Lab Soft News

Web-Based PHR Mash-Ups

In response to my recent note about mash-ups and Web 2.0 (link here), Adam Peters submitted the following comment:

     Another area where mash-ups could make a big difference is PHR's.  I can see blending content from different providers of medical information, medication information and possibly targeted advertising (there's no such thing as a free lunch) as services connected via a web or PC based PHR. 
    To extend the model to a healthcare organization, the application could allow home-based access to all or parts of the EMR and clinician access to the PHR. The user and healthcare organization would choose what to share and what to keep privileged.  In this case the health information provided to the user would be based on clinical diagnosis in the EMR as well as currently prescribed medications and of course lab test results. 
    These types of services can be provided without a great deal of difficulty and they are secure.  Ever bank on the web?  Chances are your bank isn't providing all the content on that page.  A third party hosts the web services that access your account, perform the authentication and conducts the transactions that post immediately to your account.  If you can feel secure about sending your financial information of the web you should feel secure sending health information.  Your account number is much more valuable to hackers than your ICD-9 codes from you last doctors appointment.

This is an extremely interesting comment from Adam and I want to extend some of his ideas and perhaps stimulate further discussion about this topic. I have posted a previous note about the personal health record (PHR) that you can read here.

Let's work with Adam's idea that a health system would create a web-based PHR, accessible by patients, by extracting selected data elements from the EMR, perhaps with a nightly sweep, and copying them to the PHR. Data that could be replicated in this way to the PHR might include lab & pathology results, radiology reports, clinical and operative reports, and a list of prescribed medications. It is understood that certain reports such as a newly diagnosed tumor would not be made available to a patient prior to a physician visit for a discussion of that result.

Now things get very interesting. What sort of mash-ups could be created that would enhance the value of the PHR from the perspective of patients and healthcare consumers. Stating the question another way, which extracts from other medical content web sites could be integrated with the health system clinical data. Here is a list of ideas that come readily to mind:

• Consumer-oriented descriptions of the side-effects and contraindications of medications, perhaps accompanied by a photograph of the actual tablet for identification purposes (see DrugDigest Pill Images here). Such information could be displayed when the patient right-clicks any of items in the list of current medications
• Descriptions of the indications and interpretations of various lab tests performed on a patient with special emphasis on those that are abnormal. Mash-up information could be obtained from a web site like Lab Tests Online here.
• When definitive diagnoses are recorded in the PHR, particularly relating to serious chronic diseases, web links to self-help groups and other resources (e.g., WebMD Type 2 Diabetes Support Group, link here).
• For malignant neoplasms and other chronic diseases, links to controlled clinical trials such as this site.
• Many PHRs already have a medication reminder. Integrating such an application with the list of prescribed meds from the PHR would allow the application to be preloaded with drugs names/images, doses, and alarms.

I hasten to add here that such PHR mash-ups could only be developed with serious attention to the quality of the data that is integrated with the core clinical data copied from the EMRs to the PHR. However, this goes without saying.

Bio-Reference to Buy Genomic Lab for $17 Million

Bio-Reference Laboratories (BRLI) has announced that it has agreed to acquire GeneDx, a gene-based testing laboratory, for as much as $17 million (link to story here). Bio-Reference, an independent clinical laboratory, said the deal is expected to add at least 1 cent per share to its earnings during its current fiscal year and at least 6 cents per share during its next fiscal year. Here and here are some previous notes about BRLI in Lab Soft News. Here is a link to the GeneDx home page.

Connecting With Lab Professionals in Brazil

I posted a previous note about a lab and medical diagnostics facility in Brazil called Fleury -- here is the link to it. Fleury is only one example of a Brazilian lab with very sophisticated deployment of IT.

Over this past weekend, I noticed a large bolus of visitors to Lab Soft News from Brazil. The number of visitors to this blog from other countries has remained remarkably constant since it was launched last December, accounting for about 19% of the overall total. The leading countries of origin for visitors have been, in approximate rank order, Canada, United Kingdom, France, Germany, and India. This past weekend, there was a very abrupt increase in visitors from Brazil. I emailed Pedro Gunther, a Brazilian lab colleague, to inquire about this and he responded in the following way:

I think you can blame me. I wrote an article for Labornews (magazine) and posted a link in the last edition of our electronic bulletin (Saturday). I have 7.000+ subscribers to our newsletter. It's a job of 10 years capturing people interested in lab informatics in Brazil. The shortcut for the article with links to your blog and congress is here. I hope I didn't write anything wrong.

Pedro Gunther
pedro@hotsoft.com.br
44-3226-4453

I continue to be impressed with the global reach of the web and how easy it is to reach out to lab professionals around the world. This incident illustrates how  people interested in lab and pathology informatics in Brazil have been brought into this blog community.

One of my current pet projects is to try to create an overarching lab metasite with vertical search capabilities that will encompass a wide array of web resources (links to previous notes about this topic here and here). This would create a clinical lab network that lab professionals from around the world can access to communicate with peers and obtain rapid answers to their questions. This Brazil connection shows how such a network may be evolving one piece at a time.

Superb Example of a Mash-up

I discussed the topic of Web 2.0 in previous notes here and here. Web 2.0 can be defined in the following way (link to the detailed Wikipedia definition here):

...a perceived ongoing transition of the World Wide Web from a collection of websites to a full-fledged computing platform serving web applications to end-users. Ultimately Web 2.0 services are expected to replace desktop computing applications for many purposes.

For lab professionals, the major impact of Web 2.0 will be, as noted in this definition, that web sites will eventually serve as a "full-fledged computing platforms." In other words, web applications currently running on local hospital servers will migrate to the web. I discussed this idea in detail about SaaS (software as a service) and compared it to the ASP model in a previous note that can be read here.

Another type of web-based application that is closely identified with Web 2.0 is the so-called mash-up. Below is a description of a mash-up, which commonly uses the Google Maps API as a core component (link here):

Google's easy-to-use mapping API has created an explosion of map "mash-ups," applications that add features or data to Google's map interface. Whether the mash-ups display store locations, gasoline prices, or time and weather on a map, ultimately it's the data that makes these mash-ups interesting.

I have just discovered a beta version of what I consider to be a superb mash-up. It's called Zillow and here is the link to it. The site is very useful for buyers, sellers, and owners of homes in the U.S. One enters the address of a home and Zillow displays the estimated dollar value of the home and also that of neighboring properties. For some parts of the country, satellite images are displayed in the hybrid view, showing a birds-eye view of the properties with the values superimposed on them.

Zillow is thus a mash-up, integrating street maps and satellite images of homes with publicly available property tax roll information and some sort of algorithm to calculate property value increases since the last assessment. Information has been defined as "any difference that makes a difference" and this site is a good illustration of what this means for 67 million home owners.

Some Reflections on LIS RFPs

There are two major goals when writing a "request for proposal" (RFP) as part of the process of selecting a new LIS. The first, and the one that most commonly comes to mind, is to create a complete list of the desired functional components of the system that is being sought. Those vendors who respond to the RFP will indicate whether their system has the functionality referred to in each of the line items in the RFP, sometimes indicating that it is "in development." A healthy amount of skepticism is warranted about such claims. To counter any overblown claims, the vendor's response to the RFP should be attached to the final contract, thus making any such claims legally binding.

A second goal to keep in mind during the development of an RFP is to use the occasion as an opportunity to analyze the current and evolving functional and business requirements of the laboratories to be served by the LIS. The vendor chosen in the competition will be a critical partner for many years to come.

I received an advertisement from a company called On-Line Consultant Software (here is the link) that offers to provide the following services:

The ON-LINE CONSULTANT will help you create your RFP for a new laboratory information system (LIS) and automatically evaluate vendors' responses. You'll get off to a quick start with pre-loaded questions to survey your users, ability to send RFPs (questionnaires) to vendors by email, automatically upload their responses... and easily generate detailed reports and graphs that compare vendors on functionality, cost, training, support, and other important factors.

My first instinct was to dismiss the value of this product, my personal bias being that the RFP can and should be developed locally. However, the company provides nearly 100 samples of LIS functional requirements (see link above) that I thought were very instructive, both in terms of the specific requirements and also in the terse style in which they are constructed. Here is a list of the first 15 of them:

• Store diagnosis codes in registration function.
• Support retrieval of patient records by partial (e.g. first few letters of) patient last name.
• Support interface to order communications system of HIS to automatically receive order data.
• Include test, profile, or battery name (mnemonic code) in order data.
• Process orders for profiles that include multiple tests (e.g. cardiac enzyme profile).
• Allow a miscellaneous test code so previously undefined tests can be ordered and charged.
• Ability to correct a field on a screen without having to re-enter entire order transaction.
• Allow entry of orders for future dates.
• Allow splitting one ordered test into more than one request (e.g. group tests, pre-op, coag screen).
• Allow review and verification of held orders on-line by technologist.
• Automatically check for and warn of duplicate single test orders with profile orders.
• Support cancellation of tests--logging accession #, test code, patient name, reason, date, time, and tech ID.
• Provide simple method to order additional test requests on sample already received and processed in lab.
• Allow cancellation of an order without canceling results.
• Provide access to price information within order entry function.

The total list and the product offered is worth a look for those labs seeking a new LIS. I should also point out that most labs that have completed an RFP process will be willing to share a copy of their document with colleagues. Look for labs that are roughly equivalent to your own in terms of size and complexity when seeking model documents to draw from.

Doctor-Owned Hospitals to Proliferate

It has been predicted that doctor-owned hospitals will proliferate now that federal funding will once again become available for their development. Proponents of the 200 or so doctor-owned hospitals in the United States say they are streamlining medical care with their efficient surgical centers. Here is the link to a recent article about this topic and below is an excerpt from the story:

Doctor-owned hospitals are set to proliferate now that federal funding will become available again....Critics say these hospitals could skim off the most profitable patients from an already overburdened health care system, leaving it with the sickest and poorest clientele....Meanwhile, proponents of the 200 or so doctor-owned hospitals in the United States say they are streamlining medical care....The hospitals grew rapidly in the 1990s, then stalled in 2003 as federal regulators imposed a temporary funding ban. The government was worried that these "specialty" hospitals would siphon resources and dollars from their general counterparts.The U.S. Centers for Medicare and Medicaid Services concluded earlier this month that doctors were not earning disproportionate returns on their investments. The agency, which insures the poor as well as the elderly, did add new financial disclosure rules and required the hospitals to take emergency patients.

Look for increased tension between health systems and cardiologists/orthopedic surgeons who admit patients to non-profit hospitals but also invest in competing specialized healthcare facilities in the same communities. Health system executives contend that such facilities skim off those patients and procedures with the highest profit margins. Doctors respond that community non-profit hospitals have no legal basis for excluding them from their staffs as long as they meet the same professional criteria as other physicians with admitting privileges in the facilities. In other words, they contend that they can't be excluded merely because they are economic competitors to the non-profits.

UPMC Profits Up 77 Percent to $512 Million

I posted a previous note about the 2005 compensation for the CEO at the University of Pittsburgh Medical Center (UPMC) that can be found here that stated the following:

During fiscal 2005, Mr.[Jeffrey] Romoff earned $2.88 million in compensation, or more than one-fourth of the $10.26 million earned collectively by CEOs at the 17 hospitals and two health systems in Allegheny County that reported salary information.

Now Mr. HIStalk (link here) alerts us to a news story about the financial performance of UPMC in the latest fiscal year. Here is the link to the story and below is an excerpt from it:

Profits jumped to a record $512 million -- a 77 percent increase -- at the University of Pittsburgh Medical Center in the year ended June 30, officials said Thursday....Total revenues for the health system were $5.99 billion for the year, up 17 percent from $5.12 billion in the previous year....UPMC's profit margin of 9 percent -- profit as a percentage of revenue -- soared higher than for-profit hospital companies like...HCA, one of the nation's largest hospital systems....UPMC said it continues to commercialize health care products and technologies in the United States and other countries, including a $100 million contract with Hamad Medical Corp. for emergency medical services in Qatar....Already the biggest employer in the region, UPMC said it added more than 1,800 jobs. That brings the total to more than 43,000 employees, including 2,300 employed physicians.

Here is a link to an article on the web from last June about the $100M deal between UPMC and Hamad Medical in Quatar, referred to above, under which UPMC will provide emergency medical training and technical support for four hospitals in that country. I suspect that most health system CEOs couldn't even find Quatar on a map.

You will not hear any carping about Mr. Romoff's salary from this insignificant corner of the blogosphere.

HHS Announces Safe Harbors for IT

I have written a previous note regarding "safe harbors" as they relate to health systems providing PCs to physicians for their offices and designed to interact with hospital systems such as the EMR (link here). My note at that time said that the Stark and anti-kickback safe harbors aimed at enabling hospitals to subsidize the extension of IT to their affiliated physicians are nearing completion. Here is the link to a story indicating that the new regulations have now been announced. Below is an excerpt from the story (boldface emphasis mine):

Current anti-kickback rules prohibit a physician from referring Medicare patients for certain health services to entities -- such as a hospital -- with which the doctor has a financial relationship. Because of this, hospitals were reluctant to give physicians computer hardware or software, which could be used to transmit patient data back and forth....The CMS exception under the physician self-referral law for arrangements involving the donation of EHR technology will protect the provision of software or IT and training services that are necessary and used predominantly to create, maintain, transmit or receive the EHRs of the donor's or physician's patients.... A similar safe harbor was offered by the Office of the Inspector General. It involves the donation of EHR technology and includes a cost-sharing requirement. Recipients are required to pay 15% of the cost of the EHR technology items and services.

I don't see any references to LISs in this article but such references may exist in the detailed regulations. My previous understanding was that hospitals labs with outreach programs could provide PCs gratis to physicians for office use with the understanding that the devices would be used solely for interacting with a reference lab.

With the development of browser-accessible lab portal systems and the now routine availability of PCs in physician offices, this strategy and rationale would no longer seem necessary. I am not sure about the relevance of the OIG 15% cost-sharing requirement for the physician office referred to above nor how one would even calculate the cost of IT services.

Alternative Medicine Laboratories

I can't precisely define an alternative or complementary medicine laboratory but I tend to define it as a laboratory that supports components of alternative or complementary medicine. I was browsing the web recently and came across a list of "alternative laboratory" sites (link here) and have copied the list below, eliminating the DAT sites and also those that offer home test kits, which don't fall under my definition of an alternative medicine lab:

• Athena Diagnostics (link here)
• Body Balance (link here)
• Diagnos-Techs (link here)
• EnteroLab (link here)
• Great Smokies Diagnostic Laboratory (now called Genova Diagnostics; link here)
• The Great Plains Laboratory (link here)
• YorkTest (link here)
• ZRT Laboratory (link here)

I have an interest in these alternative medicine labs and the types of testing that they offer. In a previous note (link here), I discussed how BRLI, a mainstream reference lab, describes itself as providing services of this type. In the note, I also make reference to Genova, formerly Great Smokies Diagnostic Lab, which is the "mother" of all such labs. I plan to discuss some of the alternative labs listed above in an ongoing series of blog notes. I will begin this series with a brief discussion of YorkTest, which is located in the U.K.

Here, copied from the YorkTest home page, is a summary of the services that this lab offers:

...the core area of the business lies in food intolerance testing. The YORKTEST food intolerance tests require just a small pin-prick sample which we then analyse at our laboratories - from that we are able to give advice on what foods should be avoided and what can continue to be enjoyed....When the test has been completed, our customers are entitled to a telephone consultation with one of our qualified nutritionists.....

The 113 foodSCAN Test is priced at £250.00 (link here) and the 42 foodSCAN, suitable for children and those on a limited diet, is priced at £125.00. The scientific basis for these test panels is the presence of IgG in the serum directed against various foods tested, as noted in the following explanation from their web site (link here):

Raised levels of IgG antibodies within your blood indicate food intolerance. If you have already taken the decision to eliminate a particular food and have not been eating that food for over a month, it may not show up on your results – even if you are intolerant to it. This is because the level of IgG within your blood will have reduced because of the elimination.

Here is a link to an article on the web entitled IgG Food Allergy Testing by ELISA/EIA; What Do They Really Tell Us? that questions the validity of such assays.

Ventana Medical to Acquire Australia's Vision Systems

Ventana Medical Systems has agreed to buy Australia-based Vision Systems in a deal worth $346 million. Here is the link to the press release. Here is a link to the Ventana home page and here is a link to the Vision Systems home page.

Here is how Ventana describes its company mission on its web site (link here):

Ventana Medical Systems develops, manufactures and markets instruments and reagents to automate diagnostic and drug discovery procedures in clinical histology and drug discovery laboratories worldwide. Our instrument-reagent systems are designed to standardize the preparation and staining of patient tissue or cells mounted on a microscope slide for examination by a pathologist.

Here is how Vision Systems describes its business (link here):

The company comprises two globally-based operating businesses. (1) Contract R&D Services: provides unique research and development capabilities to Vision BioSystems and external customers including many of the world's largest biomedical, industrial and consumer goods companies; (2) Clinical Diagnostics: produces automated system solutions and also manufactures in vitro diagnostic (IVD) instruments for the cancer detection market on an OEM basis.

One of the articles commenting on the transaction described it in the following way (link here):

... creates the premier global supplier of anatomical pathology solutions with one of the broadest product offerings of both systems and reagents for clinical and research customers.

There appears to be some product overlap between the two companies such as in the tissue processor and staining system lines but I assume that this will be addressed in time by the new entity. There is no question but that this new company will dominate the global anatomic pathology market.