Lab Soft News

Computer-Aided Tissue Analysis; A Major Step Forward with SIVQ

Computer-assisted image analysis will inevitably become a key component of surgical pathology. This prediction of course is predicated on the wide availability of digital pathology files and archives which is still an open issue with regard to primary diagnosis (see: Digital Pathology and the FDA; WSI Systems Called Class III Devices). Such computer analyis is already an important component of digital radiology diagnosis and case review (see: Software for Comparing Changes in Pulmonary Nodule Size on Chest X-Rays). My pathology informatics colleagues at the University of Michigan Medical School, Ulysses Balis and Jason Hipp, have been much in the news lately. They have made great progress in the development of a software tool for increasing the speed and accuracy of histology image analysis (see: U-M led team makes computer-aided tissue analysis better, faster and simpler). Below is an excerpt from the article:

[Dr. Ulysses Balis] ...is demonstrating the extreme flexibility of a software tool aimed at making the detection of abnormalities in cell and tissue samples faster, more accurate and more consistent. In a medical setting...the technique, known as Spatially-Invariant Vector Quantization (SIVQ), can pinpoint cancer cells and other critical features from digital images made from tissue slides. SIVQ isn't limited to any particular area of medicine. It can readily separate calcifications from malignancies in breast tissue samples, search for and count particular cell types in a bone marrow slide, or quickly identify the cherry-red nucleoli of cells associated with Hodgkin's disease, according to findings published in the Journal of Pathology Informatics. "The fact that the algorithm operates effortlessly across domains and length scales, while requiring minimal user training, sets it apart from conventional approaches to image analysis," Balis says. The technology...differs from conventional pattern recognition software by basing its core search on a series of concentric, pattern-matching rings, rather than the more typical rectangular or square blocks....Still, pathologists shouldn't be worried that SIVQ will put them out of a job. "No one is talking about replacing pathologists," Balis says. "But working in tandem with this technology, the hope is that they will be able to achieve a higher overall level of performance."

SIVQ can also be used with laser capture microdissection as emphasized in the recent article by Balis and Hipp with co-authors (see: SIVQ-aided laser capture microdissection: A tool for high-throughput expression profiling). For more information, point your browser to their Digital Slide Repository.

The End of Health Insurance Companies by 2020?

Here's a bold prediction from a national expert on healthcare strategies, Ezekiel Emanuel, who predicts that the health insurance companies will be replaced by ACOs by 2020 (see: The End of Health Insurance Companies). I don't totally agree with analysis but first read what he has to say in the following excerpt:

Already, most insurance companies barely function as insurers. Most non-elderly Americans...work for companies that are self-insured. In these cases it is the employer, not the insurance company, that assumes most of the risk of paying for the medical care of employees and their families. All that insurance companies do is process billing claims. For individuals and small businesses, health insurance companies usually do provide insurance; they take a premium and assume financial responsibility for paying the bills. But the amount of risk sharing that is accomplished is limited because the insurers charge premiums that vary, depending on the health of an individual or a group of employees, and use their data and market power to identify healthy people to cover and unhealthy people to exclude from coverage....But thanks to the accountable care organizations [ACOs] provided for by the health care reform act, a new system is on its way, one that will make insurance companies unnecessary.

Accountable care organizations will increase coordination of patient’s care and shift the focus of medicine away from treating sickness and toward keeping people healthy....In addition to providing better and more efficient care, A.C.O.’s will also make health insurers superfluous. Because they will each be responsible for a large group of patients...they will pool the risk of patients who have higher-than-average costs with those with lower costs. And with the end of fee-for-service payments, insurance companies will no longer be needed to handle complicated billing and claims processing, nor will they need to be paid a fee for doing so. Payments can flow directly from an employer, Medicare or Medicaid to the accountable care organizations. A.C.O.’s will require enhanced information systems to track patients and figure out how to deliver more effective care, but this analytic capacity will be directed at improving health outcomes, not at imposing barriers to those seeking treatment.

I agree with most of what Emanuel says but differ on one significant point. Hospitals and hospital executives did not invent ACOs. They were not pining away for some new business model when the ACO idea was launched as part of the healthcare reform legislation. Most seemed to be happy with the existing business model under which they manage hospital revenue from the various payers of which the federal government and health insurance companies are the major players. In my opinion, they have little interest in "keeping people healthy" although they frequently pay lip service to the idea. They are in the business of treating disease in hospitals and maximizing their bottom line. Their dialogue with payers is roughly the following, as I see it: tell us what hoops you want us to jump through in order to be maximally reimbursed. The newest hoop, as part of healthcare reform, is the creation of ACOs. The development of these organizations is not the result of hospital executives yearning to be more entrepreneurial and wishing to supplant the health insurance companies.

I can't argue with Emmanuel's premise that "A.C.O.’s will also make health insurers superfluous." This scenario is very possible. My disagreement is that hospital executives will be anxious to assume a new set of responsibilities. In my opinion, they don't want to process billing claims and they don't want to be responsible for "improving health outcomes." To the extent that these duties will be urged or required of ACOs by the federal government, I think that the hospital executives will turn to external service organizations and consultants to achieve this goal (see: Hospital Executives Search for the Formula for an Accountable Care Organization). And who will be in charge of these external service organizations? Probably the current executives of health insurance companies or the healthcare consultants who helped the hospitals create the ACOs in the first place.

Practice Fusion Supported by Advertising and Owns Anonymized Data

In my blog note yesterday, I suggested that physicians might consider Practice Fusion as an alternative to Care360 for their office EMR (see: Quest Diagnostics Offers Reduced Price for Deployment of Care360). Luckily, a reader named Sam submitted a comment about a "catch" associated with this latter product. Here is his comment:

...Practice Fusion...has the same issues as Epocrates in that is it supported by ads (unless you pay the $100/mo/provider to remove them). Practice Fusion goes a step further and takes ownership of the anonymized patient records which it in turn sells. See: [Why Peter Thiel Likes Electronic Health Record Provider Practice Fusion]:

Thanks, Sam, for your useful new information. Here's a relevant quote from the Forbes article cited at the end of his comment:

...[D]octors started signing up [for the free Practice Fusion] in droves. [Founder and CEO] Howard says he has 90,000 users—which he defines as physician, nurse or even the office secretary; and a database of 12 million patients, which he claims is bigger than the VA’s and Kaiser Permanente’s. Howard’s pitch: Doctors can get an EHR without paying a cent and pocket the entire $44,000 government check—which is what they stand to get if they comply with the meaningful use rules. In contrast, an EHR for Practice Fusion’s market of nine or less doctors can cost $50,000 per user. But nothing is really quite free, and Practice Fusion needs to find a way to make money. In the fine print of its licensing agreement, there’s a provision which says that by signing on, doctors agree to transfer their ownership of patient data, stripped of identifiers, to the company. Practice Fusion now sits on a valuable load of information that pharmaceutical companies would love to get their hands on to mine it....I ask Howard whether he plans to sell useful marketing information to a company that wants to know, say, in which parts of the country its newly-released drug is not being prescribed. He balks; he wants to make sure he’s not crossing any ethical lines. He’s looking instead at applications, such as helping pharma companies enroll patients in clinical trials, or monitoring a drug following its release on the market. Practice Fusion’s revenues which are now less than $10 million, come mostly from advertising.

Quest Diagnostics Offers Reduced Price for Deployment of Care360

Here's a recent and interesting blog note regarding a discount offer for physicians to install the Quest office EMR called Care360 (see: Quest Diagnostics Offers Big Discount On Its EMR-Practice Management System). I discussed this product  six years ago, which at that time was called a lab portal (see: Quest Software Heats Up the Lab Portal Wars). Below is an excerpt from the current note.

...Quest Diagnostics has kicked off a program offering medical practices a steep 85 percent discount off of the retail price of its Care360 EMR and practice management bundle....The deal, which reduces the physicians’ out of pocket cost to less than $100 per month,  also includes training, hosting, maintenance and 24/7 support for Care360. The lab giant says physicians can get Care360 up and running in about 45 days....[I]f I were a doctor I’d think long and hard before agreeing to a deal like this, even though the software is just about free. There’s simply too much at stake to plunge in. Yes, Care360 is CCHIT certified and, intriguingly, has incorporated the Direct Project specs allowing doctors to share information with patients and hospitals. And yes, it seems to have made efforts to support EMR access via mobile devices. This is all good. And of course, the price is right. On the other hand, I’m not sure I’d want to make this big of a commitment to any particular service provider, be it a reference lab, a radiology provider or the people who stock my vending machines with sodas. I’d argue that the more important the service is, the less you want to be beholden to the vendor. After all,what if Care360 isn’t your cup of tea?  Do you really want to disrupt your relationship with a critical provider like Quest? Not only that, it’s risky to lock in an EMR just because it’s cheap. If Care360 takes 45 days to get installed, it’s not going to be possible to uninstall it in a day or two, and that could mean misery on wheels if the product doesn’t work for you. Besides, it’s possible to get Web-based, easy to adopt or drop EMRs for only a couple hundred dollars a month more. It wouldn’t make sense to go for an EMR that might not work just to save that little. (If your margin is tight enough that a savings of $200 or $300 a month is critical, you have worse problems than finding the right EMR!)

There is an old saying in healthcare software -- free (or almost free) software is never worth the price. The reason that such a product is usually not "free" is that there is some catch that enables the free or discounted offer. The situation also reminds me of my recent note about the Epocrates office EMR (see: Ethical Questions Raised about the New Physician Office EMR from Epocrates). In this latter case, the EMR displays advertising from pharmaceutical companies. Here's what I had to say at that time:

Very distressing to me, however, is the clear link of [Epocrates] and its software to the pharmaceutical industry. I have blogged on numerous occasions about some of the ethical and legal lapses of some of these companies....I have also reluctantly come to the conclusion that even apparently trivial advertising connections to Big Pharma can lead to mischief. I had previously thought that inconspicuous advertisements in EMRs by drug companies might be tolerated if the companies were to bear the costs of these systems. I now believe that allowing these companies even a tangential relationship to physician-office electronic medical records is too risky.

In the case of Care360, the potential risk, as the first quote above states, is "getting in bed" with the largest reference lab in the U.S. Such a relationship may potentially give Quest Diagnostics some edge regarding the reference lab business of the medical practice in question. Also and as discussed above, it's "possible to get Web-based, easy to adopt or drop EMRs for only a couple hundred dollars a month more." I am sure that the author had in mind systems like Practice Fusion, although I can't speak with authority about its relative functionality (see: Practice Fusion CEO Calls His Company the Largest EMR Provider).

Besides, it’s possible to get Web-based, easy to adopt or drop EMRs for only a couple hundred dollars a month more.

Highest Rate for Testicular Cancer and Mortality in Chile

Here's an interesting observation. Chile ranks first in the world for deaths from testicular cancer, according to the World Health Organization (WHO) and Chile’s Ministry of Health (see: Highest death rates for testicular cancer found in Chile). Read on, if you are interested, in the following excerpt from the article:

In 2009, 121 Chilean men died from the disease and 63 of those were 15 to 30 years old, the age group most at risk from the disease. In the U.K., however, where the population is three and a half times the size of Chile, there were only 70 deaths from testicular cancer in 2008, according to the Cancer Research U.K.’s figures. “Testicular cancer figures are low in Chile in relation to the other types of cancers found here, but yes, the figures are high in comparison with the rest of the world,” [said a cancer specialist ].....Testicular cancer has a 95 percent cure rate if caught and treated in time. Such treatments have been available in Chile for over two decades. Cancer experts in Chile recognize that the country has an unusually high rate of testicular cancer, but no one is sure why. “Less than 5 percent of cases can be explained by exclusively genetic or hereditary causes,” [according to a Chilean urologist] “Neighboring countries with the same ‘culture’ have much lower reported mortality rates from the disease than in Chile,” [according to a cancer expert]. [Another cancer expert offered]...a different theory altogether. “This is only a theory and I have no evidence to support this but there’s a lot of natural contamination of water in Chile, by various metals especially arsenic, and perhaps this could have something to do with the high numbers of cases,” he said. “Really, though, no one knows for sure.”

Heavy metal exposure as a possible etiology seems to be a stretch for me. It occurred to me, however, that an infectious etiology might be possible. There was not much current work on this idea but I did find one abstract that draws an epidemiological parallel between testicular cancer and Hodgkin's disease among young males (see: (see: Viral etiology of testicular tumors). Here is an excerpt from the abstract from this older article:

Testicular carcinoma and Hodgkin's disease are among the most frequent malignancies afflicting young men in the 15 to 39-year age group. These malignancies share other epidemiological characteristics as well, including multiple histological tumor types, higher rates of occurrence in white, urbanized populations and upper social classes, relative infrequency among black populations, low but definite familial occurrence and an early geographically acquired lifetime risk irrespective of later migration. Both diseases are increasing in this country. This epidemiological similarity suggests exposure to an infectious agent early in life. The Epstein-Barr virus is known to be oncogenic and neonatal exposure with early infection is believed to be associated with Burkitt's lymphoma in African children. High titers of antibodies to the Epstein-Barr virus capsid antigen also have been reported in a series of studies comparing patients with Hodgkin's disease and controls. Because testicular cancer is epidemiologically similar to Hodgkin's disease and, therefore, might be expected to manifest similar Epstein-Barr virus findings, we performed a viral screen (Epstein-Barr virus, cytomegalovirus, and hepatitis A and B viruses) on blood samples from 56 consecutive patients with clinical stage I germ cell tumors of the testis who had received no active therapy after orchiectomy. Our results show a high incidence (80 per cent) of previous exposure to Epstein-Barr virus and support the hypothesis of a possible infectious origin for testicular carcinoma.

The problem with this theory is that it doesn't explain the lower incidence for testicular cancer in culturally similar neighboring countries where the males would presumably be exposed to similar viruses. I suppose there is also the possibility of some sort of anomaly of cancer data collection or diagnosis in Chile.

Hospital Website Smackdown: Mayo Clinic versus Cleveland Clinic

I knew that this time would ultimately arrive but we appear to be there now. Two prestigious hospitals are being compared on the basis of the quality of their web sites. A recent article posits a web site smackdown between Mayo Clinic and Cleveland Clinic (see: Website Smackdown: Mayo Clinic vs. Cleveland Clinic). Following is an excerpt of the article:

 In this week's Website Smackdown, I’m taking a look at the websites for two of the biggest hospital complexes in the world, the Mayo Clinic and the Cleveland Clinic....The Mayo Clinic and Cleveland Clinic rank neck and neck (third and fourth respectively) on US News & World Report’s Honor Roll of Best Hospitals, but there’s a huge difference in the quality of their websites.

(1) Most people coming to the website for a major hospital have health-related questions, require immediate need for a doctor, or need information about visiting (directions, visiting hours, etc.). Just as hospitals are in the business of patient care, their websites should reflect that same level of care for site visitors....(2) Now take a look how each site handles the critical area of “Health Information.”....(3) Finally, let’s look at one more service provided by both websites: Find a Doctor....

So what can you learn from these hospital websites?

• Know your target audience and know why they are coming to your site.
• Prioritize your navigation to serve the biggest needs of your visitors.
• Make sure you have powerful calls to action and prominent contact information.
• Emphasize customer service!    

In order not to keep you in suspense if you have not read the original article, the Cleveland Clinic has won this particular competition in the three stated categories. The author of the note supports his conclusion with screen-cap images of the web pages for the two hospitals. The secret of the quality of the Cleveland Clinic web site does not involve any magic and is based on the bulleted points listed at the end of the excerpt above: (1) understand the mind of the patient; (2) prioritize web site navigation;  and (3) emphasize contact information and customer service.

Hmmm. Trying to understand the mind of the patient browsing a hospital web site. Sounds simple enough, doesn't it? However, I suspect that this might be a difficult task for some hospital executives and healthcare professionals such as nurses and doctors. The reason for this: many of us are so immersed in our professional disciplines and the complexities of healthcare delivery that it's hard to think as patients do.

Let me give you one practical example of this. Many years ago, I discovered that a prestigious hospital had located its neurology clinic next to its neurosurgery clinic and its cardiology clinic next to its cardiac surgery clinic. Wait a minute! That makes no sense. The specialties of cardiology and neurology are part of internal medicine -- they belong on the internal medicine floor of the clinic building, don't they. This clinic design approach makes sense to patients who tend to think more about organ systems and not the way that medical disciplines have evolved and are organized.