaling the incidence of spina bifida and Down syndrome. Many affected individuals remain undiagnosed and are represented in all races and socioeconomic groups. Social and financial costs are staggering, with the latter estimated to be in the billions annually for care-related expenses.

I was interested in Dr. Laposata's call for routine antenatal screening for alcohol. Here is a link to a detailed article from 2001 that discussed the screening of pregnant women using both questionnaires and lab tests with emphasis on the former. The use of breath analysis or urinalysis for alcohol in pregnant patients were deemed not feasible by the author because of the rapid metabolism of alcohol and the pattern of drinking by most pregnant women.

I have blogged previously about the use of the carbohydrate-deficient transferrin (CDT) assay to detect chronic alcoholism. Levels are lower than normal in these  subjects (link here). I was curious as to whether this particular test had been used for antenatal testing, perhaps accompanied by the use of an additional screening questionnaire. One barrier to the use of CDT in this way would be that transferrin, and therefore the CDT levels, are much higher in pregnancy and appropriate reference intervals need to be defined (link here). I did not turn up any indications on the web that CDT had been used for this purpose.

An Explanation for the Booming Paternity Testing Market on the Web

I have previously discussed the booming paternity testing market on the web here and here. Because such tests are consumer-ordered, I have referred to them as direct access testing (DAT). In this note, I was able to report the following test volume, as reported to me by a lab executive:

In 2005, the American Association of Blood Banks, which regulates and accredits laboratories for parentage testing, conducted a study that determined that more than 390,000 paternity tests were performed in 2004.

Suzanne Butch, chief technologist in the blood bank at the University of Michigan Health System, sent me the following note in response to my question to her about why this was such a robust test market:

The number of unwed births is quite high. In Michigan, for example, in the year 2004 it ranged from a low of  17%  in one county to near 60% of births in another county (link here).  In Michigan, in order to get public assistance or a court order for child support, paternity needs to be established. The putative father can sign an agreement stating he is the father and not be tested. Or, the mother can identify the putative father and obtain an order and referral for paternity testing. The "client", not the court, pays.

I suspect that in some relatively high percentage of these cases, the putative father will resist submitting an affidavit of paternity without some concrete evidence that he is the biologic father. According to the American Association of Blood Banks, 30 percent of 354,000 men who took paternity tests in 2003 were not the biological father of the tested child (link here).

There are other pressures for putative fathers to want or need to establish the paternity of a child voluntarily and with certainty. For example, Ohio hospitals in 1998 began asking fathers who came to visit their newborns infants to sign an affidavit of paternity. A father's name on a birth certificate is not considered proof of paternity. In fact, a father's name no longer can appear on a child's birth certificate unless he signs an affidavit in a notary's presence (link here).

I believe that I was laboring under the false assumption that most paternity testing was adversarial to some degree. I therefore could not explain the apparent proliferation of web-advertised DAT paternity testing, much of which is voluntary and for which a legal chain of custody for specimens is not established. The latter would be required for court-ordered paternity testing. If some large percentage of paternity testing is voluntary rather than enforced by the court, one could easily explain the robust growth in this web-based DAT paternity testing market.

Can an Electronic Medical Record Cause Harm to Patients?

There is a high degree of anxiety in the Pittsburgh area about the possibility that a a conversion to a new clinical information system can cause harm to patients. This attitude stems from an article published in December, 2005, entitled Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System that can be read here. This study was based on the an 18-month experience at Children's Hospital of Pittsburgh. It therefore came as no surprise when a recent article in the Pittsburgh Post-Gazette carried the following headline: Anxiety Accompanies Hospital Computer Switch. Here is the link to this article and below is an excerpt from it:

UPMC Shadyside will switch to a new system that allows physicians to electronically enter orders for patients to undergo tests and receive drugs. Could a hospital computer system meant to save lives inadvertently lead to more deaths? ...The costly computer system being installed allows for "computerized physician order entry," an electronic way of directing patient care that's been promoted by business groups and patient safety experts as key to standardizing hospital care....Administrators at Children's say they strongly disagree with the [December 2005] study, and counter that the system ... has saved lives by helping make sure patients get the right medicine at the right time and in the right dose.

I don't have the space or the inclination to go into a detailed critique of the article that has spawned this controversy and there are many who take issue with its study design. Rather, I want to briefly discuss the so-called S-curve and its relationship to the effects of the conversion to a new technology. Here is a quote from Clayton Christensen, author of The Innovator's Dilemma, that describes the S-curve in the following way (link here).

Movement along a given S-curve is generally the result of incremental improvements within an existing technological approach, whereas jumping onto the next technology curve implies adopting a radically new technology.

An S-curve, a lazy "S" sloped to the right, is a way to illustrate the effects of new technology with performance graphed on the vertical axis and time on the horizontal axis. One example of such would be the installation of a CPOE (computerized physician order entry system). Initially, performance is flat or even degrades (the bottom portion of the S) because of the unfamiliarity of personnel with the new system. Performance then increases exponentially and eventually flattens out (the top part of the S). The latter is a signal for the need to switch to the next technology, in which case the process starts all over again and new gains are reaped.

So what lessons can be derived from an understanding of the S-curve and provided to UPMC Shadyside as they convert to their new CPOE system:

• Mistakes will be made in the conversion process of the new CPOE system, as they will inevitably occur with the deployment of any new technology, until users become accustomed to it and begin to extract the maximum value from it.
• It falls to the project leaders to determine a priori which drug-ordering processes are most likely to go awry during the introductory period. These most critical processes can be managed manually for a period of time or they can be closely monitored by multiple layers of personnel to catch and correct any errors that might occur.
  
• Well-designed automated systems, in the long run, will always trump complex and thus error-prone manual systems. It is not helpful if the local press publishes articles that create an air of hysteria that potentially undermine the success of the conversion process.

Misys Encompass + Hilgraeve HyperSend PDX

Hilgraeve (web site here) has announced that Misys Healthcare Systems (web site here) has interfaced Misys Encompass, a lab portal for orders and results, with HyperSend PDX, the company’s patient data extraction system. This interface will provide clients using Misys Encompass with a secure electronic health information exchange between their offices with an EMR (also known as a physician or practice practice system) and their hospital or reference lab. Here is the link to the press release.

The Encompass product has a long history. Dr. Sid Goldblatt, the founder of Sunquest, the LIS company that was purchased by Misys, brought this lab portal product to market very early in the game. In my opinion, Misys was not quite sure how to market Encompass and the product was soon overshadowed by competing products such as those of Atlas Medical (link here) and Labtest Systems (link here). Even today, I think that the Misys description of the product is skimpy (link here to a list of features).

What I found most interesting about the story was the following quotation:

Clinical laboratories need the accurate and timely patient demographic information to properly process the tests requested by physicians. Through HyperSend PDX, Misys Healthcare Systems has a reliable and secure real-time interface to their clients’ HIS systems responsible for storing accurate up-to-the-minute patient data.

I am fully aware that the nature of both the lab portal and lab outreach businesses is changing rapidly. In earlier days, emphasis was placed on simply automating the process of generating test orders from an office to a lab and transmitting the test results back to the physician and office staff. With the increasing popularity of office EMRs, emphasis shifted to the integration of lab processes with these systems. A previous note emphasized this integration of one such system, eClinicalWorks, with a variety of reference laboratories (link here).

Recently, the lab portal vendors, in response to market pressures, have emphasized  the integration of their products with hospital EMRs. However, I was surprised by the sole emphasis in the Hilgraeve press release about support for the HIS (hospital information system) interface. I have written previous notes about the growing importance of hospital EMRs (links here, here, here, and here) and this provides added evidence for this shift.

Walk-In Testing Offered by a Community Hospital Lab

As a very useful addition to our ongoing dialogue about direct access testing (DAT), John Fitzgibbon of OmniTech has called my attention to this link from the laboratory at Beaver Dam Community Hospital in Wisconsin. You may recall from a previous note here that John's company is giving away a free LIS. Scroll to the bottom of the hospital's home page to view the following, which is an offer to provide self-requested and walk-In lab testing to members of the community (bold face emphasis mine):

Self-Requested and Walk-In Testing is a service which allows a person to have selected laboratory tests run at a reduced price and without a physician's order. Payment in advance and minimal processing lowers our cost and permits us to pass the savings along to you. These tests will be done on a cash only basis (sorry, no checks, charging or insurance billing)....We are offering you these tests for your general health and wellness status.

Glucose (by glucometer)      $5.00   
Cholesterol                         $5.00 plus $5.00 drawing fee
Triglycerides                       $5.00 plus $5.00 drawing fee
Blood Type ABO/RH             $5.00 plus $5.00 drawing fee
Pregnancy (urine)                $5.00

The clarity and simplicity of this description and the very reasonable cost is impressive. I am not surprised that a program such as this has been developed in the heartland of America. Here is a link to the community page for the town which sounds the way that I thought it would.

Below are some of my impressions about this Wisconsin version of DAT:

• No one can accuse Beaver Dam Hospital labs of hatching this program to enrich themselves. They have obviously developed it to serve the community. It is also a way to make the value of lab services more visible.
• The diagnostic targets for the testing -- diabetes, cardiovascular disease, emergency blood transfusion, and pregnancy -- are well selected and reinforce the goal of enhancing the general health and wellness of the population.
• The modest scale and goals of the program are such that none of the local physicians could possibly find fault with it or suggest that it would cause problems for them.
  

Keep up the good work Beaver Dam Hospital. Perhaps other labs may see the wisdom of using your blueprint for their own "walk-in" test offerings.

GE Medical Purchases Biacore

GE Medical has purchased Biacore for $390M. Here is the link to the story. I was not familiar with the company so I visited its web site here. Below is a short paragraph describing the company's mission from its web site:

Biacore systems define the characteristics of proteins in terms of their specificity of interaction with other molecules, the rates at which they interact (binding and dissociation), and their affinity (how tightly they bind to another molecule).

I think that there is a trend developing here. In previous notes (link here and here), I discussed, first, the Siemens purchase of Diagnostic Products Corporation (DPC) and, secondly, my interpretation of the rationale behind the purchase, which I summarized using the following equation:

The power and synergy of in-vitro diagnostics + in-vivo diagnostics (i.e., diagnostic imaging) + information technology (IT)

It seems to me that GE Healthcare has been pursuing similar goals to Siemens. It purchased the Triple G LIS in August, 2003, (link here). Siemens ventured into the healthcare IT space when it purchased what was then called SMS in May, 2000 (link here).

So here we see two of the giants of diagnostic imaging, GE Healthcare and Siemens, recently purchasing companies with special expertise in protein chemistry and immunodiagnostics. It may be that their work on molecular imaging was not progressing fast enough to satisfy them so that they needed to acquire  greater expertise about the molecular basis of tumors and other disease processes. Here is a link to a web site that promotes itself as "molecular imaging central" for those who want to read more about this topic.

Lab Soft News Reaches a Milestone: 10,000 Visitors in Five Months

Early this morning, Lab Soft News reached a blog milestone: it has now hosted 10,000th visitors in five months. Although the first note for the blog was posted on December 4, 2005, I did not start using SiteMeter to record the number of daily visits until January 17, 2006. The title of this first note was, appropriately enough, Defining the LIS. Much of my energy since that time was been devoted to this very same topic.

Over the course of this five months, the blog readership from abroad has increased slightly to 20% with Canada, India, France, and the U.K. providing, in that order, the largest number of participants.

I am very pleased with the progress that has been made with Lab Soft News and will continue to plug away at the project. I think that it fills a useful niche in the clinical lab and pathology world. Drop me a note using the Comments link if you have any suggestions about how to improve the publication.