Lab Soft News

Survey Reveals Results about Average Physician Work-Week

The Dark Daily recently covered some news that may have an effect on healthcare delivery in the future. It's all about the average number of hours that physicians, particularly younger ones, are willing and able to spend on the job (see: Dartmouth Researchers Say that Doctors Now Work Fewer Hours Than Lawyers). Here's a link to the original article in JAMA (see: Trends in the Work Hours of Physicians in the United States) and below is an excerpt from the Dark Daily story:

[The Dartmouth] researchers...found no statistical support for two common beliefs within the physician community. First, that the aging physician population may be reducing their work hours, and second, that the increased number of female physicians who might leave to start families, is responsible for the decreased hours. “Those were the first stories I heard when I began this study,” he said. “While it may be true that women doctors are working fewer hours because of families, we saw almost identical drops for males and females.” ....[T]he decline in the overall number of hours worked each week was twice as high for physicians under the age of 45 as it was among older doctors. This leads Dark Daily to speculate that we now may be witnessing a major shift involving the younger Generation X and Generation Y doctors. Where Boomer docs—like other professionals of that generation—were frequently willing to work 80 hours or more per week throughout their careers, this motivation does not exist in Gen X and Gen Y doctors. This observation must also be viewed with the fact that Gen X and Gen Y doctors will likely not see the kind of salaries once enjoyed by Baby Boomer physicians at the peak of their careers. Thus, it should be no surprise that growing numbers of physicians prefer to spend more time away from work, pursuing other activities.

I think that the Dark Daily comes to exactly the right conclusions. The "Boomer docs" (those born between 1946 and 1964; see: Baby boomer) were accustomed to working hard and long weeks and, in turn, expected to be highly compensated for their efforts. By way of contract, Gen X and Y docs, regardless of gender, appear to be working fewer hours and receive less pay. Many of them are, and will continue to be, hospital employees -- hospitalists. Such physicians also work very hard and manage more complex cases than would occur in an office practice. However and when their hospital shift is over, they hand-off the care of their patients to the next shift of hospitalists and nurses. Of course, a remaining question is whether these Gen X and Y would opt for longer hours and more compensation if such opportunities were broadly available to them. Such opportunities may no longer be common in the emerging healthcare industry (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine").

Does the New Term "Liquid Biopsy" Make Any Sense?

An interesting term is now gaining some traction in medical research -- liquid biopsy. Here's an excerpt from one of the articles that uses it (see: Genentech Scientists Zero in on “Liquid Biopsies” as a Way to Replace Tissue Biopsies in Breast Cancer):

Surgical pathologists could gain new tool to diagnose many types of cancers. It might soon be possible to determine the HER2 status of breast cancer patients from blood samples rather than tissue biopsies. If this new technology proves feasible, it would give surgical pathologists and medical laboratories a different, and possibly less complex, methodology to use when assessing a case of breast cancer. In its report about the study, Medscape Medical News, wrote that “HER2 status derived from circulating tumor cells (CTCs) from breast cancer patients was generally concordant with that derived from tumor tissue” and that “CTCs could prove to be an alternative to biopsies for assessing tumor tissue for biomarker status.” (see: Circulating Tumor Cells Are Potential Alternative to Biopsy)....The research was conducted by scientists at Genentech. As most pathologists and clinical laboratory managers know, Genentech is owned by Roche...and manufactures Herceptin, the drug used to treat breast cancer patients who are positive for the HER2 mutation.  In the abstract of the presentation made at [a recent] conference, the [researchers made the following point], “Evaluation of cancer biomarkers from blood and other accessible tissues could significantly enable biomarker assessment by providing a relatively noninvasive source of representative tumor material. Circulating tumor cells (CTCs) isolated from blood of metastatic cancer patients hold significant promise in this regard.”

My first reaction to the use of the term liquid biopsy was to view it is as silly and confusing. You don't biopsy serum -- rather you collect blood and analyze the various biomarkers in the serum component. On further reflection, however, I concluded that its use may offer some benefits. It differentiates between serum biomarkers that are elaborated by circulating tumor cells (CTCs) as opposed to, say, those that are released into the blood stream from a diseased organ or solid tumor. However, it's also possible that all, or perhaps most, serum biomarkers are the result of CTCs. Here's a link to a previous note about CTCs (see: Circulating Tumor Cells for Assessing Survival in Pancreatic Cancer Patients).

CTCs can be difficult to isolate because they tend to be rare and may be released by the tumor intermittently. Biomarker assays can detect extremely small quantities of tumor protein, basically the fingerprints of CTCs. As noted above, these "liquid biopsies" are a non-invasive means to monitor the status of a malignant lesion. particularly one that is metastatic. At the very least, the use of the term may portend further integration of clinical pathology and anatomic biopsy. We seem to be ushering in an era where tumor diagnosis will be based on a mixture of lab techniques including the analysis of tissue biomarkers, serum biomarkers, and CTSs.

iPad Substitutes as the User Manual for the Hyundai Equus

I picked up, by chance, on a recent reference to the fact that a "free" iPad is delivered with each Hyundai Equus, substituting for the normal hardcopy user manual for the vehicle. Here is an excerpt from the article (see: A Week In The High-Tech Hyundai Equus Super Sedan):

There’s enough technology within the driver’s (and backseat passenger’s) reach to require a few trips to the manual, which just so happens to be an app on the included iPad. Yep, this is the car that comes with an iPad as the user manual. It makes sense, too. Instead of following a series of step-by-step instructions to, say, change the audio settings, you can just refer to the app for a quick demonstration. It’s genius from a user experience and marketing standpoint.

OK, OK! This is a car with a $96,000 price tag. They could also have thrown in a small soiree with Lady Gaga. I think that the take-home lesson from this news is not the value of the iPad as a device for displaying a user manual but rather the fact that user instructions can be developed as iPad apps and then made available for download via the web (see: New Definition for "Apps": The Smartphone Market for Medical Software). Consider, for example, the differences when reading a hardcopy book and an ebook. In the latter case, you can highlight words and automatically look them up in an integrated dictionary or make notes about particular passages. These features could be very useful for a user manual. Similar "user manual apps" could be developed and downloaded for review by patients prior to admission to a hospital showing images of hospital rooms and of the physicians who will be providing care. Patient educational and training videos could also be made available such as post-op, home-based wound care. The opportunities are limitless.

ARUP Labs offer an invaluable physician resource called ARUP Consult. There are three tabs at the top of the app: general disease categories, an alphabetical index, and algorithms for working-up various diseases with lab tests (see: ARUP Offers Lab Algorithms for Disease Diagnosis Support). You can navigate, for example, from Gastrointestinal Dissease > Hepatic Disease > Cirrhosis. Under Cirrhosis are the following subheadings: Background, Diagnosis, Tests, References, Medical Reviewers, and Related Content. There are hot links under References in PubMed to the cited articles. This program is available as an iPhone and iPad app. Dr. Brian Jackson of ARUP Labs remarked to me recently that the number of downloads for iPads now exceeds the number for iPhones. The iPad has become the preferred "professional platform" for physicians.

Some History about MUMPS and InterSystems' Caché DBMS

Newer versions of the computer language MUMPS are used in a number of important healthcare computer systems including Sunquest, Epic, and Meditech (see: Persistence of the MUMPS Programming Language in Healthcare Applications). Here's an excerpt from comments posted on a federal technology blog called nextgov about MUMPS (see: What's So Wrong with MUMPS?):

I'm not talking about the disease -- although some folks treat it as such -- but the software that is the heart of the Veterans Health Information Systems and Technology Architecture, the electronic health record system at the Veterans Affairs Department. The big obstacle for MUMPS is the perception that no one except VA uses it, a simplistic view reinforced by Sen. Richard Burr, R-N.C., during a hearing on the future of VA information technology systems [recently]. At about the same time Burr was bashing MUMPS, the Coast Guard awarded a $14 million contract to Epic Systems Corp. for an electronic health record system based on MUMPS. That should be no surprise because Judy Faulkner, Epic's chief executive officer, founded the company in 1979 after working on MUMPS for VA. Faulkner has grown Epic into a giant in the heath care IT field, including a megabillion dollar contract with Kaiser Permanente, which has 8.6 million patients and 15,000 doctors. The company competes with Genera Electric Healthcare, which also based its software on MUMPS....So, why, of why, do VA and its chief information officer, Roger Baker, want to move off a MUMPS-based VistA, and why is the Defense Department considering Epic when they can tap into the stable and free system Faulkner based her company on?

You can't really discuss MUMPS these days without some mention of InterSystems. Here is some information about this latter company and its DBMS product, Caché, which is sold almost entirely indirectly through independent software vendors (ISVs) like Epic as an embedded component of their products (see: InterSystems: Best Kept Secret in the DBMS World)

InterSystems is a privately held software company...which has played a key role in the evolution of database technology. Mention of the company is, however, almost guaranteed to draw blank stares from cognoscenti in the industry. InterSystems began in 1978 as a provider of technology in support of MUMPS, an operating system that also acted as an interpretive language runtime environment originally developed for use by the Massachusetts General Hospital. The language was also called MUMPS, or M, and included a "global array facility," really a simple multidimensional DBMS. InterSystems developed a version of this facility that it originally called InterSystems MUMPS (ISM) to distinguish it from DSM (Digital Standard MUMPS), which was offered by Digital Equipment Corp. until InterSystems bought that version as well in 1994.....In 1997, InterSystems released Caché, a postrelational DBMS that used the M Technology storage engine but layered over it object-oriented services, an M Technology compatibility layer, and an ANSI standard SQL API. Since MUMPS and M Technology were originally used mainly by hospitals and healthcare IT service and software providers, the initial customer base for Caché was heavily oriented in the healthcare direction, although there was some interest from the financial community owing to its high performance.

I want to respond to the question raised in the nextgov note about why the VA's CIO is exploring the possibility of moving away from the MUMPS-based VistA EMR and to Epic. First of all, there is a large cost to the VA, I am sure well known to this VA executive, of maintaining a large staff of programmers to support VistA. Secondly, I am also sure that there is intense political pressure exerted on the VA by politicians from states such as Wisconsin, the home of Epic, to get out of the software business and purchase an EMR in the commercial software market.

I do take issue with the somewhat misleading statement above from nextgov: why is the Defense Department considering Epic when they can tap into the stable and free system [Epic CEO Judith] Faulkner based her company on?  While it's true that standard MUMPS was originally open-source and free, both Epic and InterSystems are profit-making enterprises and, as it is well known, the Epic EMR does not some cheap (see: Are You an Enterprise or Best-of-Breed CIO? Access to Cash May Make the Difference). Put another way, there does not seem to be a big MUMPS price break baked into the cost of an Epic EMR. Epic and InterMountain are providers of technology in support of MUMPS.

Quality-Collaborative Relationships in Surgical Pathology between Small and Large Hospitals

We need to take some steps to ensure that our smaller hospitals continue to be viable both financially and in terms of the quality of care that they provide. This may be difficult for some of them in this new era of accountable care organizations (ACOs) with complex performance standards required by the government and insurance companies.

One of the challenges facing smaller hospitals, from the perspective of surgical pathology, is that the number of pathologists working in such a setting will be small -- perhaps one or two in many cases. It is impossible in such a small group to solicit multiple opinions about a challenging surgical pathology case. In a large academic pathology department, there are numerous colleagues close-at-hand to consult, all of whom will have sub-speciality expertise. These problems were evident recently in a story about an error that occurred in the diagnosis of ductal carcinoma in-situ of the breast (see: Seeking A Second Opinion as a Partial Solution to the DCIS Controversy). When there is doubt about a case in a small pathology group, the slides are packed-up and shipped overnight to a favored surgical pathology consultant for an opinion. However, this takes time and effort and is generally not pursued for most cases.

I would like to see more "quality-collaborative" relationships developing between smaller hospitals and regional academic centers, particularly in the area of cancer care. The deployment of a digital pathology system and whole-slide-imaging (WSI) on both sides of such a relationship would make frictionless, routine review of many more surgical pathology cases the norm. Under such a system and with WSI, the pathologist at the smaller hospital would simply drag the file associated with a particular difficult case into the work-queue of the consulting pathologist working at the larger academic center. This latter individual would then interpret the case as part of his or her normal work day. The consultant's opinion would then immediately be transferred back to the AP-LIS at the smaller institution. We now have an early form of this process operating with Aperio's SecondSlide, a digital slide-sharing service. I am told, however, that this system is far from frictionless because it's relatively new.

One of the speakers at the recent Pathology Informatics 2010 conference in Boston stated in a lecture that it was difficult to justify the broad deployment of digital pathology in an academic department solely on a return-on-investment (ROI) basis. I would suggest that perhaps he was looking at the wrong spreadsheet to draw this conclusion, which is to say the calculation of the ROI solely for the division of anatomic pathology. Let's say that the quality-collaborative relationship described above was based on testing and consultation between a small and large hospital for both CP and AP work. In other words, the smaller hospital would send all of its outsourced CP specimens to the larger hospital in addition to its surgical pathology consultations. The ROI for digital pathology would look very different.

In fact, sending CP specimens to the neighboring academic center reinforces the notion of the quality-collaborative relationships being discussed here. With the rapid growth of molecular diagnostics and the integration of AP and CP (see: Integration of Anatomic and Clinical Pathology), surgical pathology consultations will increasingly require the analysis of both serum and tissue biomarkers. Clarient has already established such a quality-collaborative relationship with pathologists in smaller hospitals. This was partly the basis for the recent purchase of the company by GE Medical (see: General Electric Goes Outside The Box In Healthcare). Here are more details about this deal from a financial analyst:

Clarient is basically in the business of conducting cancer diagnostics tests on behalf of community pathologists, oncologists, and physicians. In simple terms, it is a model like that used by LabCorp and Quest Diagnostics - clinicians send samples to Clarient, and Clarient tests those samples and reports back on the presence/absence of cancer and other important details (like the type of cancer).

The Oncology Concession Under Attack by Health Insurance Companies

The oncology concession is the percentage of the cost of chemotherapy (i.e., the drug markup) that is retained by the oncology group for prescribing the drug (see: Academic Oncology and the "Chemotherapy Concession"). These are a number of problems associated with such a payment not the least of which are the following: (1) there is an incentive for an oncologist to treat the patient with advanced disease with little hope of significant amelioration of it; and (2) there is an incentive to treat the patient with newer, non-standard biotech drugs that are frequently more expensive. Health insurers are now evaluating new oncology payment systems in order to remove these perverse incentives (see: Insurers Test New Cancer Pay Systems). Below is an excerpt from the article:

The insurers have begun tightening oversight of the care provided to patients with many different types of cancer, hoping to lower expenses by experimenting with new ways to pay specialists. UnitedHealthcare plans to announce on Wednesday a one-year project with five oncology practices, offering doctors an additional fee. The new fee is meant to encourage doctors to follow standard treatments rather than opting too often for individualized and unproven courses of therapy, which can include the most expensive drug combinations. By proposing a different type of payment structure, companies hope to lower doctors’ dependence on a system that generates substantial sums for cancer specialists who routinely favor top-of-the line treatments.....Many specialists favor the most aggressive care even if there is little to no evidence the patient will benefit, because both doctors and patients have every incentive to spare no expense. Patients and their families often demand one last treatment. And oncologists can reap tremendous profits, sometimes earning more than half of their income on the difference between what they pay for chemotherapy drugs and what they charge the insurers for the patient’s treatment plan.....Some insurers say there may be savings if doctors just follow standard treatments, rather than a variety of alternative regimens, for patients with the same type of cancer.....In the UnitedHealthcare program, for example, oncologists still get a fee even if the patient is not getting chemotherapy. To make sure no one is stinting on care, the oncologists involved review one another’s treatment decisions and results. The doctors involved in the program say there is no danger that they will fail to treat patients who would benefit from another round of chemotherapy.

The pilot program described above makes perfect sense to me. However, the article contains some code-speak that require some interpretation. Standard treatment, which is what the insurance companies are attempting to reimburse for, can be alternatively described as proven treatment regimens. My guess is that if oncologists were to use the terms proven and unproven to refer to the, say, two chemotherapy regimens being offered to a patient, most patients would choose the former. I also don't think that all patients with far advanced lesions should be treated. However, some of this decision-making can be based on subtle nuances of how the treatment (or non-treatment) options are presented to patient and the family by the oncologist. If as much of half of an oncologist's income is based on which type of chemotherapy is administered, an arched-eyebrow or frown by him or her can make a big difference. I would like to move to an environment where what's best for the patient always rules the day.

Blue Cross Blue Shield of Michigan Stifles Competition; Feds File Antitrust Suit

The "retail prices" that hospitals charge for inpatient care are largely made-up numbers. They are set purposely high so that the discounted rates that are then negotiated with the health insurance companies are sufficient to cover costs and possibly earn a profit (see: Why the Prices Charged by Hospital for Inpatient Care Are Irrelevant). These higher prices are only paid by the unfortunate minority who require care, lack health insurance, and have some assets. Some states like Oregon are launching web sites to provide some transparency regarding the substantial differences in the cost of an inpatient stay by hospital depending, in part, on the extent of competition in the local market (see: Comparing the Details of Hospital Charges in the State of Oregon). Here's a quote from this latter note:

Insurance companies and employer groups negotiate steep discounts for patients admitted to the hospital and are covered by their insurance. Understanding that they will be reimbursed only a fraction of their posted charges, hospitals keep increasing them in order to cover their true costs, which are far less. Note the reference above to discounts to insurance companies [in Oregon} amounting to about 60 per cent.

To help correct this contrived, anti-competitive market, the federal government, joined by Michigan, have filed an antitrust suit against Blue Cross Blue Shield of Michigan to disrupt some of these cozy contractual arrangements (see: Mich., U.S. sue Blue Cross, charge anticompetitive pricing). Here are some of the details about this case:

The Justice Department filed an antitrust suit...against Blue Cross Blue Shield of Michigan, accusing the giant health insurer of using its market clout to stifle competition and cause consumers covered by other health plans to pay more for hospital care. The lawsuit, filed in U.S. District Court in Detroit and joined by the state of Michigan, said Blue Cross contracts with at least 70 of the acute care hospitals in the state force them to raise prices and prevent other insurers from competing with them. Antitrust officials say the provisions likely resulted in Michigan consumers paying higher prices. The provisions being challenged are known as "most-favored nation" clauses or MFN. In the health care realm, they generally refer to contractual clauses between health insurance plans and health care providers that — according to the Justice Department — "essentially guarantee that no other plan can obtain a better rate than the plan wielding the MFN." Blue Cross defended its used of the discounts....The Justice Department says the Blue Cross MFN clauses in contracts with hospitals have caused them to increase their prices to Blue Cross competitors, thereby protecting Blue Cross from competition....[The Michigan Attorney General] said a joint investigation by the Justice Department and his office found that Blue Cross ramped up its practice of requiring MFN clauses three years ago when it threatened to cut payments to 45 small, rural hospitals by up to 16% if the hospitals refused. He said the probe also found that Blue Cross obtained clauses with at least 23 larger hospitals by offering to increase the amount Blue Cross paid those facilities, provided all other insurers paid more. He said the practice put other insurers at a competitive disadvantage while raising prices for everyone.

So not only did Blue Cross and Blue Shield of Michigan negotiate steep discounts with hospitals but the company also contractually prohibited these hospitals from offering similar discounts to competing insurance companies. The story gets even worse. The company actually offered to pay more to 23 larger hospitals in order to force other insurance companies to also pay more. There are obviously major problems in store for all of us with Big Medicine (Big Insurance + Big Pharma + Big Hospital Networks) and we need to address them as part of healthcare reform (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"). The part that I am not sure about is exactly who is going to protect us from Big Government.

Workflow Management as the Secret Sauce in Diagnostic Information Systems

Have you ever wondered why pathologists and radiologists would be unable to manage their daily work without their LISs, RISs, and/or PACSs whereas many clinicians balk at using hospital EMRs? One of the primary reasons for this difference is that these former systems manage professional workflow in the diagnostic services whereas clinical EMRs largely record the results of workflow decisions previously made by physicians and nurses. Because workflow support is not broadly integrated into the clinical EMRs, physicians understand that they may be able work more efficiently without them. This is one of the reasons why scribes are now being hired in some hospitals to enter data into clinical EMRs (see: Shift of Hospital EMR Data Entry Tasks from MDs to Scribes). Such an action, to the best of my knowledge, has been virtually unknown in relation to diagnostic systems.

As LISs, RISs, and PACSs have evolved over the past roughly four decades, the integration of workflow support into them was not necessarily a conscious decision on the part of the system developers and lab professionals who served as alpha and beta testers of such systems. There were merely designing information systems to generate lab, pathology, and radiology reports. However and in order to achieve this goal, these systems needed to "understand" and optimize workflow. Such a goal is not overly complex for the diagnostic services. In the clinical labs and pathology, for example, serum and tissue specimens are always collected upstream. They are then processed, analyzed, and interpreted downstream in various ways and in various labs. These interpretations and diagnoses form the basis for the final reports. Such reports are the end-product or deliverables of the diagnostic systems and services.

It appears to me that are three reasons why clinical workflow, which is to say, patient workflow, is not well integrated into clinical EMRs. The first is that these systems are relatively immature when compared to the diagnostic systems, having been in development for only about half the amount of time. The second reason is that the clinical workflow for each inpatient tends to be individualized and frequently decided on-the-fly. Thirdly, the EMRs serve at least two professional groups, physicians and nurses. They tend to have a different set of professional tasks with some overlap. It is more of a challenge to simultaneously manage the workflow for both groups. The clinical EMRs can support workflow best when it is similar across both groups as in the case the hand-off of acutely ill patients at the time of personnel shift change.

In researching this topic, I came across an interesting, older reference about groupware failures, with this term defined as software that supports the work of a group as opposed to individuals (see: Electronic Health Record Workflow Management Systems). Most systems such as clinical or diagnostic EMRs deployed in a hospital setting would meet this definition (see: Who Will Build the Diagnostic EMR (D-EMR) as a Substitute for Today's LISs?). This has relevance for the support of professional tasks and workflow within clinical EMRs for physicians and nurses:

• Groupware applications often fail because they require that some people do additional work, and those people are not the ones who perceive a direct benefit from the use of the applications.
• Groupware may lead to activity that violates social taboos, threatens existing political structures, or otherwise demotivates users who are crucial to its success.
• Groupware may fail if it does not allow for a wide range of exception handling and improvisation that characterizes much group activity.
• The groupware development process fails because our intuitions are especially poor for multiuser applications."

Making Prepared Foods Healthier Is Easy -- Getting People to Eat Them Is Not

One of the key goals in preventive medicine is educating people to eat healthier. This is much more complicated than it seems because the process involves the interplay of an individual's food preferences, cooking skills, the cost of food, and the type and quality of foods available to the consumer in his or her neighborhood. To gain some understanding of this last question, here's an excerpt from an article discussing the manufacture of food and attempts to make it more healthy (see: Making healthy food is easy. Making people eat it is not):

A serving of Kraft’s Ranch dressing boasts 370 mg of sodium and 12g of fat. That is what nutritionists would describe as “far too much” and consumers would describe as “yummy”. The Kraft food company has brilliant scientists, of course, so it can easily take the salt out of its dressing. Alas, what remains tastes horrible....It has been a hectic year for food companies in America. In April the Institute of Medicine recommended a mandatory limit on the amount of sodium in food. In May Michelle Obama, who frets that American children are too porky, urged the industry to create healthy new products....PepsiCo, Kraft, Kellogg and others have set up a body called the Healthy Weight Commitment Foundation....But will anyone eat them? It is individuals, not corporations, who hold the nation’s spoons. Things that are bad for you often taste nice. Remove the fat from cheese and it becomes crumbly. Replace a biscuit’s sugar with artificial sweetener and a scientist must add ingredients to provide bulk and turn the biscuit’s surface brown. By far the most difficult challenge, however, is cutting sodium. Salt not only enhances taste but also acts as a preservative and adds texture. New official guidelines are likely to urge Americans to eat no more than 1,500 mg of sodium each day. Currently they eat more than twice that. PepsiCo is one of many firms to set ambitious goals for sodium reduction—in March it said it would slash 25% of sodium from its main products by 2015. Some firms remove salt furtively, since their customers equate “low-sodium” with “bland”. This summer ConAgra, a food giant, cut 29% of the sodium from its Chef Boyardee Beefaroni, a canned concoction of macaroni and beef, with little fanfare on the label. Campbell’s, another canned-food maker, touts its sodium reductions, but few others do. Charles Vila, vice-president of consumer insights at Campbell’s, describes the shift to less salty nosh as one of the firm’s most important changes since easy-open cans.

In terms of reducing fat and salt in your diet, the best approach is to prepare your own food. You can then add salt in very small amounts at various times in the cooking process to gauge the effect. You will use less of it and the taste won't suffer. Note, however, that all of the discussion above concerns prepared foods for which the manufacturers decide how much salt to add -- reducing the amount while fretting that consumers may balk at buying the changed product. It would be preferable if more people were cooking their own meals and starting with fresh ingredients. This is probably not going to happen for many people for reasons of time, cost, and cooking interests/skills. Probably the best approach for the manufacturers of our prepared foods is the one that they appear to be following. Gradually reduce the salt content in a stealthy, gradual manner. In this way, their customers can get off their salt binge and not necessarily know what is happening. However, the pace at which some of the food manufacturers are proceeding seems to be a little too leisurely for my taste.

 

Who Will Build the Diagnostic EMR (D-EMR) as a Substitute for Today's LISs?

I have just come back from Washington G-2 Report's Lab Leaders' Summit and Lab Institute in Arlington, Virginia, just outside Washington, DC. This was the 28th annual presentation of the latter. Both were well received and highly successful. I personally spoke at the Lab Leaders' Summit, summarizing in my lecture what I perceived to be the current top ten IT trends in healthcare. One of the items in my top-ten list was the Diagnostic EMR (D-EMR), which I believe will now evolve on a parallel track to the clinical EMR (C-EMR). These are not terms now in common usage but I hope to make them so in the upcoming months.

One of the questions that I posed during my lecture was which of the current LIS vendor(s) will decide to build a D-EMR. I envision that such a system will be cloud-based system and encompass and support all of the leading hospital-based diagnostic services (i.e., pathology, lab medicine, radiology, and cardiology). In many ways, it will look and feel like the Cerner Millennium RHO but clearly will be architected in a much different way (see: Comments about Cerner's Remote Hospital Option (RHO)). The D-EMR will serve as a platform for the support of hospital-based integrated diagnostics as this field develops (see: Diagnostic Delay Time (DDT) and Integrated Diagnostics; Revisiting Integrated Diagnostics and the Integrated Diagnostic Report). A key and integral component of the D-EMR, as I envision it, will be a network that will link hospital labs with the external organizations that provide support and consultative services to them such as AP-CP reference labs.

While at the Lab Institute, I was discussing the domination that the Epic EMR is now exerting over the large hospital market (>500 beds) and the pressure being put on hospital labs by Epic to install their immature LIS, Beaker (see: Why Does Epic Keep Hammering Cerner? Mr. HIStalk's Opinion; More Information about Epic's Beaker LIS and Its Sibling; Assessing the True Cost of Serving as a Beta Test Site for the Beaker LIS). An executive of a large LIS company nodded in agreement about this point and added that even those hospitals that are resisting pressure from their CIOs to install Beaker are being forced to "hunker-down" on their legacy LISs instead of buying a new LIS from his company. This was obviously bad news for him. As I pondered his remark, it occurred to me that I was now able to answer my own question about who would build the D-EMR. The answer to the question is all current LIS vendors will now attempt to build it because they will have no other choice if they want to stay in business.

Let's put the proposition another way, LIS vendors, in order to gain new hospital clients and retain their current ones, will need to offer functionality that Epic can't or won't provide. Epic, in my opinion and in parallel with hospital executives, consider the C-EMR as the strategic center of hospital computing and the ancillary systems (e.g., LIS, RIS, PACS) as feeder systems to the C-EMR. Hospital-based lab professionals have always had both an inward and outward-looking view of lab services and place greater importance on diagnostic services. In this era of molecular diagnostics and soon digital pathology, they will require an efficient D-EMR plus external network connectivity in order to provide myriad specialized reference lab services. The challenge for the current LIS vendors will be to provide frictionless consultative networking that is shrink-wrapped with the D-EMR.

One of the most interesting aspects of the networked D-EMR, as I describe it above, is that it may require a new pricing strategy on the part of the LIS vendors. This will be based on the fact that the networked D-EMR can easily become revenue-generating to the extent to which the vendors themselves are able to control the lab network. Because the entire system will be cloud-based, it will also be less expensive to deploy than systems running on local hospital servers. These two factors may allow vendors to offer the D-EMR at a relatively low price and thereby more effectively compete with the claims that Beaker is free, which is to say included in the total price under which Epic sells the "total enterprise solution" that is so admired by hospital CIOs (see: Are You an Enterprise or Best-of-Breed CIO? Access to Cash May Make the Difference).