Lab Soft News

G.E. Jumps into the Hospital Connectivity Space

As someone who spent a lot of time in the past thinking about community health information networks (CHINs), the recent news about G.E. entering the HIE (health information exchange) space made me laugh out loud. The amount of money lost on healthcare connectivity endeavors such as CHINs and regional health information exchanges, a later incarnation of the same concept, has been enormous (see: A Quick Look at CalRHIO). So here we go for one more bite at the apple (see: G.E.’s Bid to Connect Computerized Health Records).

There are all sorts of obstacles to moving the nation’s health care system, choking on paper records, into the computer age. The cost and complexity of making the transition are daunting, though the government’s $19 billion in incentives for doctors and hospitals to adopt electronic health records should help. But the hoped-for benefits of digital health records ...will not really materialize unless information flows seamlessly and securely among labs, clinics, hospitals, doctors’ offices and patients. General Electric’s big health care division is introducing on Thursday a new unit, eHealth, to pursue the business opportunity presented by this challenge. The main target for G.E.’s new business unit is in providing the technology and expertise to build regional and statewide Health Information Exchanges [HIEs], as these planned data-sharing hubs are now being called. An initial $564 million grant from federal government to the states will provide seed money to get things started. Over the last two decades, there have been efforts to set up such health information-sharing networks. They were first called Community Health Information Networks and later Regional Health Information Organizations. Mostly, they failed. Hospitals and physician groups had no incentive to make the investment to share patient information, since they were not paid for doing so. But to qualify for incentive payments from the government, doctors and hospitals need to adopt electronic health records that share information across networks....G.E. said it was investing $90 million to get the new eHealth unit going. Its offerings include software for securely storing and sharing patient information, a Web portal that can pull patient information from various sources and present it to doctor, and a Web-based personal health record, called LifeSensor. It was built by a G.E. partner, InterComponentWare. So is G.E. going head-to-head in the emerging field of personal health records — controlled by individuals, not a doctor, hospital or insurer — with the likes of Google and Microsoft?

I do take issue with the statement above that hospitals lacked an incentive to share patient information and paying them for doing so will provide sufficient motivation. My view has always been that hospital executives view patient information as proprietary and providing some small payment for them to pursue a connectivity goal will be insufficient. The problem is that they will never state their true objection but rather moan about the complexity of medical information and the challenges of clinical data exchange. Incidentally, hospitals have had no problem sharing financial information because this is how they are reimbursed (see: CCHIT Certification and "Meaningful Use" of EMRs).

I have covered both the Microsoft and Google forays into the PHR development and, of late, Google's partial withdrawal from this field. I have come to the personal conclusion that the Google executives have decided either that they have bigger fish to fry (e.g., the cell phone market with Android) and/or the healthcare market poses too many risks and too little profit for a technically innovative and adroit company (see: Google Health Running Out of Steam, According to Experts). For Microsoft, working several years behind the curve and having power lunches with hospital executives probably feels just about right (see: Microsoft's Cell Phone Operating System Lacks Key Functionality). I suspect that G.E. decided to hold its nose and jump into the HIE fray. After all, McKesson, a serious competitor, has had success linking physician offices and office EMRs with its RelayHealth product (see: Developing an Electronic Medical Record Ecosystem (Network).

Another Saga of "Blame the Vendor" Leaks Out of the UK

There are days when I am sure that Neal Patterson, CEO of Cerner, regrets the little pas de deux that his company has been engaged in with the British government and its NHS for years. Mr. HIStalk alerts us to another chapter to this continuing saga with its "blame the EMR vendor" theme:

Speaking of Cerner, St. Bartholomew’s Hospital in London faces fines of $650,000 per month for lengthy patient backlogs that it blames on the “dreadful” Cerner Millennium. I doubt it’s that simple, but blaming the computer is always convenient.

Here's an excerpt from the source (see: Barts faces fine over IT failures):

St Bartholomew’s Hospital in London faces being fined £400,000 a month for missing patient care targets as a result of the troubled NHS IT programme....Tory MP Richard Bacon, a member of the Commons public accounts committee, which scrutinises public spending, said the £12.7bn NHS IT programme had led to Barts developing a backlog of thousands of patients waiting for treatment....He said the Cerner Millennium system had caused “havoc” wherever it had been deployed in the NHS. The hospital was failing to meet a Department of Health target that no one should wait more than 18 weeks to receive hospital treatment from the time they are referred by a GP.

I have covered the issue of "blame the vendor" in a previous notes (see: Do Hospital Executives Use Their IT Vendors as Scapegoats?). My guess is that there's plenty of blame to go around with the NHS' EMR program and that their electronic medical record problems are multifactorial (see: NHS Computer Czar "Outed" by his Mum). I also believe that any large-scale IT project mounted by the NHS will inevitably end in chaos, with or without Millennium in the mix. You have a mixture of a creaking government bureaucracy, hospital personnel who may not be motivated to put in a day's work, and a host of grand-standing politicians playing to the crowd. Did you note the name of the Tory MP quoted above -- it's BACON. From what I know about the usual wait for hospital admission in the U.K., 18 weeks seems like good performance. Comparable in some ways to Canada (see: The Fundamental Flaws in the Canadian Healthcare Delivery System). Does everyone understand the irony of the British government fining a hospital $650,000 per month that it itself owns and manages. The government hospital executives will surely ask for a larger operating budget to cover their recurring fines? Another alternative is to withhold payments to Cerner. Blame the vendor.

Are You a Primary Care Pathologist, Asks Dr. Henderson

A new pathology blogger has appeared on the scene -- Dr. Gregory Henderson. He calls himself a primary care pathologist and his first blog note is about this very topic (see: You Might Be A Primary Care Pathologist). Here are the criteria he lists to determine whether one falls into this category:

• If you have ever taken phone calls from patients to help explain their diagnosis, you might be a primary care pathologist.
• If you have ever scrubbed into a surgical procedure to help the surgeon identify key areas to sample for frozen section, you might be a primary care pathologist.
• If you have ever manned a booth at a community health fair that educates women about Pap and HPV testing, you might be a primary care pathologist.
• If you have spent an enormous time over the past 3 months helping your hospital prepare for the impending H1N1 epidemic, you might be a primary care pathologist.
• If you look around your lunch table most days and see physicians of other specialties and no other pathologists, you might be a primary care pathologist.
• If your pattern of practice looks anything like any of the pathologists on this CAP website, you might be a primary care pathologist.

I need to confess that my first reaction, on reading his inaugural note, was to flinch a bit. After all, the notion of "primary-care-anything" seems to be quickly losing its luster in our rush to become uber-specialists, particularly those who can bill for a procedure. However, and after reading his list, I have changed my mind. There is a tendency for one's first blog note to focus on a topic that one really cares about. It goes to the nature of this obsession -- the need to communicate one's ideas on a broader scale. There is the ring of authenticity and sincerity about his list that any pathologist will be proud of. I wish him the best of luck in his future blogging career. I am sure that he will provide us all with better insights into the valuable services that individuals like him provide to their communities. Oh, and the fact that Dr. Henderson refers to Lab Soft News on his home page as one of his favorite blogs had no influence on these remarks.

Microsoft's Cell Phone Operating System Lacks Key Functionality

If I say PC and operating system, some of you will probably respond associatively: Windows and Microsoft. If I say cell phone and operating system, most of you will probably stare at me. That's really not a problem. The critical differentiating feature for cell phone operating systems is not it's name but rather what it can do for you. In previous notes, I have presented the idea that the smartphone is the next PC and will have great relevance for healthcare, pathology, and lab medicine. What users should now be looking for in their cell phones is nearly the same, or better, functionality than their PC.

My Palm Pre browses the web so efficiently that I can read email and search the web without any sense  of being inconvenienced. Despite its best efforts and having been in the cell phone OS business for a long time, Microsoft still can't seem to get this right. Some of the details were revealed in a NYT review of a Windows Mobile phone (see: Another Try for a Windows Phone, but It’s Still Clunky). Below is an excerpt from the article:

If you’ve never heard of a Windows Mobile phone, or never particularly cared what kind of software runs on your phone, prepare yourself. In the coming months, Microsoft will release a steady drumbeat of ads intended to make you want a device powered by its software....Windows phones have been around for years, mostly competing with BlackBerrys for the allegiance of business users. But while BlackBerry crossed over into the consumer realm with more user-friendly phones, Windows Mobile remained in its corporate cube, because of devices that could be so frustrating to use that few people would choose one without a corporate mandate....For much of the last year, Microsoft has been saying that its new mobile software upgrade would significantly simplify the user experience. And the upgrade does simplify things, but not much. Instead of poking around with a stylus, Windows now features icons that are big enough to hit with your fingertip. That helps you navigate the phone’s software menu and interact with various programs, but when it comes to the one application smartphone owners use the most — Web browsing — it falls far short....But unlike the iPhone or the Palm Pre, a Windows phone still lacks a multitouch screen, so you can’t pinch and pull the display to a chosen size. Instead, you press buttons and sliders in a scheme that sorely lacks precision....Likewise, instead of simply connecting you to a free Wi-Fi hot spot, Windows forces you into a three-step decision tree that would make a technician’s heart sing, but would strike fear into the heart of just about anyone else who just wants to log on.

There's a lot that's wonderful about the current crop of smartphones. Although I am very fond of my Pre cell phone from Palm, I recently purchased an iPod touch, which is an MP3 player that lacks cell phone capabilities. However, it can connect to the internet effortlessly using W-Fi so I can still place VOIP calls anywhere in the world using a Skype application that I have downloaded and installed. It is quite a remarkable device.

For me, the greatest feature of my Pre is being able to effortlessly surf the web with the essential enabling element being hand-gestures such a "pinch" or "pull" interpreted by the device's touch screen as a zoom-in and zoom-out. Similarly with the Pre, I can change applications, still keeping all of them resident, with a finger-sweeping gesture on the screen to the right or left. The review of Windows Mobile above provides further evidence for me that Microsoft is still wandering in the wilderness. Fortunately for us, there are cell phone OS developers who understand the web and the need on the part of users for a friendly user interface in order to surf it.

American Academy of Family Physicians Cozies Up to Coke

I sometimes think that many prestigious U.S. organizations have badly lost their way recently.  Another possibility is that it's business as usual for all of them and the web provides us with insights into business deals previously gone unnoticed. Here's only one example. A major factor into our obesity epidemic is the sugar-loaded soft drinks. Our politicians are so concerned about this that they want to tax the sugar beverages to restrict usage and, uh, generate new tax revenue (see: Federal Tax on Soda Pop Proposed: Can This Be Justified?). We now learn that one professional physician society has established a tight (i.e., six-figure) relationship with Coke in order to provide "nutritional" information on its web site. Here's the news (see: Looking for health advice? Dr. Coca-Cola will see you now):

When the American Academy of Family Physicians [AAFP] announced it had received a substantial grant to enhance educational information about nutrition on its FamilyDoctor.org site, you’d think health experts would have been happy. But the money was earmarked to focus on the role of beverages and sweeteners in a healthy diet. And it came from the world’s largest beverage maker, the Coca-Cola Co....“We urge the AAFP to regain its credibility by rejecting the deal with Coca-Cola,” [a recent letter from physician critics] stated. “If the AAFP declines to do that, we urge your organization to reassert its support for the public health (and its own independence) by supporting a warning label on caloric sugar-sweetened beverages and a federal tax on soft drinks to support health promotion or health insurance programs.” The letter noted that soda is “the only food or beverage that has been demonstrated to promote overweight and obesity.” ...But the signatories warned that the six-figure grant from Coca-Cola will prevent the doctors group from “criticizing sugar-sweetened beverages in the strongest language.”....In 2003, the American Academy of Pediatric Dentists took a $1 million payment from Coca-Cola. Before the payment, the dentists' group acknowledged the connection between sugary drinks and dental disease. But after the payment, the president of the AAPD told reporters that the ‘scientific evidence is certainly not clear’ on the role soft drinks play.

I think that there is a need to try to explain how a professional physician society could accept a grant from a company such as Coca-Cola. Surely every physician member in the group would immediately understand that this was a big mistake. I suspect that the short answer is money but this response begs for a more in-depth explanation. Here's one for your consideration. Physician professional societies have two major sources of income. The first is membership dues but this does not amount to serious money. Dues are intentionally set low to encourage greater membership. The second source of revenue are the meetings sponsored by the society. Unfortunately, the net revenue generated by medical conferences is headed south. This is a result of the feeble economy and also a more punitive environment regarding conference sponsorship, particularly regarding various types of payments from pharmaceutical companies.

But wait! Why would physician professional societies need a robust revenue stream? The physician leaders of societies work on an unpaid basis. Well, partly to offset the losses from their print medical journals, which are dinosaurs and will soon disappear, and also to develop their web sites devoted to healthy living and good nutrition. Also keep in mind that many such societies, particularly the largest, have hired executive directors who have salaries in the high six figures and a large cadre of well-paid staff members. As a result, the leaders of such societies are increasingly on the hunt for companies that are willing to write big checks for the endorsement of some of their (frequently) unhealthy or unnecessary products. Hence the embarrassing news about the AAFP noted above.

Health Promotion Goes Mainstream at NBC-Universal

I, like many other people, am concerned about the toll that the chronic disease epidemic,  including problems such as diabetes, is taking on the U.S. population (see: Seeking Solutions to the Chronic Disease Epidemic). Furthermore, I am convinced that many of the complications and side-effects of these chronic diseases could be avoided if people took better care of themselves. Needless to say, a similar case can be made for the so-called "lifestyle" diseases. So, what is the best way to raise the consciousness of the majority of Americans about these issues? A recent note in the WSJ Health Blog gave me an idea (see: GE Continues Health Push — By Selling Ads). Below is an excerpt from it:

Earlier this year, GE’s CEO made a big speech about how the company planned to expand its health care business. We figured that meant selling more electronic health records systems, CT scanners and the like. Turns out, it also means selling health-themed ads on NBC, the TV network owned by GE. NBC Universal said last week that it was launching something called “Healthy at NBCU” as a companion to GE’s company-wide “healthy imagination initiative.” As part of the program, Campbell Soup will pay to sponsor two health series on the TODAY show, where the company will run ads for its “heart healthy” soups. Ad sales are down for lots of media companies, but advertisers are still willing to pay to tie themselves to a cause, like the environment — or healthy living. Advertiser spending on cause sponsorships in the U.S. is expected to rise slightly to $1.57 billion this year, this morning’s WSJ reports. NBCU has already made similar pushes to bring in marketing from companies who want to tie themselves to environmental causes and women’s issues. Since the end of 2007 the company has brought in incremental revenue “heading toward” $100 million from its health, environment and women’s packages, on top of what it gets from selling regular ads, according to the WSJ.

I now believe that probably the best way to effectively educate the majority of Americans about healthy living is through the main-stream media such as NBC-Universal. If corporations are enthusiastic about sponsoring health-themed TV series, I am all for the idea. If we can educate the population while improving sponsor recognition, so be it. I recently watched one of the celebrity physicians, Mehmet Oz, on his TV show, scrub suit and all. He is both charismatic and a believable spokesperson. His answers to health questions were short, to the point, and accurate. He is also very popular, I am sure, with women, who have much more of an interest in personal health issues than men.

FDA Convenes Advisory Committee to Discuss Whole Slide Imaging

The FDA's Hematology and Pathology Devices Advisory Committee will be convening today and tomorrow to discuss discuss, and make recommendations, about what they describe as "public health issues" related to the use of digital whole slide imaging (WSI) systems that are now being used to replace conventional light microscopy for diagnostic surgical pathology. The meeting will be open to the public. Within the scope of this meeting, digital pathology is defined as the conversion of images that can be observed by conventional light microscopy on histologic glass slides into digital whole slide images via digital scanners. These latter images are then viewed with a computer monitor to render pathologic diagnosis of the lesion of interest. Finally, this process involves digitally archiving and retrieving these images for access at some later time. The committee will not be discussing computer-assisted image analysis or remote real-time microscopy at this time. 

The FDA background briefing for this meeting as a PDF file and downloaded from the FDA web site makes interesting reading for those interested in digital pathology. Below is more detail extracted from this briefing paper about what the FDA hopes to achieve by this meeting. Obviously, the major thrust will be the establishment of a set of principles for evaluating the accuracy and reproducibility of pathologists using this tool including both objective and subjective perspectives.

FDA hopes to gather information about how to evaluate and compare the performance characteristics of both the light microscope‐the reference method‐‐and the digital WSI method.  As background for the panel discussions, there will be presentations to cover the principles of light microscopy and the possible criteria and studies for analyzing the accuracy and reproducibility of the diagnostic performance of pathologists using the light microscope for examination of human tissue specimens, the principles of digital WSI, and the criteria and studies for the evaluation of the diagnostic accuracy and reproducibility of pathologists using digital WI for examination of human tissue specimens.  There will be a discussion of the objective and subjective aspects of reading direct images from a microscope and from a digital screen. 

Some Laboratory Managers Getting Carried Away by Lean/Six Sigma Projects

Don't get me wrong. I am just as enthused as the next person about correcting lab errors and work product defects. The bone that I have to pick with some of the Lean/Six Sigma experts is that this approach to lab management seems to becoming the answer to all lab problems. Some aspects of Lean/Six Sigma have always seemed to me to be vaguely ominous -- turning lab professionals into automatons who paste tape outlines on benches so that the scotch tape dispenser does not wander around the lab. All of my concerns came to the surface when I read a recent article in the Wall Street Journal (see: How Labor Is Liberated). Here is the excerpt from the article that caught my eye:

"Jean-François Zobrist ...captured his leadership philosophy with a distinction. There are, he said, two kinds of companies: 'Comment' in French, or 'how' companies, and 'pourquoi,' or 'why' companies. 'How' companies spend their time telling workers how to do their jobs—where to place the machinery, when to come to work and when to leave, and so on.The second is that it becomes difficult, if not impossible, to change any of the myriad rules about how to get things done. You want to move that cart to a different spot on the shop floor? You need clearance from your manager, who may have to ask his manager, and so on, creating a never-ending 'chain of comment.' The result, as Zobrist put it, is that it becomes impossible to get the work done without disobeying somebody in the chain of command. A pourquoi company is different. It replaces all the myriad 'hows' with a single question: Why are you doing what you're doing? The answer is always the same: to keep the customers happy. As long as what you do satisfies that commandment, Zobrist doesn't worry about how you do it. Freedom at FAVI meant replacing the chain of comment with a single pourquoi." This has two consequences. The first is that you end up judging employees by everything except what counts, which is whether the job gets done and the customer is happy.

So, for me, lab personnel who spend most of their time worrying about "how" or "comment" questions may be too involved with improving daily work processes and perhaps avoiding some of the more challenging "why" or "pourquoi" questions. I am sure that lab executives who specialize in Lean/Six Sigma can readily point to customer feedback to buttress their claims that they are pursuing goals that please their customers. For a change of pace, however, how about responding to this question: Is your laboratory sufficiently innovative in addressing the questions of tomorrow that many clients may not even be asking about? In order to begin to explore some of these strategic "why" questions, it might help to begin with consideration of the four rapidly developing fields that I think will pose the greatest challenges for labs in the upcoming years: (1) molecular diagnostics; (2) information technology; (3) digital pathology; and (4) ultra-fast histology processing. Here's another "why" question. Is your lab a regional or national leader in these four areas?

Health Insurers Emerge as Major Foes of Healthcare Reform

Both Big Pharma and the hospital industry stand to profit greatly from healthcare reform. New customers for drugs and services will undoubtedly emerge from this legislation. So who will be getting the short end of the stick? It turns out that this may be the health insurance companies that will now face unwanted competition, perhaps in the form of a public insurance option. They may also be forced to insure some customers whom they would have rejected in the past, thus reducing their profits. Did someone say competition? That's unfair! This is America. Here are some of the details from a recent article in the Washington Post (see: Health Insurers Emerge as Obama's Top Foe in Reform Effort):

For months, President Obama and his administration waged their fight for a health-care overhaul without a clear opponent, even courting the industry executives and interest groups that helped kill reform efforts 15 years ago. But attacks on the leading Democratic reform plan this week by the insurance lobby left little doubt that two of the most powerful institutions involved in the debate -- the White House and the nation's insurance companies -- have abandoned any real hope of forging a compromise. What was a tenuous truce has turned quickly into an all-out battle, with both sides ratcheting up the hostilities...."The insurance industry has decided to lead the charge against health reform, and everyone recognizes their motives: profits," said White House deputy communications director Dan Pfeiffer. "We are going to make sure they can't sink this effort at the last minute."...The insurers, however, showed no sign of being chastened. America's Health Insurance Plans, an industry trade group, opened a fresh line of attack with a multistate advertising campaign warning that senior citizens enrolled in private Medicare plans could lose benefits under the legislation...."We want to begin to build an awareness of the potential implications to seniors," said AHIP President Karen Ignagni. She declined to say how much money would be spent on the commercials airing in six states, but one advertising analyst said the industry has enough cash to pose a serious threat....The insurance sector and health maintenance organizations spent more than $116 million on lobbying in the first six months of this year, according to an analysis by the nonpartisan Center for Responsive Politics.

So stay tuned to see who triumphs in this quest for meaningful reform of our healthcare system. To add some spice to the conversation, we now have an estimate of the amount of money being spent on political lobbying by the health insurance and HMO organizations during the first six months of this year -- $116 million dollars. I really have no idea what the final product from Congress will look like but continue to hope for the best. In a previous note, I was very pessimistic about any sort of change (see: American Attitude toward Reform Through the Eyes of David Brooks). Here a quote from it:

I would personally like to see some fundamental changes in our healthcare system, particularly modifications of the current fee-for-service approach that rewards unnecessary and inappropriate procedures. Such an approach is wasteful and can also harm patients. I now don't believe that such a change is going to happen. There's just too much money flowing into lobbying efforts from special interest groups representing insurance companies, big pharma, hospitals, and physicians to maintain the status quo.

Physicians Using an iPhone Application to Triage Their Patients

John Moore, who blogs over at Chilmark Research has discovered an iPhone application that reinforces my belief that smartphones may soon rival the stethoscope as an essential healthcare delivery tool (see: iTriage: A Business Model Gaining Traction). iTriage assists physicians in referring their office patients to regional hospital emergency rooms when necessary. I have posted previous notes about the myriad healthcare applications that can potentially be deployed on smartphones and this is certainly a good example of the potential of these devices. Below is an excerpt from his note:

iTriage is a slick iPhone app.... Since its launch in April 2009, iTriage has maintained an enviable position as one of the top downloaded apps in the iPhone AppStore, currently in the top 10% of all apps downloaded....The parent company’s (Healthagen) business model is to solicit providers, mostly large integrated delivery networks (IDNs) to become premier sponsors who pay an annual subscription fee...to Healthagen to have their facility listed along with some brief marketing content, including the ability to upload videos, as to why one would want to go to their facility (typically ER) versus others. Thus, Healthagen is tapping into the marketing budgets of IDNs....On October 5th, HCA announced that they would become a premier sponsor as well for their facilities in South Florida.  What is particularly cool about this announcement is that in addition to the standard promotional marketing content that one may find in iTriage on a given HCA facility, HCA will also be providing real-time information on expected wait-times in ER, right there in the palm of your hand on your iPhone and in a recent upgrade of the software, a Blackberry as well.  (In November, they’ll release versions for Android and PalmPre.) This is all part of a larger push by HCA, which includes posting wait-times on billboards in this region to drive consumers seeking medical attention to their facilities as a significant percentage of those admitted to ER wind up being admitted for more extensive care.

 I am not surprised that the executives at HCA immediately understood the value of iTriage for their hospitals. What a clever way to market their emergency departments to community physicians! Adding expected wait-times will provide added valuable information for healthcare consumers who download the application. I pointed out in a previous note how emergency departments are an important portal for inpatient admissions to hospitals (see: Hospital Admission of Patients with Chronic Disease from the Emergency Department). Here is a quote from that note:

In 2005-2006, hospital admissions through EDs accounted for approximately 60% of acute care hospitalizations in Canada (excluding hospitalizations in Quebec and those among women admitted for childbirth and infants born in hospital). These patients accounted for 65% of in-patient days, 11% of which were alternate level of care (ALC) days.

We have only scratched the surface of smartphone applications that are directed to both physicians and healthcare consumers. For example, it would be relatively easy to adapt content currently on the web concerning the interpretation of lab tests for smartphones (see: The Mobile Web and the Future of eHealth). Here is a quote from this blog note:

...[I]t's now time, in my opinion, to begin to adapt [the content of] consumer-oriented web sites about the significance and interpretation of lab tests to the mobile web. One good example of such a site is Lab Tests Online. Such modification would allow, for example, patients who have just completed a physician visit to use their cell phones to query [their smartphones to] obtain a better understanding of their test results.