Lab Soft News

eClinicalWorks Creates Healow; Integrates Multiple EHRs with Mobile App

eClinicalWorks has always been one of the most popular office EHRs (see, for example: More on eClinicalWorks: A Successful PMS for Office Practices; President of eClinicalWorks Discusses PHRs and Patient Portals). I consider the company to well managed, innovative, providing a product valued by its office-based physician customers. Their EHR seems to be reasonably priced and designed to meet its customer' needs. Interestingly, the company now comes to market with a product to integrate electronic records from multiple EHR vendors (see: Healow integrates patient medical records from multiple EHR systems), Here is an excerpt from a blog note about this news:

eClinicalWorks has created a new business called Healow (Health and Online Wellness).The $25 million investment is aimed to better connect patients, doctors, and medical data. They started with the Healow mobile app. The app is built on the back of eClinicalWorks’s Join the Network. This is a secure system that allows the transfer of medical data to and from EHR systems designed by eClinicalWorks as well as their competitors. Healow uses this ability to allow patients access to their medical records as well as to manage their own healthcare. The app allows the patient to integrate the data from all of their healthcare providers. With this kind of access, the patient can get a full view of their medical history in one place. In addition, the data can be used to help you manage your medication and appointments by setting up reminders. It allows you to enter notes into the app about things the patient would like to discuss with their physician, and it even allows for a secure way to send messages to the physician. If their physician uses eClinicalWorks’s EHR, the physician can use the app to push data updates into the system as well. This app is another example of how mobile technology can be used to integrate all the aspects of a patient’s care, improve the doctor-patient relationship, and keep the patient informed about their own healthcare.

EHR interoperability is absolutely critical. The current dominant hospital EHR vendor for large hospitals, Epic, seems to be more interested in promoting interoperabiity among it own hospital clients than across 'foreign" systems (see: Judith Faulkner, EMR Interoperability, and Washington IT Politics; A Reader Comments on Epic Interoperability and Care Everywhere; More on Epic's (Non)-Interoperability and the Recent NYT Puff Piece; Surescripts May Capture the Health Information Network (HIN) Business). The initiative by eClinical Works makes a lot of business sense to me. The physician office EHR business may be drying up in the long-run. More and more physicians are taking salaried positions with hospitals. They will then be forced to accept the EHR product chosen by the hospital executives rather than one fine-tuned for ambulatory care settings. EHR integration, particularly with a mobile app, may be a sweet spot where the company can thrive.

Cancer Business Highly Remunerative for Sloan-Kettering Executives

I have posted a number of previous notes about the so-called oncology or chemotherapy concession that refers to the markups on the chemotherapeutic agents administered by oncologists to their patients (see: Academic Oncology and the "Chemotherapy Concession"; The Oncology Concession Under Attack by Health Insurance Companies). When the oncologists are salaried hospital employees, much of these profits are retained by the cancer hospitals that employ them. A recent article took a close look at Memorial Sloan-Kettering Cancer Hospital in New York and the salaries of their executive officers (see: The Profit Of Prestigious Cancer Care). Here is an excerpt from the article:

In 2011, the hospital and research institution of Sloan-Kettering had an operating profit of $406 million even after everything it spent on research and the education of a small army of young cancer doctors. The cash flow comes from more than just drug markups. It also comes from the high pricing enabled by a great brand and an enterprise that has learned how to expand the reach of its brand. One of Sloan-Kettering’s major revenue sources is the outpatient clinics it has been opening around New York City in recent years so that patients don’t have to travel to the busy Upper East Side of Manhattan ....There is a cancer-screening and treatment outpost...in Harlem and a chemotherapy clinic in Brooklyn, and clinical-care facilities can also be found in five of the New York City metropolitan area’s wealthier suburbs....Building on the deserved allure of the Sloan-Kettering brand, these outposts eat into the profits of area hospitals, which would otherwise be providing the same high-margin outpatient cancer care either on the basis of what their own doctors prescribed or according to instructions from Sloan-Kettering’s specialists.... Sloan-Kettering’s foray beyond the Upper East Side of Manhattan also represents a rare outbreak of competition in the current hospital marketplace.Sloan-Kettering may be fishing for business in these wealthy suburbs, but it does have a financial-aid process that is both proactive and well publicized to patients seeking care....That kind of brand strength produces not only lavish cash flow but also lavish incomes for the nondoctors who work to generate it. Six Sloan-Kettering administrators made salaries of over $1 million in 2010, the most recent year for which the hospital filed its nonprofit tax return.... Including those six, 14 made over $500,000. Compared with their peers at equally venerable nonprofits, these executives are comfortably ensconced in a medical ecosystem that’s in a world of its own. For example, Sloan-Kettering listed two development-office executives, or fundraisers, as making $1,483,000 and $844,000.

As this article points out, Sloan-Kettering is taking advantage of its brand by expanding its cancer care services in the New York area and grabbing these high-profit patients from other health systems. The New York hospital market is highly competitive so this may just be the nature of the business in the area (see: NYU Longone Tries to Claw Back Market Share after the Sandy Debacle). 

I am sure that there will be various opinions among the readers of this blog as to whether fourteen of the Sloan-Kettering executives should be compensated with salaries of more than a half-million dollars each. We have arrived at a point where many U.S. hospital executives are among some of the highest wage earners in the country. This may be justified on the basis of the responsibility that they bear. What galls me, though, is the non-profit status of many of these institutions. I posted a note five years ago about non-profit hospitals drifting from their mission (see: Non-Profit Hospitals Drift from Their Mission Despite Subsidies). Apparently institutions like Sloan-Kettering are still able to convince the IRS that they qualify as a non-profit despite the very high salaries of their executive officers and the aggressive way in which they market themselves.

Google Strikes Deal with French Government Regarding Online Content

I have posted previous notes about the question of whether Google is a search engine and news consolidator or a publisher of content (see: When Does Sophisticated Web Search Result in the Creation of New Content?; Google as an Enabler and Protector of Global Information Exchange; Is Google a Publisher or a Search Engine? Can Google Have It Both Ways?; Google's Deal with Publishers; Broad Current Acceptance of E-Books). According to a recent article, this question has been sorted out, for the time being, in France (see: French Publishers Forge Deal With Google, Breaking Ranks With Europe). Below is an excerpt from the article:

Publishers in France say they have struck an innovative agreement with Google on the use of their content online. Their counterparts elsewhere in Europe, however, say the French gave in too easily to the Internet giant.The deal was signed this month by President François Hollande of France and Eric E. Schmidt, the executive chairman of Google, who called it a breakthrough in the tense relationship between publishers and Google, and as a possible model for other countries to follow. Under the deal, Google agreed to set up a fund, worth 60 million euroes, or $80 million, over three years, to help publishers develop their digital units. The two sides also pledged to deepen business ties, using Google’s online tools, in an effort to generate more online revenue for the publishers, who have struggled to counteract dwindling print revenue. But the French group, representing newspaper and magazine publishers with an online presence, as well as a variety of other news-oriented Web sites, yielded on its most important demand: that Google and other search engines and “aggregators” of news should start paying for links to their content. Google, which insists that its links provide a service to publishers by directing traffic to their sites, had fiercely resisted any change in the principle of free linking. The agreement dismayed members of the European Publishers Council, a lobbying group in Brussels, which has been pushing for a fundamental change in the relationship between publishers and Google. The group criticized the French publishers for breaking ranks and striking a separate business agreement that has no statutory standing. The deal “does not address the continuing problem of unauthorized reuse and monetization of content, and so does not provide the online press with the financial certainty or mechanisms for legal redress which it needs to build sustainable business models and ensure its continued investment in high-quality content,” Angela Mills Wade, executive director of the publishers council, said in a statement. German publishers were also scornful, with Anja Pasquay, a spokeswoman for the German Newspaper Publishers’ Association, saying: “Obviously the French position isn’t one that we would favor. This is not the solution for Germany.”

A few comments about this article. First of all, $80 million dollars over three years to keep the French publishers relatively satisfied strikes me as very good news for Google. The amount is trivial for Google and serves to drive a wedge into the European publishing industry on the basis of the French accommodation. I am not surprised that the European Publishers Council and the Germans expressed regret about the deal. So much for European unity. Every country will be trying to strike the best perceived deal for itself.

Secondly, how likely do any of you readers think that Google will be able to help the French publishers in any substantive way to "develop their digital units." I suspect that much of the European book and newspaper industry is either not knowledgeable about the web or resistant to learning any new tricks from the "Silicon Valley" types. Google is buying a temporary hiatus from the French until digital publishing is even more entrenched. Most content publishing will soon be digital. The European newspaper, magazine, and book publishers need to understand this reality and come to view Google as an ally, not an enemy, in the process of monetizing their content going forward. They are swimming upstream.

Not Much Progress in the Development of Physician Practice Web Sites

I have always thought that the development of practice web sites by physicians would be a wonderful way to reach out to patients and provide medical information as well as services such as the ability to book office appointments. In retrospect, such sites have not been evolved in the same way as other business segments (see: Physicians’ websites are more “electronic brochures” than online health resources). Here is an excerpt from the article:

A new survey finds that doctors’ websites are woefully lacking when it comes to serving patients. No surprises there – after all, the most commonly used technology in a doctor’s office is still the fax machine. Here are the details of [a recent] survey [of] ...300 doctors with the highest patient satisfaction ratings in Boston, Denver and Portland. The specialists analyzed were OB/GYNs, urologists and orthopedic surgeons. 69 percent of these physicians have websites but only 33 percent of them have anything more than biographical and practice information on it. Only 99 in fact have information centered around patients such as medical conditions and treatment options. It gets worse with only 4 percent – 12 doctors – made at least one blog posting in the past 12 months on their websites to inform patients on trends and research.“Doctors in these cities are still using their websites primarily as electronic brochures about their practices rather than as online health resources,” said ,,,[a member of the survey group]. The results are all the more revealing given a recent Pew Internet survey that shows that patients continue to search for health information online. So doctors are missing a real opportunity to bridge the chasm they currently have with with patients by keeping website information limited to their bios.“In 14 years of helping doctors find new patients, our foremost conclusion is that patients look for health care information first and health care providers second,” [a spokesperson] said in the statement. “Any doctor offering online health education engenders public trust, attracts a better informed patient and grows his practice.” 

Unfortunately, this story confirms some of my perceptions about physician practices. Please note that my comments should not be construed to suggest that physicians in private practice are professionally inadequate. Rather, I think that they often lack an understanding and appreciation of information technology and marketing. Although they are running businesses for which a web site would be an important asset, physicians often do not perceive themselves in this way nor do they allocate resources for IT and marketing. I am sure that there must be local web designers to whom physicians could outsource the development and maintenance of web sites. However, if the physicians running such practices do not appreciate the value of this way to communicate with their patients, such resources would not develop. 

Medicare Costs Rise as Knee Replacements Increase for Seniors

A portion of the financial challenge facing Medicare is the soaring cost of healthcare delivery in general. Another specific factor is the increasing cost of care for older patients who are covered by the program. One good example of this is knee arthroplasty for seniors on Medicare. This idea was detailed in a recent article (see: Medicare knee replacements surge 162% since 1991). Below is an excerpt from it:

The popularity of total knee arthroplasty surgeries among Medicare patients has grown considerably as beneficiaries are living longer and seeking to increase their mobility, but the shift has led to fiscal concerns for the entitlement program....Overall volume growth has been driven both by the increased number of Medicare enrollees and by increased per capita utilization....The number of total knee replacements increased 161.5% between 1991 and 2010, when 243,802 such surgeries were performed. Per capita utilization nearly doubled during that period, to 62.1 procedures per 10,000 Medicare beneficiaries from 31.2 surgeries per 10,000 enrollees....For patients, knee replacements are relatively safe and have low rates for complications, mortalities and length of hospital stays. However, 30-day readmissions rates have risen to 5% in 2010 from 4.1% in 1991. Shorter hospital stays are causing the increase, a change that should have been expected by health policymakers....The volume of revision knee replacement surgeries has increased to 19,871 in 2010 from 9,650 in 1991....There were 243,802 knee replacement surgeries in 2010, a jump of 161.5% from 1991. More and more patients taking advantage of the surgeries will lead to higher Medicare program costs. The procedure itself costs about $15,000 to $30,000...The bundled Medicare payment for the procedure is spent on the device implants, facility fees, therapy providers and the surgeons. The surgeon probably will receive about $1,500 of the total....New Medicare payment models, such as the bundled payments used for knee replacements, aim to achieve lower costs while maintaining high quality to prevent patients from being readmitted.

The trend toward more knee and hip replacements among Medicare enrolees seems to be inexorable. This trend will accelerate as obese Americans grow older. If you were a Medicare administrator, how would you respond to this challenge? One approach would be to put pressure on hospitals to decrease the cost of the surgery. This can be accomplished, in part, by encouraging competition among the providers. Hospitals such as the Brigham and Women's Hospital in Boston are standardizing the process by which total knee replacements are performed. Here is a quote from a previous note about this (see: BIG MED):

A few years ago, [an orthopedic surgeon] gathered a group of people from every specialty involved—surgery, anesthesia, nursing, physical therapy—to formulate a single default way of doing knee replacements. They examined every detail, arguing their way through their past experiences and whatever evidence they could find. Essentially, they did what [was] considered the obvious thing to do: they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit. They came up with a plan for anesthesia based on research studies—including giving certain pain medications before the patient entered the operating room and using spinal anesthesia plus an injection of local anesthetic to block the main nerve to the knee. They settled on a postoperative regimen, too....Knee surgeons are as particular about their implants as professional tennis players are about their racquets. But the hardware is easily the biggest cost of the operation—the average retail price is around eight thousand dollars, and some cost twice that, with no solid evidence of real differences in results....These have been hard changes for many people to accept. [He] has tried to figure out how to persuade clinicians to follow the standardized plan....To change or add an implant, a surgeon had to show that the performance was superior or the price at least as low.

Standardization of knee and hip replacements by large hospitals will be one path to reduce the cost of these procedures. I think that more and more patients will be directed to large referral centers by their insurance companies. As noted in the quote above, the cost of knee and hip implants are a major component of the cost of the procedures. The growing volume of joint replacements in these large referral centers will enable them to seek greater volume discounts from the prosthesis manufacturers.

More Data on Physicians Leaving Private Practice; Discussion of Findings

The idea of many physicians leaving private practice for salaried, hospital jobs seems to be well established (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; The Increasing Tempo of Physician Practice Purchases by Hospitals; Some Independent Physician Practices on the Brink of Financial Failure). I have been on the hunt for articles that provide more details about the factors that contribute to this trend. Below is excerpt from an article that sheds more light on the topic (see: Due to Rising Costs and Health IT Mandates, More Doctors Leaving Private Practice):

By 2013, only 36 percent of doctors are projected to remain independent while subscription-based services for patients continue to increase. An increasing number of U.S. doctors are expected to leave private practice for hospital employment over the next 18 months, due to rising costs and technology mandates, according to a new report from Accenture. By the end of 2013, Accenture also estimates that one-in-three doctors remaining independent will offer patients with subscription-based services, such as telemedicine or online consultations, for sustaining profit – a trend that is expected to increase three-fold over the next three years. Over the past decade, the number of independent U.S. physicians has dropped dramatically, from 57 percent in 2000 to 39 percent in 2012. By the end of 2013, Accenture predicts this number will likely drop further, to 36 percent, and is 3.6 percent lower than Accenture’s 2011 report. The Accenture findings resulted from extensive market analysis on U.S. physician employment and a survey of 204 physicians in independent practice that was conducted in May 2012. Among the other key findings of the survey:

• The majority (87 percent) of physicians surveyed cited the cost and expense of running a business as a chief concern.
• Most doctors (65 percent) joining health systems said they expect to make the same or less compensation than in private practice.
• Sixty-one percent cited business operations as a main reason for seeking hospital employment rather than remaining independent.
• More than half of doctors (53 percent) cited electronic medical record requirements as a main reason for leaving private practice.

A couple of points in this article jumped out at me. The first was that the approximately one-third of physicians remaining independent will offer what is described as "subscription-based" services such as telemedicine or online consultations to sustain profit. So, on the one hand, we see physicians using information technology (IT) to assist them in delivering patient services more efficiently. This reminds me of a radiologist who said that the use of RIS/PACS technology, combined with digital imaging, enabled him to maintain his income. This was despite significant drops in the professional component reimbursement he was receiving for each case. In other words, IT was helping him to increase his efficiency. 

Contrast this with the statement in the article above that more than half of physicians "cited electronic medical record requirements as a main reason for leaving private practice." In other words, IT in the form of the EHR, was driving physicians out of private practice. This may be partly due to the expense of deploying office EHRs or that the use of this technology was hindering their efficiency and productivity (see: "Usability Failures" of EMRs Frustrate Physician Users; When Doctor's Say "No" to EMR Deployments). I am not sure how to interpret this latter finding because the salaried physician working in a hospital environment will surely be required to work with an EHR. However, this may be less of a source of frustration because the hospital-based, salaried physicians may be less concerned about their personal productivity. This does become the concern of the hospital executive officers, however. They may attempt to use features of the EHR to increase hospital reimbursement but such a strategy may be short-lived (see: Distrust of "Templated" Physician Notes in EHRs; Implications for the Future).

NYU Longone Tries to Claw Back Market Share after the Sandy Debacle

Market share is a concept that all hospital executives understand very well. The long-term consequences of Sandy on some of the prestigious New York hospitals like NYU Longone are now becoming painfully clear (see: NYU Langone has reopened, but can it regain market share?). Here's an excerpt from a recent article about this topic:

As of mid-January, most of NYU is up and running again, including the labor and delivery unit.  But the question still looms whether NYU [Longone] will lose some of the patients and even doctors who sought refuge at NYU’s biggest competitors after the storm. If that happens, the storm could end up having a long term impact on NYU's valuable share of the fiercely competitive health care market in New York City. Most of the 500 NYU doctors who left for other hospitals have since returned....But more than a dozen have applied for permanent privileges at competitors Mount Sinai Hospital and Beth Israel, according to those hospitals, and there are probably more at other institutions. It’s not clear how many of those doctors would also keep their privileges at NYU. [An NYU executive] says he's not concerned about the shift, and he isn't surprised by claims that other hospitals tried to recruit some of the NYU doctors working there after the storm.... NYU's loss was in some ways its competitors' gain. Hospitals like Lenox Hill, Mount Sinai and Beth Israel all saw spikes in their monthly birth rates during November and December, when NYU was closed. NYU doctors were still able to bill insurers directly for their services, and some competitors - including Beth Israel - helped offset the salaries of doctors employed by NYU. But "doctor bills make up about 10-12 percent of the fee" for a test or procedure done at a hospital...."The rest of it went to those other hospitals....[The] president of Beth Israel, says while they did not make any efforts to poach NYU doctors,  Beth Israel did benefit from new doctors and patients being exposed to the hospital. He predicts that Beth Israel "will have a higher occupancy rate going forward. I think some patients and physicians will see the opportunity here and have enjoyed their experience and may seek new relationships. ....[A] total of five New York institutions closed for at least some time after the storm. But they managed. The important question now isn’t whether hospitals return to pre-Sandy conditions, but whether they should...."When two very large hospitals -- Bellevue with 900 beds and NYU which also has close to 900 beds -- were suddenly taken out of service, we did have some backlogs and wait times at other places, but the system was able to absorb most of that capacity [according to an expert on New York bed capacity]." 

My guess is that NYU Longone will claw back most of the patients it lost to other institutions and many of its physicians will return. However, Sandy, as an "experiment of nature," seems to have shown that New York is overbedded. The consequences on patient care of losing about 1800 beds for a protracted period of time was not as serous as one would have predicted. In other words, the hospitals that remained in business were able to pick up the slack. I am sure that more information will be forthcoming about how other hospitals accommodated to the loss of the Bellevue and NYU beds. Of course, Belelvue is a special case. Here are some details about it that you may not know:

Bellevue Hospital is the oldest continuously operating hospital in America. We trace our roots back to 1736 when a six-bed infirmary opened on the second floor of the New York City Almshouse. This was four years before the birth of George Washington and forty years before the signing of the Declaration of Independence.Since its humble beginnings as a haven for the indigent, Bellevue has become a major academic medical institution of international renown. Over the centuries, we served as an incubator for major innovations in public health, medical science and medical education. Often referred to as a national treasure, Bellevue defines the very best traditions of public medicine as a public service vital to the well being of our civil society.

Distrust of "Templated" Physician Notes in EHRs; Implications for the Future

Here's a note from Mr. HIStalk in which he quotes from a comment submitted by Hospitalist DZA MD about a Time Capsule article that Mr. HIStalk had previously posted (see: Monday Morning Update 2/4/13):

Hospitalist DZA MD left an insightful comment on my [May 2008] Time Capsule article about doctors getting lost in the barrage of generally useless information cluttering up EMRs:

Anything that is templated has exactly zero clinical information value to me. I don’t care if Osler himself dropped in “dyspnea improved,” “no diarrhea” … If I want to know the validity of that kind of thing, I will look at the narrative part of the nursing note …The only data I look at that actually represents signal is the vital signs and lab data. The rest of the discrete data is noise …The narrative and visual graphics (including graphic displays of lab and vital signs data) are for us (clinicians). The templated stuff is for the suits and insurance grifters. QED.

Dr. DZA obviously does not trust "templated data" entered into the EHR by physicians. We will take this to mean distrust for computer-generated data relating to a patient that has been created on an automated basis and with a few keystrokes and frequently little forethought. Here's an excerpt from one of my previous notes about such automated data entry (see: Three Ways to Document a Physician/Patient Visit in an EMR):

So when exactly does an automated EMR feature designed to save time and energy when documenting physician care lead to a scam? The answer to this question seems obvious to me. A scam occurs when documentation in an EMR is generated automatically and with little or no forethought by the physician about the status of the patient. What is going through a physician's mind in such a setting is obviously hard to document. However, it often becomes evident ex post facto. For example, a note may indicate that a patient is doing well but lab or imaging studies performed at approximately the same time provide evidence to the contrary.

Here't another note on physician data entry into the EHR (see: EMRs and the Data Entry Paradox; Same Concept Not Applicable in the LIS World). The irony surrounding templated data entry by a physician is that it's having the opposite effect than was intended for EHRs. Computer technology was intended  to emancipate physicians from the drudgery of entering hand-written notes into the paper chart. Instead, it now seems to be casting a shadow on the accuracy and integrity of some of the data being entered. Many complained previously about the legibility of handwritten physician physician notes but there was never any doubt about who wrote them and why.

Physician notes do not exist in a vacuum. There will frequently be other roughly contemporaneous entries into the EHR such as nursing notes, lab tests, and imaging reports. I am sure that inaccurate, templated physician notes will be closely scrutinized by plaintiff's attorneys in medical malpractice suits and used to discredit physician testimony. As a result, hospitals will be forced to place restrictions on the used of template-generated notes.

The Value of a Restrictive Blood Transfusion Strategy for Hospitalized Patients

In a previous note, I quoted a NYT article stating that the Cleveland Clinic was purposefully reducing blood transfusion as a quality initiative, although there are certainly cost-saving implications involved (see: Avoiding Blood Transfusion as a Hospital Quality and Cost-Savings Measure). Here's a quote from that note:

The statement [from the article] ...that patients who "received blood transfusions during surgery had higher complication rates afterward and a lower long-term survival rate" is quite dramatic and could probably be challenged. However, the fact that it even appeared in an article about the Cleveland Clinic's quality/cost containment initiatives, in my mind, is highly significant.

In reaction to that note, Dr. Claire Friedman submitted the following comment:

At [The Hospital of the University of Pennsylvania], the [Medical Intensive Care Unit] (MICU) has adopted aggressive transfusion guidelines to prevent unnecessary transfusions; we now only transfuse for a hemoglobin less than 7.

According to her, the key journal article underlying this decision is the following: A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care. Here is an excerpt from its results and conclusions section:

RESULTS: Overall, 30-day mortality was similar in the two [test] groups....However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill ...and among patients who were less than 55 years of age ... but not among patients with clinically significant cardiac disease....The mortality rate during hospitalization was significantly lower in the restrictive-strategy group ....

CONCLUSIONS: A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.

I draw two major conclusions from this article regarding blood transfusion to hospitalized patients. The first point relates to the transfusion trigger, the factor or constellation of factors that precipitate a decision to transfuse blood. I and co-authors coined this phrase in an article published in 1980 (see: An Analysis of Blood Transfusion of Surgical Patients by Sex: A Quest for the Transfusion Trigger). The hemoglobin level has always been used by clinicians as one of the most important factors in assessing the need for blood transfusion. The hemoglobin level used in this regard seems to have trended downward by two or more grams during the last three decades. The second point in the article is that a "restrictive blood transfusion strategy" now seems to be gaining favor. I interpret this to mean that physicians prefer not to transfuse blood at all unless they are pushed to do so. Possible exceptions to this rule are patients with acute myocardial infarctions and unstable angina for whom oxygen delivery to damaged heart muscle takes precedence.

Pathology Informatics Conference Moved to May 13-16, 2014

The Association of Pathology Informatics (API) has decided to change the date of its signature pathology conference, Pathology Informatics 2014, to May 13-16, 2014. The usual 2013 Fall conference will be skipped over as a consequence of this date change. The 2014 conference will be held at the Wyndham Grand Pittsburgh Downtown. This follows three previous, and successful, Fall conferences in Boston, Pittsburgh, and Chicago in 2010-2012. The rationale behind this decision was based on the following considerations:

• The Fall CME calendar has become extremely crowded with a large number of other pathology conferences and LIS user groups.
• One of the two predecessor conferences to Pathology Informatics 201X, AIMCL/Lab InfoTech Summit, always took place in the Spring and met with considerable success at this time of the year.

For 2013, the API Education Committee is planning numerous pathology informatics offerings including a series of webinars and lectures/panels in collaboration with other pathology societies including ASCP, CAP, AMP, and USCAP. There will thus be no gap in informatics educational offering due to the repositioning of this major conference. The overarching goal for the API is to continue to position Pathology Informatics 2014 as the premier pathology informatics conference of the year.