Lab Soft News

Advances in Portable Ultrasound Devices

I have posted a number of previous notes about portable ultrasound devices. The technology has been widely and rapidly adopted in emergency medicine (see: World's Smallest Ultrasound Device Unveiled) because it increases the speed and quality of diagnoses and also generates additional revenue. It's a good example of how technology is causing "leakage" of imaging procedures to specialties other than radiology. I came across another article about this same topic with special emphasis on the increasing sophistication of chip technology (see: Chip Advances Lift Ultrasound Market, Help Save Lives). Below is an excerpt from it with boldface emphasis mine:

Two hours after the patient had a heart attack...doctors at St. Luke's-Roosevelt Hospital Center in New York discovered his heart was being compressed by pooling fluid and rushed him to surgery. The quick assessment was made possible by a portable ultrasound machine from Siemens AG dubbed the P10, the smallest currently on the market....New ultrasound devices like the P10 are possible in large part because of analog chip makers, which are racing to develop electronics that allow portability....By improving quality and shrinking size, component makers are hoping to open new markets from emergency care to emerging economies. Expanded use of ultrasound ...could offer inexpensive improvements in patient care, the companies say....Traditionally, ultrasound has been used by radiologists, cardiologists, obstetricians and gynecologists. Now it is an option for new classes of specialists, including anesthesiologists and emergency-care physicians, and even those in Iraq looking for shrapnel in wounded soldiers. It is also within reach for clinics and hospitals in developing countries.

Two ideas in this article caught my attention. The first was the analogy between the deployment of new chips in portable ultrasound instruments and in cell phones. We are all familiar with how the feature/function set of cell phones has rapidly increased while their cost and size have rapidly decreased. We may see a similar phenomenon with portable ultrasound devices. Continuing with this cell phone analogy, this evolving technology allowed less developed countries to set up a sophisticated telecommunications networks without first installing an expensive land-line infrastructure. Downsized ultrasound devices and the development of other imaging devices designed specifically for third-world countries will allow them to rapidly develop more sophisticated healthcare delivery systems.

Physican Blogs Criticized on Basis of Privacy Issues

Blogs authored by physicians are starting to attract more attention, particularly with regard to patient privacy issues (see: Doctor Blogs Raise Concerns About Patient Privacy). Below is an excerpt from this article with boldface emphasis mine:

[Physician-authored] blogs have raised concerns about privacy issues on the Web.....One physician blogger, who draws about 12,000 readers a day, is New Hampshire internist Dr. Kevin Pho. His blog, "Kevin, M.D.," offers a doctor's eye view on medical issues that appeal to both his peers and the public."...Blogging can be a great marketing tool for raising a physician's profile and attracting new patients, says [a healthcare consultant]. But not all physician blogs are geared toward marketing. In fact, just the opposite seems to be the case in some extremely candid blogs, like "White Coat Rants," "Cancer Doc" and "M.D.O.D.," which bills itself as "Random Thoughts from a Few Cantankerous American Physicians." These are more like diaries in which doctors vent about reimbursement rates, difficult cases and what a "bummer" it is to have so many patients die....Dr. Deborah Peel, a psychiatrist and founder of the group Patient Privacy Rights, thinks physician blogs often step too close to the limits of patient privacy."The problem with physicians blogging about patients is the danger that that person will be able to identify themselves, or that others that know them will be able to identify them," she says.

My own thoughts about physician bloggers are mixed. On the positive side, I think that they put a human face on physicians and the practice of medicine. They thus enable patients to better understand some of the complexities and pressures facing physicians on a daily basis. Clearly, none of the physician bloggers would ever name the patients whose cases they might reference in the blog. Nevertheless, a patient referred to even anonymously may be able to identify himself or herself. I personally would view this as a breach of confidentiality. I don't follow these physician blogs but the best strategy for them, I think, would be to refer to patients only in a veiled and abstract manner if at all. I will make it a point to follow Kevin M.D. more closely in the future. His numbers suggest that he has developed an enthusiastic groups of readers.

Growth of Walk-In Clincs Slows Down

I have posted as number of previous notes about walk-in clinics. I had latched onto the idea that such clinics would serve as a new model for healthcare delivery, offering reasonable prices and convenient locations. It now appears that there was probably too much hype associated with this new form of service and there has been a noticeable decline in the opening of new facilities. A recent Wall Street Journal article provides the details (see: Health Clinics Inside Store Likely to Slow Their Growth). Below is an excerpt from the article with boldface emphasis mine:

The boom in walk-in health clinics located inside pharmacies, supermarkets and big-box retailers is showing signs of slowing.[See the chart at the left illustrating the largest walk-in clinic operators in the U.S. as of May 1, 2008.] Hailed as an inexpensive option for treating minor health ailments like sore throats and rashes, the retail clinics have grown in number to 963 as of May 1 from just 125 three years ago. The clinics typically feature nurse practitioners who can prescribe basic drugs, and the price for a visit ranges from $50 to $75. But in recent months, retail health-clinic operators based in New York, Nevada, Indiana and Alabama have closed their doors, shuttering 69 clinics in 15 states...Now, the biggest retail-clinic operator, CVS Caremark Corp., says it is scaling back expansion plans for its MinuteClinic brand...Research shows that patients are enthusiastic about the clinics' convenience and quality of care, but acceptance has been slow...Some operators are finding that the clinics are complex to manage. Earlier this year, CheckUps, a clinic operator based in New York, abruptly closed 23 clinics that it operated inside Wal-Marts in Florida, Mississippi, Alabama and Louisiana....Not everyone is trimming sails. Walgreen Co. says it still plans to more than double the number of its Take Care health clinics this year by adding about 240 locations between now and the end of the year, bringing it closer to the number operated by rival CVS.

My sense is that this apparent slowdown in walk-in clinics is due to the fact that some of the operators did not really understand the business. In other words, part of the bubble has burst. Some of the existing clinics are pursuing new business models such as establishing relationships with local healthcare systems in order to ensure a better referral network. However, I hope that such relationships do not result in a distortion of the basic walk-in clinic business model such that they begin to more closely resemble physician office practices with all of their inefficiencies and opaque pricing policies.

Search Engine for Healthcare Professionals

Search engines have been a critical factor in making the web so useful. I am personally partial to Google. I also find Google Scholar useful when researching complex medical topics. I often tend to use it even before PubMed. In fact, Google Scholar can be used as a portal to search medical article archived in PubMed. Here is a brief description of PubMed:

PubMed is a service of the U.S. National Library of Medicine that includes over 17 million citations from MEDLINE and other life science journals for biomedical articles back to the 1950s. PubMed includes links to full text articles and other related resources.

Now comes news about some recent refinements of a search engine designed specifically for healthcare professionals but also available to healthcare consumers (see: SearchMedica Offers Medical Professionals Six New Specialized Clinical Web Searches). Below is an excerpt from the article with boldface emphasis mine:

SearchMedica.com, the leading search engine for medical professionals, today unveiled six new searchable disease categories. Now, medical professionals can search the Web for credible, clinical information within general medicine or eight more specific categories....Although SearchMedica encourages medical professionals to register to receive updates about new content and tips on how to use various advanced tools, registration is not required....SearchMedica provides free, open access to the Web's most authoritative content for medical professionals. The new organization of disease categories keeps with this mission and simplifies the search process for medical professionals....Medical professionals consistently use SearchMedica with a patient's symptom or disease state in mind....Specialists, however, can refine their search into one of eight therapeutic categories. These categories...include cardiovascular, diabetes/endocrine, infectious, musculoskeletal, cancer/hemic, pediatric, mental/nervous system and respiratory disorders.

I found SearchMedica.com to be sophisticated and very well organized. For example, searching for the keyword anemia in the cancer/hemic category yielded 102,760 results. The opportunity is then provided on the data retrieval page to further refine the search using the following categories: Research/Reviews (15684); Evidence-based Articles (1799); Practice Guidelines (995); Practical Articles/News (4884); Patient Education (3575); Clinical Trials (8142); CME (301); Complementary Medicine (97); and Practice Management (269). In the left hand column of the retrieval page, the option is also provided to narrow the search on the basis of the following types of anemias: normocytic anemia, hemoglobinopathy, infectious anemia, aplastic anemia, cell anemia, chlorosis, spastic anemia, deficiency anemia, macrocytic anemia, and gaucher disease.

I am definitely going to turn to SearchMedica more in the future when the need arises for me to learn more about various diseases. It's a wonderful resource.

On the Corrosive Influence of Big Pharma on Academic Physicians

Although I am not generally enthusiastic about the need for more rules and regulations, I believe that the relationship between some academic physicians and some pharmaceutical companies has gotten completely out of control. The final straw for me was the recent news that scientists in some of these companies have been ghost-writing medical articles about clinical drug trials for academic physicians (see: Merck Wrote Drug Studies for Doctors). The Association of American Medical Colleges (AAMC) recently published a model policy governing interactions between the schools and the pharmaceutical industry (see: Group Urges Ban on Medical Giveaways). I quote from the article describing this news below with boldface emphasis mine:

Drug and medical device companies should be banned from offering free food, gifts, travel and ghost-writing services to doctors, staff members and students in all 129 of the nation’s medical colleges [according to recommendations from the Association of American Medical Colleges]....Drug companies spend billions wooing doctors — more than they spend on research or consumer advertising. Medical schools, packed with prominent professors and impressionable trainees, are particularly attractive marketing targets. So companies have for decades provided faculty and students free food and gifts, offered lucrative consulting arrangements to top-notch teachers and even ghost-wrote research papers for busy professors....In addition to the gift, food and travel bans, the report recommended that medical schools should “strongly discourage participation by their faculty in industry-sponsored speakers’ bureaus,” in which doctors are paid to promote drug and device benefits....Dr. Vagelos, formerly of Merck, said that the report’s recommendations were certain to face resistance among faculty who liked the present system.

Although I believe that medical school faculty is a good place to start cleaning house, the process of disengaging from some of the pharmaceutical company perks should not stop here. However, the AAMC does wield extensive influence over the nation's medical schools so that this was an appropriate organization to launch this reform effort. Don't you just love the quote from Dr. Vagelos to the effect that this new set of regulations will be opposed by medical school faculty who "like the present system." Duh!

Calculating the TCO and ROI of an EMR

The topic of calculating the total-cost-of-ownership (TCO) and return-on-investment (ROI) for an EMR and LIS arises frequently. Art Vandelay addresses it in a recent HIStalk note (scroll to bottom). I copy his comments, including his pun, below with boldface emphasis mine. He makes specific reference to the recently revealed capital costs and yearly maintenance fees associated with the Kaiser Epic HealthConnect project which I covered in a recent note (see: An Update on the Kaiser HealthConnect Project).

Art Vandelay on TCO (Total Cost of Onerous-Ship)

Kaiser’s announcement about its annual maintenance costs is déjà vu. I often feel it is the "total cost of onerous-ship" in my organization. Kaiser’s maintenance for HealthConnect is right in the middle of the range we see for TCO, which ranges from 20 to 36% of the cost of installation. (Before you fall off your chairs, I am very detailed in the costs I include, right down to power and cooling, percentage of time operations staff spend on monitoring, usage of tapes, and partial FTEs of support staff).

The wide variation in our TCO is driven mostly by the maintenance contract we negotiate with the vendor. The next largest driver is the human resources we need to maintain the application and supporting hardware. For example, clustered databases, redundant servers, and those with bi-directional interfaces typically require the most support. The rest of the costs are relatively minimal.

Two observations. Kaiser’s costs are not out of range by my calculation, but I would have expected more efficiency from their scale. Maybe their geographic distribution eats into their efficiencies. I would bet they will begin to look at more offshore support if their financial prospects don’t improve. They will likely also be eagerly awaiting Epic’s web browser client transition. That would hopefully move them away from one of the world’s largest Citrix farms.

Second, if users are looking for a real return on investment, the TCO can be a large hurdle to jump. In Kaiser’s case, the investment in the system has to cover the 25% maintenance (forever) and then be large enough to pay back a $4B investment in a reasonable amount of time. That can be a daunting proposition. By my calculations, a 50% annual ROI would break-even in 10 years when considering depreciation in the mix. A 50% annual ROI without depreciation would break-even in 7 years.

Art's comment is so clear and insightful that there is no need for me to comment further about it.

Paternity Testing Available at Your Local Drug Store

Home test kits are very big business and the list of tests available to consumers as kits will surely expand. I have posted a number of previous notes about paternity testing kits, many of which were only available on the web. The distribution channels for such kits is now expanding with them now, logically, available in drug stores (see: Drugstore Shopping List: Aspirin, Shampoo, Paternity Test). Below is an excerpt from the article with boldface emphasis mine:

A company called Identigene said today that its paternity test is now available over the counter at Rite Aid and Meijer drugstores around the country. Identigene [DNA Paternity Test], which costs $29.99 at the store plus another $119 for lab fees, is the similar to tests widely available online. The kit includes Q-tip-like swabs for the mother, child and alleged father. Rub the swab on the cheek, send it to Salt Lake City in a postage paid envelope, and a few days later get your results by mail, phone or Internet. But don’t try and take the answer to the judge. For the answer to be legally binding, you’ve got to pay a few hundred bucks extra for a third party (or in this case, fourth party) to administer the tests and confirm that everybody is who they say they are....The test isn’t sold in New York, where state rules require a doctor’s prescription or a court order, the company said. But it’s not far to Jersey, where the test is available.

The availabilty of the Identigene paternity test kits in retail pharmacy chains as well as the new option of providing court admissible DNA testing (see: DNA Paternity Testing: Legal DNA Tests) are both clever strategies by the company to increase product sales. I am sure that the current interest by Congress in genetic testing (see: Congress Near Deal on Genetic Test Bias Bill) is closely linked to the growing popularity of such testing, both at home and in the doctor's office. I should add, in conclusion, that I am having trouble imagining a scenario whereby a family decides to pursue paternity testing of their children outside of some legal action but I am ready to be educated in the matter.

The Meaning of Patient-Centric in Relationship to the LIS

When participating in a recent discussion group that was attempting to define the LIS of the future, the term patient-centric was raised.  I began to wonder whether the notion of patient-centricity has any relevance for the design of an LIS. Understanding that the term has become somewhat of a cliche recently, I decided to develop this note in order to begin to explore the relevance of of the concept for the LIS.

First of all, I suspect that most lab professionals will probably view physicians as the primary "customers" of the clinical labs. If they consider patients as customers at all, it's probably in a tangential manner with the physicians as the critical intermediaries. For the record and in order to pursue this discussion of the patient-centric LIS, I think that both physicians and patients should be viewed as customers of the clinical labs and therefore of the LIS.

Having gotten this point out of the way, I think that there are three important criteria for a patient-centric LIS:

• Patients should have ready access to their test results that are archived in the LIS, understanding that some test results such as reports of malignant disease need to be first presented to a patient by their personal physician in order to place them in the proper medical context.
• Lab test results need to be portable, which is to say that they can be electronically replicated to systems or media controlled by the patient such as personal health records. Such portability is critical if and when patients seek a second opinion about a diagnosis or wants to change healthcare providers.
• Lastly, the patient should be able to acquire some knowledge about the significance of various test results. Such knowledge can be provided by the laboratory generating the results or the patient can be guided to reliable sources of lab information on the web.

Regarding the portability of lab results, I personally believe that all labs should have the capability of generating PDF files of test results for patient use. I have made this point in previous notes (see: What Patients Really Want: An Introduction to the e-Patient). Below is an excerpt from this latter note:

Every lab report transmitted to physicians should be available in PDF format. With the approval and support of clinicians and their staff members, these PDF reports should then be made available to patients, often as attachments to office emails, as soon as they are distributed. Abnormal results for individual patients can be explained by supplementary notes and links can also be provided to high-quality web sites that discuss lab tests and provide reference ranges.

The three criteria listed above that help to define a patient-centric LIS seem eminently reasonable to me and will also serve to make pathology and the clinical laboratories more visible and accessible to patients and healthcare consumers.

General Surgeons as the Primary Care Docs of the Operating Room

I have published a number of previous notes about primary care physicians (PCPs), two recent ones in particular that suggested the need for them to upgrade their skills in order to survive (see: Have PCPs Become Obsolete?; More on Redefining the Role of the PCP). It had never occurred to me until reading a recent blog note (see: Are General Surgeons the Primary Care Docs of the Operating Room?) that general surgeons may be in somewhat the same boat as PCPs. Below is an excerpt from the note with boldface emphasis mine:

The number of general surgeons per capita has fallen by about 25% in the past quarter century...One key driver of this trend is a move toward specialization by young docs. In 1992, 55% of surgeons did a subspecialty fellowship after finishing surgical residency; now that figure is over 70%, the authors report. This sounds a lot like what’s happening on the medical side of the profession, as younger docs increasingly head for medical subspecialties that often pay more and give doctors more control over their work life than primary care jobs. The primary care version of surgery seems to be general surgical call at the hospital for things such as abdominal emergencies and trauma; [researchers have noted that] surgical subspecialists are qualified as general surgeons, [but] they sometimes seek to avoid this burden [of hospital surgical call].

When you think about the professional role that has evolved for PCPs and now, apparently, general surgeons, it's no wonder that young trainees seek to subspecialize. Throw into this mix the fact that performing a " procedure" can double your income (see: Performing Procedures Can Be Lucrative for Physicians) and its a wonder that we have any generalist physicians at all.

For me, the on-call issue is a distraction that can be solved relatively easily. The hospitals can hire their own surgicalists about which I have previously blogged (see: The Emergence of the Surgicalist) and taking a fair amount of call will be a condition of their employment by the health system. In terms of referral patterns and with a shortage of general surgeons, I envision that the PCPs will refer to the surgical subspecialists. But what happens if there is a shortage of PCPs?

 

A Web Site for Calculating Radiation Exposure

Radiology and radiologists seem to be on the defensive on two separate fronts. The first is that the cost of medical imaging procedures is being closely scrutinized by payors (see: Some Dark Clouds on the Medical Imaging Horizon). The second is that various groups, including consumers, are paying more attention to radiation exposure during such procedures. Despite the fact that the radiation dose associated with any individual procedure may be relatively small, the number of procedures per patient over a lifetime of care is increasing. The number of procedures per each complex workup is also increasing.

A recent note by David Williams of Health Business Blog (see: Chastizing Aimee) discusses a web site that provides a tool for for calculating patient exposure during medical imaging procedures called Aimee. Below is an excerpt from his note with boldface emphasis mine:

American Imaging Management (AIM), a radiology cost containment company owned by health insurer WellPoint, has a web-based patient exposure tool called Aimee that provides information for doctors and patients about the amount of radiation associated with various scans. The site is well-designed and easy to use. Simply click on the relevant scan and portion of the anatomy and the site provides a summary of the purpose of the exam and suggests safer alternatives when appropriate. At the bottom of the page is a display that expresses the radiation exposure in millisieverts (mSv) and as its equivalent in chest x-rays and background exposure. I like the site because it raises awareness about radiation exposure and provides alternative recommendations patients could discuss with their physicians.According to AuntMinnie, a radiology news and information site, some physicians [i.e., radiologists] are less sanguine [about the value of the site].

The criticisms that are being leveled at this radiation exposure website by radiologists include the following: (1) the ownership of the site by a radiology cost-containment company that has a stake in reducing imaging costs; ( 2) the oversimplification of a complex scientific topic; (3) the lack of relevance of the tool for pediatric patients who receive lower exposures; and (4) the lack of discussion or promotion on the web site of the myriad benefits of medical imaging.

I agree with David on this matter that some of these criticisms are valid but the general goals and values of this patient-oriented tool are beneficial for healthcare consumers. For me, this goal is to increase consumer awareness of exposure to radiation in diagnostic studies. The notion of a well-informed medical consumer is pivotal to the concept of Health 2.0 that I have previously discussed in Lab Soft News. If I were a radiologist, I would work through my professional societies to try improve the quality of Aimee based on some of the criticisms listed above.