Lab Soft News

Apple's iAds Launch; Chances for Success

With iAds, Steve Jobs is seeking to integrate advertisements into the apps that run on the iPhone/iPad and that people pay to download. This Apple advertising initiative has some relevance for the readers of this blog because I believe that smartphones will be the devices of choice for physicians to review clinical records maintained in EMR, including lab test results. Much of this functionality will be provided by apps, some of which may contain advertisements, perhaps from pharmaceutical companies. Here is an excerpt from a recent article about iAds featuring quotes from Jobs (see: Reflecting on Apple’s iAd Play):

“Most mobile advertising really sucks,” declared Steve Jobs in his preamble to the iAds unveiling. Sure enough, the demonstration iAds drew a sharp and heady contrast with the incumbent WAP [Wireless Access Protocol; an open international standard for application-layer network communications in a wireless-communication  environment] banner model, combining, as Jobs pointed out, the emotional impact of television with the rich functionality and transactional possibilities of a native application. Much was made of the idea that these apps could appear within other apps, take over the screen and be explored by users without leaving the original app or losing context, which would be restored when the advert-app was done....To answer [the question of audience size for "app" advertising], Jobs declared the platform could offer as many as a billion impressions per day. That’s one ad every three minutes across an average app usage time of 30 minutes per day, multiplied by 100 million devices....I’ll just mention, for comparison, that Google’s ad exchange is estimated to handle about 10 billion impressions per day on the Internet.

With the possible exception of beer commercials on TV, I don't particularly like advertisements and usually try my best to avoid them whenever I can. I understand Jobs' goal of making them exciting and entertaining when integrating them into iPhone apps. However, I think that most consumers have the ability to recognize a commercial when they see one and will try to get past it as quickly as possible. For me, the ads presented on the Google search engine retrieval pages (SERPs) are as unobtrusive as possible. My eyes have been trained to not even see them unless I have some need to refer to them. It's not a good idea to dismiss any idea coming from Steve Jobs. However, I personally believe that the iAds initiative will not be highly successful and will certainly not threaten in any way the Google ad revenue stream linked to web search.

Bridging the Information Gap Between Physicians and Patients with an iPad

John Moore, who blogs over at Chilmark Research, has recently discussed the iPad and its potential healthcare applications. In a recent note, he says the following about what he perceptively describes as the information gap between physicians and patients (see: iPad in Healthcare: A Game Changer?):

One of those local healthcare institutions [attempting to close the information gap] appears to be Beth Israel Deaconess Medical Center...where an ER doc has provided his own iPad review, based on actual use during a shift.  Particularly like his comment about using it for patient education.  Might the iPad truly bridge the information gap between patient and clinician?  One thing is for certain, it will make it much easier for patient and clinician to confer over a given diagnosis, results and creation of a treatment plan with supporting documentation/graphics.

I found myself grinning slightly about John's use of the term information gap from the perspective of physician/patient relations. Perhaps even five years ago, this idea would never have surfaced at all. If it did, most physicians would have responded in the following way: Duh! Of course there's an information gap between physicians and patients. I went to medical school and then trained in my specialty for ____ years. I am being paid to render advice to my patients and they are supposed to follow most if not all of my recommendations.

One of the major factors for improving the health of the general population, and reducing healthcare costs, is encouraging consumers to take ownership over their own health by pursuing a healthy lifestyle (see: Preventive and Predictive Medicine as Components of the Healthcare Continuum; Seeking Solutions to the Chronic Disease Epidemic; Seeking the Correct Definition for a "Lifestyle Disease"). One of the ways that physicians can function as an effective "health coach" (see: "Cancer Coaches" Start to Play Significant Role in Cancer Care) is by reviewing with their patients the reports from the clinical labs and radiology and commenting on their relevance. The iPad is an appropriate device for sitting down with patients and paging through the various reports with them as a means for decreasing the information gap. Many physicians may also have access to the digital images as well via the PACS, which provides another collaborative opportunity.

Antiphospholipid Syndrome (APS): An Autoimmune Clotting Disorder

I became aware of a very detailed description of the Antiphospholipid Syndrome (APS), an autoimmune clotting disorder, via a Twitter message with a link to the ARUP Consult (see: Antiphospholipid Syndrome - APS). I have previously discussed this very useful web site (see: ARUP Offers Lab Algorithms for Disease Diagnosis Support). I raise the topic of APS here for two reasons. First, to familiarize readers of this blog with the syndrome. Secondly, I want to emphasize how Twitter and the web in general have the capability of familiarizing physicians and healthcare consumers about relatively obscure diseases. Below, copied from ARUP Consult, is a description of APS:

Antiphospholipid syndrome (APS) is an autoimmune disorder in which autoantibodies are directed against phospholipid-protein complexes. APS is characterized by thrombosis (arterial, venous, or small vessel) and/or pregnancy complications and persistently positive tests for antiphospholipid-protein (aPL) antibodies.

[Following are some salient details about the disease:]

• aPL antibodies are present in a low percentage of young healthy subjects (1-5%) and up to 10% of patients with venous thrombosis
• Higher prevalence in patients with autoimmune disease such as systemic lupus erythematosus (up to 50%), malignancy, liver disease, and vascular disease
• Most patients with aPL antibodies do not have an underlying autoimmune disease
• Presents clinically as venous, arterial, or small vessel thrombosis, and/or obstetric complications
• Treatment decisions depend on the extent of clinical symptoms and may range from no treatment to long-term anticoagulation

Refer to the ARUP Consult for the complete description of this disease. I present only a small portion of the information about it. Here also is a clinical summary of the syndrome from eMedicine.

Cancer Survivorship, an Emerging Subdiscipline in Oncology

The special challenges of caring for cancer survivors is spawning a new subdiscipline in oncology, survivorship. There are various resources now available focusing on aspects of this new field. One of them is a site providing links to 14 articles presented at the Fourth Biennial Cancer Survivorship Research Conference in Atlanta, Georgia, in June 2008 (Cancer Survivorship Research: Mapping the New Challenges Supplement). Here is a brief summary of some of the general topics covered in these articles:

• Health-related outcomes and care
• Beliefs and survival
• Quality of life
• Patterns of adaption to the disease
• Protective buffering of cancer survivors by family and friends
• Partner-assisted emotional disclosure
• Impact of cancer on spousal labor earnings
• Time costs of informal care-giving

It should be stressed that not all aspects of survivorship care relate to emotional and social support of these patients as suggested by these articles. Most cancer patients have undergone major surgical procedures, subjected to countless imaging studies, and exposed to myriad powerful drugs. Some will have a genetic predisposition to the development of new neoplasms or will suffer recurrences of their primary lesions. This is a patient population that deserves very close clinical scrutiny over many years. The good news is that we will soon have a  cadre of healthcare professionals specially trained for this task and cancer survivors will derive great benefit from this expanded view of clinical oncology.

New Definition for "Apps": The Smartphone Market for Medical Software

Back in the day, the term apps, an abbreviated form of application, was used to refer to software programs in general. However, I became aware via a podcast, Behind This Week's Cover Story (The Apps Economy), that the definition had shifted when I wasn't looking. The term apps now refers, at least in popular culture, to any of the small programs that can be downloaded from a web site like iTunes and then run on an iPhone or other smartphone. The importance of apps has recently gone ballistic with the announcement by Steve Jobs that apps will be a vehicle for channeling advertisements to iPhone users (see: Steve Jobs Promises Developers That Apple’s iAds Won’t “Suck” and Will Make Them Money). This is a strategic move against Google by Apple to capture more advertising revenue. By way of comparison, Google's main source of revenue is search-based ads and the company is betting that smartphones, in time, will be commonly used to launch more web searches than PCs. Google is also entering the smartphone market with the Android operating system and the Nexus One phone.

Keep an eye on this apps software market as it relates the devices in the pockets of healthcare professionals. I have commented previously on the use of smartphones for reaching out to them as major users of hospital clinical data, particularly that of the clinical labs (see: Smartphones as the New PCs; Connecting to Healthcare Professionals and Consumers). There's already a host of IPhone apps developed specifically for physicians (see: Physicians Using an iPhone Application to Triage Their Patient).

I believe that hospital-based physicians and nurses will be more inclined to use their iPhones, and other types of smartphones, than the hospital-provided terminals at nursing stations and patient rooms. If hospitals set up barriers preventing access to their EMRs by smartphones, they will ultimately need to dismantle them. Physicians will favor the use of a single, readily available device for access to the hospital EMRs. The  smartphones in their pockets will serve this purpose nicely. As the available memory of smart phones expands, physicians will also store patient records across care episodes for comparison purposes. I know! I know! Smart phones can be dropped and also misplaced. None of this will be accomplished without appropriate security measures.

Many hospital executive and EMR vendors will fight this trend toward smartphone use by physicians and nurses but will ultimately lose the battle. Their major argument against such use will be security and HIPAA. Another underlying reason is that most EMRs are based on older technology and cannot be easily adapted to web-oriented functions. In the final analysis, opponents will come to realize that smartphones are the new PCs and patients will derive great benefit from having their records in the "pockets" of physicians around the clock. Such access will also accompanied by easy access by physicians to professional web reference sites regarding such topics as drug doses and diagnostic assistance.

Optical Scanning of Sputum Smears to Detect Tubercle Bacilli

The fastest growing technology in the field of pathology and lab medicine is digital imaging and, tangentially, the use of algorithms in the interpretation of digital images. This latter technology is commonly used in connection with IHC and FISH-stained slides to quantify a previously subjective interpretation. Now it turns out that image analysis and algorithms may also be of value in the identification of tubercle bacilli in microbiology labs in developing countries (see: Technology: For Nations That Lack the Expertise, an Automated System for Detecting TB):

One of the difficulties of diagnosing tuberculosis is that there is no simple blood or urine test. Instead, a laboratory technician must take a sample of sputum coughed up from the lungs, stain it and inspect it under a microscope for the telltale bacteria, which resemble long-grain rice. It takes expertise that is often rare in poor countries. Guardian Technologies, a Virginia company that was started to help airport X-ray scanners distinguish explosives in luggage from innocuous plastics and liquids, has developed a system that automatically scans microscope slides for the bacillus. The company’s software algorithms can spot distinctive shapes, colors and densities that untrained eyes may miss. In a recent test in South Africa, which has some of the highest TB rates in the world, the technology was 93 percent accurate in detecting the bacillus on microscope slides and had a false positive rate of less than 2 percent, the company said. The original Guardian system fit a digital camera to a standard microscope. Now, it is making an automated version that can hold 50 slides and work all night while no one is in the lab. New technologies like Guardian’s hold great promise for poor countries with inadequate laboratories, said [a company spokesperson].

One of the major advantages of globalization, from the perspective of healthcare, is that various technologies requiring less trained personnel and lower capital investment are now being developed for use in developing countries. One example is ultrasound imaging (see: Ultrasound in Developing Countries - Photos). Part of the incentive for developing hand-held ultrasound imaging devices is for the deployment in such countries (see: Compact Ultrasound for Improving Maternal and Perinatal Care in Low-Resource Settings). Such devices will also soon be carried by some physicians in addition to their stethoscopes (see: Advances in Portable Ultrasound Devices).  One of the ironies of this emerging global strategy is that these technologies are frequently appropriate in U.S. settings as in the case of free clinics in poor neighborhoods and smaller public health laboratories. These sites don't constitute an initial attractive market for the instrument manufacturers. However, once developed for developing countries, they can then be purchased and deployed in the U.S..

Will a Three-Year Medical School Curriculum Increase the Supply of Primary Care Physicians?

I think that it would be very feasible for some percentage of medical students to complete their required course work in three years. I also think that pre-medical undergraduate course requirements could also be completed in three years by some students. These two changes could lead to the an M.D. degree in six years. KevinMD, a noted physician blogger, recently wrote about a three-year medical curriculum at Texas Tech, linking the proposal to the need for more primary care physicians and student debt-load reduction. Below is an excerpt from his note (see: (see: Primary care and the three year medical student):

It’s well documented on this blog that the primary care shortage will only worsen once most of America has access to affordable health insurance. As I wrote in a recent op-ed. not only will there a shortage of primary care physicians, but nurse practitioners and physician assistants won’t alleviate the problem either, mostly because they are also enticed by the lucrative allure of specialty practice. Enter the three-year primary care physician. Texas Tech University is experimenting with such a program. Apparently, the fourth year of medical school was deemed expendable:

The program was designed out of the conviction that most of the fourth year of medical school was focused on electives in various medical specialties—programs that are important for those considering specialized residencies, but that may not be necessary for those committed to primary care. Texas Tech believes that, with a few adjustments, it can provide those who plan careers in family medicine with the necessary parts of the fourth year earlier—and free up the year.

....I can see how medical students can be enticed by a year less of medical school. For some, that can both shave off $50,000 or more in medical school tuition and bring them a real-world physician salary earlier.But that would also lock the student in a primary care track early on. The fourth year is where students taste the various medical specialties that ultimately influence their residency decisions. Maybe that’s the point. Perhaps shielding them from the lifestyle advantages, not to mention the financial benefits and relative lack of bureaucratic hassles, of specialty practice is one way to convince more to choose primary care as a career.

I have posted a previous note about reducing the time for physician training (see: Earning an MD Degree in Six Years to Reduce the Debt-Load of Medical Students). I agree with most of the points made above including the observation that much of the fourth year for medical students is occupied with the selection of a medical specialty. This is accomplished, in part, by "audition or away rotations" so that students' favored residency programs can get a close look at them and vice-versa. However, I don't think that it's realistic to lock medical students into primary care by reducing medical school by one year and altering the curriculum for such students. It might work in the short-run but these are bright high-achievers. Many in primary care practice will soon become disillusioned with their practices. Armed with an M.D. degree, they will seek advanced specialty training at some later time. I do part ways with Kevin on one major point -- I think that most of the the primary care positions in the future will be filled by physician assistants and nurse practitioners.

"Machiavelli's Laboratory" Off to a Roaring Start

Dr. Jules Berman has authored a new book, Machiavelli's Laboratory, and made it available for a free download on the web (see: Jules Berman Publishes "Machiavelli's Laboratory" About Ethics in Science). He provides a choice of either HTML or PDF formats. Jules has noted the following in a listserve message:

In under one week, the book has had over 2,500 downloads (mostly the HTML and PDF formats), thanks in no small part to Bruce Friedman's plug in his LabSoftNews blog.

I have always understood that the readers of Lab Soft News are a highly selected and discerning group but this experience has left me speechless. I must confess that I have not personally downloaded the book but I have a good excuse -- I have been too busy plugging it on this blog. Let's try to get the number of downloads to, say, 5,000. The book is free, of course, but I suspect that Jules may be trying to make his profits on the volume.

University of Michigan Health System to Provide Video Profiles of Its Faculty Physicians

I just received notice that the Office of Planning and Marketing of the University of Michigan Health System will be offering "video vignettes" to supplement faculty profiles on its web site. Here's a description of the program:

The Department of Public Relations and Marketing Communications [of the University of Michigan Health System] is implementing a new consumer Web site, named UofMHealth.org. The site will focus solely on the potential patient and be a patient acquisition site for the many clinical services and other products that UMHS (university of Michigan Health System] provides.

• Phase I strategic tactics: Overhauling Find a Physician, integrating and syndicating content about UMHS products and services and overhauling search.
• Target Audience: The potential patient. UofMHealth.org will be the gateway for consumers trying to make a health care decision. Often times they are looking at profiles of our health providers to help make a decision.
• Video Profiles: We know our providers are more than a photo or list of medical degrees and we want to show consumers what makes you tick through a 1-2 minute video. For the video profile interview, you choose from a variety of questions such as: What drives your passion for medicine; What excites you about the work that you do; Why is Michigan the place to come for treatment of _____; How does research affect your work; What role does technology play in the care you provide; and many more.
  

What a great idea by the marketing arm of the University of Michigan Health System! A video vignette of a faculty physician, particularly a telegenic one, will always be much more persuasive than a head-and-shoulders photograph. Note the suggested topics in the third bullet point above. They have obviously been carefully selected to tap into the various interests and passions of the physicians being represented such that potential patients will view them in the most favorable light.

Long-Term Health Consequences of Binge Drinking

In a recent post, I presented data describing per capita alcohol consumption in OECD countries from 1980 to 2007 (see: Binge Drinking in Wales; Trends in Alcohol Consumption Across OECD Countries). One blog reader, L. Needham , responded with the following comment:

What's interesting though is that the definition of 'binge drinking' is not discussed. Oddly enough, my undergraduate research and thesis (later published) centered on alcohol 'addiction' and binge drinking. Saving the boring details ~ what is termed binge drinking versus a more generalized 'alcohol life-style' -- has a dramatic effect on how one can view and interpret such social settings. I say this not to discount or refute the concerns of the article, but rather to caution those drawing conclusions from the words...there is more that needs to be revealed/ evaluated in such settings.

Here's a definition for binge drinking:

Binge drinking is the modern definition of drinking alcoholic beverages  with the primary intention of becoming intoxicated by heavy consumption of alcohol over a short period of time. Or alternatively, a consistent amount of alcohol over a long period of time. It is a kind of purposeful drinking style that is popular in several countries worldwide, and overlaps somewhat with social drinking since it is often done in groups.

I don't know much about the literature relating to the pathophysiology of various types of drinking behaviors. However, it's possible that the liver, and perhaps other organs, suffers less acute damage on the basis of moderate exposure to ethanol over time than large amounts of alcohol in bursts as the result of binge drinking. The next question is whether episodic high-level ethanol exposure leads to a more chronic disease such as liver scarring. I did a Google search, binge drinking and long-term effects, and came up with the following for what it's worth: 

It's no secret that those persons who begin to drink early in their teen years have an increased risk of developing alcohol dependence during their lives, often at a young age. But new research shows that teen binge drinking has other long - term effects on the health, particularly a higher risk for developing heart disease, high blood pressure, and diabetes....The study, published in the Journal of Clinical Endocrinology & Metabolism, compared binge drinkers (called early peak drinkers) with those who began drinking alcohol later in life and maintained a moderate drinking pattern (stable drinkers). Researchers found that even if early peak drinkers drank less over a lifetime than stable drinkers or curtailed their drinking as they matured - they still had a greater risk for health problems. The study authors speculate that heavy drinking causes changes in the endocrine system and cardiovascular system that carry over to later life, and also that early peak drinkers may have developed other unhealthy lifestyle habits that are detrimental to the body.