Lab Soft News

Some Clues About the Microsoft Healthcare IT Strategy

I recently received a comment from a healthcare blogger, Dr. Peter Kim, in response to my note about Microsoft's EMR product, Amalga (see: Amalga Makes Inroads in the EMR World). It raises some interesting points so I reproduce it below. You may want to take a look at Dr. Kim's blog (see: The EMR/EHR Show). He has also blogged specifically about Google's role in EMR development (see: Is Google The Answer To EMR?).

...I have strong doubts that either company [Google and Microsoft] will successfully make it into the EMR/EHR market as we know it. By that, I mean, with local interfacing with the myriad of very specific, idiosyncratic systems. EMR's today exist at the hub of each office/implementation's world, including interfaces with hospital systems, local lab services, radiology groups, specialists' systems, etc. Each interface is unique, and requires major man-hours of locally expert debugging...and political negotiating. MONTHS is more the actual norm.

I wouldn't want to bet money against Big G or Microsoft, but that's a snarly, entrenched tech version of the proverbial "land war in Asia (or the Middle East)" that I'm not sure even the big boys can afford. And EMR's must be reliable for the long haul -- patient *lifetime* order of magnitude -- if anything. Are Google and Microsoft going to send a team of specialists to each doctor's office, and troubleshoot their systems at a moment's notice (medical system downtimes must be in minutes, not days), for the years required? Or are they going to change the ENTIRE infrastructure of how every aspect of the medical system communicates with every other aspect, to a degree that support staffer can be in Bangalore and still fix issues in seconds? It hasn't happened, yet.

First of all and for the sake of clarity, let's not refer to EMRs in a generic way. I am most comfortable discussing (1) hospital EMRs, (2) office/clinic EMRs, and (3) personal health records (PHRs). Dr. Kim seems to come at this problem from the perspective of an office physician and asks the rhetorical question: Are Google and Microsoft going to send a team of specialists to each doctor's office...? The answer to this question is obviously no. Neither Google or Microsoft will get anywhere near the specialized office EMR market. It's too fragmented, office personnel require too much hand-holding, and the market penetration is low. Not going to happen! Dr. Kim and I are in agreement on this point.

Microsoft's healthcare strategy is more obvious to me at this time than that of Google and consists of at least the following three elements:

• Develop a hospital EMR with Amalga starting with selected alpha sites as noted in the first paragraph above. The company will thus be able to determine whether their product is competitive in the U.S. market.
• Sign high-profile deals with major health systems (see: Kaiser tiptoes into HealthVault) to offer the HealthVault PHR to patients served by these health systems. Turf to the central IT groups of these health systems the task of replicating selected clinical data elements from their EMRs to the HealthVault PHR as a service to their patients.
• Develop high-profile deals with national reference labs like Quest similar to that already announced by Google: Quest Diagnostics, the world's leading provider of laboratory testing, information, and services is providing patients secure access to their Quest Diagnostics lab test results through their Google Health Account.

You can also throw into the Microsoft mix the deals that the company has announced regarding physician networks (see: Microsoft HealthVault announces new partners in health info sharing quest). Here's the description of such a project:

Microsoft's HealthVault has announced a collaboration deal with communications giant AT&T and computer platform service provider Covisint that will allow patients to share medical information with participating doctors via the Internet. Through the initiative, AT&T will provide broadband access and a dashboard for physicians to access the healthcare information, while Covisint will provide the underlying software that vets the patient info. Microsoft's HealthVault acts as the online storage system for the patient data.

Note the reference to "participating" doctors. Physicians will be required to use a special dashboard. This is not an office EMR -- it's a connectivity solution for office physicians and their patients that the physicians and their office staff will be required to adapt to.

:: Update on 9/30/2008 @ 8:25 a.m.

John who blogs over at Chilmark Research comments on HealthVault versus Google Health (see: HealthVault Surges, Google Flounders).

Reduced Cost of Offshore Surgical Procedures Puts Pressure on U.S. Hospitals to Compete

Community hospitals and large health systems in the U.S. are insulated from market forces, when compared to other businesses, because of their non-profit status, the reimbursement system, and the lack of competition from other hospitals in many communities. One of the reasons that I personally favor medical tourism is that it can introduce an element of competition with respect to some common surgical procedures such as hip and knee replacement. A recent health blog note in the Wall Street Journal underscored this point about competition and suggested that some hospital systems are beginning to get the message (see: Medical Tourism Starts at Home). Below is an excerpt from the it:

More than 20 years ago researchers at Dartmouth found huge variations in the intensity and cost of health care depending on where patients with the same conditions were treated....Now some employers are finally taking advantage of the price discrepancies by sending their workers across the country to get care that costs less and has comparable or better quality than at hospitals close to home, the WSJ reports....Employers just threatening to send employees overseas for care has prompted some domestic hospitals to step up with offers to match the foreign prices. Supermarket chain Hannaford Bros, based in Maine, offered employees the option of getting hip and knee replacements at a hospital in Singapore. A hip replacement there costs about $43,000 in the U.S. compared with $9,000 in Singapore, WSJ writes. Several U.S. hospitals told Hannaford they would match Singapore pricing. Hannaford is self-insured and it turned to Aetna, which manages the company’s health benefits, to vet the U.S. hospitals. Hannaford has negotiated a deal for hip, knee and spine surgery with a hospital in Boston and is still negotiating with a hospital in Maine for a better deal.

In addition to the point about U.S. hospitals trying to match the Singapore hip and knee replacement pricing, another interesting element in this article is that Hannaford Bros, the supermarket chain, turned to Aetna to "vet the U.S. hospitals" that were willing to match the Singapore prices. I envision an interesting cottage industry developing to assess both the overseas hospitals offerings to perform various surgical procedures and the U.S. hospitals that are offering to perform the same procedures at a competitive price. Travel costs will presumably be factored into these calculations. The process for evaluating hospital quality and morbidity/mortality associated with major surgical procedures will be well known to health insurance companies like Aetna. Hospital/procedure quality data are also available to the general public. Hospital Compare, as one example, describes itself on its home page in the following way:

Welcome to Hospital Compare.  In this tool you will find information on how well hospitals care for patients with certain medical conditions or surgical procedures, and results from a survey of patients about the quality of care they received during a recent hospital stay. This information will help you compare the quality of care hospitals provide....Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services, and other members of the Hospital Quality Alliance: Improving Care Through Information (HQA). The information on this website comes from hospitals that have agreed to submit quality information for Hospital Compare to make public.

The State of New York offers an assessment of the quality of hospitals in the state (see: New York State Hospital Profile). One may quibble about the quality of these ranking services but it's a good start.

The EMR as a Data Shredder: Implications of a Single-Source-of-Truth Policy

My colleague in pathology at the University of Michigan, Dr. Ulysses Balis, has taken to referring to EMRs as data shredders. What does he mean by this? The use of the term simply reflects that fact that after an LIS transmits test results to an EMR as an HL7 stream, they are reformatted based on the rules and constraints of the EMR system. The sad part about this daily scenario is that pathologists and lab medicine experts have been perfecting lab result formatting for many decades and the EMR support personnel frequently have little or no understanding about this knowledge domain. They thus turn to lab professionals for help in formatting the data that had been optimized in the LIS prior to transmission but which were then shredded by the interface and the EMR.

Lab data formatting is an integral and critical element of any lab report. Let's use the term of truthfulness to describe the degree of quality, accuracy, and interpretability that is sought in the development of a lab report. Or, for Stephen Colbert fans, one can also use the term truthiness. Lab test results that has been shredded are therefore less truthful. The best way to maintain the truthfulness of test results generated and transmitted from the LIS to "whatever" system is to replicate a true copy of them to the other system. In other words, the LIS needs to be viewed as a single-source-of-truth (SSOT).

Here's the Wikipedia definition for SSOT with boldface emphasis mine:

In information systems, Single Source Of Truth (SSOT) refers to the practice of co-locating in one area only (e.g. one cell of one row of one table of one database) any data that can be referred to by any of the other federated applications present within the overall enterprise. Deployment of this architecture is becoming increasingly important in enterprise settings where incorrectly linked duplicate or denormalized data (a direct consequence of intentional or unintentional denormalization of the data model) poses a risk for retrieval of outdated, and therefore, incorrect information. A common example would be the electronic health record, where it is imperative to accurately identify patient identity against a single referential repository, which acts as the SSOT. Duplicate representations of data within the enterprise would be implemented by the use of pointers rather than duplicate database tables, rows or cells. This ensures that data updates to the authoritative location are comprehensively distributed to all federated database constituencies of the larger overall enterprise architecture. SSOT systems provide data that are authentic, relevant and referable.

In order to achieve SSOT status for the LIS and other sources of clinical information, hospitals need to pursue a federated information system architecture. The practicality and feasibility of this model/architecture for healthcare is only now becoming apparent and has certainly not been utilized by any EMR in widespread usage. There is therefore only one course of action for lab professionals trying to cope with an EMR shredder problem. For relatively simple test results passed to the EMR, they need to collaborate with the EMR support personnel to renormalize the data post-shredding. For complex results such as molecular diagnostics, they need to insist that lab customers log on to the LIS for reporting purposes or have access to an image of the report. Finally, they need to actively lobby for the development of a federated architecture that enables the so-called "ancillary" information systems to function as SSOTs.

:: Update on 10/1/2008 @ 11:15 a.m.

There is an updated definition of single-source-of-truth (SSOT) posted on the Wikipedia, which I reproduce below:

In Information Systems Design and theory, as instantiated at the Enterprise Level, Single Source Of Truth (SSOT) refers to the practice of structuring information models and associated schemata, such that every data element is stored exactly once and no more (e.g. in no more than a single row of a single table). Any possible linkages to this data element (possibly in other areas of the relational schema or even in distant federated databases) are by reference only. Thus, when any such data element is updated, this update propagates to the enterprise at large, without the possibility of a duplicate value somewhere in the distant enterprise not being updated (as there would be no duplicate values to update). Deployment of this architecture is becoming increasingly important in enterprise settings where incorrectly-linked duplicate or denormalized data elements (a direct consequence of intentional or unintentional denormalization of any explicit data model) poses a risk for retrieval of outdated, and therefore, incorrect information. A common example would be the electronic health record, where it is imperative to accurately validate patient identity against a single referential repository, which serves as the SSOT. Duplicate representations of data within the enterprise would be implemented by the use of pointers rather than duplicate database tables, rows or cells. This ensures that data updates to elements in the authoritative location are comprehensively distributed to all federated database constituencies in the larger overall enterprise architecture. SSOT systems provide data that are authentic, relevant and referable.

Promoting Health in Developing Countries with New Delivery Model

An article just published discusses a project by some heavy hitters to develop a new sustainable healthcare model for Bangladesh, one of the poorest countries in the world (see: Grameen Health to Establish Independent Collaborations with Pfizer, GE Healthcare, and Mayo Clinic to Create Sustainable Healthcare Delivery Models for the Developing World). Below is an excerpt from it with boldface emphasis mine.

Grameen Health...will establish independent partnerships with Pfizer Inc., GE Healthcare, and Mayo Clinic to create sustainable models for healthcare delivery in the developing world....These multiple, independent collaborations will focus on social business models in which the businesses are self-supporting and any profits are re-invested into the system in order to reach more of the poor. This approach is cost-effective and maximizes the benefits that patients receive. The models will be transferable to other healthcare delivery systems....The independent collaborations will initially explore and evaluate ways to improve the existing Grameen Health delivery and financing systems in Bangladesh, with the aim of creating models that can be adapted for the needs of the 4 billion people around the world whose annual income is less than $3,000.

The article goes on to list four key steps that Grameen Health will pursue in order to implement their health program:

• Implementing primary health promotion and disease prevention programs. These are the most cost-effective steps in affordable health care, and include maternal and child health promotion and nutrition programs.
• Analyzing ways to expand and improve the current low-cost micro-health delivery and insurance programs at Grameen Health’s 38 existing Kalyan clinics.
• Developing continuous training programs for nurses, technicians and physicians.
• Reviewing operating efficiencies and scope of services (e.g., telemedicine, mobile health care) at Grameen Health’s Kalyan clinics.
• Introducing genomic, epidemiological, and outcomes research capability for the prevention and treatment of diseases relevant to the population in Bangladesh, with an emphasis on the best use of existing tested and approved procedures and drugs.

Wait a minute! Could it be possible that this same sustainable model, or some semblance of it, could be transferred to the U.S. if it is successful in Bangladesh? I have my fingers crossed. I have placed into boldface those phrases above that caught my eye and that would be useful to implement here. As just a few examples, low cost micro-health delivery programs could translate into walk-in clinics. I have posted a number of notes about the shortage of medical technologists ( see: ARUP Labs Responds to the Lab Personnel Shortage) and other health professionals but we don't seem to be making many inroads in the solution department. How about health promotion and disease prevention programs (see: Wellness, Preventive Medicine, and the Classic Disease Model). I hope that the proposed model works because we badly need some help from our Bangladeshi friends. Perhaps they could also experiment with inexpensive point-of-care lab testing while they are at it. We also need some guidance in this area.

Amalga Makes Inroads in the EMR World

I have published previous notes about Microsoft's EMR venture, Amalga (see: Microsoft Renames and "Integrates" Its Healthcare Software Line; Developing an Electronic Medical Record Ecosystem (Network)). I have also posted previous notes about both the Microsoft and Google PHR products, HealthVault and Google Health.I was very interested to learn in a recent article (see: El Camino Opts to Aggregate Data) that the Amalga product is now being deployed at El Camino Hospital. Below is an excerpt from the it with boldface emphasis mine:

El Camino Hospital of Mountain View, Calif. has selected Amalga from Microsoft...as its data platform. El Camino plans to use the product to aggregate its clinical, financial and administrative information, which currently resides in disparate, transaction-based systems, and integrate it into a single system that will allow it to better evaluate and improve quality of care, according to Microsoft. Amalga will also be used to monitor patients in real time to identify gaps in quality of care and improve patient outcomes.

Some of the language in this article struck me as being distinctly odd. Aggregate data? Hospital data platform? Monitoring patients in real time? What will they think of next? Perhaps this is how they talk in Silicon Valley. However, and for students of healthcare IT and EMRs, El Camino Hospital may have a familiar ring. It was the first deployment site for the TDS system which was one of the dominant HISs in the 1980s and 1990s. For some of today's EMR company execs, this combination of Microsoft + El Camino might cause them some sleepless nights. Could lightning strike twice in the same spot? In a previous note and pertaining to the emerging role of Microsoft in EMRs (see: HIMSS President Slams PHRs: I Wonder Why?), I made the following observation:

What [HIMSS President] Leiber and the EMR companies fear is that Microsoft and Google will launch a fully-featured EMR/PHR combo that will deliver both value and functionality. Microsoft already has an EMR product in the market....

To this group of Nervous Nellies you can now add hospital CEOs. Recall that the Amalga software was developed at Bumrungrad Hospital in Bangkok which I have covered in previous notes focusing on medical tourism. The Amalga home page prominently features a link to the following article: Why put up with expensive, run-of-the-mill health care at home when you can be treated just as well abroad?. Is this the best way for Amalga to ingratiate itself with its future U.S. hospital clients?

So what do the incumbent EMR companies and hospital execs have to fear from Microsoft and Google. Microsoft is, after all, uh, Microsoft. In addition to deep resources and technical expertise, both of these companies will also bring new ideas to the table. There have been frequent references on the web, often couched in scary terms, about both Microsoft and Google embracing cloud computing for health records (see: Cloud computing puts your health data at risk). There is absolutely no other way in which these two companies will approach the management of health records but with cloud computing. It gives them a cost advantage over the EMR incumbents (can you spell "free PHRs") and it plays to their technical expertise, particularly that of Google. I personally believe that cloud computing, and perhaps Microsoft and Google, may drag much of healthcare computing, kicking and screaming, out of the dark ages.

More on the Epic Systems Culture: HR Responsible for All Hiring Decisions

I have posted a number of previous notes about Epic Systems with particular emphasis on it's corporate culture (see: Epic Systems and Its Corporate Culture; More on the Epic Culture: Is This a Cult or a Company?; Epic Flexes Its Political Muscle in Wisconsin with Boycott). These notes have drawn considerable attention, particularly from IP addresses inside the company. The CEO and founder of the company, Judith Faulkner, shapes the company's culture but she rarely speaks to the press. I was therefore interested to discover an article from December, 2002, describing her own views about the Epic corporate culture (see: Epic's Founder Judy Faulkner Speaks on Culture, Business Beliefs, and Recruiting). Below is an excerpt from it:

All potential employees go through a rigorous screening process. HR is responsible for all hiring decisions. There are no job descriptions. The employees in the workgroup have no input. Faulkner believes, "teams hire people they like ... this eventually breeds bad attitudes and ego-protection" Faulkner tries to take personality out the decision process and hire on skills. "Beware of the articulate incompetent ... a bad weed is a flower in another garden," according to Faulkner. She believes it takes three years for a person out of college to become an "Epic Person," and six years for those hired from the outside.

As I have said in the past, it's difficult to argue with success and Epic is one of the most successful EMR companies around. I must admit, however, that I found the above quote intriguing. I worked in the area of LISs and lab software for 24 years. I can say with absolute uncertainty that the very last group in the organization to whom I would turn for a hire recommendation, let alone a hire decision, would have been human resources (HR). In the large health system environment in which I spent most of my career, the function played by HR was to understand the myriad personnel rules of the organization and ensure that new hires were acceptable under these rules. This had little relationship to the competency or suitability of the new people being interviewed.

So how can one understand and explain Judith Faulkner's quote above? There is only one way that I can explain it. She clearly understands and controls her HR group with an iron hand. The members of the group certainly understand the type of individuals that she wants to place into the organization. However and in my opinion, members of a workgroup need to provide some input into the selection of their co-workers. I reject the idea that members of a workgroup will select new hires primarily on the basis of their congeniality. In work teams, particularly small ones with a lot of responsibility, everyone needs to pull their load. In such a setting, it would be suicidal to recommend, say, a gregarious person who was a slacker.

Epic is a privately held company that is dominated by its founder. One important locus of control is obviously through the company executives and line managers. Faulkner clearly also exercises additional leverage and control through the HR department and their control of new hires. As I have said before, she must be doing something right but my gut tells me that the company is paying a high price in terms of personnel turnover by ignoring input about new hire decisions from team members.

Home Town Newspaper Covers Data Innovations

Data innovations (DI) is a significant player in the lab software space. I have posted previous notes about the company. DI provides to the lab industry a comprehensive set of interfaces between LISs and analyzers. It also sells lab middleware, both under its own label as well as in the form of products sold by major in-vitro diagnostics (IVD) companies under their own labels. A recent article about the company by its home town newspaper, the Burlington Free Press, provides useful information (see: Data Innovations expands). Below is an excerpt from it with boldface emphasis mine:

Data Innovations' products, known as middleware, and services provide the link between a lab's analyzers and its information system. They interface with analyzers and with equipment for automation....Nearly 1,000 instruments, automation systems, and information systems are supported by Data Innovations' middleware....Data Innovations' products traditionally were designed for the reseller market and are sold to suppliers of analyzing instruments and to suppliers of laboratory information systems. Customers include McKesson, Roche Diagnostics, GE Healthcare and Ortho Clinical Diagnostics and many others. In March, GE Healthcare headquarters announced that it would provide Data Innovations products, along with GE services, to customers for instrument interfaces, replacing GE-developed modules. When Data Innovations acquired P.G.P. of Brussels, Belgium, in 2007, it added a related component that serves more than 1,200 direct customers....Forty employees in South Burlington staff departments of sales and marketing; software development, customer service; quality assurance regulatory and documentation; implementation consulting services; training; finance; human resources and a production department that builds and ships the company's systems...."Within the last few years, we have been developing and growing the [I]mplementation [C]onsulting [S]ervices. The ICS consultants combine their knowledge of our software and services with their knowledge of advanced laboratory workflow to make our customers' processes more efficient and therefore more profitable," [a company spokesperson] said.

This article contains three of the magical words in today's lab software industry: middleware, workflow, and consulting. I have made many references to middleware in previous notes. You can generally define this category of software as a product that is interposed between the LIS and a lab analyzer that serves as an interface but can also offer additional functionality. Hence the middleware label. For example, some middleware now serves as a rules engine that can process test results coming from the lab instrument.

In part because of the growing popularity of Lean/Six Sigma, the term workflow has taken on additional weight in the eyes of lab managers. An understanding of workflow implies the knowledge and ability to increase the efficiency of a lab and reduce costs. For example, the term appears consistently in press releases from Siemens Medical Diagnostics describing the value that the company brings to the table for customers.

Finally, a brief discussion about the role of lab software companies as consultants to lab managers. A number of LIS vendors and IVD manufacturers have attempted to recast one of their business units as lab consultants. One such example is Ortho Clinical Diagnostics' ValuMetrix Consulting Service. Some LIS vendors have had difficulty carving out a niche as paid consultants to their lab clients, partly because of the monthly support fees that the clients pay to such vendors for software support. It has been difficult for the vendors to differentiate between these paid-for software support services and consulting services that lie outside of these recurring payments. I suspect that the focus of Data Innovation's ICS unit will be, in part, the development and deployment of lab rules. I have posted a number of previous notes about such rules in the past. It may be relatively easy for the company to offer remunerative consultation services in this area, particularly when it is easy to demonstrate the payoff of rules deployment calibrated in staff reductions. Autoverification rules in particular hold such a promise.

More Ideas about Developing and Refining an RFP

A recent post addressed the topic of how hospital lab personnel need to control an on-site demo by sales personnel from an LIS vendor (see: How Not to Conduct an On-Site LIS Demo). Art Vandelay has submitted the following comment in response to this note:

Great write-up. I agree totally. One other point on appending the RFP to the contract - I recommend going back and re-reviewing the RFP responses after the demo and getting everything noted in-writing. It keeps more vendors than not, honest about their functionality and the realistic timing of the functionality. In their defense, it also helps to clarify what is 'between the lines' in our functional descriptions.

Wise counsel indeed from Art that requires some additional discussion about more of the details about the RFP. An RFP for a LIS is constructed by listing, in short declarative phrases, the various functionalities for the new system. These functionalities are commonly arranged under major category headings such as test ordering or quality control. In a typical RFP, these statements may number many hundreds or even more. Some of them may be ambiguous or too general in nature (e.g., the LIS will have flexibility for creating rules). The vendor will reply to each of them in one of the following three ways: yes, no, in-development. In many case, this little minuet with the LIS vendor results in a set of imprecise requirements and responses by the vendor. For example, does "in-development" mean "vaporware" or "close to being available" for a new customer.

Art's comments suggest that there needs to be a meeting of the minds between a potential customer for an LIS and vendor representatives about critical RFP requirements. There are various ways to achieve this goal such as email exchanges or face-to-face meetings documented by notes. In the case of notes, subsequent email exchanges are required to confirm that they reflect the understanding of the vendor. These emails should be considered by both sides as contractually binding. This is a lot of work but a well-selected LIS can serve a lab for many years.

Charles River Acquires Molecular Imaging Company

I have posted a number of previous notes about contract research organizations (CROs) which are flourishing as Big Pharma continues to outsource a major share of its research and clinical trial initiatives to these companies (see, for example: CROs Continue to Prosper; Benefits of Big Pharma Outsourcing). In recent months, I have covered the growth of Charles River in addition to Covance in the CRO sector (see, for example: Charles River Expands Its Ohio-Based Lab Operations). This latter company is now expanding into the molecular imaging field according to a recent report (see: Charles River buys imaging company for $12.5M). Below is an excerpt from the article:

Charles River Laboratories International Inc. has bought Molecular Imaging Research for about $12.5 million in cash, the company said Monday. Molecular Imaging Research, or MIR Preclinical Services, is based in Ann Arbor, Mich. The privately held company provides imaging and other services to pharmaceutical and biotechnology clients and has expertise in oncology and inflammation. Charles River Discovery Services, which provides services to evaluate the efficacy of compounds, said that with the acquisition it will have expertise in four key therapeutic areas including metabolic and cardiovascular diseases and oncology and inflammation.

Here's how Molecular Imaging Research (MIR) describes its services on its home web page:

MIR employs a wide array of novel imaging technologies including preclinical MRI, CT (µCT), high resolution PET (µPET), bioluminescence and fluorescence imaging to measure response to therapy at anatomical, functional, and molecular levels. We can measure biological processes, such as signal transduction, angiogenesis, apoptosis (proteases), DNA damage, and other biologically relevant processes important in animal models of human disease.

For me, this purchase is interesting on two dimensions. Firstly, it illustrates how the range of services offered by the CROs is growing broader by adding expertise in new technology in addition to project management services. In a similar vein, Covance claims to have developed the world's largest central laboratory network (see: A Look at the World's Largest Central Laboratory Network). Secondly, it illustrates the rapidly growing importance of imaging technologies in the pharmaceutical research enterprise.

One is left with the impression from both this and earlier reports that Big Pharma is becoming inextricably bound to its CRO partners and may be unable to discover and test new drugs in the future without their assistance. Stated another way, the CROs are rapidly acquiring special scientific and technical knowledge and an IT infrastructure that their Big Pharma partners may not possess or be able to replicate. This is the inevitable result of outsourcing core competencies, assuming that a company is able to define exactly what they are.

Leadership and Our Need to Work with Constant Interruptions

Nick Carr's recent provocative piece in the Atlantic Monthly (see: Is Google Making Us Stupid?) has spawned an ocean of comment and controversy. His basic idea is that web-browsing and web-searching, often using Google, has modified the power of concentration for many of us. I have covered his ideas in previous notes (see: How Google is Changing Our Information-Seeking Behavior; Is Google Making Us Stupid?). My marginal relationship to Nick's article has resulted in referrals from Nick's blog, Rough Type, and Atlantic now running at 5.5% of the total per month, nearly as much as from Yahoo and Google.

A recent blog note (see: Are We Becoming Pancake Leaders?), reacting to some of Carr's ideas, touched on the topic of how we now work in "minute-segments" in a way that I found interesting. Below is an excerpt from it (boldface emphasis mine):

First, our Google culture is a reflection of the reality that leaders confront every day. A reality full of constant interruption....In research by UC Irvine computer science professor Gloria Mark, "We don't have work days -- we have work minutes that last all day." She and her team shadowed information workers ...and timed every event. What they found is that the "average amount of time that people spent on any single event before being interrupted or before switching was ... three minutes and five seconds, on average." ...The life of a leader is not one where we attend to any one thing for very long...Leaders have to learn how to influence others in brief moments. They just don't have people's attention for very long. Our Googling habits are just another indication of how "we work minutes that last all day."

The idea of us being forced to work all day in minute-segments of time resonates with me. More specifically, I now work in a home-office with few interruptions and I have a sense that I have never been more productive in my life. The major limiting factor for me now is my own innate ability to concentrate over a longish period of time. I end up attending to work in something like hour-segments.

Various forms of technology (e.g., fax, email, instant messaging, web search) all serve to increase the tempo of both our work-time and our leisure-time. It's hard for me to envision any respite from this accelerating tempo of our times unless one has the discipline to carve out uninterrupted time for some specific type of work and then stick rigidly to the rules. It's possible but it just takes discipline.

One type of work activity in this latter category comes immediately to mind -- reading surgical pathology cases. I know that some pathology groups have enforced a no-interruption policy for their surgical pathology reading rooms. Obviously, calls from clinicians need to be answered. However, in these days of cells phones, I suspect that it would be possible to organize slide-reading time into, say, 30 or 45-minute segments, with critical calls returned during breaks. After all, surgeons do not return calls when they are attending to critical patient needs.