Lab Soft News

NYT Highlights the "Virtopsy" Used for All Military Autopsies

The virtopsy is an emerging subject of interest in medical diagnostics (see: Introducing the Virtopsy, a Variant of the Catopsy Theme, The Classic Forensic Autopsy on the Verge of Being Obsolete, Reinventing the Autopsy: CT Imaging as a Routine Part of the Procedure, Additional Discussion About Reinventing the Autopsy). I have referred to the procedure in some of my notes as the catopsy because of the combination of the classic autopsy and the CT scan. The New York Times has now given increased exposure to this new approach to the medico-legal autopsy with a front page story (see: Autopsies of War Dead Reveal Ways to Save Others). Below is an excerpt from it with boldface emphasis mine.

Under Capt. Craig T. Mallak, pathologists from the Armed Forces Medical Examiner System conduct autopsies and CT scans on all service members killed in Iran and Afghanistan. Since 2004, every service man and woman killed in Iraq or Afghanistan has been given a CT scan, and since 2001, when the fighting began in Afghanistan, all have had autopsies, performed by pathologists in the Armed Forces Medical Examiner System. In previous wars, autopsies on people killed in combat were uncommon, and scans were never done. The combined procedures have yielded a wealth of details about injuries from bullets, blasts, shrapnel and burns — information that has revealed deficiencies in body armor and vehicle shielding and led to improvements in helmets and medical equipment used on the battlefield. The military world initially doubted the usefulness of scanning corpses but now eagerly seeks data from the scans, medical examiners say, noting that on a single day in April, they received six requests for information from the Defense Department and its contractors....The medical examiners have scanned about 3,000 corpses, more than any other institution in the world, creating a minutely detailed and permanent three-dimensional record of combat injuries. Although the scans are sometimes called “virtual autopsies,” they do not replace old-fashioned autopsies. Rather, they add information and can help guide autopsies and speed them by showing pathologists where to look for bullets or shrapnel, and by revealing fractures and tissue damage so clearly that the need for lengthy dissection is sometimes eliminated.

As noted in the story above, there was initial reluctance on the part of the military officials to adopt the virtopsy but it has now proved its value beyond doubt. Also, and as  noted above, a wealth of imaging information is now being made available by the military that could potentially facilitate the rapid adoption of the virtopsy. It urgently needs to be adopted for civilian forensic cases as well as for standard hospital autopsies of patients who have died of medical diseases. However, I suspect that the virtopsy will only be slowly embraced by civilian forensic pathologists or hospital-based pathology departments. Here are the reasons behind my prediction:

• Civilian forensic pathologists are overworked and underfunded. Given the current financial downturn, the various city and state governments that support the services of the medical examiners are struggling to meet basic needs. They will probably have little interest in new initiatives no matter what their value. Many forensic pathologists may also balk at having to acquire the new skills involved in the interpretation of CT images.
• There is no question is my mind that virtopsies would yield far better results than current methods -- the success of the Army with the technology bears out this conclusion. However, there is no urgent driver in the civilian world analogous to that in the military of savings soldiers' lives on the basis of the new virtopsy findings about the nature of injuries.
• For hospitals and pathology departments, there is no reimbursement for autopsies and frequently inadequate compensation for forensic cases. On this basis alone, it may be difficult to convince chairpersons of pathology departments to sink capital into enhancements of the pathology suite and new training initiatives.
• The only bright spot in this story is the increased interest in the merger of pathology and radiology, discussed in many previous notes. If this trend takes hold, the notion of training pathology residents rotating through the autopsy service in the interpretation of CT images could be very appealing. For academic departments, there is also the intriguing possibility of extracting more usable information from autopsy cases.

Federal Tax on Soda Pop Proposed: Can This Be Justified?

I have come to accept the idea that there are five "toxic" substances that are broadly consumed by the U.S. population: salt, sugar, fat, nicotine/tar from cigarettes, and ethyl alcohol. Our citizens would be healthier if their intake of these foods/chemicals was reduced in some way. Meanwhile and in the face of a major economic downturn, the federal and state governments are seeking additional revenue while cloaking some of these new programs as public health initiatives. This has been the broad public support in the past for the high taxation of both cigarettes and liquor, which are commonly known as sin taxes. Here is the latest news about a possible tax on soda pop (see: Soda Tax Weighed to Pay for Health Care) with boldface emphasis mine:

Senate leaders are considering new federal taxes on soda and other sugary drinks to help pay for an overhaul of the nation's health-care system. The taxes would pay for only a fraction of the cost to expand health-insurance coverage to all Americans and would face strong opposition from the beverage industry. They also could spark a backlash from consumers who would have to pay several cents more for a soft drink....The Center for Science in the Public Interest, a Washington-based watchdog group that pressures food companies to make healthier products, plans to propose a federal excise tax on soda, certain fruit drinks, energy drinks, sports drinks and ready-to-drink teas. It would not include most diet beverages. Excise taxes are levied on goods and manufacturers typically pass them on to consumers....The Congressional Budget Office...estimated that adding a tax of three cents per 12-ounce serving to these types of sweetened drinks would generate $24 billion over the next four years....Proponents of the tax cite research showing that consuming sugar-sweetened drinks can lead to obesity, diabetes and other ailments. They say the tax would lower consumption, reduce health problems and save medical costs. At least a dozen states already have some type of taxes on sugary beverages....The main beverage lobby that represents Coca-Cola Co., PepsiCo, Kraft Foods and other companies said such a tax would unfairly hit lower-income Americans and wouldn't deter consumption.

There are a number of interesting tidbits contained in this news excerpt. For example, the proposed sin tax, in its current form, will be levied against sugary beverages but not against artificially sweetened beverages. On the face of it, this seems logical because sugar currently appears to be the health culprit. However, who's to say that the artificial sweetening agents will not, in time, prove to be unhealthy? The rules of fair play would suggest that all soda pop should be taxed. My instincts tell me that the real reason for this distinction is that most of the congressmen probably consume diet drinks from time to time.

The determination of whether a tax of three cents per 12-ounce serving of sweetened drinks will deter consumption is a matter of the price elasticity of demand for the product. Of some interest is that the Wikipedia article on this topic specifically cites the demand for sugar as being very elastic because there are substitutes for sugar to which consumers may switch to.

The quote from the beverage lobby representatives that "such a tax would unfairly hit lower-income Americans" can be interpreted in two ways. The most obvious is that such people can ill-afford any increase in the price of beverages. However, I also have the nagging sense that sugary beverages are disproportionately consumed by people in the lower socio-economic classes. Perhaps this is because I rarely see anyone on airplanes or at professional meetings consuming anything but bottled water or diet drinks. My suspicion, based in part on the work of David Kessler as described in his new book, The End of Overeating: Taking Control of the Insatiable American Appetite, is that sugar is additive and that this addition is more common among lower income people because sugary beverages provide a cheap fix for this addiction (see: Crave Man). Similarly, more people in the lower socio-economic classes are addicted to cigarettes but they no longer provide a cheap fix.

:: Update on 6/29/2009 @ 7:25 p.m.

See: Soda Tax: From YouTube, to New England Journal, to Congress

An "Independent" Autopsy after the Death of a Relative in a Hospital

Any patient who dies in a hospital is entitled, at no charge, to an autopsy to determine the cause of death. If family members refuse permission for the autopsy, the physicians caring for the patient are then required by law to determine the cause of death. I recently came upon an article in the New York Times written by a woman whose previously well sister passed away in a hospital of septicemia (see: The Autopsy, a Search for Reassurance). In this article, she raises the issue of the need for an "independent" (i.e., private) autopsy. This article requires additional discussion. Below is an excerpt from it with boldface emphasis mine:

If I could have arranged for an independent autopsy by a pathologist outside the hospital where my sister died, I might have done it. But at the time, I had no idea how to go about it and felt too dispirited to try. Recently, I typed “autopsy expert” into a search engine and found Dr. William Manion, a pathologist and lawyer in New Jersey....Some clients hire him because they want to sue doctors, he said in an interview, but others are just looking for peace of mind. Some are upset because they feel doctors didn’t take the time to explain what happened....Similarly, he said that people whose relatives died of undiagnosed, advanced cancer sometimes recalled symptoms from a few months back that they might have overlooked or dismissed. He tells them that the cancer must have been there for a long time, and that they couldn’t have done anything....As for my concern that a hospital might try to cover its mistakes in an autopsy report, Dr. Manion didn’t buy it. Pathologists based in hospitals are reliable, he said, in part because they have to pass muster with various accrediting groups....The Web site for the College of American Pathologists keeps a list of board-certified pathologists who perform private autopsies. Most charge $3,000 to $5,000....But it’s important to decide quickly; Dr. Manion says an autopsy is best performed within 24 hours of the death, before organs deteriorate too much.

By New York Times standards, this particular article leaves much to be desired. Its fundamental flaw, in my opinion, is that the author turns to an individual, Dr. Manion, who derives financial gain from referrals away from hospital pathologists for a general assessment of them. He, in turn, describes hospital-based pathologists as "reliable," in essence damning them with faint praise. I have personally spent more than four decades in pathology and been involved with thousands of autopsies. I have never seen a single instance where an autopsy report was less than totally objective in terms of the cause of death, particularly in cases of potential malpractice. I have also been personally involved in numerous lively discussions with clinicians, including many surgeons, about autopsy findings. In the final analysis, the objective judgment of the pathologist about the cause of death of a patient has always held sway. The veracity of an autopsy report goes to the very core of the practice of the specialty.

I will also defend the right of any family to choose to have an autopsy performed by an "independent" and qualified pathologist without a relationship to the hospital where the patient died. In most such cases, the patient and family have had an uneasy relationship with hospital medical staff or administrative personnel. They may feel that they want to "do the best thing" for their relative or may be in a litigious frame of mind, with or without good cause. I agree with Dr. Manion that in the majority of such cases, the treating physicians have been uncommunicative or perceived by the family as uncaring -- this is frequently the basis for their mistrust of all of the hospital physicians. However, I would advise families seeking an independent pathologist to take some care that the individual selected is well trained and board-certified.

Diabetic Tatoos: Lifestyle Merges with Medical Necessity

The interest in "tats" on the part of the younger generation seems to be moving in a more positive direction for some of them. There is growing interest in so-called diabetic or biohazard (HIV-positive) warning labels (see: Tattoos being used for medical alerts) affixed in a permanent manner to the body. Below is an excerpt from the article with boldface emphasis mine:

Increasing numbers of people who have serious medical conditions, such as diabetes, are turning to tattooing to identify themselves on the chance a health emergency leaves them unable to communicate, says Saleh Aldasouqi, a diabetes expert....There's a tattoo trend surfacing — one that could save lives. "Like it or not, a lot of people are resorting to this way of medical identification," [he] says....[He] first met a patient with a medical tattoo last year when Illinois correctional officer Todd Walsh, who has had type 1 diabetes since childhood, came to him for care. Walsh, 37, sports on his wrist a black and red "star of life," a six-pointed star with a spiraling serpent inside, often seen on ambulances. The word "Diabetic" is inscribed below it. Walsh has had numerous episodes of potentially life-threatening low blood sugar, which can cause disorientation and even unconsciousness. He had worn medical alert bracelets over the years, but he says they often broke and the cost was adding up. "This is a more permanent solution," he says....At Fatty's Custom Tattooz in Washington, D.C., owner Matthew "Fatty" Jessup says he has carved numerous health-related tattoos. "I've done a biohazard symbol for a few people with HIV," he says.

Medical "tats" seem to be a way to put a positive spin on the now popular body art. However, I have a concern that some of these warnings might be missed by EMTs called to a scene of a patient who has collapsed on a sidewalk in a diabetic coma. I am also concerned that a HIV-biohazard tat might be overlooked in a dark bar after one drink too many. What may be desirable for the latter could be a more conspicuous site than an arm or ankle.

CCHIT Certification and "Meaningful Use" of EMRs

Meaningful use is a concept that has emerged as basis for determining whether federal funds can be used to subsidize the purchase of certified EMRs by hospitals. CCHIT has established a presence as the key certifying organization. I must confess that I have not been following CCHIT very closely but my instincts tell me to be very suspicious of any organization that is closely linked to HIMSS. In a previous note, I discussed the role of HIMSS as a trade association (see: HIMSS Describes Itself as a "Trade Association" in a Press Release). HIT blogger Dana Blankenhorn holds the same suspicions regarding CCHIT as he opines in a recent note (see: Will meaningful use go down CCHIT rabbit hole?). Below is an excerpt from his opinion piece with boldface emphasis mine:

CCHIT, a creature of the HIMSS vendor group, currently controls certification of Electronic Medical Record systems, and wants its certification to control meaningful use. It has lined up its allies (including consumer groups) to retain that power. Trouble is, as John Chilmark writes, if HIMSS wins its fight then control over defining health IT passes from the public sector to the private sector, which could use it to define out innovation, as it has in the past. As John Halamka notes, there is a reason why the phrase meaningful use is vague. He predicts, “Each year, the definition of meaningful use will be expanded, setting the bar higher and requiring more features and more data exchange.” That’s important. One thing we can be certain of is that, over time, health IT technology is going to change. If you lock in details now, or if you let some private group define meaningful use in terms favorable to current technology, you lose the chance to adapt to change. Conservatives are constantly harping on the idea that, if regulation is to exist, it must be simple, straightforward, and light. Focus on results, and let the market direct the rest.

Certification and governmental regulation tends to favor the large and powerful incumbent companies in any particular industry. That's why big companies tend to favor such initiatives although one might assume that most of them would oppose market restrictions. These companies have scores of personnel who devote all of their time to meeting certification requirements. The more complicated the criteria the better for them because this makes it more difficult for new entrants in the market. HIMSS functions as a trade association and works closely with its larger industry partners to ensure that any certification scheme inhibits new market entrants. And here's the most insidious part of this strategy. The companies can assert with a straight face that they are working to ensure patient safety and information exchange while protecting their market share. [Applause]

Each year, the large HIT companies in search of new hospital clients, will invest more capital into certification and proportionally less in R&D. Meaningful use will soon be equated with the continuing ossification of EMRs. Less capital will be invested in new functionality for their EMR products because it will become more onerous to "certify" as safe any new features. Recall also that all of the major EMRs are highly proprietary by design in order to lock-in hospital clients so that "information exchange" will require a major and costly rework of them. Information exchange has not been a high priority for most hospital CEOs anyway as I stated in a previous note (see: Differentiating Between RHIOs and HIEs):

The primary goal of hospital executives is to increase their admission rates and they have very little interest in making clinical information more portable for patients. Although clinical belongs to the patients for whom it is generated, hospitals generally view it as proprietary to them. The consequences of the broad sharing of patient clinical information is to enable healthcare consumers to shop around among competing hospitals.

Update on 5/25/2009 at 10:15 p.m.

Mr. HIStalk comments on CCHIT thusly:

The Washington Post follows up its somewhat critical HIMSS piece with another that goes after CCHIT. The title is more exciting than the article: “Group Seeks Sway Over E-Records System — Health Association With Ties to Stimulus Lobbying Effort Pursues an Oversight Role.” All it says is that HIMSS created CCHIT, lobbied for big stimulus dollars, and now recommends CCHIT as the EMR certifying body. “Critics in the health-care industry have expressed concern that the certification commission is too close to information technology and health-care companies to be the best judge of what equipment doctors and hospitals ought to buy. Although the group is funded through a contract with Health and Human Services, it is run by a former HIMSS executive and one trustee also is the president of the trade group. Several board members work for technology vendors.”

Virginia Data Held Hostage by Hacker Who Asks for Ransom

One can see a new type of computer crime unfolding in slow motion before our eyes (see: Virginia Officials Begin to ID, Notify Hacker's Victims). Medical and personal data have been stolen from an official Virginia state web site by a computer hacker who is now demanding a $10 million ransom. Below is an excerpt from the article with boldface emphasis mine:

While there is no tally yet on the numbers of people impacted by the breach, [a spokeswoman for the Virginia Department of Health Professions] says advisory letters may soon be mailed to people whose Social Security numbers and other personal data may have been compromised. "The Social Security number is the main thing we’re concerned about," she says. [She] declined to update the criminal investigation and referred inquiries to the Richmond, VA office of the FBI, where a media spokesman official would only say that "the investigation is ongoing." The hacker broke into the Virginia Prescription Drug Monitoring program Web site last month and left a ransom note that read: "I have your [stuff]! In *my* possession, right now, are 8,257,378 patient records and a total of 35,548,087 prescriptions. Also, I made an encrypted backup and deleted the original. Unfortunately for Virginia, their backups seem to have gone missing, too. Uhoh: (For $10 million, I will gladly send along the password." Despite the hacker's claims, [the spokesperson] says it's not clear how many records were breached at the site, which is used by pharmacists and other health officials to monitor prescription drug abuse.

I suspect that similar types of computer crimes have occurred in the past but I am just now aware of them. Obviously, a computer hacker could operate from any country in the world and hide his true location. He or she could also be bluffing, having merely hacked into the Virginia site, leaving a trail of crumbs and not even bothering to copy the data that was being held for ransom. Of course, data kidnapping is different and less dramatic than the kidnapping of a person. I am sure that the FBI will not recommend the paying of a ransom. There is no guarantee that the kidnapper will "return" the stolen data and paying such a ransom would only encourage new episodes of the crime. Meanwhile, the people "impacted" by the crime can only worry about what will happen next. I am sure that there is a ready market for stolen on the web for stolen Social Security numbers.

Medicolegal Liability and Malfunctioning Healthcare Information Systems

According to a recent blog note by Mr. HIStalk, EMR vendors can't be held responsible for errors that creep into data reported by their systems to hospital physicians. Below is an excerpt from his note with boldface emphasis mine:

Penn researcher Ross Koppel’s new JAMA article concludes that healthcare IT vendors enjoy contractual and legal protections that keep them out of trouble even when their products cause patient harm.  Anyone who has signed a vendor contract from either side of the table knows that vendors disclaim most responsibility, saying it’s the licensed user’s job to notice software or hardware errors and prevent them from harming patients (like when an allergy warning doesn’t display or a dose is calculated incorrectly). HIMSS unleashed a vindictive and wildly pro-vendor barrage against Ross in 2005 for daring to write an article describing patient harm that occurred with a hospital’s IT implementation, but I expect they’ve got bigger, multi-billion dollar fish to fry this time.

Here's a link to an abstract of the 2005 JAMA article. Also, here's a link to a 2005 reference describing the nature of the criticism leveled by HIMSS personnel against Koppel and referred to in Mr. HIStalk's note (see: When Technology Isn’t Always the Answer: A Case Against Computerized Order Entry):

Although Koppel offered suggestions for reducing the medication error risks inadvertently caused by CPOE systems, the University of Pennsylvania report was still met with criticism from proponents of CPOE systems, including the Healthcare Information and Management Systems Society (HIMSS), which asserted that the systems, when properly implemented, are extremely beneficial to the safety of health care. “The study points out some design problems that could cause confusion or error if they were present,” said Jonathan Teich, MD, Ph.D., chair of the HIMSS Patient Safety and Quality of Care Steering Committee. “However, almost all of the flaws that were mentioned in the research have been realized previously; remedies have been found and have appeared in published literature.” Joyce Sensemeir, RN, MS, HIMSS director of professional services, added that while the report can serve as a “cautionary tale” about what could go wrong, it should not be taken as the standard of what occurs with proper CPOE implementation.

I frankly can't see a practical way to hold EMR vendors responsible for errors that might crop up in hospital electronic records. I can therefore understand why these vendors include "hold harmless" clauses in their contracts. First of all, these companies would probably spend most of their time and resources in court litigating both valid and frivolous suits against them without such a contractual exemption. We all understand that healthcare is a litigious environment. Secondly, the performance of any EMR is a combination of the vendor product plus the various tables and settings established by the local hospital software support group. In most cases of erroneous results, it would probably be difficult to establish fault. Putting the onus for the quality of EMR results on hospital personnel seems to me to be placing responsibility on the proper group. I have published previous notes about how HIMSS operates largely as a trade association for healthcare IT companies (see: HIMSS Describes Itself as a "Trade Association" in a Press Release, Possible Adverse Consequences of Increased Federal Investment in HIT).

A Brief History of the @ Sign

I came across an article on the web that discusses the history of the @ sign (see: Internet Star @ Least 473 Years Old). I found it to be very interesting and want to share it with you. Below is an excerpt from it:

Because it is used in every e-mail address and many tweets, you might be forgiven for thinking that the remarkably common symbol @, which English-speakers know as the “at sign,” but Italians call a “snail,” and south Slavs know as a “monkey,” is a fairly recent invention....The Italian newspaper La Repubblica reported in 2000 that Giorgio Stabile, who was then a professor of the history of science @ La Sapienza University in Rome, had come across the symbol in [a] merchant’s letter, where it was used to indicate an ancient measure of weight or volume, an amphora. The Spanish word for amphora was “arroba,” and the Oxford English Dictionary explains that the unit was approximately 25 pounds of a solid or about 3 gallons of a liquid. In modern Spanish, the @ symbol on keyboards is still called an arroba — as a Google image search illustrates. The word “arroba” itself was a Spanish corruption of an older Arabic word.

The symbol ended up on typewriter keyboards after it evolved over the centuries into commercial accounting shorthand for the phrase “at the price of” in records of transactions written by English merchants. That’s why the symbol was sitting on a computer keyboard in 1971 when an engineer named Ray Tomlinson decided to use it in the first e-mail address to send the first e-mail. As Mr. Tomlinson himself has explained in a description of that first e-mail: I chose to append an at sign and the host name to the user’s (login) name. I am frequently asked why I chose the at sign, but the at sign just makes sense. The purpose of the at sign (in English) was to indicate a unit price (for example, 10 items @ $1.95). I used the at sign to indicate that the user was “at” some other host rather than being local.

Comparative Effectivenss, Healthcare Cost Reduction, and Virtual Decision Trees

I have posted a number of previous notes discussing how to assess comparative effectiveness and efficacy of various medical treatments (see: A Look at Deloitte's Healthcare Reform Pyramid: A Strategy for Reducing Costs, Is My Chemo Working? -- FLT PET Scans May Provide the Answer, Using Diagnostics to Monitor the Effectiveness of Treatment). The topic of comparative effectiveness is important for lab professionals because lab tests will necessarily be a key element in any such program. Dana Blankenhorn, who frequently blogs about the health industry, discussed this topic and its relationship to cost-containment in a recent note (see: Industry commits to comparative effectiveness). Below is an excerpt from the note with boldface emphasis mine:

$2 trillion. Insurers, drug companies and other market players [arrived at this potential savings in healthcare expenditures] by estimating what current health care inflation is doing to costs, then promising to shave that inflation by 1.5%....The significance is that this is twice what the President estimates it will cost to extend coverage to the uninsured. Advocates on both sides will cite it as meaningless, but it’s proof the industry wants to be seen as being in the reform camp. While some think the number was pulled from the air, it was likely pulled from the work of Dr. Ralph Snyderman, now helming Proventys, which is building “virtual decision trees” to guide best practices and deliver the kinds of savings he was able to achieve at Duke. All of which means industry and government have joined together in believing that comparative effectiveness can be made to work at the point of care, and committed to moving toward it.

Here some more information about Proventys and virtual decision trees (see: Proventys stars University chancellor in birth of a salesman):

The main way Proventys [assists physicians care for cancer patients] is by building virtual decision trees from clinical trial data, then selling the results to insurance carriers and self-insurance pools for use at cancer centers. “Collect patients’ data as they undergo chemotherapy, before and after, and  mine that data to see what were the most important predictive factors” for success, “that’s the way to do it” [said Dr. Snyderman]. Dr. Snyderman is confident that insurers will gladly pay for a service that gives them greater confidence in a positive result at the lowest possible cost. “What we need to look for, given the way the reimbursement system works, are people who have incentives to gain on the bottom line with this, who will share savings with the developer,” he explained.

I believe that physicians, in general, have an aversion to use the use of decision trees or care maps, or whatever you want to call them when the are used to regulate their treatment of patients. I don't think that calling them "virtual  decision trees" makes them in any way more appealing. This distaste on the part of physicians is derived, in part, from the face that they are viewed, appropriately, as recipes for cookbook medicine and partly from the fact that they take extra time to review and follow. I believe that are two ways to persuade physicians to utilize decision trees when treating cancer patients. The first is for insurance companies to provide financial incentives for close alignment of the treatment of, say, cancer patients to the recommended regimens. This might occur on the basis of the skill and knowledge of the physician or by close attention to the applicable virtual decision tree. The second is by providing easy access by physicians to the relevant on-line virtual decision trees. Ideally, this can be accomplished using smart cell phones equipped with a web browser. Of course, office PCs can also be used for this same purpose.

Steve Ballmer on the Future of Computing: Three Screens and the Cloud

I believe in cloud computing and think that this model will soon be embraced by most industries, with the probable exception of healthcare, and will also rapidly become the norm for personal computing. I have posted a number of notes about this topic. I have also posted a number of notes about smart phones, viewing them as types of mini-computers, and emphasizing their role in e-health and m-health, with the latter "m" standing for mobile (see: Making e-Health Information Accessible with Smart Phones, The Mobile Web and the Future of eHealth).

Nearly all of my own daily computing work takes place in the cloud and I have never worked more efficiently in my life. All of these ideas coalesced in my mind when I heard Steve Ballmer, CEO of Microsoft, utter a simple statement in a podcast that I listened to recently (see: The Future of Microsoft, The Future of Technology). He said the following in a lecture at Stanford: the future of computing involves three screens and the cloud. The three screens to which he refers are PCs, cell phones, and televisions. Azure is Microsoft's platform for the cloud on top of which new applications can be built in this new environment.

For me, It's relatively easy to predict that the healthcare industry will be the last to embrace the cloud. Past history suggests that healthcare has always been last in the queue to adopt new concepts in IT. The reasons for this are numerous and include the fact that the industry is highly regulated, conservative, and suffers serious penalties for mistakes. However, it's still interesting to speculate about changes that may be encountered in, say, hospitals when the norm for computing consists of "three screens and the cloud." The first type of screens that popped into my head in healthcare were the ubiquitous TVs in patient rooms.

Such TVs, wired to provide web access, could provide an opportunity for inpatients to review parts of their own medical records. I would advocate perhaps a 24-hour time lag for patient access to, say, pathology, lab, and radiology reports. This "period-of-grace" would provide the hospital clinical staff a 24-hour window to present critical data to patients prior to their ability to access it. Such access could serve to engage more patients in their own care processes while hospitalized. Consider also, for example, the benefits of allowing patients to view the list of medications they are currently taking accompanied by pictures of the pills. I believe that the error rate when dispensing drugs in the patient care units could decline rapidly if access to such data was available.