Lab Soft News

Cultural Differences in the Use of Painkillers in Britain Compared to the U.S.

Cultural differences on the part of both physicians and their patients by region and by country are of great interest to me. It turns out that the British patients may be a little more stoic regarding pain than Americans or, alternatively, their treating physicians regard them as such (see: No painkillers please, we're British). Here are the details:

In Britain, the popular U.S. painkiller OxyContin is considered similar to morphine and used sparingly. Vicodin isn't even licensed. And at most shops, remedies like ibuprofen are sold only in 16-pill packs. To avoid risks including addiction, strong painkillers are often kept at arm's length from patients — even if that means some people will be left suffering. Many British doctors say the country has a more conservative approach to doling out painkillers than in the U.S., where overdose deaths from powerful drugs including OxyContin and Vicodin, tripled over a decade, according to a government report there earlier this month....Prescriptions for opioid drugs must be written on a special pink pad — and even those from private doctors get cross-referenced with the country's national health service so that patients' primary doctors know what their patients are getting from others. [A physician] also said British doctors may be less inclined to automatically do what their patients want. "In the U.S., doctors might wish to please their patients and prescribe them something because they're clients," he said. "But in the U.K., the patient doesn't pay the doctor directly so I can choose not to prescribe painkillers without the fear of suffering financially myself."....[Kyle] Hultgren, [managing director of the Center for Medication Safety Advancement at Purdue University,]  said aggressive pharmaceutical advertising puts more pressure on American doctors. "Patients sometimes openly ask for medications because they've seen them advertised," he said. "Physicians need to be very disciplined and explain to patients why a certain medication may not be right for them."

Distilling all of this information, I think that, for me, the key factors highlighted in this article are the following: (1) U.S. doctors are more anxious to please their patients; (2) U.S. patients are more inclined to push back on physician advice and may tend to be more knowledgeable about drugs; and (3) British physicians are more conservative across the board about writing analgesic prescriptions. Understanding that these drugs are highly subject to misuse, I come down on the side of making the patient as comfortable as possible. However, this can lead to problems. I have a number of friends who have been supplied with too generous a supply of OxyContin or Vicodin by their surgeon after surgical procedures. They tend not to consume all of the pills supplied at discharge and then don't know how to get rid of the excess. There is no place to return them and, appropriately, they can't flush the pills away. So they sit in a drawer.

Sensitivity of CT Scans for the Coronary Arteries May Lead to Unnecessary Surgery

The ordering of CT scans is now being closely scrutinized as to whether the procedure is being overutilized (see: Medicare Claims Show Overuse for CT Scanning; Treat the Patient, Not the CT Scan; Major Increase in CT Scans in Hospital Emergency Departments). Now comes news of a  study suggesting that the use of coronary computed tomography angiography (coronary CT scans) may lead to unnecessary surgery due to the excessive sensitivity of the procedure (see: New Heart Disease Test Brings Higher Costs and More Procedures). Here is an excerpt from the article:

[C]oronary computed tomography angiography...uses CT scans to visualize patients’ coronary arteries and has become increasingly popular in the past five years. Previous methods for testing for heart disease involve an exercise-based stress test using ECG (electrocardiography), cardiac perfusion scans or other readings. The sensitivity of the newer approach, however, might also prove to be its weakness. “If you pull a 75-year-old off the street and give him the test, it’s unlikely that the coronary arteries will be completely normal,” ...said [the co-author of a study] in a prepared statement. But whether a slightly abnormal reading indicates a level of sickness that should necessitate surgery, such as catheterization or revascularization, is one of the big questions at hand for this and many other diagnostic advances. In a study of more than 282,800 Medicare beneficiaries who received non-invasive testing for heart disease between 2006 and 2008, only about 3 percent received the newer CT-based screening. Those who did receive this form of screening, however, were more than twice as likely to later receive coronary catheterization and two and a half times more likely to undergo cardiac revascularization when compared with those who were tested with profusion scans. These CT patients were similarly more likely to undergo these procedures as those who had gotten ECG-based tests....The findings don’t suggest scrapping the higher-tech test, but the take-away message is that this, and many other new tests should be evaluated to see if they are really improving life for patients in the long run.

New types of CT and MRI imaging keep coming to the forefront. What may not be keeping pace are studies that focus on whether the changes detected by these new imaging studies result in the overdiagnosis of disease (see: Sports Medicine Said to Overuse M.R.I.’s). Perhaps better stated, the question needs to be asked when and if the detection of minimal disease by imaging studies warrants medical or surgical intervention. Here is a quote from a previous note on overdiagnosis (see: The "Overdiagnosis" Problem in Our Health Delivery System):

[O]ne physician-author has studied [the] problem [of overdiagnosis] (see: Health Blog Q&A: H. Gilbert Welch, Author of ‘Overdiagnosed’). [Here] is an excerpt from a blog note about him and his ideas:

...Welch and co-authors...write about the hazards of looking too hard for conditions or illnesses in healthy people, including additional procedures that carry no benefit but may cause harm, higher health-care costs and the psychological impact of being told you’re sick. ....But the reality now is that we can find abnormalities in just about everyone and that can start a whole train of harmful events. So we all need to adopt a more balanced approach. Overdiagnosis doesn’t necessarily lead to overtreatment, but it often does.

At least in my mind, the increased use of CT and MRI is becoming inextricably linked to overdiagnosis and overtreatment. I am not sure how to counteract this phenomenon other than to promote more research such as the study cited above, Unfortunately, such research takes time and, meanwhile, the use of a new imaging procedures may become entrenched in clinical practice.

Practice Fusion CEO Calls His Company the Largest EMR Provider

Practice Fusion is a free, web-based EHR designed to support physician office practices. Here's how the company describes its product on its web site:

You'll immediately appreciate the benefits of using Practice Fusion's free, web-based solution. Our user-friendly EHR can be activated in less than five minutes, eliminating the difficult conversion process that has become industry standard. Practice Fusion stands out in a marketplace dominated by expensive, complicated and ineffective EHR systems.

Here's an excerpt of an interview of the company CEO, Ryan Howard (see: Practice Fusion, #1 in EMR With 25M Electronic Medical Records, Debuts iPad App):

With great power comes great responsibility, and in few places is that more true than the healthtech industry. Practice Fusion is the leading provider of electronic medical records, now helping 130,000 doctors to track records for 25 million patients, CEO Ryan Howard told me today. That’s over 3x the EMRs hosted by Kaiser Permanente or the VA. Practice Fusion is free for doctors and patients. It monetizes through a marketplace for labs, pharmacies, and drug companies who pay for preferred placement in front of doctors who direct a staggering $40 billion in spend a year through the platform. Its new iPad app...will let these doctors access records while out of the office....Practice Fusion’s doctor and record uptake rate is growing exponentially. It counted 70,000 clients in April when it raised a $23 million series B, and by September when it took $6 million more in funding it had 100,000 health care providers on board. Now Practice Fusion is at 130,000, and with each new doctor comes roughly 2,000 new patients who can access their own medical records from anywhere. Doctors can begin using the product in minutes, and can pay to have all their existing paper records scanned in over a few days. Practice Fusion’s competitors can take 6 months or longer to get doctors set up.

To start, I want to emphasize the difference between an office EMR and a hospital EMR, which I have stressed in previous notes (see: Office EMRs as a Risky Investment for Small Physician Practices). Obviously, automated business and clinical record-keeping for an office practice is much less complex than for a hospital. In fact, that's why so many hospital-owned office practices balk at the installation of the same EMR software that runs in the hospitals. Such systems tend to be over-engineered for an office practice.

You can't help but be impressed by the simplicity of the Practice Fusion business model -- quick software installation and no charge for the service due to monetization "through a marketplace for labs, pharmacies, and drug companies who pay for preferred placement in front of doctors." The product is obviously the market leader in its segment. I am not sure that Epocrates EMR can make inroads in this market, having come to market relatively late but with a brand name (see: Ethical Questions Raised about the New Physician Office EMR from Epocrates).

I am also impressed with the availability of Practice Fusion app for the iPad, which I recently discussed in terms of the lack of such functionality for many hospital EMRs (see: Need to Enable Clinicians to Use Their iPads/iPhones for Access to EMR Data). I am sure that the Practice Fusion  physician clients love this feature. The bad news about all of this news is that the physician office information domain seems to be moving farther away rather from the hospital information domain. How are we going to ever integrate these two critical healthcare information sectors?

Menthol as Nicotine's "Partner" in Cigarette Addiction

Increased attention is being paid to the pathophysiology of addiction. It turns out that the addition of menthol as a flavoring agents seems to be a partner to nicotine in promoting addiction (see: Menthol May Be Nicotine's Partner In Addiction). Here is an excerpt from the article:

According to a new study, people who smoke menthol cigarettes seem to have more difficulty quitting than those who smoke regular cigarettes. Nicotine is definitely addictive, but scientists have been debating for several decades the effect of menthol in hooking people on tobacco. Some researchers suspect that menthol allows smokers to take deeper drags or puffs on cigarettes, drawing in greater amounts of nicotine and its byproducts....In a cessation program at his university, [the director of a smoking cessation program] found that people who smoked menthol cigarettes seemed to have more difficulty quitting than those who smoked regular cigarettes....The current cost of smoking, particularly in the northeastern United States, would certainly be enough to make a poor person want to break the habit. In New Jersey, a pack of cigarettes costs $8; in Manhattan, a pack costs $11....Those who smoke menthols say it creates a cooling, soothing sensation. Menthol is a cooling agent, [an expert on the topic] says, and that makes it easier to inhale more smoke per cigarette and perhaps get more nicotine. A [recent] study...found that African-Americans who smoke menthol cigarettes inhale a higher volume of carbon monoxide compared to those who smoke non-menthol cigarettes....They also take in more byproducts of nicotine that can be measured in the blood or the saliva. Among African-Americans who smoke, the vast majority smoke mentholated cigarettes, and many of these studies compared biochemical markers in black and white smokers. It may have more to do with the fact that African-Americans metabolize nicotine more slowly....That would mean that they are more likely to retain nicotine.

I have always wondered why African-Americans seem to favor menthol cigarettes. Although you can't discount taste and the accepted norms in a community, the ideas pertaining to menthol cigarettes in this article seem to me to make sense. Menthol sooths the throat and allows the smoker to hold the smoke longer in his lungs and thus absorb more nicotine.The idea that African-Americans may metabolize nicotine more slowly than white smokers was also new to me.

There is no good news in this story for smokers. A one-pack-a-day smoker about $8-11 per day to suport his habit. Moreover, it's getting harder and harder or a smoker to even get a job (see: Tobacco-Free Hiring Takes Hold; Both Smoking and Smokers Excluded). Good reasons to try to stop smoking addition to the personal health benefits that accrue.

If you are feeling sorry for smokers, point your browser to the Center for Public Accountability in Tobacco Control web site. It was developed by Dr. Michael Siegel, a physician with 21 years of experience in tobacco control, who recently became disillusioned by the direction in which the anti-smoking movement is going.

Epic Moving into the Meditech-Dominated, Smaller Hospital EMR Market

Epic Systems continue to grow (see: Epic Systems Planning to Add 900 New Jobs) and looking for new business, having grabbed most of the contracts in the 500+ bed hospital business (see: Does Epic Exercise a Near-Monoply for EMRs in Larger U.S. Hospitals?). In a previous note, I suggested that Cerner was perhaps feeling the Epic heat and trying to expand into the smaller hospital business, going head-to-head with Meditech (see: Is Cerner Modifying Its EMR Business Model?; A Closer Look at Meditech's "Sweet Spot" in the Hospital Software Market). Perhaps in response, Epic now may be eyeing this mid- to small-tier hospital market according to Mr. HIStalk (see: Monday Morning Update 11/14/11):

“Re: Cheyenne Regional Medical Center. Going Epic.” The 218-bed hospital gets board approval to replace McKesson Horizon with Epic in a $19 million deal, saying it will cost about $5 million over five years to implement Epic. It says Meaningful Use money will offset that amount, and after that, Epic will actually be cheaper that McKesson. Epic doesn’t usually sell to hospitals that small, so either CRMC is affiliated with a larger Epic customer or Epic is started to push down into Meditech territory.

Recall that Epic is already making inroads into the smaller hospital market with its remote hosting model via its large, neighboring hospital clients (see: Epic Helps Convert Its Large Hospital Customers into Epic Hosting Sites/Consultants). What can I say other than Judith Faulkner, CEO and founder of Epic, continues to be ambitious and is growing her company into the industry giant. This excerpt from an article may provide further evidence of this fact (see: Epic Wants To Build Large Auditorium In Verona):

Health care software giant Epic Systems Corp. is proposing building a large auditorium on its Verona campus for its annual user group meeting....The company is proposing a 13,000-seat auditorium on [the] campus. Capacity wise, it would be the third largest in Dane County -- behind Camp Randall Stadium and the Kohl Center. Verona City Administrator Bill Burns said preliminary plans were unveiled and discussed at Monday night's planning commission meeting. "It certainly is a large building -- a large venue," Burns said. "As Epic discussed at the presentation, the reason that they're doing this is a very important part of their business -- their annual user group meeting -- and being able to get all their clients together in one place and do a lot of collaboration and learning from each other."

For the non-football fan readers of this blog, Camp Randall Stadium is where the University of Wisconsin plays its football games. Here's Mr. HIStalk's latest opinion about Epic's future and that of its rivals in the EMR market (see: Monday Morning Update 11/21/11):

Since both Epic and its competitors just keeping doing what they’ve always done, you might suspect the leading team will keep piling on points in this embarrassingly lopsided victory. Time and customer money is running out to mount significant competition, so the only Plan B is to hunker down, try to keep existing customers happy since new ones will be hard to come by, and hope Epic’s dominance causes it to stumble to the point that customers will walk away from their huge investment and go shopping yet again for systems they didn’t want the first time around. That or just cede the core inpatient systems market to Epic and find less-competitive territory, which some pretty cool small companies are already doing.

:: Update on 11/21/2011 at 11:13 a.m. (see: Foster more Epics across region)

The company has 5,200 employees -- up from 4.300 in May -- with no end to the hiring in sight. Company officials expect the workforce to grow to about 6,000 by the end of 2012.

Need to Enable Clinicians to Use Their iPads/iPhones for Access to EMR Data

I don't understand why it's so hard for the major hospital EMR vendors other than Epic to enable iPads/iPhones to input and review EMR data.  I am sure, however, that there are software issues involved. This was the subject of a recent Q and A on HIStalk  (see: Monday Morning Update 11/14/11). Here is the exchange from that blog:

Q. From Commodore: “Re: Cerner running poorly on the iPad. Do other inpatient vendors have native apps?”

A. The only one I know of is Epic, which has Canto....There may well be others. I tried using a couple of my hospital’s clinical apps [with] the iPad using the Citrix portal and that’s definitely not something that’s workable for clinicians. The shrunken screen is impossible to comfortably read, you have to constantly zoom to hit tiny drop-downs with your finger, and the clicking doesn’t feel sure-footed at all. I think it’s safe to say that for most vendors, there’s not much to brag on if your iPad capability consists of running an emulated desktop screen. Only your marketing people will be impressed.

I have raised the idea of the two-screen revolution in previous notes, with one being the PC and the other, now, the iPad/iPhone screen (see: A Possible Scenario of the Two-Screen Revolution for Physicians). Here are more details:

I believe that one of the major barriers to EMR adoption, aside from poorly designed user interfaces (UIs), is that most physician lack a major personal stake in the development of a comprehensive clinical database. EMRs tend to be static, based on outdated software, and offer few useful tools to physicians other than the ability to order tests and drugs and regurgitate prior clinical records....By way of contrast, the two-screen revolution provides physicians with a more significant value-proposition for the EMR. However, this does not guarantee that they will begin to relish the role of a data-entry clerk for the EMR.

By dragging their feet in enabling "small screen access" to EMR data, the vendors other than Epic are continuing to emphasize the inflexibility of their systems and unresponsiveness to the user community. Also, as emphasized by Mr. HIStalk, running an emulated desktop screen on Citrix will simply not suffice as a solution.

Pfizer Cuts Deal with PBMs to Continue to Profit from Lipitor

Pfizer seems to be desperate to extract as much additional profit as possible from its blockbuster drug Lipitor. The drug is coming off patent and can soon be manufactured as a generic.The company's first strategy was to pay the generic drug manufacturers not to produce the drug -- a "pay for delay" strategy (see: Pfizer’s Latest Twist on ‘Pay for Delay’). It has now come up with a new twist on this delaying strategy. It has cut a deal with the pharmacy benefit managers (PBMs) to force pharmacists to keep filling prescriptions with the more expensive Lipitor for six months when the generic version is ordered by physicians (see: Plan Would Delay Sales of Generic for Lipitor), Here is an excerpt from the article:

Pfizer has agreed to large discounts for benefit managers [such as Medco Health Solutions] that block the use of generic versions of Lipitor, according to a letter from Catalyst Rx, a benefit manager for 18 million people in the United States. The letters have not previously been made public. A pharmacy group and an independent expert say the tactic will benefit Pfizer and benefit managers at the expense of employers and taxpayers, who may end up paying more than they should for the drug....“I’m stunned,” said ... a health policy expert at the University of Southern California, after reviewing the letters. “This is just an egregious case. Clearly there’s been some negotiation between Pfizer and the large P.B.M.’s saying we’re going to make this cost-beneficial to them, but the plan sponsors are going to eat it.” As for the people who actually take Lipitor, after Nov. 30, they will typically see their co-payment for a 30-day supply drop to the $10 level of the generic substitute, according to one of the pharmacy letters. The co-payment for Lipitor now is often $25 or more. When patients submit a prescription for a generic version of Lipitor, though, they are to be given Lipitor instead....Two generic drug makers are set to compete starting Dec. 1. Watson Pharmaceuticals is making a generic version authorized by Pfizer under a profit-sharing agreement. Pending federal approval, Ranbaxy Laboratories of India also plans to sell a generic version. When a drug’s patent protection expires, the law permits only limited generic competition in the first six months. After May 31, other generic versions of Lipitor are expected to flood the market, lowering prices sharply. Then, according to the letter from Catalyst Rx, the generic block lifts, Lipitor’s co-payment rises, and drugstores are told to fill Lipitor prescriptions with the cheaper generic versions....Paul M. Bisaro, chief executive of Watson, said the Pfizer discounts would undercut its generic price and raise overall health care costs while enriching pharmacy benefit managers.

It seems to me that Pfizer is opting for a short-term gain by cooking-up this deal with the PBMs. As noted above, this is at the expense of the employers who offer health insurance plans and the patients who are forced to cough up a higher co-payment. The company clearly has little concern for its long-term reputation among these latter groups. Here's an additional insight about the relationship between Pfizer and Ranbaxy (see: Pharmacies accuse Pfizer, Ranbaxy of secret Lipitor deal):

There's no question Pfizer reaps major benefits for every extra month without generic rivals for Lipitor. The [California] pharmacies say in their lawsuit [against Pfizer and Ranbaxy], Pfizer eked out an extra $18 billion through its patent settlement with Ranbaxy. That 2008 settlement gave Ranbaxy that Nov. 30 launch date, and with first-to-file status, Ranbaxy would have 6 months as the only independent generic rival to the best-selling cholesterol drug. Watson Pharmaceuticals...has the right to sell an authorized generic version.

Greater Adoption of the Scribe Model for EMR Data Input

Medical scribes are now in high demand in hospitals and large clinic settings. These personnel are basically "electronic transcriptionists" who were first deployed in hospital Emergency Departments (EDs) to  transcribe clinical data into the EMR on behalf of nurses and physicians (see: The Emergence of EMR Scribes as a New Category of Hospital Employees; Shift of Hospital EMR Data Entry Tasks from MDs to Scribes; Medical Students Recruited to Serve as EMR Scribes in Toledo). The use of such scribes is now increasing, both in EDs as well as other healthcare settings. Mr. HIStalk posted this recent note about the trend (see: Monday Morning Update 11/14/11):

A Jacksonville, FL woman starts a booming business that provides scribes to do patient care documentation for ED physicians. The scribes, often pre-med or nursing students, are contractors billed out at $20-25 an hour, a bargain according to the company’s medical director. “For every hour we spend, we get about 15 minutes at the bedside of patients and 45 minutes of every hour documenting everything … part of it’s insurance. Part of it’s medical-legal. Part of it is a federal mandate to have everything documented electronically.”

This movement toward greater use of scribes is on the rise. It seems to be a return to my medical school days when house officers would walk past the inpatient unit clerk and say to him or her something like: Lytes times three for Patient Jackson. I can envision the same scenario occurring these days with the scribe sitting in front of a PC instead of recording the order on the lab or pharmacy order slips.

Regarding data input into EMRs, it never made sense to convert the most highest trained and priced personnel in a patient unit into clericals. On the other hand, I can also understand the rationale of having the healthcare professionals who make patient care decisions entering such data. I just don't see this happening ultimately, however. Medical scribes are a logical  category of physician and nurse extender. Therefore, the movement toward more EMR scribes will be inevitable. If the trend works in the EDs, it will also be relevant and appropriate in critical care units.

Obviously, patient unit and clinic personnel such as nurses and secretaries can function in the capacity of an EMR scribe in addition to personnel who function exclusively in such positions. There will thus be a need for a "scribe policy" in hospitals and clinics such as the one that I found on the web for Washington University Physicians Family Practice Plan. Here is an excerpt from it. Note the need to document the identify of the scribe who enters clinical data:

For the purpose of this policy, a scribe is defined as an individual who is present during the physician’s performance of a clinical service and documents (on behalf of the physician) everything said during the course of the service....The use of scribes by Washington University teaching/attending physicians is acceptable.  However, residents, interns and fellows may not act as scribes. Ancillary providers such as NPs, MA’s, RNs, secretaries and other staff may serve as scribes. Individuals serving as scribes must sign a scribe agreement prior to scribing. Scribed documentation must clearly support the name of the scribe, the role of the individual documenting the service (i.e. scribe) and the provider of the service. The physician is ultimately responsible for all documentation and must verify that the scribed note accurately reflects the service provided.

Epic Systems Planning to Add 900 New Jobs

Here's some news about the continuing growth of Epic Systems (see: Epic to add 900 new jobs):

Epic Systems plans to add 900 new jobs to its campus in Verona, Wis., according to the newspaper of the University of Wisconsin-Madison, The Badger Herald. The newspaper reported that Epic also planned to add three new office buildings to house the new employees. Epic, whose technology has often been at the top of research firm KLAS’ list of for most satisfied customers, has experienced a flood of new business since the passage in 2009 of the American Recovery and Reinvestment Act, which included incentives for the adoption and use of health information technology. Epic’s founder and CEO Judith Faulkner is a member of the federal Health IT Policy Committee. Several other health IT vendors have grown their business since the passage of the government stimulus package. In June, Allscripts, which has 5,500 employees across 24 states, announced it would add 300 jobs in Chicago. In September, Carrollton, Ga.-based Greenway announced that it would add 400 jobs in the coming three years, nearly doubling its workforce.

Considerable challenge, adding 900 FTEs and finding a place for all of them to work. Also a challenge will be keeping all of the Epic clients happy with so many new, inexperienced employees.

The -Omics Cloud: A Healthcare IT Solution Already Developed for Genomics Research

In my mind, the future of personalized medicine, the emergence of -omics labs, the cloud, and the future of HIT are quickly converging. The pace of this conversion mpw seems to be accelerating based on a recent brief note that I came across in medGadget (see: Dell to Help Develop Personalized Therapy for Pediatric Cancers). Here is the note in its entirety:

At a [recent] press conference ...Dell unveiled a commitment to a project that, with help from massive computational resources, will help fight childhood cancer.  Specifically, Dell will install 8.2 teraflops worth of cloud servers at the TGen Translational Genomics Research Institute in Phoenix, Arizona to help with sequencing tumor genomes that can then used to select a personalized therapy for each child.  Moreover, the genomes are kept in a database that is used by subsequent patients to compare their cancer DNA to those of others.  The institute is currently capable of performing the molecular characterization and DNA comparison for each patient, but the process takes weeks.  The new computers should bring this process down to hours, a significant breakthrough when fighting aggressive cancers. The FDA has already given the go ahead for a clinical trial involving 14 kids with neuroblastoma, a rare cancer with difficult to identify treatment options.  This will be the first FDA approved trial using molecular-guided individualized therapy and so, in a sense, it will herald a groundbreaking in this exciting field.

In bulleted format, here are my thoughts about this news and the ramifications for HIT:

• We are at an evolutionary dead-end with our current EMR technology. Hospitals will happily pay tens, if not hundreds, of millions of dollars to use old technology designed to mimic the traditional paper medical record.
• All of these EMRs are transaction-based with little "intelligence" and even less ability to integrate and analyze the deluge of patient data generated by the EMRs and their "feeder" systems such as the LIS.
• LISs are highly functional -- pathology and the clinical labs would be unable to function for a day without them. Nevertheless, LISs vendors are not keeping up with the development of modules that can support the exploding -omics science.
• It is highly unlikely that many of the incumbent EMR and LIS vendors will be able to jump to a new generation of analytic healthcare information systems. They are too tied to their current technology, current business models, and their need to recover their sunk development costs.
• In my opinion, most of the progress in cutting-edge healthcare computing will be generated in academic research labs, non-profit biomedical research institutes like TGen, and smaller for-profit reference labs.
• Evidence for this statement is supplied by the note above with these key facts:
  • Dell installing 8.2 teraflops worth of cloud servers.
  • The sequencing in hours of the genomes of aggressive pediatric tumors.
  • Development of massive databases for tracking the genomic changes of individual tumors and making genomic comparisons across patients with the same tumors in the pursuit of better chemotherapy.

Here's what I think that the future holds. Hospitals will continue to install their transaction-based EMRs, LISs, and RISs. They will continue, in the short run, to pay premium prices for products from a company like Epic because of the monopoly it holds on the larger-hospital EMR market. Meanwhile, the "-omics cloud" will continuously evolve on the research and reference lab side, providing the answers pertaining to personalized medicine. There will be no need to install "personalized medicine servers" in hospitals. The most likely scenario will be that hospitals will develop working relationships with the developers of the best research-oriented "-omics clouds", sending them relevant diagnostic and clinical data from the hospital-based EMRs, LISs, and RISs. These research clouds will thus support "personalized medicine" as part of their mission but at a fraction of the cost of current EMRs.