Lab Soft News

Two Missing Pieces in the Medical Tourism Industry

I have written a number of previous notes about medical tourism, some of which you can review here, here, here, and here. I believe that this is a significant trend in healthcare that needs to be tracked by the clinical lab industry. Here is a link to a recent article that discusses early efforts to provide accreditation for healthcare facilities in Kerala, which is a state in the south-west tip of India (link here). Below is an excerpt from the story:

Kerala Tourism is stepping up plans to make the state into one of the top five medical tourism destinations over the next five years. Although Kerala enjoys a comparative cost advantage, lack of accreditation of hospitals has been the major drawback in attracting this category of tourists to Kerala. [T]o overcome this, Kerala Tourism has taken the initiative to provide accreditation to hospitals in the State and to promote medical tourism....The Quality Council of India, functioning under the Union Ministry of Health and Family Welfare, through the National Accreditation Board for Hospital and Healthcare is to provide accreditation. Kerala Tourism will promote only hospitals that are granted accreditation.

I am sure that many Americans consumers, medical insurance companies, and companies offering healthcare to their employees may lack confidence in an Indian healthcare accreditation body such as the Quality Council of India, but this is clearly the first of many steps that will be taken to improve the quality of medical tourism by those countries promoting these services. There will definitely be a need for U.S.-based accreditation bod(ies) to evaluate offshore healthcare services on the basis of well-established criteria. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has launched the Joint Commission International (JCI) to accredit hospitals world-wide (link here) but I don't know how effective or accepted this program has been thus far.

The second missing critical piece in medical tourism is a system for indemnifying patients for malpractice related to offshore medical or surgical procedures. To quote an Indian web site on this specific topic, the issue of legal recourse for unsatisfactory treatment across international boundaries is a legally undefined issue at present (link here).

There is obviously a connection between such an initiative and the accreditation body described above.  A U.S. accreditation body for medical tourism will provide insurance companies a better understanding of their risk when issuing such policies. I suspect that the compensation offered for offshore malpractice claims will be limited to some maximum fixed amount so that, again, the insurance company will be able to better calculate their risk when underwriting such policies.

Comments to Lab Soft News Encouraged

Comments from readers about any note published in Lab Soft News are encouraged. I believe that the most successful blogs are based, at least in part, on establishing a dialogue with readers. My interest in stimulating comments also speaks to one of underlying concepts of the blogosphere, which is that the readers of any blog possess a valuable fund of knowledge that can be brought to bear on the discussion. The bottom line is that this blog will become more useful to its readers if some of them contribute to the dialogue.

I have been asked by a reader if notes can be submitted anonymously. I understand that this may be desirable in some cases and it is certainly possible. When you click on the comment link at the bottom of each note, you will be asked for your name, URL, and email address. If you wish, you can enter a pseudonym in the name field and leave the URL and the email fields blank. The URL field is only relevant if you are a blogger and want to inform others about your own blog.

The name you submit will be displayed with the comment but not your email address. I will be able to view your email address if I need to respond to you for some purpose. In order to submit a comment, you will be asked to respond to a CAPTCHA test. This part of the comment process has been introduced to foil bots that try to enter advertising spam as comments. Below is a definition of a CAPTCHA test (link here):

A CAPTCHA (an acronym for "completely automated public Turing test to tell computers and humans apart"....) is a type of challenge- response test used in computing to determine whether or not the user is human.... A common type of CAPTCHA requires that the user type the letters of a distorted image, sometimes with the addition of an obscured sequence of letters or digits that appears on the screen. Because the test is administered by a computer, in contrast to the standard Turing test that is administered by a human, a CAPTCHA is sometimes described as a reverse Turing test. This term, however, is ambiguous because it could also mean a Turing test in which the participants are both attempting to prove they are the computer.

My Not-So-Secret Life as a Blogger

The July edition of CAP Today, the monthly tabloid publication of the College of American Pathologists, contains an article that I have written (link here) entitled My Not-So-Secret Life as a Pathology and Lab Medicine Blogger. It describes in detail how I became interested in creating this blog and also some of the technical details about its daily publication process. Here also is a caricature of me that accompanied the article playing off my new "soapbox" role.

I view Lab Soft News as a component of an emerging web laboratory world. Two recent contributors to this on-line web-world are Bio-Rad's quality-control-oriented QCNet (link here) and the recently  launched LabsAreVital web site from Abbott Diagnostics (link here). These two sites provide tangible evidence of the interest of IVDs in providing useful content to lab professionals. Here is a link to a previous note about corporate educational activities.

I have begun to develop informal relationships with the production personnel of these emerging web sites as well as with the publishers of lab print publications such as CAP Today and The Dark Report. My goal is to create a "clinical laboratory network" that will provide sophisticated content to lab professionals each day. To tie all of these resources together, I would like to develop a "lab web gateway" that can serve as a portal to all of them. It will be designed to allow users to obtain an instant summary of breaking lab news and provide pointers to all relevant resources in response to a specific question.

New Pathology Chief Named at Mass General

David N. Louis, MD, a neuropathologist and a pioneer in deciphering the complex molecular structure of tumors, has been named chief of the Massachusetts General Hospital Pathology Service, effective September 1 (link here). A leader in both the clinical and research arenas, Louis has been serving as associate chief of the Pathology Service and director of the Molecular Pathology Unit. He is a professor of Pathology at Harvard Medical School. Louis will succeed Robert Colvin, MD, who after leading MGH Pathology since 1991, last year announced his intention to step down from his role as chief. Colvin will continue on staff as a senior faculty member in Pathology.

Massachusetts Medical Society Endorses eClinicalWorks

eClinicalWorks is among four office EMR software products being promoted to the 18,500 members of the Massachusetts Medical Society. Here is the link to the article discussing this program and below is an excerpt from it. Previous notes posted on Lab Soft News have made reference to this physician office EMR product (links here and here). It will be of interest to lab professionals who read this blog that eClinicalWorks provides integration with a large number of LISs, hospital labs, and commercial reference labs, the list of which can be reviewed here.  

Less than 20 percent of doctors [in Massachusetts] now use EMR technology....A tutorial on EMR technology at the medical society’s Web site estimates the cost to a practice for the adoption of such technology ranges from $15,000 to $35,000 or more per doctor. Under the medical society agreement, doctors who select eClinicalWorks will get a 10 percent discount on the licensing fee, discounts on training and other benefits. Typically, eClinicalWorks costs $10,000 for the first physician and $5,000 for each additional physician, with additional annual costs for maintenance and support, under the client/server model. If the program is accessed over the Internet, through an application service provider [ASP] model, the cost is $500 per month per doctor....eClinicalWorks, which joins Allscripts, NextGen Healthcare Information Systems, and e-MDs as software vendors under the program, was selected for several reasons, including its cost and Massachusetts roots ....Agreements with Allscripts and NextGen are still being negotiated.....

I find this announcement very interesting on a number of counts, including the following:

• I was initially surprised that a state medical society would endorse a specific EMR product. On further reflection, I think that it is a good idea. First of all, it serves as a stimulus for the adoption of the technology by its members, which will be good for all concerned. Secondly, the society has negotiated a discount for the product which will be benefit its members. Thirdly, the society is negotiating a relationship with several other EMR companies so that it can't be accused of favoritism.
• I have always believed that an ASP model was appropriate for the deployment of an office EMR in small practices. It's less expensive than a local installation and the office staff is relieved of the system maintenance and disaster-recovery responsibilities. It speaks to the sophistication of the leadership of the society that it sought out a vendor offering this particular system installation option.
• I find it interesting that the eClinicalWorks has been so successful in the Massachusetts environment when competing against larger companies such as AllScripts and NextGen. The product has obviously resonated with its current physician clients in that state because it meets their needs at a reasonable price.
• I look very favorably on the ability of the eClinicalWorks product to integrate tightly with LISs, commercial reference labs, and hospital lab outreach programs. I believe that this feature is well appreciated by both the physician clients and the clinical labs serving these office practices.

Skype and Netgear Launch Mobile Wi-Fi Phone

I have posted previous notes about the deployment of voice-over-Wi-Fi phones for nurses working in hospitals (link here ) and Wi-Fi access for patients who want to use their PCs when in the hospital (link here). The evolution of the Wi-Fi phone continues with the product announcement of a Skype wireless mobile telephone and a router equipped to optimize Skype. Skype (link here) is a very successful service using the the Voice-over-Internet-Protocol (VoIP) that allows one to make telephone calls, or even conference calls, using a broadband Internet connection instead of an analog phone line. PC-to-PC calls using USB headphones and Skype to anywhere the world are free. Using SkypeOut, a PC to a land-line telephone or to a cell phone can be made for a modest per-minute charge. Here is the link to the story and below is an excerpt from it:

The Netgear phone is pre-loaded with Skype’s software, ready out-of-the-box to use with a wireless network. All a user needs to do after turning on the phone is enter a Skype username and password. The Skype software pulls up the user’s full contact list, displays the connection status on the phone screen, and allows the consumer to connect to any other Skype user for free.

Most consumers are accustomed to picking up their telephone or cell phone to make a call and will resist using USB headphone plugged into their PC for the same purpose. The telephone "appliance" has been enormously successful, in part, because of the great convenience it offers to users. This new product, and the others that will undoubtedly follow, can only serve to increase the adoption rate of VoIP in business and at home.

Free or very inexpensive calls on a global basis will surely make the world a smaller place. In the near future when we pick up our phone to contact a colleague in some distant city, one of our primary concerns will be the time difference in that city. With a display screen on this new family of Wi-Fi phones, I am sure that it will be relatively simple to show the local time for the person we are calling and alert us when it is the middle of the night for him.

Tipping Point for Technology to Transform Healthcare

I am blogging from the annual meeting of the AACC in Chicago. Yesterday, I attended a keynote lecture by Carolyn Kovac, Ph.D., from IBM entitled: Computing in the Age of the Genome. One of her major points was that  we are at a point in our history when powerful forces are aligned to result in radical changes in healthcare. She refers to this confluence as a tipping point. She gives credit for the popularization of this term to Malcolm Gladwell who wrote a book by the same name which goes into greater detail about this phenomenon (link here).

She preceded her remarks about the tipping point in medicine by introducing the term information based medicine, which is described in the following way on the IBM web site (link here).

The convergence of life sciences, healthcare, and information technology is revolutionizing the discovery of new treatments and the practice of medicine. This new paradigm—information based medicine—improves existing pharmaceutical and medical practices with the knowledge generated from the integration of diverse clinical and biomedical data.

Dr. Kovac lists the following four transformational changes that are now aligned to produce a tipping point in the U.S. After each of them, I will provide some additional ideas about the relevance of each of them. Some of these ideas were provided by her and some come from me.

• Changing demographics

Comment: One major demographic change is the aging of the population, producing a greater demand for healthcare services from those who are living longer with chronic disease. Recall that many forms of cancer are now considered to be a chronic disease. The large bolus of the yuppie generation that was born beginning in 1945 is now reaching an age when their demand for services will grow steadily. They will demand greater participation in their own healthcare decision-making.

• New economic models

Comment: A solution for providing healthcare for the uninsured in the U.S. must be developed. Greater co-pays will be required from the insured population to reduce the cost of such programs. More affluent healthcare consumers will be willing to pay more out-of-pocket for those wellness programs that prove to be effective.

• Technological innovation

Comment: Not much more needs to be said here other than genomics, proteomics, personalized medicine, and nanotechnology.

• Globalization

Comment: The entire healthcare market is rapidly becoming global. Many controlled clinical trials are moving offshore. Newly affluent consumers in developing countries like India, China, and Russia are demanding high quality care. Medical tourism is thriving with U.S. consumers traveling off-shore for complex surgery and other forms of treatment.

e-Prescribe Thrives at the Henry Ford Medical Group

Electronic prescription writing using e-Prescribe is thriving at the Henry Ford Medical System in Detroit, Michigan. GM, Ford Motor Co. and the Chrysler Group requested that Henry Ford launch e-Prescribe last year. Here is the link to the story and below is an excerpt from it:

Henry Ford Medical Group has filled more than 1 million prescriptions electronically since it launched a program [17 months ago] at the request of American automakers to cut costs by boosting the use of generic drugs.... Henry Ford expects e-prescribing to save the Detroit-based health system $1 million this year. It believes that other insurers whose patients use Henry Ford doctors will save another $2 million thanks to the program.

e-Prescribe has been developed by ZixCorp for the BCBS health insurance network and is being rolled out in other states such as North Carolina (link here), Massachusetts, Pennsylvania, and Louisiana (link here). Zix refers to its e-prescribing product on its web site as PocketScript (link here). e-Prescribe thus appears to be the name of the BCBS network version of the same or similar software. I personally think that it is confusing to trademark a name such as e-Prescribe that is identical to the name for a generic process such as e-prescribing

When various healthcare process are enhanced by computerized versions of the manual process, the rationale that is usually cited for the change is increased efficiency or error reduction. In the case of e-prescribing, the major advantages commonly cited are the production of legible scripts and the ability to flag drug-drug and drug-test interactions.

It's very interesting that, in the case of the deployment of e-Prescribe within the Henry Ford system, little effort has bee made to mask the fact that the primary driver has been the cost reductions that have been achieved by the conversion to generic drugs. In addition, the fact that "Big Auto" has requested this change is also overtly stated. For me, this is primarily a reflection of the political and economic power of the car manufacturers in Michigan.
 
Given that the Henry Ford physicians are nor forced to follow the e-Prescribe suggestion to convert any specific script to a generic equivalent, it's also interesting that the substantial cost savings could be achieved so rapidly. This suggests that the physicians did not place an extremely high value on the use of various name-brand drugs, given that they could be weaned off them by the mere suggestion of a generic alternatives. It is also possible that strong pressures were being applied to the physicians concurrent with the software roll-out.

Increased Attention to Errors in the Clinical Labs

I have devoted a number of previous notes to the topic of errors in the clinical labs (here, here, here, and here). There is increasing media attention to this topic. One notable example is an article entitled Hospitals Move to Cut Dangerous Lab Errors: Improved Specimen Collection And Efficiency Help Increase Accuracy of Medical Testing. The article appeared in the June 14 issue of the Wall Street Journal (link here). Below are some excerpts from it:

...Hospitals and health-care-quality groups around the country are working on initiatives to bring more rigorous standards to pathology labs....In the largest effort, a group of nine major academic medical centers is participating in a lab-safety collaborative to redesign the archaic and error-prone systems for collecting, labeling, handling and interpreting blood and tissue samples.... While malpractice claims for pathology errors are relatively low in number, they are the second-most costly to hospitals after neurology payouts....In a study of 335 pathology-related malpractice claims,...63% of these claims involved the false-negative diagnosis of cancer and 22% involved the false-positive diagnosis of cancer. One of the most persistent problems is the poor quality of specimens to begin with. In diagnosing cervical cancer, for example, biopsies must be taken from a certain part of the cervix known as the "transformation zone," but gynecologists fail to collect cells from the zone often enough to miss lesions 30% to 40% of the time....In patients with thyroid nodules, 300,000 fine needle aspirations ....are done annually in the U.S. to rule out cancer, but 25% of the time the tests miss tumor cells and produce false negatives....

I continue to be struck by the frequency with which tissue sampling errors by clinicians that result in erroneous reports from pathologists are categorized as lab errors. Although the WSJ article quoted above does make reference to errors that occur as the result of inadequate lab processes and the efforts to improve them, the most dramatic examples cited are tissue sampling errors made by clinicians. Unfortunately, there is no escape from the headline of the article which refers categorically to lab errors.

I have somewhat reluctantly concluded the following: if an erroneous report is generated by a hospital laboratory, regardless of whether the tissue was sampled inadequately or the specimen was mislabeled, it will be described as a lab error. Given this reality, it seems to me that the optimal approach in the labs is to establish systems to dramatically reduce the incidence of all errors that can occur in both the pre-analytic and analytic phases of testing. As noted in previous posts (links here, and here, here) and also in the WSJ article quoted above, the Lean/Six Sigma systems can be used effectively to achieve this goal.

Voice Recognition Versus Speech Recognition

It seems to me that there has always been some confusion between voice recognition and speech recognition and the two terms are often used interchangeably. The former is defined as the following (link here):

Voice recognition is the conversion of spoken words into computer text. Speech is first digitized and then matched against a dictionary of coded waveforms. The matches are then converted into text as if the words were typed on the keyboard.

Voice recognition is defined in a very similar way (link here):

The ability of a computer to understand spoken words for the purpose of receiving commands and data input from the speaker.

The following article illustrated for me that the two terms can actually be used to describe two different processes. Here is the link to the story and below is an excerpt from it:

A large Dutch bank has begun offering its customers access to their accounts with a telephone system that operates entirely by voice recognition....ABN Amro customers will call, state their account number, answer a pre-scripted question, and the system will then analyze their voice to confirm their identity. They can then check account balances, trade stocks, or transfer money without entering any further numeric codes or passwords....[T]he system can weed out even the best mimics, and will continue to work when an account holder has a cold, she said....The ''Voice Vault'' technology ABN Amro is using has traded hands several times and is now owned by British-based Biometric Security Ltd.

So voice recognition can be viewed as a security application because it is a unique attribute of an individual and speech recognition, by way of contrast, can be understood as a process for interacting with computers. When and if deployed as a front-end to LISs, both types of technology can be used to facilitate the process.

There are now two ways in which physicians and other healthcare professionals can access test results from an LIS when away from their office PC:

• Cells phones equipped with a browser and with Internet access
• Voice/speech recognition via cell phones, suitable for quick access to a limited set of test results

Both of these technologies can be also used by hospital-based physicians or community physicians when making hospital rounds. However, both have serious limitations for viewing complex data. The ideal solution for viewing any electronic data in hospitals is a lightweight tablet computer with Wi-FI access to both the EMR and any other ancillary hospital systems, including the LIS and the RIS. Here is a link to a web site devoted exclusively to news about tablet PCs that's worth a quick look.