Lab Soft News

On Mini-IT Departments Embedded in Hospitals

i have spent many years thinking about the issue that I will refer to here as decentralized versus centralized control of IT in hospitals. In the following excerpt from HIStalk, a reader comments on what are called "mini-IT departments." Mr. HIStalk responds with a hint that the would prefer that they not be tampered with.

(Comment from reader) "Re: mini-IT departments. I disagree with what I think this means. In healthcare IT the needs of specialized areas is often better served by IT personnel who have some degree of separation from the Central IT Commissar. The analogy makes the assumption of a symmetry' between IT personnel and clinicians, while there is a great asymmetry. Clinicians enable healthcare; IT personnel facilitate it; clinicians are accountable for patient harm and death; IT personnel are not. When IT personnel move away their control mentality and become part of the clinical team, everyone (including the poor patients) will be better off."

(Mr. HIStalk response) I editorialized this week in Inside Healthcare Computing about that topic, which I called "Rogue IT Shops: Provide Rules, but Leave Them There." Darn, now I've given away my conclusion. Well, my arguments were equally fun.

I have personally managed an LIS unit embedded within a department of pathology (a mini-IT department) and also served served as an IT director for "ancillary systems" with a large portion of my salary coming from the health system CIO. I am thus familiar with the issues on both sides of the fence. It will probably come as no surprise to the readers of Lab Soft News that I strongly believe that "min-IT shops" in pathology and radiology should be allowed to operate semi-autonomously. I use this adjective cautiously because there is sometimes value in directives from higher management echelons.

Central IT personnel strive for uniformity across departments. For ease of management, they like to work with a small number of name-brand vendors for both software and hardware. They work with large numbers: large numbers of users and large hardware and software vendor contracts. The complaints of physicians are considered minor irritants that can be dealt with. Their primary concern is keeping the CIO and CEO of the health system happy.

IT personnel working in an "ancillary department" such as pathology, clinical labs, radiology, and pharmacy work side-by-side with the personnel who are delivering direct patient care. In such "mini-shops," system functionality trumps all other issues. The nameplate on the hardware or software is not a major concern. Harmonization/integration with other hospital software is agreeable but also not a driving force.  As noted above, Mr. HIStalk says that "rules" need to come from above. I would stipulate that the "rules" coming from above need to have some rational basis and they must result in greater efficiency and effectiveness of those clinical units in hospitals that are affected by the rules.

A New Advertising Approach for a Web Search Engine

The April 23, 2007, issue of the New York Times contained a full-page advertisement for About.com, a web search engine. The advertisement contained an image of three attractive young women and featured this headline: If it's about health information with a human touch, it's About.com.

This ad definitely caught my attention for the following reasons:

• The young women are identified as "professional guides" (i.e., About.com employees) at the service of those using this search engine.
• This search engine was emphasizing its "soft" human values rather than its "hard" technical attributes (i.e., the code under the hood).
• About.com was also highlighting its health content, which can be linked to from the home page as a subsection.

The manner in which About.com has chosen to structure its home page is also very interesting on a number of counts for what is primarily a search engine:

• In the left hand column of the home page, you can browse (not search) by channel. Channel is the term chosen for high-level categories such as auto, health, or travel. You can also click on a button to browse by topic (button located at the bottom of the channel list), which takes you to a  detailed alphabetical list of specialized topics.
• In the lower left of the home page, there a set of tools provided to help the user with a specific quest: compare prices, travel center, yellow pages, and find a job. Such tools anticipate the needs of users and also simplify the search.
• In the middle column of the home page, a list of featured articles is offered such that this search engine takes on the trappings of a web portal.
• From the home page, you can also link to the "our story" section of the web site. Here the role of the guides referred to above is explained in more detail:
  
  • Today, when you read an article on About.com, you are tapping into a powerful network of 500 Guides -- smart, passionate, accomplished people who are experts in their field. Our Guides have written books, appeared on national television and won many awards in their field.

So what is this all about? The search engine business is an extremely competitive one because billions of dollars of ad revenue are at stake. Healthcare is one of the most important components of search and a favorite topic of consumers browsing the web. The About.com business strategy is obviously to enhance the web search experience by adding a strong human factor (the expert guides) to improve search results out of the gate. Whether the quality of searching with this approach is superior to that of the more technical algorithm-driven approach of, say, Google, will get played out in the months ahead.

 

Owning Versus Enabling in Healthcare

Jeff Jarvis has posted a very insightful blog note in response to the news that Time Warner was thinking of reducing its financial stake in the cable industry because information access (i.e., owning a cable company) has become a commodity (see: No more wire hangers). The company has decided instead that it wants to own or control content. Jarvis opines that owning content also has no future. Below is an excerpt from the note:

Time Warner has decided it wants to own content instead. But I’ve argued that owning content also has no real future. For that matter, owning isn’t a verb with value. Enabling is what you want to do. Google doesn’t own. It enables. MySpace enables — and its vulnerability is that it still owns and controls. Craigs List enables. YouTube, Flickr, FaceBook enable. Pure enablement is the model of the future, I think. So what media should a media conglomerate own, if not cable? Newspapers? Ha! TV stations? You have to be kidding. Magazines? Stop, you’re killing me. Networks? Nope; they all accrued their value by controlling a scarcity that no longer exists. So I’ll repeat the question: What should they own? AOL? Oh, that was below the belt. No, I wouldn’t want to own AOL or Yahoo or even MySpace. They try to control. And controlling will not work in an economy that is based on handing over control, of distributed control.What enables instead? Hmmmm. Google. YouTube. DoubleClick. Blogger. What they have in common is as obvious as Google’s strategy: They enable.

There is a significant lesson here for the healthcare industry in general and the lab industry in particular. There is high quality lab-oriented content widely available on the web. In writing this blog, I depend totally on web resources and search engines like Google for discovery. Using Google Alerts, I am notified about breaking lab news via email as it happens at no charge. All that I need to do is supply the service with a set of key words to filter for the lab news that interests me. Google functions as, to use Jarvis' term, the enabler that allows me to generate this blog.

Lab Soft News is itself an enabler for both lab professionals or healthcare consumers who link to it after performing their own searchs for a lab topic of interest to them. So what specific enabler niche does a professional blog like as Lab Soft News fulfill? The blog, and others like it, serves as a filter for busy professionals who want a quick dose of lab news accompanied by a brief analysis. As I have noted before, also in response to a Jeff Jarvis note (see: Content on the Web Is Already Free), readers of this blog are "paying" for access to this blog with a very precious currency, their attention. It's not really free.

Mr. HIStalk Comments on KLAS

Mr. HIStalk recently published an exclusive interview with Adam Gale, EVP of Operations for KLAS. Below is an excerpt from a HIStalk note consisting of a comment from one of the readers about the interview and the response by Mr. HIStalk (Monday Morning Update 04/30/07):

(Reader Comment) "I was also a bit disappointed with the KLAS interview. We have heard on multiple occasions some inconsistencies related to the KLAS process. It would have been nice to see them go right after it and take the aggressive position. Open the books to the public so we can see what the process should be and provide a mechanism to report back if we feel the process has been breached."

(Mr. HIStalk Response) That's a great idea. The weak part of the process might be that the behaviors of the telephone surveyors are not monitored. HIMSS Analytics (and Dorenfest before them) used to do a terrible job of that. The surveyors were paid just to get answers, not to ensure quality, so they would freely tell you that, if the question wasn't even appropriate, that they'd just put down some answer so they (and you) could move on. They were your accomplices in just getting the call over with, even if its conclusions would be fatally skewed. I like the idea of giving respondents a clear method (like an e-mail follow-up) to express any concerns.

Once again, Mr. HIStalk is right on target. I had a single interaction with a KLAS surveyor a number of years ago that I found it very frustrating. Mr. HIStalk's comment brought back the memory of that telephone conversation, which I have reconstructed below from memory so consider it only an approximation:

Q. How would you rate the "SuperLIS" on a scale of 1-10.

A. Impossible question to answer. This system is not suitable for all labs. It's designed for more those more complex labs that need to address more complex computing issues.

Q. OK. For a more complex lab such as yours, how would you rate the "SuperLIS" on a scale of 1-10.

A. Impossible question to answer. I would need to have much more information. What is the LIS that the lab is currently running. Why do they want to change systems? How large is the IT staff devoted to managing the LIS? I would also need to understand the business model of the lab. For example, do they have an active lab outreach effort?

Q. What's an LIS?

A. [dial tone]

So you get the idea. Extremely complicated issues such as the evaluation of an LIS can't be reduced to a numerical scale. I finally told the surveyor that I needed to opt out of the survey but I did not hang up, as indicated above. I have paid little attention to the KLAS ratings since that time. The LIS vendors with whom I interact tell me that they are happy to trumpet their standing when it's high but will ignore their KLAS score when its low. Given that the company is still in business, I assume that they are able to sell their products to various parties -- just not to me.

Electronic Communication of Pathology Results

Dr. Ray Lin Department of the Department of Laboratory Medicine, National University Hospital at Singapore, has called my attention to a white paper published by the Royal College of Pathologists of Australia in November 2006 entitled Electronic Communication of Pathology Results. It's a short but fascinating document. I have copied the key elements of it below.

VIEWING OF RESULTS

1. Results must be displayed in their full context in order to allow proper interpretation.
2. Wherever numeric pathology results are displayed, the relevant units of measurement and reference intervals must be simultaneously visible at all times. It is not adequate to provide access to this information through daughter windows in such a way that viewing it becomes discretionary.
3. Any textual comments issued with a report must be displayed before a viewer can exit from a result enquiry session.
4. Viewers must not have the capability to modify the result display in such a way that units of reference, reference intervals or textual comments can be omitted. Systems should incorporate the option to freeze the units of measurement and reference interval column(s) if the user wishes to scroll through cumulative results.
5. Electronic results displays must include a function that enables the viewer to identify clearly where a test was performed.
6. Where results from different pathology services are displayed adjacent to one another (e.g. in an Electronic Health Record), there must be a flag to indicate that this difference should be considered when interpreting and comparing the results.

GUARANTEEING OF RESULTS

1. The College does not support the truncation or modification of pathology reports following release by a pathology service for the purposes of electronic display formats.
2. As electronic systems may be beyond the control of the pathology service, results transmitted electronically should only be guaranteed if they have been 'rendered for display' and are not therefore subject to modification.
3. If ‘atomic results’ are transmitted, the pathology service should advise that whilst the integrity of individual results is guaranteed, no responsibility is accepted for the manner in which the results are displayed following transmission, and using or displaying results in
an incomplete manner is not supported.

This white paper by the Royal College of Pathologists of Australia concerning Electronic Communication of Pathology Results is both clearly written and extremely relevant to lab operations in the U.S. today because test results from LISs are commonly replicated to electronic medical records (EMRs) in hospitals. These EMRs then become the primary reporting vehicle for the labs to physicians. I was impressed with the very clever use of terms in the report such as "atomic results," which I take to mean replicated test results that are stripped of important accompanying data such as the test reporting units or reference ranges.

My first instinct after reading this document was to suggest that all of the U.S. pathology professionals societies should adopt a similar or identical set of recommendations for use in this country. However, it also occurred to me that there may be few if any EMRs running in large U.S. health systems that would be actually compliant with these recommendations. Given that some of the major U.S. EMR vendors also have installations in Australia, this thought made me wonder if all of the Australian EMRs are compliant with the recommendations or whether they were published as a suitable HIT goal for vendors to work toward. Perhaps someone from Australia could respond to this question.

 

Cost of Deployment of EMRs in Physician Offices

In previous notes, I have distinguished between hospital EMRs and physician office EMRs. You can link to these notes for background reading. Although the data management demands of these two types of systems are usually quite different, there are frequent calls for both increased deployment of office EMRs and also the integration of these two disparate islands of health information. I came across an article in the former category (see: AMA supports health IT adoption in doctor's offices; calls for increased security of patient data and funding assistance). Link to the entire article, if you care to read the whole thing, but what caught my attention was the reference in the article to the cost of office EMRs. Below is the relevant excerpt:

A common barrier to HIT implementation in physician practices, especially smaller practices, is the significant cost. The AMA strongly urges Congress to consider direct means to assist physicians, such as grants, low-interest loans, increased reimbursement for the use of HIT, accelerated depreciation for HIT investments, tax credits, and other economic incentives. A study by Robert H. Miller found that initial electronic health record costs were approximately $44,000 per physician with ongoing costs of about $8,500 annually. A report by the Congressional Research Service estimates similar per physician cost, with HIT start-up costs ranging from $16,000 to $36,000.

Germane to the question of cost-per-seat for an office EMR, Mr. HIStalk posted the item below regarding a contract between eClinicalWorks and the city of New York:

And speaking of eClinicalWorks, it gets a humongous deal -- $19.8 million -- to provide its EMR system to 1,300 New York City providers who care for Medicaid recipients, prisoners, and other disadvantaged patients. eCW will open an office in Manhattan to manage the new business. That's over $15,000 per doc, well above their standard price of $5,000, so hopefully the city gets something more than the usual software.

I have discussed eClinicalWorks in previous notes. Mr. HIStalk later elaborated on this item to state that the term "provider" in the reference above referred to medical practices and not to individual physicians. Assuming  an average of two physicians per practice, the initial cost per seat under the terms of this eClinicalWorks contract was estimated by him to be only about $6,600. So, as far as initial cost for the installation of an office EMR, we have estimates varying from about $6,600 to $44,000. This, in turn, raises the question of why this wide difference in cost for office systems. Can it be accounted for totally on the basis of a much better product at the high end with a higher levels of functionality?

I suspect that the answer to this question is the following: At the high end of the price range are undoubtedly those office EMR products supplied by the vendors who are selling hospital EMRs for many tens of millions of dollars. The CIOs of these health systems, above all, want their physicians running the "same" EMR that is installed in their hospital(s) to achieve integration. For them, $44,000 per seat probable looks like a bargain. Not so for the physician-owned practices for which there may be less pressure to integrate with the EMR running in one of the local hospitals. The physician proprietors of such practices are much more interested in optimizing the activities of their own enterprise at a relatively low cost.

Business Risks of Medical Tourism

In a large series of previous notes about medical tourism, I presented this topic largely in a favorable light. I have done this, in part, because I wanted to alert the readers of Lab Soft News that off-shoring of various types services has become very prevalent and that the delivery of healthcare services will not be immune from this trend. It has also been my hope that that the threat of such competition will force the U.S. healthcare delivery system to become more cost-competitive and more aware of the quality/cost of the services that are being delivered here.

A recent comprehensive article about medical tourism discussed some of the risks of medical tourism (see: Business risks of the medical tourism industry) so I thought that I would present an excerpt from it in order to alert the readers of Lab Soft News about this perspective of the industry:

• Risk of political instability, public unrest or war

Hospitals are affected by everything that affects the tourism industry. Of all the major medical tourism destinations probably Singapore is the lowest risk location in this regard. India’s standing in the world has improved over the last couple of years and its competitiveness as a medical tourism hub has increased greatly. Thailand on the other side has become less stable in 2006.

• Risk of international and local terrorism

International terrorists can hit anywhere in the world and any place hit by a major attack is likely going to suffer a severe short term economic impact. While there are still tourists in Bali for example, the whole island economy has suffered significantly from the terrorist bombings of 2002 and 2005. In 2006, Mumbai was the site of a major terrorist incident in which over two hundred people were killed when several bombs exploded almost simultaneously on a local railway....Thailand is quite unique in regards to terrorism. The South Thailand insurgency with the associated violence has attracted comparatively little international media attention, although more than one thousand people have lost their lives since the escalation of violence started in 2004.

• Risk of health epidemics

South-east Asia is still bird flu central. While the virus has been found in many parts of the world, it is still in Asia, where most of the cases continue to make news. Remember SARS?...Even established players like Singapore Airlines had to lay off 1000+ local staff to cut cost following the devastating effects of the SARS epidemic on the travel industry in 2003.

• Risk of appreciating domestic currency

Currency fluctuations impact medical tourism operator the same way they impact exporters of other goods or services. In 2006 and 2007 the Thai Baht for example has appreciated against the US Dollar, the Yen and the Euro. The more the Thai Bhat strengthens, the less cost incentive foreign patients will have to come to Thailand for treatment.

• Risk of staff shortage

Increasing demand for nurses, pharmacists and last not least doctors with overseas training drives up the prices for local talent. Some places make it very difficult or even impossible to recruit foreign medical staff and any quick-fix solution like ‘importing’ specialists from abroad is not always an option. Thailand is one of these countries which make it impossible for foreign doctors to practice medicine.

• Risk of increased international and local competition

From Turkey to Nicaragua and from India to Taiwan, there seem to be fewer and fewer countries who have not yet declared themselves as medical tourism destinations. That some of the countries have a horrendous health care situation for their own citizens does not hold them back. In contrary, many regions seem to see medical tourism as an opportunity to make money and at the same time improve their own health care options. While not all the new self-declared medical tourism destinations are a threat to established players like Thailand or Singapore, newer entrants like India will eventually want a bigger share of the cake....An interesting development is also the increasing competition among European countries. It has now become normal for many Europeans to travel to Hungary or Poland for dental treatment, to Turkey for LASIK or to take a canal ferry to Belgium for coronary bypass surgery.

This article is so well written and so comprehensive that I really have nothing to add to it  -- it stands very well on its own. Link to the original article is you want additional details.

 

Wal-Mart to Open 400 In-Store Clinics

I have posted a number of previous notes about an initiative by Wal-Mart to open a number of walk-in clinics in their stores staffed by nurse-clinicians that will treat common health problems for  modest fixed fees. After a trial trial run of 76 clinics in 12 states, it appears that the company is now ready to expand this line of business (see: Wal-Mart to open 400 in-store clinics). Below is an excerpt from the story:

Wal-Mart Stores Inc. said on Tuesday that it will contract with local hospitals and other organizations to open as many as 400 in-store health clinics in the next two to three years. Should current market forces continue, the world's largest retailer said up to 2,000 clinics could be in Wal-Mart stores over the next five to seven years. Wal-Mart said the effort marks an expansion of a pilot program it started in 2005, when it leased space within its stores to medical clinics. Currently, it said 76 clinics are operating inside Wal-Mart stores in 12 states....The company has tried to counter such attacks [from critics], taking steps like selling generic drugs for $4 per prescription, and joining with the 1.8 million-member Service Employees International Union, one of its most vocal labor foes, to call for universal health-care coverage for all Americans by 2012.The retailer said on Tuesday that $4 prescriptions now account for more than 35 percent of all prescriptions filled at Wal-Mart, and nearly 30 percent of the $4 prescriptions are filled without insurance.

Wal-Mart has approached this new business venture cautiously and now appears ready to rapidly expand its scope and scale. I can see multiple advantage for the company in such a venture beyond the possibility that it may turn a profit. First of all, the clinics will undoubtedly increase foot traffic in the stores where they are opened. Secondly, the company can use the presence of the clinics, in addition to their generic drug program described above, to project the image of a more compassionate company. Finally, the clinics provide a low-cost healthcare option for Wal-Mart employees, many of whom may not have company-supplied health insurance.

As I have noted previously, look for Wal-Mart to expand the range of clinical conditions that its walk-in clinic personnel will treat and also begin to address wellness issues. It would be a natural progression for such clinics to begin to offer, for example, a set of CLIA-waved lab tests similar to those performed in a physician's office. For example, screening for hypercholesterolemia would be a logical next step that would also have value in the area of public relations. As noted above, part of the rationale for opening these clinics and the $4 generic drug program is to silence some of Wal-Mart's critics who view the company as a heartless corporate monolith.

Branding Medical Imaging Services

The May 1, 2007, edition of the New York Times published a special section on Personal Health. There was a full-page advertisement on the back cover of the section for NYUImaging that included the following copy:

• If the world comes to NYU Medical Center for diagnostic imaging excellence, shouldn't you
• You have a choice for your imaging. Choose NYU
• NYUImaging: It's where better outcomes begin

I have frequently heard it said that the best way to assess the quality of a hospital is to evaluate the ancillary services of that hospital such as the clinical labs, pathology, and radiology. The reason for this is that the best clinicians, understanding the criticality of such services, will only work in hospitals providing excellent ancillary services. I don't want to argue that the clinical labs and pathology fill a more important niche than, say, medical imaging, although it might be possible to make this case. What interests me most about this advertisement is why the NYU Medical Center has chosen to aggressively brand its medical imaging services rather than its clinical labs and pathology services.

For me, the answer to this question is obvious -- most clinical lab services are a commodity and medical imaging services are not. Because of this and other quirks of the medical reimbursement system, the profit margins for medical imaging are high, making funds available for the marketing of such services. Healthcare executives have a strong incentive to invest capital in medical imaging systems because of their attractive return on investment.

It seems to me that there are only a couple of strategies for pathology and the clinical labs to get out of this bind, one of which is for the leadership to place more emphasis on genomic and proteomic testing. Such testing services not only provide a path to the early health model but also, at least for now, are not commoditized. Another strategy to combat commoditization, and one that I have advocated in this blog, is the merger of pathology and lab medicine with radiology to form the new discipline of "Diagnostic Medicine."

A Urologist and His Web Site

I have written a previous note about Dr. William Catalona (see: Court Ruling on Use of Donated Tissue), who has been engaged in a legal dispute with the University of Washington School of Medicine about the disposition of prostate tissue samples contained within a tissue repository that he helped organize at the school. You can read more about this dispute here. At any rate, Dr. Catalona has created his own web site devoted, in part, to providing prostate cancer information to healthcare consumers (see: The site for prostate cancer information from Dr. William Catalona). He has also created his own foundation called the Urology Research Foundation (see: About the URF), one function of which is to support this web site.

Partly enabled by the web, this type of "Catalona effect" will become more prevalent. By this I mean that eminent researcher/clinicians will establish their own disease-oriented foundations, often embedded within, or co-located with, prestigious medical schools and health systems. All one needs to do is scan the way in which Dr. Catalona's web site is organized in order to understand its scope, scale, and agenda for this foundation:

• Q and A -- Prostate Cancer
• National Media
• Suggested Reading
• Dr. Catalona's Articles
• Donations
• New Patient Packet
• Video Library
• Postop Advice
• Litigation Briefs

Not all medical schools and health systems will be able to tolerate co-existing with such disease-oriented foundations, but the ones that can will certainly benefit from an enhanced patient referral stream. Welcome to the era of physician-branding of surgical care, frequently aligned and even synergistic with a health system's own branding efforts. Within the new patient packet available at Dr. Catalona's web site are included forms developed by the Northwestern Medical Faculty Foundation.