Lab Soft News

Common Lab Tests Predict Higher Mortality in Healthy Seniors

WebMD reports a study (link here) whereby certain combinations of 13 common lab test results can predict high mortality in otherwise healthy septagenerians. Below is an excerpt from the article:

The finding comes from a detailed study of 1,189 remarkably healthy 70-something men and women, originally studied as examples of successful aging. Twelve years later, about half of these people were dead.... UCLA researcher Tara L. Gruenewald...analyzed results from 13 lab tests performed when these men and women first entered the study. These "biomarkers" covered risk factors for heart disease (such as blood pressure), tests of immune activation, tests for stress and steroidal hormones, and tests for metabolic factors [such as cholesterol]. Certain combinations of lab tests formed "trees" of death. For example, there were 28 deaths among 30 people in one particularly lethal "tree." This tree was a combination of high levels of adrenal hormones and high levels of C-reactive protein or CRP....[T]he findings, in combination with breakthroughs in understanding the genetic basis of common diseases, is leading to an era of individualized medicine.

This study is a good example of an approach to the use of biomarkers whereby a researcher starts with a study population and, in effect, works backwards. The process is analogous to analyzing tissue samples of metastatic prostatic tumor and determining which of its genes are upregulated and which are downregulated. These results can then be used to determine which biomarker pattern can be use to predict a tumor with the potential to metastasize. In this case, there was high mortality among septagenerians in a lab test "tree" with elevated CRP. CRP is the most sensitive of the acute phase proteins but, on a chronic basis, the test is a useful marker for existing arterial disease and future risk (link here).

With regard to individualized medicine, the key question in this case is what treatment a priori might have been offered to these subjects in the "lethal tree" to reduce their high morality rate. I called a cardiologist friend and he said that one obvious approach would have been to start them on a statins or, for those already being treated with a statin, to increase the dose.

Lab InfoTech Summit 2007 Brochure Now Available

The brochure for Lab InfoTech Summit 2007 is now available here. The conference will be held on March 5-7, 2007, at the Venetian Resort Hotel in Las Vegas. You can also point your browser to the official conference web site (link here) to view the brochure and register on-line. I will periodically highlight in Lab Soft News from now until next March some of the interesting aspects of the conference. For one, the workshop on the development and deployment of lab rules will be webcast to lab professionals without any cost. More details about this activity will follow.

For those interested in attending the conference, I would urge you to make your hotel reservations at the Venetian relatively soon. We have reserved a block of 175 rooms at the hotel for the prime conference nights at a rate of $219 per night. The rate currently offered by the hotel on its own web site for March 5, 2007, is $399.

Progress in the Development of Lab-on-a-Chip Technology

Lurking in the background as a challenge for all of us is the development of lab-on-a-chip technology. This will be an example of disruptive technology that will change the nature of the clinical lab industry. Here is a link to a story about one example of this technology and below is an excerpt from it:

The Accelr8 technology ( link here) is a "microfluidic" lab-on-a-chip designed to manipulate and analyze bacteria without growing them first. Samples are first washed out of the patient's lungs with saline solution in a procedure called bronchoalveolar lavage. The organisms are then separated, suspended in a specially designed fluid, and pumped into the chip. Inside the chip, the bacteria flow into several different compartments -- eight in the current version of the chip -- and are made to stick to a bacteria-friendly surface using an electric current. Antibodies then flow in. The antibodies bind specifically to certain strains of bacteria, and mark them with fluorescent dyes of different colors. The dyes color-code cells from known strains. A microscope monitors the viable cells -- those that are still reproducing -- and the rate at which they duplicate helps to identify their species. In the next step, different antibiotics are pumped into the chambers.... The death of the bugs is confirmed by checking with a special dye. Once the bacteria-carrying fluid is injected into the chip, the entire procedure is automatic-- including the counting of fluorescent-marked cells, which is done by a computer -- and takes less than eight hours.

I make reference to this particular chip not to endorse it but rather to provide a glimpse of the future. Here we have a classic example of so-called disruptive technology (link here) that has the potential to overturn existing technology in the market. For comparison purposes, it differs from sustaining technology that improves the performance of established products. Using the current example of a lab-on-a-chip as it applies to the microbiology lab, the chip (or set of chips) has the potential to replace an entire microbiology lab, some of the personnel working in that lab, and can perform a set of tests in one eight-hour shift rather than multiple days.

Such chips are obviously not yet ready for daily use. However, in my mind, they will be an integral part of lab practice in five to ten years. There is only one way to react to such disruptive technology -- embrace it before the competition does.

The Three Root Causes for Major System Failures

Below is an excerpt from an email written by my colleague at the University of Michigan, Dr. Ulysses J. Balis. He currently serves as the Director of Informatics in the Department of Pathology. This is his response to a hospital physician who asked him why major systems fail.

1. Application Not Designed to Scale:  Because not all database programmers are created equal, neither are the mountains of code that they produce.  An inappropriately recycled segment of code designed to perform multiple joins for a complex report retrieval can quickly generate highly non-linear query cross-products. If such a returned table has, for example, 40 rows, the execution time will be .020 seconds. However if it contains 4500 rows, the execution time can reach 30 minutes. This difference is due to the intermediate query cross-products that take up to several billion (not million) rows to fully populate. With the use of some simple intermediate tables, this cross-product problem can be easily avoided and the system performance will scale linearly with set size. Because it is quite common in deployment timetables to ignore system load-testing prior to go-live, it is also quite common to launch a new system and to discover only then that the application cannot respond to the live transaction volume.  This is the class of deployment error plaguing Kaiser at present (link here).

2) Inadequate Resources to Properly Deploy/Enhance the Application:  No commercial product comes ready to deploy in a hospital "out of the box". Some local additional effort will always be required at the time of deployment including the need for co-development of the application to allow it to perform at the expected level of functionality. If neither the vendor or the client can provide the resources to make these necessary changes, the final build will be inadequate in scope and the deployment will fail. This is the prototypical area of IT software deployment where more time or more development resources can prevent a go-live failure. However, throwing additional resources at a project immediately prior to go-live is not a sure thing because 10X additional programmers does not necessarily equate to 1/10th the completion time for a code change.

3) Inadequate Training of Users:  Regardless of the quality of the software deployment, if end-users are not ready for the change, the deployment will either greatly suffer or fail.  A common pitfall is to train users and then to push back the go-live date because of the need for more development/fixes. In the interim, users will invariably forget most of what they learned during training and the ensuing go-live will be a disaster.  A simple operational rule mitigates this reality: If you move the go-live date by more than two to three weeks, you must retrain the entire staff.  The new training regimen can be an abbreviated but it must be offered shortly before the new go-live date. People generally do not retain skill sets that they are not actively using.

Why Cats (and EMR Consultants) Don't Bark

In a previous post (link here), I discussed EMR consultants, emphasizing the following quote from Mr. HIStalk (link here):

Name the consultant and I'll tell you with 80% accuracy which product they'll recommend even before they bill the first phone call, although that's offset by the 50% of hospitals that ignore the advice they're paying for anyway.

I have been asked why healthcare executives pay very high prices to name-brand EMR consultants for such little value and why, in turn, the consultants do not feel compelled to provide a higher level of services to the hospital executives that engage them. In other words, why pay good money when the recommendations are totally predictable or ignored. The answer to this question is similar to the question of why cats don't bark. It is not in their nature to do so and it is not in the nature of EMR consultants to behave otherwise.

HIT consultants do, in fact, deliver substantial value to health system executive but it has little to do with recommending the most suitable EMR for the health system. It is the "nature" of EMR consultants to seek two goals: (1) to reproduce themselves; and (2) to generate new consulting contracts and more revenue. EMR consulting firms have an informal working relationship with a particular vendor and will pick that vendor perhaps 80% of the time, as observed by Mr. HIStalk. This avoids the nuisance of having to learn the details about a new system. The vendor, in turn, will steer potential clients to their favored consulting firm, knowing the positive bias of the firm.

All EMR consultants and hospital executive know that at least three-quarters of all installed EMRs will underperform or fail. The "value" delivered by the consulting firm for the hospital executives is an insurance policy -- the health system executives will have someone to blame when the installed systems perform poorly. It is then imperative for the consulting firm, when singled out as the cause of the problem, to deflect blame from themselves to some other person or group. Here is the list of the four prime candidates to blame:

1. Hospital physicians and nurses who have proven to be untrainable on what is obviously an excellent EMR that has been road-tested in multiple other hospitals. This excuse can backfire and should be used with caution because physicians and nurses can bite back. Here is the appropriate statement that can be whispered to the hospital board members: "Our physicians and nurses dropped the ball on this one because they were so busy delivering quality care."
2. The healthcare system CIO or one of his/her major lieutenants, but only if that person is known to be incompetent and/or deeply wounded politically. In this case, the CEO needs an excuse to fire the CIO and owes some later favor to the consulting firm. If the CIO is fired, the consulting firm will immediately hire him or her in order to have someone on the team who has actually worked in a healthcare setting.
3. The EMR vendor, but only if the failure is one in a series that have received major publicity and another favored vendor has already been lined up. This is clearly not a favored option because the new system needs to be learned and this takes time.
4. The healthcare system technical personnel. Having floated this excuse, the consultant then launches into a highly technical critique about hardware and arcane system architecture until told to sit down. This discussion frequently leads to a proposal from the consulting firm to manage the hospital IT department on an outsourced basis.

RentACoder: LIS Database Requested

Need an LIS? A little short on ready cash? Try RentACoder. Here is the link to a recent entry on the site and below is the software request:

I represent a small clinical testing laboratory. We are looking to build a database to house, organize, and inform us about the specimens we process. The big database will be the "Sample" and the sub-databases will be Patient, Test Panel, Referring Provider, Client Program, and Payor. We will be building additional reporting, billing, and analytical modules on top of this skeleton database, but we figured that this project would be big enough to grapple as it is. Please provide a quote and an estimate on how long it would take for you to complete this project.

So what's RentACoder all about? Here's a brief description of how it works from the home page. More information can be obtained at the web site.

Need a program created? Receive bids from our pool of 159,811 registered coders. Review work histories and resumes online, and then conduct business stress-free using our "Safe Project Escrow" (link here).

Posting a bid request is free, and you are under no obligation to accept any bids sent to you unless you choose to. Once you accept a bid, you will place your payment into escrow. The money is not released to the coder till they complete the work according to your original specification. There are no service charges or finders fees for buyers (link here).

Do you have a question about who owns the software code upon delivery? Here's the answer:

All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased (link here).

Among the top ten coders competing for jobs on the web site, one of whom has completed nearly 400 of them successfully, the home countries are the following: Romania (3), India (2), USA (2), Ukraine (1), Russia (1), and Argentina (1).

So, is this the way to build an LIS? It seems to be one way to get the job done.

Toyota Opens Health Facility in New San Antonio Plant

I have published a number of note about new settings for primary care delivery such as walk-in clinics in retail drug stores and big-box stores (links here) and also on-the-road clinics for Schneider long-distance truckers (link here). Toyota, in a brand new truck plant deep in the heart of Texas, has decided to attack its healthcare costs, which have doubled in the last five years, while also increasing quality. Here is the link to the story and below is an excerpt from the it: 

In designing its newest plant, in San Antonio, Toyota is trying to tackle the [soaring healthcare cost] problem by building a clinic at the factory to provide a wider array of treatments and services than a typical factory medical office. The workers at the San Antonio pickup plant can have their eyes checked and their teeth repaired at the $9 million clinic, which also offers pediatric services, laboratory tests and physical therapy. By offering better primary care and preventive medicine, Toyota expects to rein in its health-care expenses. Companies that have adopted this approach tend to spend more for primary care and drugs, but that increase is more than offset by a drop in costly hospitalization and specialty care expenses....Toyota will gauge the success of the clinic by monitoring employees' health-care indicators, such as smoking-cessation rates and blood-pressure levels, and by tracking expenses ....Toyota would not require San Antonio workers to go to the on-site clinic, but it encourages them to do so by charging higher co-pays and deductibles for workers who choose to go elsewhere.

The on-site health care center will be operated by CHD Meridian Health Care (link here). The center will be open to Toyota’s 2,000 employees working at the plant and their dependents as well as the 2,100 employees of companies manufacturing parts for Toyota Tundra pickups at the 1.5 million-square-foot, $1.28 billion facility (link here).

There are lots of interesting issues raised by this story -- I will comment on a few of them:

• Toyota, as everyone knows, believes and invests in continuous quality improvement. Wellness programs can result in higher quality employee health. The company obviously believes that it can achieve better healthcare outcomes by more directly managing this function.
• Also of interest is that the company anticipates higher primary care and drug costs in connection with this new facility but that they will be offset by lower costs for specialist referrals and hospitalization. This makes sense intuitively and should also result in fewer sick days because of the earlier intervention.
• Although healthcare cost containment is one of the primary goals of this program, it's interesting that the company is establishing quantitative monitoring measures such as smoking cessation and blood pressure control. I wonder how frequently large multi-physician clinics entertain the idea of measuring the quality and efficacy of their professional services.

NHS Computer Czar "Outed" by his Mum

I have published previous notes about some of the twists and turns of the British National Health Service (NHS) and its struggle to computerize healthcare in the UK (links here). Richard Granger is the Director General of IT for the NHS. Prior to taking up this post in October 2002, he was a partner at Deloitte Consulting (link here). We now become better informed about his educational background courtesy of his mum. Here is the link and below is the story:

Richard Granger is one of the highest paid civil servants in charge of a £20billion project to transform the NHS's computer system. But despite his colossal £280,000 a year pay packet, Granger's 'Connecting for Health' project is over-budget, behind schedule and threatening to become the biggest IT disaster in history....His mother revealed that the man overseeing largest civilian IT project in the world failed his computer studies course while at Bristol University....The retired teacher, who hasn't spoken to her son for ten years after a family row, said yesterday: 'I can't believe that my son is running the IT modernisation programme for the whole of the NHS.

Clearly the Granger family does not believe in taking prisoners. However, I find that I must respectfully disagree with Mrs. Granger about one issue. Having deep technical knowledge about computing is not necessarily a requirement for leadership success in healthcare IT. In fact, sometimes it is a distinct disadvantage. In my experience, the most technically sophisticated individuals frequently have difficulty communicating with those lacking a similar technical background and also difficulty in understanding barriers to successful implementation of a system.

However, this does not get the leaders of HIT projects off the hook completely. One must assume that, in order for them to succeed, they must have other stellar leadership qualities. I am not sure if Richard Granger qualifies in this department but this article, and the "support" from his family, makes me want to root for him, at least for a while.

Should RHIOs Become ASPs?

I have posted a few previous notes about regional health information organizations (RHIOs) and the links can be found here. I don't have confidence in most of these initiatives. How can one integrate health information across a region when the providers of that information, the hospitals and health systems within a region, are themselves not well integrated within their own enterprises. Most tertiary care referral hospitals are also not highly motivated to share their clinical information.

However, on the theory that there has to be a pony in here somewhere, the idea now surfaces that RHIOs could succeed as ASPs of EMR software for small hospitals. Here are some previous notes about ASPs. Here is the link to the story and below is an excerpt from the article (boldface emphasis mine):

When he was US Health-IT czar, David Brailer stressed solving problems with interoperability, and as a result there are now several regional health information organizations (RHIO) in development...Unfortunately, the  most important healthcare providers -- small physician clinics that deliver most care -- are essentially off the information grid. So is the next logical step for RHIOs to become application service providers (ASP)?...Another consultant... believes that most big hospitals have little to gain from data exchange other than emergency-room information. [He] is working with the Great Plains Healthcare Alliance, which is securing a USDA loan to provide shared lab, pharmacy, radiology, and EMR applications to 26 small hospitals and their attached clinics in Kansas. While this model may make sense for rural providers, can a typical RHIO provide these services in a competitive market when local hospitals and technology vendors offer other options? The jury is still out. Although RHIOs have no experience in providing EMRs, for example, if RHIOs can subsidize the cost of an EMR, they may have an advantage.

The article does a good job of hitting all of the points why RHIOs will not succeed as ASP providers of EMR software to small hospitals even though the author tries to maintain a positive attitude toward the idea. Below is a summary of these points:

• The RHIOs have no experience in providing EMR software any form. It's even less likely that they would be successful using the ASP model that entails not only providing the application but also running it on remote servers for clients.
• Where would the RHIOs obtain the requisite EMR software in the first place? They don't have the expertise or time to write it and why would the for-profit companies that control such products lease them to a competitor.
• The article concedes that the RHIOs might have a chance if they obtain government subsidies to offset the true cost of the software. It would make much more sense for government grants such as those from the USDA to go directly to the companies that have developed the software. Such companies would have a better chance at running multiple instances of the EMR software for small hospitals using the ASP model. However, my guess is that such companies would prefer to lease their software to medium-size or large hospitals that can afford to pay for it and have the hospital personnel run it locally.

The Academic Medical Center as a Metastatic Lesion

I have written a number of previous notes about the entrepreneurship of the University of Pittsburgh Medical Center (UPMC) (links here). I am forced to return to this topic once more today by some news that has just come to my attention. Please indulge me -- I just can't help myself. Here is the link to the recent story that caught my attention and below is an excerpt from it (boldface emphasis mine):

The University of Nevada at Las Vegas] wants the 2007 Legislature to pony up more than $200 million toward construction associated with the Health Sciences Center, so it needs public support....For one thing, most people still think the project is going to be similar to the proposal made by the University of Pittsburgh in 2004. The University of Pittsburgh concept was to create an academic medical center in downtown Las Vegas where patients could receive medical care and students could be trained. But hospitals, university officials and local leaders, fearful of competition and the fact that they wouldn't have control over the project, discouraged that and said they could accomplish the same goal with existing resources.

Here is an article from August 2005 confirming the fact that UPMC wants to develop an academic medical center in Las Vegas:

The [University of Nevada at Las Vegas] and [Las Vegas] officials have been in negotiations with the University of Pittsburgh Medical Center, also known as UPMC, for months to jointly build and operate the training and research center...[A representative of a local hospital] emphasized that Nevada already has the medical expertise to strengthen and expand the University of Nevada School of Medicine and does not need outside help.

I understand that prestigious clinics like Cleveland Clinic and Mayo Clinic have developed branches of their prestigious hospitals in Florida and Arizona. However, I believe that academic medical centers constitute a special case and that it is questionable behavior for them to create distant clones of themselves.

It seems obvious to me that UPMC, flush with cash, is seeking to extend its reach into a booming city but one with a preexisting and established medical school (link here). Frankly, I am surprised that city and state officials have let this situation progress this far. However, this may also reflect the city's propensity to place its bets on "winners" and perhaps they don't place their own medical school in this category. Or perhaps they want to motivate their local institution to achieve a higher profile.

There is one compelling reason, however, for UPMC not to establish an academic medical center in Las Vegas. One of the basic tenets of a research institution is that it will seek to publish the results of any research that is successfully completed there. Such a goal clearly cannot be accomplished in Las Vegas because, as we all know, the mantra of this city is -- What happens here, stays here (link here).