Lab Soft News

Judith Faulkner of Epic Becomes Target for Tea Baggers and the Religious Right

Judith Faulkner, the founder and CEO of Epic, has become a favorite target for Tea Bagger and religious-right web sites. In these sites, she is usually referred to as a health czar. A Google search for the terms Faulkner, health, and czar yielded about 1,250,000 results. This is a large number of hits given the specificity of this search. I provide below only one recent example of such an article, copied from The End Times Are Here (see: Beloved Doctor Benched for Not Being Proficient with Electronic Medical Records System). Below is a quote from the article:

We have hospital administrators driving hard to implement Obama’s medical records solution, such as the one called EPIC Systems being pushed by his medical records czar, Judith Faulkner. In so doing, they are acing out excellent doctors whose only deficit is that they are not proficient with the new records technology. Are we really willing to stand by as Obama’s representatives bully those good doctors that criticize these electronic medical records systems? Are we willing to sacrifice good doctors for merely competent computer jockeys?

What did Judith Faulker do to deserve all of this attention originating outside of the healthcare community? My interpretation is that she stands astride a number of key political and organizational cross-currents, all of which are hot buttons for the Tea Baggers and religious right. Many of these hot buttons track back to her. They are the following:

• She is a documented donor to the Democratic party and, presumably, a supporter of President Obama (see: Judith Faulkner, EMR Interoperability, and Washington IT Politics).
• She has not been reluctant to dabble in Wisconsin politics (see: Epic Flexes Its Political Muscle in Wisconsin with Boycott).
• Here name is being mentioned as a possible Democratic candidate for governor of Wisconsin in the recall election that  the current governor Scott Walker is all but certain to face next spring (see: How the recall opens up politics)
• She sits on a key national healthcare IT committee, the Health Information Technology Policy Committee.
• Her company is the beneficiary of the federal funding for healthcare IT projects that is integral to healthcare reform and Obamacare.
• Electronic medical records (EMRs) have become symbolic for some people of governmental intervention into the lives of citizens.
• She is the founder and CEO of a technology-driven company that may make her a target for technophobes.

All of this may have little bearing on the future of healthcare or EMRs. Nevertheless, I am not sure of the long-range implications of this attention paid to an executive of an healthcare IT company. For the first time in my memory, however, healthcare IT is becoming intensely politicized on the national level along with healthcare in general. I have a nagging feeling that IT may become the "sharp end of the stick" in this fight and that some public opinion is being mobilized against the automation of health records. Think about the consequences of what we have already encountered regarding the politicization of public health vaccination programs.

Earnings Sluggish for Digital Pathology Companies; Discussion of Implications

The October issue of Laboratory Economics contained an article on the front page about the digital pathology market (see: DIGITAL PATHOLOGY MARKET POSTS SLUGGISH GROWTH). Here is the full text of it:

After several years of 10% to 15% annual growth, the U.S. clinical market for digital pathology has lost speed. Medicare Part B carrier spending on CPT 88361 (digital pathology for quantitative IHC) increased by only 4% to $18.9 million in 2010. CPT 88361 is used to bill Medicare for the reading of digital HER2, ER and PR slides from a computer monitor. Laboratory Economics estimates the total U.S. clinical market for digital pathology is currently about $80 million (or about 4x the size of Part B carrier expenditures on 88361).

Approximately 500 academic medical centers, hospitals and independent labs have a digital pathology system in place. The market leaders are Aperio Technologies and BioImagene (owned by Roche-Ventana). At this point only the Aperio and BioImagene systems have FDA clearance for HER2 scoring. No vendor has received the Holy Grail: FDA clearance to use digital pathology as a primary diagnostic tool. The lack of FDA clearance for primary diagnosis means no vendor can scale up so that prices can come down, according to Michael Farmer, principal at the IVD consulting firm McEvoy & Farmer (Seattle, WA).

“At this point, a digital pathology system costs as much or more than an Xpress or Peloris or a Benchmark Ultra—and yet they are not viewed as being as essential as a high-throughput tissue processor or top-of-the-line IHC system at most of the labs,” says Farmer. Meanwhile, Allen Gown, MD, chief pathologist at PhenoPath Laboratories...believes glass slides will remain the principal media for pathologists for the next 10 years. “No digital image will ever be as efficient for ease of use as a glass slide,” he told pathologists in a presentation at the Med3000-PSA conference in Palm Springs, California, September 21-23. Gown said the biggest problem is the storage of digitized images. “The technology gets obsolete very quickly, but I can still look at glass slides from 100 years ago.” Over time, Gown thinks digital pathology’s principal use will be for telepathology at remote locations and possibly quantification of IHC and FISH stains. “But we’re waiting for more quantification tools,” he added.

Here is an additional quote from Jondavid Klipp of Laboratory Economics about this topic: Vendors tell [us] that the [digital pathology] market is not driven by cash revenue collection, but by cost savings and other competitive advantages provided by digital pathology. I agree totally. It's going to take a long time to make a convincing return-on-investment (ROI) case for digital pathology (DP). Unlike the radiology procedures, histology slides are not digital-from-birth and surgical pathology reports will generally look the same after the new technology deployment. No new tests are being generated by DP with attractive profit margins. Many pathologists are also balking at the need to retrain with the new technology.

However, the future of surgical pathology rests with a conversion to DP. Here's my take on the competitive advantage of the technology. I believe that the pathologists in smaller hospitals can and should create business and strategic relationships with the pathology groups in larger neighboring hospitals. The former will automatically queue up their most difficult daily surgical pathology cases for consultation with the pathologists in the larger hospitals with an expected report by the end of the day. This is easily accomplished when the slides in both facilities are digitized on a routine basis. In exchange for this daily support, the smaller hospitals will agree to send all of their esoteric CP work to the large hospitals rather than shopping the work around to the large commercial labs. This generates a totally different ROI calculation and quality perspective on the conversion to DP for both the smaller and larger hospitals.

Identifying Risky and Biased Medical Web Sites

Jill of All Trades MD has posted a note about how to identify medical "booby traps" on the web. By this I mean web sites and blogs providing medical advice that is skewed, unscrupulous, or designed to sell you some product like vitamins. I am also bothered by "disease foundations" that sponsor what appear to be unbiased web sites but which receive most of their funding from pharmaceutical companies and medical device and may exhibit favoritism in this regard. Here are her mildly edited rules for raising suspicion about medical sites on the web (see: 5 tips to evaluate medical websites):

• In general, please be wary of any website with the ending “.com”, and opt for those websites with “.gov” or “.org”.
• If you are reading info online that is starting to become frightening to you, that is your signal to turn the computer OFF and make an appointment to see your doctor instead.
• Always ask yourself, “Who is writing this article?”  Is it written by a physician?  Most of the time, it’s not.  Many online health articles are written by journalists with “special focus” on medical information....Whatever that means, it’s NOT typically sufficient enough to be giving patients medical advice.....The scarier and more controversial their writings, the more money they make.
• Find out who sponsors the article, and if the writer is affiliated with any entity that wants to sell you a product.  Does the author work for a drug company?  What are they trying to sell you?
• Anything you read is one dimensional......Medicine is complex, that’s why it takes a minimum of eleven years of school to become a doctor.  Otherwise, doctors would be out of a career. Trust your doctor.

One warning. It may be difficult to ferret out whether drug company money is behind a medical web site but most should openly list their sponsors. It doesn't hurt to dig deeper than the home page of a medical web site when researching such sponsorship. For me, the antidote for this type of slanted news is to check facts and opinions on multiple sites, particularly using the .gov, .org, and .edu sites for reference purposes. The Big Pharma supported web sites may push a particular drug or even set up fake questionnaires to convince the reader that they have a certain disease or condition (see: Rigged Depression Survey on the Web Steers Readers to Lilly's Cymbalta). I randomly picked the Arthritis Foundation out of the air and immediately found their web site with Google search. For what it's worth. here is a list of their Proud Sponsors. Here is a list of their Proceeds Sponsors. Here is a list of their Event Sponsors. The bottom line is that the five "veracity rules" above seem sound to me as a starting point. But don't totally write off .com sites. If you did so, you would not arrive at this blog. The company that hosts this blog, Typepad, is a for profit entity.

Are Doctors Becoming Obsolete? No, But Their Roles Will Be Changing

A recent article with a very provocative title caught my attention (see: Are Doctors Becoming Obsolete?). There is no possibility whatsoever that physicians will become obsolete. However, I think that their roles will inexorably change driven in part by cost-containment pressures. Here is an excerpt from the article:

The idea that physicians are going to be far less important in the medicine of the future seems to be a central assumption of many next-generation health companies....The logic goes something like is: Patients are accustomed to seeking insight from their doctors but doctors are far less good at providing this advice than most patients realize. As more consumer-based tools for managing health become available, patients will recognize that they now have the means and the motivation to take care of their health better than their physicians, and medical care will move directly into their hands....What these data don't convey, however, is something I've had the privilege to experience first-hand: Doctors enjoy an exceptionally durable bond with patients -- especially those patients with chronic illnesses. The level of trust reported by patients for their physicians is remarkable, and the role of physician as trusted adviser is difficult to overstate. It's a huge burden to manage disease on one's own, and it's generally reassuring to know your physician is with you at every step -- something I believe still happens, by the way, although obviously not in every case....So perhaps there are really two questions here: First, will doctors become obsolete? I doubt it, and suspect that reports of their demise have been greatly exaggerated. Second -- and arguably more interestingly: Should (most) doctors become obsolete -- or less provocatively, does the practice of medicine need to change? Here, the answer must be yes. We urgently need to track and review outcomes that can already be measured, and we must dramatically improve our ability to measure patient health and real-world effectiveness, so that physicians can get better, and patient care can improve.

I think that physicians are over-trained for the management of yearly physicals, minor health problems, and scrapes/bruises. These can be easily managed by nurse practitioners (NPs) and physician assistants (PAs). Such individuals will be trained to refer the potentially serious problems to physicians, assisted by medical algorithms. Such a change will be inexorable and driven by cost containment pressures and the physicians themselves who are generally opting for multi-year speciality training. The perennial shortage of primary care practitioners (PCPs) is lamented by some but I view it as an opportunity. Another opportunity is the growing sophistication of telehealth such that the nurse practitioners and physician assistants working in rural areas can turn to on-line specialists for support with complex cases. The Wikipedia entry for telehealth makes the interesting distinction between it and telemedicine: telehealth is an expansion of telemedicine, and unlike telemedicine, which more narrowly focuses on the curative aspect, it encompasses preventive, promotive and curative aspects.

The practice norm in cancer hospitals is the multi-disciplinary team (MDT) (see: The Value of "One-Stop" Breast Cancer Clinics Confirmed in the U.K.; Repurposing Outpatient Clinics and Medical Procedure Units as Integrated Diagnostic Centers). For breast cancer patients, the following specialties are commonly represented on the team: Breast Cancer Surgery, Medical Oncology, Pathology, Plastic and Reconstructive Surgery, Radiation Oncology, Radiology, and Survivorship (see: Breast Cancer: Multidisciplinary Team). Can we take this same model and move it into other care venues with a NP or PA triaging the patients? This has great appeal for me but is obviously best suited for the larger clinics and office practices.

Predicted Migration of "Some" LIS Functionality from Pathology to Central IT

In a note posted last week, I discussed some criticisms of hospital IT systems by lab professionals, notably excessive log-on security and unhelpful help-desk personnel (see: Criticism of Hospital IT Services by Lab Professionals). Steve A. submitted the following comment in response to the post:

This is right on. But the origin of the problem is that "LIS" has slipped out of control of the laboratory into the larger emr/IT sphere. Pathologists (with help of lab organizations) need to reassert their authority over the reporting of lab results, be it on paper or on computer. But it is probably already a lost battle...

I agree with Steve. Many of the problems raised in my previous note can be tracked to the EMR and the hospital central IT personnel who manage that system. Like Steve, I think that some of the battle has been lost but I believe that there is a favorable solution on the horizon. First, though, a little history. For about three decades starting in the 1970s, lab professionals exercised almost total control over the LIS. During this era, hospital executives were preoccupied with the financial and patient management systems. In the absence of any clinical systems to call their own, they gratefully ceded control of the LIS to pathology.

There was a major shift beginning about two decades ago. EMRs became more mature and hospitals added CIO and CMIO positions to their executive suites. In recent years, vendors like Epic have begun to promote an "enterprise-wide solution" encompassing an EMR plus numerous ancillary systems like an LIS (Beaker) and an RIS (Radiant) (see: Are You an Enterprise or Best-of-Breed CIO? Access to Cash May Make the Difference; The Feasibility of Using the Epic EMR as a "Platform" to Extend Its Functionality). Epic is now dominating the large-hospital market because of the high success rate of deploying the Epic EMR and also because an Epic contract shifts the system integration solution from the hospital CIO to Epic (see: Why Does Epic Keep Hammering Cerner? Mr. HIStalk's Opinion). CIOs are thus pressuring lab professionals to cooperate and install Beaker.

I expect little significant push-back from the majority of pathologists as a result of this power shift. For many of them, pathology informatics has always been a step-child that does not resonate with their core competencies. Beaker is currently a very immature LIS but the company will inexorably improve its basic lab modules (see: Details about Epic's Beaker LIS, Supplied by the Company; A Pathologist Describes His Firsthand Experience with a Demo of Epic's Beaker LIS). Some larger hospitals will undoubtedly install the system in upcoming years, functioning as beta sites. In collaboration with Epic, they will work to improve the core LIS modules and functions such as biochemistry and hematology. These core modules will then rest largely under the control of the hospital central IT group with periodic "advice" from lab professionals.

Despite this scenario, the battle for pathology informatics has not been lost and, in fact, is very favorable. In my opinion, the future of pathology and lab medicine lies with molecular diagnostics, including all of the -omics subdisciplines, and digital pathology. Epic will never be able to adequately  support these emerging disciplines. The science is just moving too quickly and the company will not squander its resources too far afield from basic clinical computing. Even most of the large, incumbent LIS vendors have had difficulty supporting molecular diagnostics and digital pathology. The future will thus lie with emerging vendors of -omics and digital pathology (DP) systems. These new systems will provide sophisticated support for imaging algorithms and also integrate imaging systems with current LIS functions like reporting and billing. These emerging -omics/DP systems will also serve as nodes on a national diagnostic laboratory network for referrals of esoteric testing and consultation. Because much of this processing and storage will be in the "cloud," lab personnel will again operate quasi-independently from central IT personnel.

In summary, I envision the following scenario: (1) some core lab computing functions will transfer to the central IT group in hospitals; (2) a set of new vendors will arise to support -omics and digital pathology; (3) these new systems will be selected, purchased, and installed by and in pathology; (4) these systems will have both an inward orientation, with reporting through the hospital EMR, and also an outward orientation as nodes on a national lab network; (5) this external network orientation will be critical for the survival of smaller hospitals because hospital labs will continue to receive -omics and tissue specimens but will be unable to perform many of the requested tests.

Criticism of Hospital IT Services by Lab Professionals

I received the following comment from Dan Kurtycz who is a pathologist. It contains criticism mainly of IT security and help desk support. These strike me as a mainly central IT problems but some of the blame may also lap over to laboratory IT personnel. Below is his comment followed by my response:

There seems to be a lot of real anger about IT services among laboratory professionals. There are lots of complaints about security being more important than getting patient results to where they need to go. Is the need to change passwords every other month really necessary when you cannot retrieve web reports on your patient's PaO2 [partial oxygen pressure]? Promises are always greater than delivered results. The "Help" Desk often is not. Fire comes into the eyes of many of the med techs and pathologists around the table when we discuss such items. There is a feeling just shy of disgust. It might be that we really do not have enough qualified IT experts to go around, and that each institution is paying for bachelor's level IT when they really need graduate school level IT? Do they not perceive that the duty is to the patient? There are all of these questions and more...

Dan seems to be raising three issues here which I summarize in the following way:

• The security requirements (e.g., password protection) of some EMRs are being raised to a level that is counterproductive and hindering the ability of clinicians to care for patients.
• Help desk personnel, whether in pathology or central IT, are frequently unhelpful.
• Pathology and hospital central IT personnel do not always perceive that their "first duty" is to facilitate quality patient care and support the front-line physicians and nurses who are delivering such care. This may have a relationship to their educational background,

Below are my responses to these issues. Feel free to weigh in with your ideas using the comment feature.

• There is a need to strike a balance between adequate information system security and the efficiency of clinical workflow. I personally think that security and HIPAA are often weighed too heavily in this equation.
• IT help desk personnel are under intense pressure. Callers may be frustrated by hospital procedures and clumsy, opaque information systems that are out of their control. Callers often target help desk personnel with their anger who may then be snippy.
• Clinicians' and laboratorians' criticisms about EMRs and LISs are often swept under the rug because many such systems are expensive, complex, and difficult to modify. This leads to uncertainty and finger-pointing. Some system workarounds, however, may be possible. I think that it's important to hold public forums to air the grievances of the medical professionals who interact with these systems to avoid the "fire in the eyes" syndrome that Dan describes above. At the very least, such sessions may be able to pinpoint the source of the problems. In my experience, however, they frequently turn into unhelpful gripe sessions.

Do We Need MRI Monitoring of Carotid Atherotic Plaque to Assess Statin Treatment?

I continue to be impressed by the ability of cardiologists to both control many of their own imaging studies and also to generate ideas for new types of cardiovascular imaging studies. A case in point is a recent article discussing the use of MRIs to assess the response of carotid artery atheromas to treatment with a statin (see: Cholesterol therapy monitoring with MRIs could improve outcomes). Below is an excerpt from the article:

MRI scanning could become a powerful new tool for assessing how well cholesterol drugs are working, according to ...cardiologist Binh An P. Phan, MD. Phan is co-author of an MRI study of patients who had recently begun taking cholesterol medications. The study found that intensive treatment with cholesterol drugs significantly reduced the amount of cholesterol in artery-clogging plaque....Imaging technologies traditionally used to monitor cardiovascular disease, such as angiograms and ultrasounds, show the overall size of the plaque buildup. In the new study, MRI scans were more precise, showing the amount of cholesterol within the plaque....The scans were done on patients’ carotid arteries in the neck, rather than on their coronary arteries. Carotid arteries are easier to image because they are closer to the surface of the body, and do not move as much as coronary arteries of a beating heart. Since atherosclerosis occurs in blood vessels throughout the body, plaque buildup in carotid arteries is a good representation of what is occurring in coronary arteries.The findings confirmed the researchers’ hypothesis that the reason why cholesterol medications shrink the overall size of the plaque is because cholesterol is being removed from within the plaque. Thus, using MRI scans to monitor the amount of cholesterol in plaque may help doctors to better determine how well cholesterol medications are working. If an MRI showed cholesterol was not being reduced, more aggressive therapy might be needed, [the author of the study ]said.

Statins are very effective in reducing the level of serum cholesterol. Cholesterol and lipids are frequently contained within arterial atheromas. Intensive treatment of high cholesterol levels can thus reduce the size of atheromatous plaques. MRI scanning of the carotid arteries can document a reduction in size of such plaques. However, do we need to document this drug effect with such an expensive imaging procedure or is it sufficient to monitor the effectiveness of statin therapy with serum cholesterol levels? Is this an example of diagnostic overreaching? I am sure that the author of this study can cite cases where serum cholesterol levels do not accurately reflect the degree of atherosclerosis in the carotid artery.  However, the real issue in my mind is whether we necessarily need to turn to the most expensive and technologically advanced diagnostic procedure in order to draw conclusions about the clinical status of a patient.

"Point-of-Work" Drug Testing; A Growth Industry

As everyone knows, drug abuse is a major problem in the country. I blogged about workplace drug and alcohol testing problems nearly five years ago, so it's probably time for an update (see: Workplace Drug Testing: Some Statistics). A press release from USA Mobile DrugTesting focused on employee drug problems in small businesses (see: Small biz employs more drug, alcohol users). Below is an excerpt from it:

Small businesses may be at increased risk when it comes to hiring employees who abuse alcohol and drugs, according to USA Mobile Drug Testing. Although the government encourages alcohol and drug-free workplaces, a large number of small businesses do not have the necessary policies or testing procedures in place to protect them against substance-abusing employees....[SAMHSA (Substance Abuse and Mental Health Services Administration)] says small and medium-sized businesses can avoid this by instituting drug testing programs and putting a drug-free workplace program in place. “Although business owners may think that starting a drug testing program is not possible because they fear the costs or lack the staff to manage it, in reality any business can put together an effective program,” [said a spokesperson for the company]....U.S. Department of Labor studies show that workers who abuse drugs and alcohol are more likely to skip work or, when they are on the job, are one-third less productive, costing employers approximately $7,000 a year. Employees using drugs are also more likely to cause workplace accidents or file workers’ compensation claims. Sardisco notes that having a drug testing program is far cheaper than paying accident or workers’ compensation claims and that some states offer discounts on worker’s compensation premiums just for testing employees.

USA Mobile Drug Testing is a nationally-branded franchise business focusing on mobile drug testing and provides drug and alcohol testing for corporations and government employers. I usually don't post excerpts from press releases but the business model of this company interests me -- "point-of-work" drug testing as an analogue of point-of-care testing (POCT) in inpatient and outpatient settings. On-site mobile drug testing, according to the press release, avoids time away from work for employees. I suspect that the majority of companies utilize the drug testing services of the large national reference labs like Quest and LabCorp. The LabCorp web page addressing employer drug testing has this interesting paragraph:

Numerous Testing Options: Providing consistently good service is our primary focus. We are committed to research and leading-edge technology that enable us to provide your organization with an innovative test portfolio reflecting societal trends, including oxycodone, ecstasy, and medical professionals panels.

I interpret the reference to "societal trends" to mean that the company will test for the "drugs du jour" based on the socioeconomic status of the workers being testing. The need for a "medical professional" panel is probably warranted on the basis that physicians and nurses have access to drugs that the man-on-the-street may have never heard about.

Should Over-Budget Healthcare IT Projects Be Described as Black Swans?

A recent article described overbudget IT projects as "black swans" (see: Black swans' busting IT budgets). Although I agree that many healthcare IT projects are budget-busting, I disagree with the idea that these situations can be categorized as unexpected, rare, and unpreventable, the definition of a black swan. I rather think that cost-overruns for IT projects are eminently predictable and due to planning errors on the part of both vendors and their clients (see: Do Hospital Executives Use Their IT Vendors as Scapegoats?; Another Saga of "Blame the Vendor" Leaks Out of the UK; The "True Cost" of Implementing an EMR or LIS). Here's an excerpt from the article:

One in six big IT projects go over-budget by an average of 200%, according to new research. The study by Oxford University and McKinsey also found that spending on technology was three times more likely to spiral out of control than construction or other major projects. Researchers said that rare but high-impact problems, dubbed "black swans", were often to blame. They can lead to cost over-runs capable of bankrupting vulnerable firms. The study analysed 1471 large-scale global IT projects costing more than $170m. It found that while most projects ran less than 30% over budget, a sixth ended up costing on average three times as much....Researchers put this down to "black swan blindness" - a tendency for IT decision-makers to ignore low probability but high-impact risks to project plans...."IT managers tend not to see these black swans, because they assume that they're rare, and will probably happen to somebody else. They are wrong. They happen much more often than people think" [said one of the study authors]....People always thought that the public sector was doing worse in IT than private companies - our findings suggest they're just as bad” [he said]...."People always thought that the public sector was doing worse in IT than private companies - our findings suggest they're just as bad...."Managers are very likely to run into black swans. They need to be able to identify them and prevent them."

If I understand the conclusions of this research project correctly, large-scale IT projects that run "less than 30% over budget" are considered successes but that one sixth of them can end up as much as three times over their projected budgets. These latter are referred to as black swans in the article. First of all and referring to my experience in hospital and lab IT projects, many budgetary problems are caused by project scope-creep, lack-of-fit between the software and the hospital or lab workflow, and the reluctance of system users to adapt to the newly installed system. Most high quality, mature LISs are designed on the basis of time-tested, optimized lab workflow. It makes no sense at all to install a new LIS and then modify it to the suboptimal local status quo. In such a case, the labs would be far better off sticking with their existing, but perhaps, outdated, LIS.

It seems to me that one way to address the potential for budget-busting LIS and EMR projects would be to pose the following question to the proposed new vendor: which of your last X installs were more than 20% over the initial quoted price and what was the reason for the cost overruns? The vendor will probably be reluctant to answer such a question for competitive and confidentiality reasons, but be persistent. You could get an answer. I would also call the hospitals recently installing the software to determine their perception of cost-overruns. Be aware that most CEOs and CIOs will have ready answers to explain away IT budgetary problems and may also have incentives to not blame the vendor because of the need for a long-term working relationship or contractual constraints. Hence, such problems are often described as no one's fault and unavoidable.

An Introduction to Reproductive Tourism Including Surrogate Pregnancy

I have posted a number of previous notes about medical tourism but a variation on this theme, reproductive tourism, has now come to my attention. Below is an excerpt from an article about this topic from the Orchid Cellmark web site (see: Reproductive Tourism). This commercial lab focuses on paternity and forensic DNA testing, hence its interest in this topic. By the way, LabCorp has again extended a tender offer for Orchid Cellmark (see: LabCorp again extends Orchid Cellmark tender offer):

REPRODUCTIVE TOURISM  (Tuesday, September 27, 2011)

Let's imagine that you and your spouse have been unable to conceive a child, and that your doctor has recommended in vitro fertilization (IVF). You have learned that in the United States, IVF will cost between $10,000-$15,000 for a single cycle. However, you have found that by traveling to another country, you could obtain what appears to be the same service for about $3,000. Would you have the procedure performed in the US, or travel abroad?

Each year thousands of people travel to other countries in order to procure reproductive services - IVF, surrogate pregnancy, and other assisted reproductive technology treatments. The term for this choice is "reproductive tourism." A popular destination for Canadian and US citizens is India, where the growing industry is only lightly regulated, and also relatively inexpensive. It has been reported that reproductive tourism in India is now a half-a-billion-dollar-a-year industry, with surrogacy services offered in 300+ clinics across the country....

WHO TAKES PART IN REPRODUCTIVE TOURISM?

There are several groups of people who take part in reproductive tourism. Here are three: 1) People who require assistance to have a child, and wish to pay discounted rates, 2) women who require IVF, but have needs that are restricted in their country (maternity age restrictions, embryo sex-preference restrictions, etc.), 3) people who have chosen surrogacy, and wish to accomplish this outside of the laws or stigmas within their homelands.

DETAILS TO CONSIDER

There are many questions surrounding the subject of reproductive tourism. Here are three:

1) Are all the reproductive operations throughout the world equipped to safely perform procedures? With few regulations, the safety and quality of work performed at many of these clinics is uncertain...

2) Are surrogate mothers treated and compensated fairly? This query is the heart of the controversy surrounding surrogacy. Are women who choose to become surrogates in third world countries, with few economic opportunities and very little education, making informed decisions? It doesn't seem likely, and in countries where compensated surrogacy is illegal, the answer is unknown.

3) Are international immigration laws standardized to accommodate the situations and technologies of 2011? Some countries, such as England, consider the woman who bears a child to be the mother, and her husband to be the father. Clearly, this makes no allowances for surrogacy - either traditional (using a woman's own eggs that have been fertilized with donated sperm through IVF) or gestational (using donated eggs and sperm, where the gestational host bears no genetic ties to the baby). In such cases, even an immigration dna test may not point to the contracting parents. Some countries, such as the Ukraine, have attempted to adapt to these issues by naming the contracting parents on the birth certificate. Other countries have responded by refusing to recognize such documents, and by insisting on parental dna tests for children born abroad before conferring citizenship, or even the right to enter the parents' native country.

Sorry for the long excerpt but I found this article to be very interesting. Here are some of the issues that jumped off the page for me:

• Some people with a sexual preference for a child may be traveling outside of the reach of U. S. laws (see: The End-of-Men and the Role of the Clinical Labs in This Culture Shift).
• At least in my mind, surrogacy implies that the fetus is being carried by a woman other than the "intended mother." The "intended mother" may donate her own eggs that have been fertilized with donated sperm through IVF (traditional surrogacy) or both the sperm and eggs may come from other individuals (gestational surrogacy).
• Major concerns have arisen about whether surrogate mothers are being fairly treated in developing countries.
• There is also a great deal of ambiguity and potential legal barriers when a couple returns to the U.S. with an infant-in-arms without a passport.