Lab Soft News

Lab InfoTech Summit Scheduled for April 9-11, 2008

I am now turning most of my attention to planning the fifth annual Lab InfoTech Summit conference that will again be held at the Venetian Resort Casino Hotel in Las Vegas. The dates for the event are April 9-11, 2008. Here's a PDF version of the advertisement for the conference that will appear in the October issue of CAP Today. The ad includes a list of nine of the key topics that will be covered at the meeting. I think that you will find many of them both interesting and provocative. Stay tuned for more information in upcoming weeks about both faculty and exhibitors.

Phlebotomist Bites Child; Parents Annoyed

I have devoted numerous previous notes to phlebotomists and their critical role in the clinical lab. I view them as the true unsung heroes of the industry. Their mission is critical and without them the work of the labs would grind to a halt. If you pass one of them in your lab today, please smile and tell them how much you appreciate their contribution. At any rate, my interest in them caused me to pause when I encountered the following article: Hospital Lab Worker Bit Boy, Parents Say Woman Fired After Blood-Test Incident. Below is an excerpt from the article:

A hospital lab technician bit a boy's shoulder as she used a syringe to draw blood from his arm, his parents told police. The technician, who worked for a subcontractor that does blood work for St. Vincent Hospital, was fired after last week's incident involving 3-year-old Victor Buntin, the hospital said. "Taking a bite out of him like he's an apple -- this is heinous," Victor's father, James Buntin, told 6News' Rafael Sanchez on Tuesday....Faith Buntin said she let it go because her son was crying, ostensibly over the testing. Back at home, she said, she saw teeth marks on his left shoulder....The family filed a report with Indianapolis police and is seeking criminal charges. A detective has been assigned to the case, Sanchez reported. St. Vincent spokesman Johnny Smith said the hospital is "reviewing the capabilities" of the employees of the subcontractor, Mid-America Clinical Laboratories.

Frankly, I am surprised that incidents like this are not more common. Drawing blood from adults can be difficult and drawing blood from squirming kids is even more challenging. I hope that this possible criminal suit is deemed not to have merit but I am apprehensive on the basis of the child's name and the mother's name -- Victor and Faith.

Now we come to the most intriguing part of this story. Why bite the child when it would appear that there should have been other options to maintain order. Well, I am guessing that the phlebotomist was trying to draw blood from Victor and both her hands were holding the syringe and tube. Grabbing the child's shirt with her mouth probably seemed to be the only available option for the phlebotomist under the circumstances. Let's just chalk this one up to a bad day at the orifice.

Professional Blogs as Meta Information Resources

I was recently listening to a podcast by economist Paul Romer (see: Romer on Growth). This lecture is part of a series of podcasts called EconTalk addressing fundamentals of economics with interviews by the host, Russ Roberts. His guests include some of the leading economists in the country. If you choose to download and listen to only one set of podcasts, this is the one to choose. Professor Romer addresses the topic of economic growth in this particular podcast and explains why the U.S. has been able to maintain an admirable growth rate over many decades despite the very large size of the base economy.  He speculates that thee gains has been achieved in part on the basis of what he refers to as meta-ideas or what I will refer to here as meta-resources.

Economic growth is frequently stimulated by new technology or the development of new ways to use existing resources in a beneficial or more efficient way. A key example of an important a meta-resource for the U.S. are our large universities that educate our students about current technology and encourages them to develop new ideas. Research universities also act as facilitators for various types of research, assembling both the facilities and faculty to participate in such ventures.

I view professional blogs (see: Professional Blogs as Publication Vehicles for Physicians in Academic Clinical Tracks) as a meta-resource analogous to scientific journals but different from them in many ways. In previous notes, I have referred to this type of blog as a business intelligence blog. A professional blog encourages innovation and new ideas by acting as a filter and distributor of news and opinion in a field. Busy professionals need such filters because they are preoccupied with their daily work. A variant of the professional blog is the meta-blog which functions as a type of index for other blogs covering similar topics.

By supporting a particular professional blog, workers in a field exhibit trust that the blog will periodically present them with new ideas in a condensed fashion that will enable them to work smarter and and possibly in new ways. The turn-around-time for presenting a new idea on a blog is measured in minutes or hours as opposed to months or years for a print scientific journal. Because of the increasing rapidity of the circulation of new ideas in this information age, the velocity for the promulgation of new ideas on the web is critical.

The Concept of "Deprecation" as It Relates to Clinical Lab Reporting

In a recent note (see: The Clinical Laboratories as a Knowledge Hub for Hospitals), I theorized about a concept that I referred to as the clinical lab knowledge hub. One of the unusual aspects of reporting lab knowledge to the "customers" of the clinical labs was described in the following way in this note:

...I strongly advocate the development of a federated information system architecture for hospitals under which the lab hub is allocated "white space" in a hospital's integrated clinical reporting system. Lab professionals can then format and contextualize the test knowledge that is presented to clinicians on-the-fly. This knowledge has only a short half-life because of the rapidly changing clinical context of these patients.

This notion of the "short half life" of lab knowledge is very subtle and needs further explanation. Luckily, Dr. Ul Balis was able to come to my rescue and point out to me that some of the elusive aspects of this facet of lab reporting has already been named and described in the IT literature. It's called deprecation and below is a definition for the term from the Wikipedia (boldface emphasis mine):

In computer software standards and documentation, the term deprecation is used to indicate discouragement of usage of a particular software feature, usually because it has been superseded by a newer/better version. The deprecated feature still works in the current version of the software, but it may raise error messages or warnings recommending an alternative practice. Features typically get marked as "deprecated", rather than simply removed, in order to provide backward compatibility for software users. When other programs depend on the deprecated feature, their programmers need time to change their code to avoid the feature.

When standard test results (i.e, test information) are reported to clinicians, they will always be valid in terms of their accuracy but they may not continue to be relevant over time. A good example of this phenomenon are the arterial blood gases analyzed for a seriously ill patient in a critical care unit. Clinicians quickly lose interest in them as the patient recovers.

By way of contrast, consider a "knowledge report" including an interpretation that is generated for a patient and takes into account multiple biomarkers, suggesting a differential diagnosis of various types of neoplasms for the patient. Let's further assume that this same patient, some days later, undergoes a tissue biopsy and a definitive diagnosis of the tumor that has been arrived at. The identify of this tumor is then reported via a second "knowledge report." I use "knowledge report" here to indicate that lab information has been organized or contextualised to produce new meanings and generate new conclusions.

In the case of this second patient, the first report should be considered, or perhaps even marked, as deprecated. There is nothing intrinsically wrong with it, considering the context in which it was generated. It merely had a short half-life and was superseded by a subsequent knowledge report that announced the definitive tumor diagnosis. It is maintained in the patient record for "backward compatibility," which is to say in order to maintain the patient record audit trail.

More on Using Hospital Outcomes for Marketing Purposes

In response to my recent note about the use of patient outcomes information to market hospital services (see: Pediatric Hospital Tracks Patient Outcomes to Improve Quality and Patient Satisfaction), Bev M.D. submitted the following comment:

The Cleveland Clinic tracks outcomes for several of its [departments] and publishes them in glossy paperback books; recently mailed on a "cold-call" basis to my orthopedist husband, who has never referred a patient there. Also see Paul Levy's blog at BIDMC [Beth Israel Deaconess Medical Center], who just recently published results for ventilator associated pneumonia. I believe this trend is increasing.

Terrific comment, Bev. Your ideas open up a whole new sets of ideas for inquiry and discussion. To add to the mix, another blogger was prompted by the Paul Levy article to which you refer (see: Paul Levy Opens Up on Ventilator Associated Pneumonia) to respond in the following way:

...[L]et’s give Paul a round of applause for doing several things. First, breaking the mold by talking in public about things most hospital administrators never want to discuss publicly. Second, writing realistically about the challenges in improving patient safety, and putting data out in public which is less than folks would like to see. Third, attempting to create an advantage for his institution by taking a leadership role in addressing the awful record of the US hospital industry in patient safety and quality.

My initial remarks about outcomes data turned on my observation that few hospital executives seem inclined to use such data for marketing purposes. Bev has now brought to our attention that Cleveland Clinic is, in fact, pursuing such a strategy and sending the information to one critical group of its customers, physicians, who can both understand the data and also refer patients to the hospital if suitably impressed by it. For me, this illustrates the value of transparency in healthcare, a critical component of Health 2.0. As I write these words, I have also become more aware of the fact that physicians are both gatekeepers for health data and also consumers of such data when referring their patients for care.

The discussions about the Levy blog note above also underscores a critical component of this discussion about outcomes. If and when hospital directors such as Dr. Levy begin to analyze outcomes data for marketing purposes, they will inevitably encounter problems amenable to correction. It is incumbent upon them to bring such problems to the attention of both healthcare providers AND the public-at-large. Healthcare consumers need to know that one can both be treated for pneumonia in a hospital and also catch it there.

:: Update on 9/26/07 @ 11:20 a..m.

Dr. Bruce Beckwith has emailed me the following correction to this note: 

Read with interest your post today.  I have one small correction, Paul Levy is not a physician.  That may be one factor in why he released the data. Keep up the good work with the blog.

Thanks, Bruce. I have no idea whether physician hospital directors would be more or less inclined to highlight complications such as respirator pneumonia. A physician director may have a better grasp of the problem and how to correct it.

Anti-Aging Medicine as a Major Driver of Complex Lab Testing

I have posted blog notes in the past about the anti-aging phenomenon and its relationship to the clinical labs. A Google search using the term "anti-aging" yielded approximately 2,570,000 hits, so one can infer that this is a trend with broad interest and support. A recent article in the New York Times (see: Publications on Fitness and Health Head to Web) provides evidence about how this phenomenon, as well as the web as a channel for health information, is going main-stream. Below is an excerpt from it:

Hearst Magazines has decided to buy as well as build internally with the purchase of RealAge Inc., a consumer health Web site....[I]ndustry analysts estimate that the price is somewhat under $100 million, based on the volume of traffic on the RealAge site and its yearly revenue....
A Harris poll, published in July, found that 52 percent of adults sometimes or frequently went to the Web for health information, up from 29 percent in 2001....Aging baby boomers will develop more health issues and want to stay young as long as possible. And employers’ efforts to limit health care costs mean that workers will steadily pay more of their medical bills themselves....RealAge, according to Hearst executives, is a valuable property in this environment. Founded in 1999 by Charlie Silver, an entrepreneur, and Michael F. Roizen, a physician and medical researcher, RealAge refers to a test that weighs 125 factors — as diverse as diet and tobacco use, pet ownership and a spouse’s level of education — to determine someone’s “real age.” Afterward, users are given a list of things that are making them younger or older, and suggested steps to lower their effective age. In the first half of this year, the RealAge Web site had 2.1 million unique visitors a month, and more than 8 million registered users have taken the Real Age test. Most are female and their average age is 45....

Dr. Roizen, with Dr. Mehmet Oz, are two of the most well known practitioners and advocates for anti-aging medicine. They appear frequently on television with Oprah Winfrey. Although the RealAge questionnaire that is used to assess one's biologic age, as opposed to one chronologic age, utilizes only common lab results such as total cholesterol and HDL, physician-directed assessments of one's "true age" commonly measure a complex sets of biomarkers. I believe that anti-aging evaluations will be one of the major drivers for clinical lab utilization in the future in the "wellness and fitness" arm of healthcare. The other arm is disease diagnosis/prognosis/assessment.

What lessons can be drawn from this information that will be relevant for lab professionals? Here are some of my current ideas:

• The anti-aging phenomenon is real and will not go away, at least in the near future. It will constitute a major component of healthcare delivery.
• Every lab should now begin to develop sets of anti-aging biomarker panels based on current and future research in this field.
• For now, many of the therapeutic "interventions" to promote long life are, appropriately, based on lifestyle improvements or relatively innocuous vitamin and herbal remedies. However, I envision that more powerful drugs will be coming to market in the near future that will interact with some of our basic genetically-driven aging processes.

Pediatric Hospital Tracks Patient Outcomes to Improve Quality and Patient Satisfaction

A recent article in the New York Times caused me to think about the notion of tracking patient outcomes as both a marketing and quality tool for hospitals (see: Managing Outcomes Helps a Children’s Hospital Climb in Renown).  Below is an excerpt from the article:

Not content to play a regional role, the Cincinnati Children’s Hospital Medical Center has emerged as a national name in pediatric medicine, drawing patients from distant cities like Boise.... Reasons for the hospital’s national renown include its market-niche focus on certain rare or complex conditions.... There is also diligent attention to quality and efficiency, inspired by a chief executive from a manufacturing background. And then there is a distinction that might seem unremarkable if it were not so infrequent in American health care: Cincinnati Children’s Hospital rigorously tracks how its patients fare, both in the hospital and after they leave. Many hospitals might claim to offer high-quality care. But they often have only the vaguest notion of how well their patients are doing, aside from a few basic measures like whether they survive surgery. Cincinnati Children’s is among the relatively few medical centers that meticulously collect a wide range of data, to let the hospital see whether patients are getting good, effective care — and to look for ways to improve. By precisely tracking how many patients develop surgical infections, for example, and why, Cincinnati Children’s has been able to identify ways to reduce that number by more than half — to 42 last year compared with 95 in 2005.

This story focuses on a Cincinnati pediatric hospital that has carved out a niche and a national reputation for itself by treating rare diseases and also by tracking patient outcomes, both intra-hospital and post-discharge. To someone not familiar with hospitals and healthcare delivery, a story such as this would be very perplexing. Such a person might assume that it would be both routine and natural for hospitals to keep detailed records of patient outcomes.

Actually, it is quite rate for hospital executives to address patient satisfaction and quality issues in this way and the story reinforces this very point. If it were not so rare, the story would never have seen the light of day. Note the reference in the story to the fact that the chief executive of the hospital had a manufacturing background. He may have inaccurately assumed that this approach was the norm among  his hospital peers because manufacturers of products always assess the quality of their products in this way.

It's interesting to speculate why tracking objective health outcomes for hospitals patients is not a routine approach for improving quality whereas subjective post-discharge hospital surveys of patient satisfaction are quite common. The only answer that I can come up with is that many hospital executives view "outcomes" research as a specialized domain for physicians and nurses and too esoteric for their marketing departments. This is pure speculation on may part. Does anyone out there have a  better idea?

More on Robotic Hospital Rounds

I posted a note recently addressing the issue of enabling physician rounds in hospitals using robots equipped with video cameras (see: Robotic Physician Rounding Shaves a Day Off LOS). The rounding physician would interact with his patients from, say, his office  rather than being physically present in the hospital. This note elicited the following two comments from readers of the blog , both of which are very interesting:

• On September 14th, John Norris commented: Perhaps [patients] left [the hospital] because they didn't want to face the robot? If each bed had a simple teleconferencing setup, I'd think that could be done in a way that would be more familiar to patients than a 'robot'.
  

• On September 15th, Robert Blackwelder commented: I am a urologist in rural No.Calif.. Our hospital is considering involvement in a project that would put a robot in the hospital to allow enhanced consultation with specialists--not to replace personal contact with the local attending. This is likely to be a major improvement over the current phone consult.

Both of these ideas have merit and are worth further discussion. Firstly, Robert Norris' suggestion that each hospital bed could be equipped with a PC and simple teleconferencing setup has great appeal for me. Such an arrangement would permit hospitalized patients to browse the web and access health education materials, both those developed by the hospital and from other sources. i understand that many inpatients these days tend to be seriously ill but this should not be an excuse for failing to provide patients ready access to their email as well as other web sites. Teleconferencing capabilities at each bed would not only enable rounds by their physician but also closer contact with relatives, some of whom may live too far away to visit  regularly.

Dr. Blackwelder's comment is also particularly apt. I had totally missed the point that teleconferencing capabilities at each bed, or using a robotic device, would allow ready access to hospital patients by consulting specialists, particularly in rural areas. I am particularly enthused about the idea of a three-way conversation at the hospital bedside by the patient, the local treating physician, and a specialist consulting on the case. Such a three-way conversation would allow for a better understanding of the role of the consultant and and would also integrate the patient more closely into the medical dialogue.

The Clinical Laboratories as a Knowledge Hub for Hospitals

Dr. Anand Dighe, Director of the Core Laboratory and Information Management at Massachusetts General Hospital (MGH), delivered a lecture at the recently completed APIII conference in Pittsburgh entitled Laboratory Informatics: Becoming a Key Hub in the Hospital Information Network. I believe that Anand has developed a very important concept in this presentation. For me, the essence of his lecture was contained in the following statement:

Labs should aim to provide to provide an array of information intensive services and become the hub for the creation, maintenance, and dissemination of a wide variety of lab related knowledge.

Prior to making this statement, Anand had demonstrated how what he called enhanced test results should  be presented to clinicians. This involves the inclusion of an interpretation of test results in the lab reporting process as well as ready access to the MGH lab test handbook by the clinicians. Knowledge, as opposed to information can be defined as organized or contextualised information which can be used to produce new meanings and generate new data. I view Anand's concept of enhanced test results as being identical to the development of knowledge.

The labs, or the lab hub to use Anand's term, should not function as a mere conduit for transferring test results (i.e., information) from the lab bench or instruments to the EMR. These data should be be first converted to knowledge and this is accomplished by having lab professionals interpret and contextualize them. In addition, the clinicians themselves can subsequently extend this knowledge generation process by being given access to lab on-line resources such as an electronic handbook.

Although it is theoretically possible to report lab "knowledge" to clinicians through EMRs as they are currently designed, I believe that this process will not be possible as lab knowledge grows more complex day-by-day. It is for this reason, that I strongly advocate the development of a federated information system architecture for hospitals under which the lab hub is allocated "white space" in a hospital's integrated clinical reporting system. Lab professionals can then format and contextualize the test knowledge that is presented to clinicians on-the-fly. This knowledge has only a short half-life because of the rapidly changing clinical context of these patients.

Screening Your Dog for Lymphoma and Appropriate Chemotherapy

As veteran readers of this blog will appreciate, many of my previous notes have been devoted to the topic of cancer diagnosis using serum  biomarkers. Although much of this research holds great promise, it would be an overstatement to say that the use of biomarkers in this fashion constitutes routine clinical practice. I was therefore somewhat surprised to read a recent article on the web (see: 'PetScreen' Helps Detect Cancer In Dogs Early) indicating that testing for lymphoma with biomarkers was now a relatively routine matter for our canine pals:

Losing a pet is like losing a member of your family; but now a simple blood test could help save the lives of countless pets by detecting cancer early....The blood test, called PetScreen, is the first of its kind designed to catch canine lymphoma tumors early. "Lymphoma is one of those diseases that actually does respond very, very well to chemotherapy," explains the test's developer Dr. Kevin Slater....Once a small blood sample is sent to a British-based bioscience lab, technicians look for certain proteins or "markers" that lymphoma cells produce. If the sample tests positive for cancer, a second test can then determine which type of chemotherapy treatment may be the most effective. "If it can be caught earlier -- when the tumor is much smaller," Dr. Slater adds, "the chances of successful intervention through chemo are much greater." Dr. Slater has also worked on human biomarker research and believes that the successes with animals may also have an impact on early cancer detection for people.

The PetScreen web site is both professional and clearly written. Many of the British web sites I have encountered share these same qualities. This is how the company describes its mission on the home page:

PetScreen is a pioneering company dedicated to improving cancer detection and treatment in pets. We have developed the first ever screen for lymphoma cancer in dogs and we are now working on additional dog cancer screens for the other major canine cancer killers. Additionally, we are working on the development of screening tests for the major cat cancers.

Even more impressive is the following paragraph, which can be found on the page labeled Information for Vets:

If cancer is detected, PetScreen [is] able to provide a Directed Chemotherapy Assay (DCA) which highlights resistance from the start and identifies the treatment most likely to be effective for an individual patient. The DCA is analogous to a microbial antibiotic sensitivity test. It uses advanced cell culture techniques to grow malignant cells from a tumour biopsy. The cells are cultured with a range of different chemotherapeutic agents and the relative efficacy of each drug is measured. The results of the DCA service are available in seven days, providing a report showing possible sensitivity or resistance for each individual patient’s tumour.

Well, I for one, find this set of lab products devoted to the diagnosis and treatment of canine lymphoma very impressive. I hope one day to report that similar tests are available for humans.  For now, however, I will cease using the term "going to the dogs" to refer to a hopeless situation.