Lab Soft News

Job Prospects Dimming for Residents in Radiology; Defining the Underlying Problems

I closely track job prospects in radiology because of the similarity of the field to pathology. Two years ago, I posted a note about the declining job prospects in radiology (see: Radiology Jobs Trend Downward; Blame Technology and Reimbursement). A recent article provides more evidence about this decline (see: Job Prospects Are Dimming for Radiology Trainees). Below is an excerpt from it:

For years, medical students who chose a residency in radiology were said to be on the ROAD to happiness. The acronym highlighted the specialties — radiology, ophthalmology, anesthesiology and dermatology — said to promise the best lifestyle for doctors, including the most money for the least grueling work....Recent radiology graduates with huge medical school debts are having trouble finding work, let alone the $400,000-and-up dream jobs that beckoned as they signed on for five to seven years of relatively low-paid labor as trainees....At St. Barnabas Hospital in the Bronx, a dozen radiologists in training....are suddenly stranded on an expensive road to nowhere. All received termination notices recently because their hospital is ending their residency program next year as part of a plan to replace its radiologists with a teleradiology company that reads diagnostic images remotely....

Few specialties have been immune to the same factors depressing radiology: deep Medicare cuts, cut-rate competition driven by technology, doubts about the health value of many tests and procedures and new measures to tilt public money to primary care....Starting in the 1980s, the advent of technology like M.R.I.’s and CT scans, combined with a fee-for-service system, created ballooning demand for imaging and drove the compensation of radiologists to unsustainable heights, he said....By 2001, with the supply of radiologists limited by a 1997 Congressional cap on all Medicare-supported residencies, nighttime demand was unmanageable for smaller emergency rooms. So-called nighthawk radiology services began pooling the diagnostic imaging loads of several hospitals and transmitting them electronically to American radiologists stationed overseas or working from home.... Now the nighthawk companies, staffed by recent radiology graduates, are competing for the daytime work, too....

Medicare payments, which, besides their pay, is supposed to cover malpractice insurance and education in the program....But the hospital will not release the money to other programs where the radiology residents could complete their training, [a] hospital spokesman said, because it plans to use the money to expand primary-care residencies. That decision could be seen as a small victory for national policies intended to bolster primary care. But to many St. Barnabas residents, it mainly shows that the system of graduate medical education is broken....”St. Barnabas, a 461-bed community hospital that lost $10 million last year and pays its chief executive nearly $1 million annually, now contracts with a traditional group practice of 18 radiologists to be its radiology department....

In desperation to find a new traineeship... a fourth-year resident, offered to work without pay. He said hospitals told him that it would be unethical to accept free labor, or that training him would still be too costly without additional money for malpractice insurance and benefits. One hospital, McLaren Macomb, in suburban Detroit, instead offered several residents slots in its “unfunded program,” in which most radiology residents essentially pay for their own positions through donations, typically from a spouse or parents: $65,000 a year to cover a $42,000 salary and $2,000 for expenses.

There are so many juicy issues raised in this story and I hardly know where to begin. For this note, I will restrict myself to teasing out only the following major points that I hope to discuss in more detail in later posts.

• Radiology has historically been viewed as a highly desirable field for recent graduates because of good hours and attractive compensation.
• After the boom years fueled by the emergence of new imaging modalities, radiology is now contacting due to cost-cutting by insurance companies and the federal government. 
• Radiologists are also becoming more efficient individually due to the deployment of RISs/PACSs. 
• Many saw their net worth declining in recent years and are also postponing retirement, diminishing the availability of open hospital slots.
• As a cost-saving measure, hospital CEOs are dismissing their local radiology groups and outsourcing both night and day work to outside teleradiology ("nighthawk") groups. 
• With no radiologists on-site to train radiology residents, a group of them have been dismissed by St. Barnabas Hospital in the Bronx.
• Medicare money, earmarked to resident training, is diverted by St. Barnabas executives to primary care specialities, leaving the radiology residents in the hospital adrift.
• Other hospitals are offering "unfunded" radiology training programs where the young physicians are being asked to pay for their post-graduate training. This is on top of their medical school debts and without rosy prospects for subsequent employment as fully trained radiologists.
• The situation in radiology training will self-correct (i.e, new medical school graduates will know to avoid the field) but there are large numbers of them still in the training pipeline.

More Speculation about the Cerner Purchase of Labotix

In yesterday's note, I mused about the Cerner purchase of Labotix (see: Cerner Enters Lab Automation Market with Purchase of Labotix but Why?). The post elicited the following comment:

I have never been a fan of Cerner for a host of reasons. Nevertheless, their acquisition of Labotix is dumb, at best. The lab industry is littered with similar disasters. Within a few years Labotix will quietly slide away as a "diversion" to Cerner's core business. The message is "stick to your knitting" and you won't get burned. Charging into a low margin hardware business will not save a software business. The wonks at Cerner will eventually figure that out.

Here's the last two sentences of my note:

Cerner may have purchased Labotix with its 22 associates and contractors as a blocking strategy to keep any smaller LIS-focused competitors, or even some of the IVDs, from acquiring it and getting an edge in that market. Time will tell.

I am not sure that the purchase of Labotix was dumb. If the purpose was to keep other companies from acquiring it, the move may have been very smart. I agree that the acquisition would seem to have little to do with Cerner's core competencies and business model, It certainly will act as a diversion if any attention is paid to the company. It won't be a diversion if the company is ignored and left to slowly atrophy. 

Cerner Enters Lab Automation Market with Purchase of Labotix but Why?

My impression about Cerner over roughly the past decade has been that the company left the pathology and clinical lab market behind in its pursuit of the larger EHR market. Now comes the news that it has acquired Labotix and seems to be interested in integrating its AP-LIS with this open-source lab automation system (see: Cerner Corporation Enters the Clinical Laboratory Automation Market by Acquiring Labotix Automation). Below is an excerpt from the article about the purchase from the Dark Daily:

Never before has a major LIS vendor boldly acquired a lab equipment manufacturer with an intent to integrate and sell both products as a bundle to medical laboratories. In an unexpected move, healthcare informatics giant Cerner Corporation... purchased a clinical laboratory automation company....Cerner announced that it acquired Labotix Automation Inc., of Peterborough, Ontario. The acquisition gives Cerner an interesting foothold in the clinical laboratory automation market. For many pathologists and medical laboratory managers, the deal raises interesting questions, since Cerner—primarily known among labs for its laboratory information system (LIS) and its anatomic pathology laboratory information system (AP-LIS)—now is the owner of a company that manufactures hardware.....The flagship product for Labotix is what it calls the Rapid Response Universal Specimen Handling (RRUSH) system. One distinguishing feature about this lab automation system is that it is open source. It transports and sorts specimen containers, then delivers them to the appropriate analyzers for processing or storage. Labotix has systems installed at five client clinical laboratories in the United States, Europe, and the Middle East. The company has 22 associates and contractors. Cerner Corporation’s acquisition of Labotix, a manufacturer of automation systems for clinical laboratories, caught many in the medical laboratory testing industry by surprise. It will be the first time a major LIS vendor has acquired a lab hardware manufacturer with the assumed intent to sell a bundle that would feature both its LIS and its newly-acquire laboratory automation equipment....Labotix President and CEO John Gustafson told Dark Daily. “They have a laboratory information system and this acquisition gives them a line of laboratory automation equipment that is very complimentary.“ The open source architecture allows medical laboratory users to connect any lab analyzers or other instruments to the RRUSH system”....Labotix can trace its roots back to the late 1980s. That is when Rodney S. Markin, M.D., Ph.D., was developing early lab automation systems at the University of Nebraska in Omaha. In 1993, Markin founded LAB-InterLink, Inc., based in Omaha. By 2000 the company had merged with Labotix in Ontario.....Two years ago, Labotix acquired Integrated Laboratory Automation Solutions, Inc. (iLAS) of Troy, Michigan, and hired the iLAS employees....iLAS had a total laboratory automation (TLA) system that was designed by pathologists at Detroit Medical Center in Michigan.

My first impression about this news was excitement. My thoughts were that Cerner was in the process of rediscovering its roots and beginning to understand the synergies involved in a tight integration of an AP-LIS with a clinical laboratory automation hardware. This could pave the way for a totally automated "lights-out" laboratory. This goal is increasingly important given the aging of medical technologists (see: Comments on the Medical Technologist Shortage). Then I began to have some different ideas. Why this sudden change of heart for Cerner that is doing so well as an EHR vendor with a 2012 market cap of $12B (see: Cerner)?  

Epic is certainly giving Cerner a run for its money -- it seems to me to be the EHR vendor of choice for large U.S. hospitals (see: Why Does Epic Keep Hammering Cerner? Mr. HIStalk's Opinion; Is Cerner Modifying Its EMR Business Model?; Epic Deemed Unbeatable by HIStalk in the Large Hospital EMR Market). Could this Labotix purchase be a plot on the part of Cerner to halt the momentum of Epic's LIS (see: Allina Health Begins a Phased Rollout of Epic's Beaker LIS; Lessons from the API Strategic Summit: Beaker LIS Is Not "Free"). Nope. That can't be right. Beaker is the LIS choice de jour for some hospital CEOs and CIOs as part of their pursuit an "enterprise wide solution" with Epic. They would assume that a lights-out lab strategy is a form of energy conservation. I think that I now have the answer. Cerner may have purchased Labotix with its 22 associates and contractors as a blocking strategy to keep any smaller LIS-focused competitors, or even some of the IVDs, from acquiring it and getting an edge in that market. Time will tell.

Hybrid Model of On-Site and Remote Radiology for Enhanced Patient Workflow

Because teleradiology is so well established and digital pathology (i.e., telepathology) still in its infancy, we need to look carefully at how teleradiology is evolving to order to plan our own future in pathology. I have always held the opinion that digital pathology will not replace pathologists in smaller hospitals but rather support and supplement their work. Currently, pathologists in smaller hospitals select their most challenging surgical pathology cases and send the glass slides, via expedited delivery, to their favorite consultants for an additional opinion. The time interval for the return of the consultant reports will be variable but will usually will be measured in days.

Under a digital pathology model, the same hospital pathologists will instead send the whole slide image (WSI) file for a case to the consultants and ideally receive the reports back in 24-48 hours. National pathology networks are also now evolving that can provide such services (see: PathCentral Debuts Agnostic Global Pathology Network). This model should result in enhanced quality and little disruption to patient throughput and lab workflow. Below is an excerpt from an article discussing a hybrid teleradiology model that has been adopted in a 370-bed California hospital (see: Partnering for Progress: Imaging and the Rapidly Growing Hospital):

Mercy San Juan Medical Center is a 370-bed acute-care hospital in Carmichael, California, that is part of the not-for-profit Dignity Health System. It has experienced significant growth since it opened its doors in 1967....Most patients are affected by imaging, so timeliness, access, and partnership in care of the patient are critical. As the patient load seen by the facility has increased, so have the service lines offered to those patients, according to [the] COO of the hospital. “The case complexity of the patients we are seeing continues to increase over time,” she says. “In addition to being a level II trauma center, we feature neurosciences as a key service line....When patient volume is a key consideration, nothing is more critical than throughput, and the need to get patients through the hospital quickly and appropriately has made imaging a linchpin of care....Without radiologists partnering with us and aligning toward that effort, we will not survive.” Toward that end, Dignity Health System has taken a hybrid approach to its radiology coverage, using a radiology group that is part of the Dignity Health Medical Foundation for daytime and on-site work, in addition to using subspecialty teleradiologists from Virtual Radiologic (vRad).....“This model allows them to access radiology seamlessly. Even at the busiest of times, vRad can help us load balance so that we meet the turnaround times the referring physicians ...need.”....“We have an extensive specialist group of neurologists, neurosurgeons, and interventional neuroradiologists,”...“We’re quickly becoming the center of choice for ambulance and transfer patients from other hospitals for diagnosis and treatment of any type of neurology-related condition.”Without both subspecialty radiologists working remotely and on-site interventional neuroradiologists, this offering would not be possible....

The reason that I like the model described above so much is that improved patient workflow is the most important rationale for deploying teleradiology support in the hospital rather than cost-savings. Mercy San Juan Medical Center has created a hybrid radiology staffing model comprised of its own radiology group for daytime and on-site work and Virtual Radiologic (vRad) for load-balancing and off-hours work. 

Obviously, the key to deploying such a hybrid model is the allocation of work assignments between the two collaborating radiology groups. However, I suspect that this could be a relatively simple matter using computer algorithms based on the orders for various radiology procedures, the complexity of the cases, the degree of urgency of each case, and the available resources at the time from the two professional pools, local radiology and on-line vRad. Obviously, in some hospital settings, such a hybrid model can be controversial in the sense that it takes work away from the local radiology group. Here's a very detailed look from a legal perspective at Alternative Hospital-Radiology Practice Models that was posted on the American College of Radiology web site. 

Google Launches Renewed Effort in Cloud Computing; Reaction in Hospitals

The future of large-scale, complex computing will undoubtedly involve the cloud. This scenario should include healthcare but the industry will embrace cloud computing late and perhaps never (see later). Cloud computing is an area where Google has lagged in development but is now trying to catch up according to a recent article (see: Google Elbows Into the Cloud), Below is an excerpt from it:

In a battle for dominance in cloud computing, Google is taking on Microsoft and Amazon in their own back. Google said... that it was doubling its office space near Seattle, just miles from the campuses of Amazon and Microsoft, and stepping up the hiring of engineers and others who work on cloud technology. It is part of Google’s dive into a business known as cloud services — renting to other businesses access to its enormous data storage and computing power, accessible by the Internet. In cloud computing, dozens or even thousands of computer servers are joined to create a giant machine capable of handling many tasks at once, from storing data to running Web sites and mobile apps to tackling complicated analytical problems. Individual software developers, large companies and governments rent these services to run their operations often at a fraction of the cost of buying and managing their own machines. Amazon Web Services, or A.W.S., is far and away the leader in this area. Amazon expects that this business will eventually be as big as its retail operation. A.W.S. is followed by Microsoft’s Windows Azure and offerings from other companies including Rackspace, Verizon, I.B.M. and Hewlett-Packard. Google says the cloud business is a new source of profit and a way to improve the Internet by providing other companies access to its sophisticated computing services. Analysts say it is also a strategy to lure developers and businesses to use Google products instead of those of archrivals like Amazon and Microsoft. The cloud business has become so vital to these companies....because it is crucial to other businesses like mobile apps and online video and music. Most of the apps that run on Google Android phones, for instance, are built using Amazon’s cloud, and Google would like to wrest back control....Amazon was the first to rent its data storage and computing power to outside customers when it started A.W.S. in 2004, and Microsoft and Google followed. Another company with huge data centers and computing power, Apple, does not rent its cloud. Amazon earned $800 million from its cloud services last year, according to analyst estimates....But to reach a broader market, Google has followed Amazon’s lead by offering a cloud platform that works with a much broader range of services....Google has the weakest corporate ties. It sells businesses cloud-based word processing, storage, and spreadsheet tools, but its operation is still much smaller than Microsoft’s.

I have always assumed that the reluctance of hospital CIOs to adopt cloud computing has been due to their innate conservatism, often citing security and confidentiality as the rationale. However, I think that there is a new factor in this equation. Most hospitals are now pursuing an IT strategy called the enterprise-wide-solution (EWS). This involves working primarily with a single vendor such as Epic or Cerner and deploying their EHR software plus their ancillary products such as their LIS and RIS. From the vantage point of the hospital CIOs, one of the major advantages of such an approach is that the software is integrated from the start. In other words, there is no burden on the CIO to integrate a series of modules from different vendors. By way of contrast and if multiple best-of-breed software systems are selected, there is an increased burden on the CIO to ensure that they interoperate.

There are only a handful of EWS vendors that offer an EWS. Epic, for example, now exercises what is looking like a near-monoply on EHR software in larger hospitals (see: Does Epic Exercise a Near-Monoply for EMRs in Larger U.S. Hospitals?; The Feasibility of Using the Epic EMR as a "Platform" to Extend Its Functionality; The Cost of Deploying an Epic EMR and the "Oreo Cookie" Analogy). Hospital executives would thus would need to seek the approval of a vendor like Epic or Cerner in order to pursue a cloud strategy. There is no possible advantage for these vendors in bringing a third party cloud computing vendor into their relationship with hospitals. If they were to offer a "remote hosting option," they themselves would provide it (Comments about Cerner's Remote Hospital Option (RHO)). This would allow them to keep their high profit margins and still maintain client control. Put another way, part of the appeal of cloud computing for hospitals would be its flexibility and lower cost. This is currently a sellers' market for EHR vendors with little need to offer any price advantage to the queued-up hospital customers.

In my opinion, long-term strategy and information technology go hand-in-hand. In an information-rich industry like healthcare, you can't change business practices without major shifts in your IT. In the case of healthcare, this means that much of the hospital long-term strategy is being developed and managed in Kansas City and Verona (see: CIOs and Central IT Departments Have Become Increasingly Less Useful; Some Hospitals Can't Get Past the Final Epic Deployment Step: the "Judy Check"). Lower cost, flexible cloud computing provided by third parties like Google and Amazon is simply not in the cards for hospitals.

Intestinal Ova Detected by iPhone Camera in Tanzania

The idea of using an iPhone to run health apps and for various types of physiologic monitoring with plug-in devices has been much in the news (see: Patients as Monitors of Their Own Health; Conflation of Health Monitoring by Mobile Devices with Access to EMR & PHR Data; Healthcare Consumers as Self-Trackers; Process Enabled by New Apps). A recent article raises the possibility of using the iPhone camera for the diagnosis of intestinal worm infections in rural Tanzania (see: Worms detected by converted iPhone microscope). Below is an excerpt from it:

Scientists used an iPhone 4S to diagnose intestinal worm infections in schoolchildren in rural Tanzania. They attached an $8...ball lens to the handset camera lens, and used a cheap [flashlight] and double-sided tape to create an improvised microscope. Pictures were then taken of stool samples placed on lab slides, wrapped in cellophane and taped to the phone. They were studied for the presence of eggs, the main symptom of the parasites. When the results were double-checked with a laboratory light microscope, the device had managed to pick up 70% of the samples with infections present - and 90% of the heavier infections. [The inventor of the technique] told the BBC he had read about smartphone microscopes being trialled in a laboratory and decided to "recreate it in a real world setting". "Ultimately we'd like something like this to be a useful diagnostic test. We want to put it in the hands of someone who might be able to use it," he said."70% (accuracy) isn't really good enough, we want to be above 80% and we're not quite there yet," he added. "The technology is out there. We want to use materials that are affordable and easy to procure." ...."You need the ball lens to help with the magnification - but any mobile phone with a decent camera and a zoom function will be sufficient," he explained. The smallest eggs visible using the smartphone were 40-60 micrometres in diameter....."Intestinal worms are estimated to affect up to two billion people around the world, mainly in poor areas. "These parasitic infections cause malnutrition, stunted growth, and stunted mental development,"...."It's a big deal, a big problem."

So, tape a ball lens over the iPhone camera lens, use double-sided tape to mount a stool sample slide on the phone, and illuminate the field with a flashlight. Check for ova and parasites in the sample. Pretty simple, rather effective, but not yet perfect. I am sure that diagnostic accuracy of the system can be improved easily enough with an improved clip-on lens and some simple holder to mount and stabilize the glass slide to the iPhone. Also, and as the article mentions, any decent mobile phone with a camera and zoom lens will suffice. If you have an inexperienced observer or unusual findings, any images can be sent to a distant expert for further interpretation. 

Patients with a Cancer Should Seek Treatment in Cancer Hospitals

For cancer care, I strongly recommend that patients choose oncologists working in well-known cancer hospitals (see: Some Tips for Selecting a "Good" Doctor and a "Good" Hospital). The reasons for such a choice are the following: (1) these physicians generally have specialized practices with better patient outcomes; (2) they often engage in research and teaching and thus are on the forefront of science and technology; and (3) they are generally salaried so that their livelihoods are not dependent on the selection of higher-priced therapies which may not be optimal for patients.

In multiple previous notes, I have commented on the oncology or chemotherapy concession (see: Academic Oncology and the "Chemotherapy Concession"; The Oncology Concession Under Attack by Health Insurance Companies). Oncologists receive a percentage of the cost of the chemotherapeutic agents they prescribe, providing a financial incentive for them to use more expensive drugs but not necessarily the most the most appropriate or best ones. A recent article in the New York Times discussed how many oncologists are not selecting the optimal treatment for women with ovarian cancer (see: Widespread Flaws Found in Ovarian Cancer Treatment). Here is an excerpt from it:

Most women with ovarian cancer receive inadequate care and miss out on treatments that could add a year or more to their lives....The results highlight what many experts say is a neglected problem: widespread, persistent flaws in the care of women with this disease, which kills 15,000 a year in the United States. About 22,000 new cases are diagnosed annually, most of them discovered at an advanced stage and needing aggressive treatment...[A new] study found that only a little more than a third of patients received the best possible care....Ovarian cancer spreads inside the abdomen, and studies have shown that survival improves if women have surgery called debulking, to remove all visible traces of the disease. Taking out as much cancer as possible gives the drugs a better chance of killing whatever is left....Surgeons who lack expertise in ovarian cancer should refer women to specialists if the women are suspected to have the disease, but often do not....Only 37 percent [of ovarian cancer patients in a recent study] received treatment that adhered to guidelines set by the National Comprehensive Cancer Network....The guidelines for ovarian cancer specify surgical procedures and chemotherapy, depending on the stage of the disease. Surgeons who operated on 10 or more women a year for ovarian cancer, and hospitals that treated 20 or more a year, were more likely to stick to the guidelines, the study found. And their patients lived longer. Among women with advanced disease — the stage at which ovarian cancer is usually first found — 35 percent survived at least five years if their care met the guidelines, compared with 25 percent of those whose care fell short. But most of the women in the study, more than 80 percent, were treated by what the researchers called “low-volume” providers — surgeons with 10 or fewer cases a year, and hospitals with 20 or fewer.....In 2006, [another] study was published that many doctors thought would change the field forever. It compared standard intravenous chemotherapy with a regimen that pumped the drugs directly into the abdomen....Expert guidelines said [intraperitoneal infusion of chemotherapy] should be offered to every patient considered strong enough to endure it.

Although IP therapy (intraperitoneal administration of chemotherapy) has been determined to be greatly beneficial in ovarian cancer patients with spread of the neoplasm in the abdominal cavity, the approach has not been widely adopted by community oncologists. Why not you may ask? Here is the answer according to an academic oncologist; the answer was buried deeply in the article:

Part of the reason [for not using IP therapy] may involve money....With IP chemotherapy, patients also need a lot of intravenous fluids, which means unusually long treatment sessions. Oncologists are paid for treatments, not for time, so for those in private practice, long sessions can eat away at income. You don’t make a lot of money with somebody in the chair getting IV fluids. Chair time is money. I’m being a cynic here, but I think that is part of the issue....Where I live, in the Pacific Northwest, IP chemotherapy is pretty much only being done in the major medical centers, and by very few private-practice oncologists. Many say it’s too difficult, and they don’t even offer it to patients, which I think is unethical.

Most Web Site Internal Search Engines Are Inadequate

I have been frustrated for years by the inadequacy of many web site internal search engines. I will use the search engine of the New York Times as one example of my point. After I have read a story in the print edition of the newspaper, I will then often try to access the same story on-line using the NYT internal search feature in preparation for writing a blog note. For search terms, I may use two or three of the exact words from the newspaper headline and then fail to retrieve the article most of the time. I often then include in the search the last name of the reporter. This usually works for me.

By way of contrast, my Google searchs on almost any topic, even with what may be inadequate search terms, almost always satisfy me. Keep in mind that Google, of course, covers all of the information on the web and the NYT search engine covers only what's printed in the newspaper and perhaps some of their on-line information. 

How can you explain how one of the premiere information-gathering companies in the world, the New York Times, fares so poorly in searches on its own web site? I think that the explanation is that it is engaged primarily in the print information business and began to publish on the web relatively late. Google has always been in the web search business.

Why doesn't the NYT simply use Google as its internal search engine? That's how I provide an internal search of this blog. I think that the answer is that the NYT sees e-information companies like Google and Craigslist as competitors (see: Search Neutrality and Why the Cure May Be Worse Than the Disease; NYT Complains that Innovation Being Snuffed Out by Craig's List). Better to do a job poorly then admit that a competitor does it better. 

For the rest of us who may be interested in retrieving information from the NYT web site, there is an easy solution. Simply use Google whenever you want to perform such a search. As one of your search terms, include the following: site:nyt.com. No frustration and you can easily get the story you are looking for. Here's a link to the Google advanced search page that includes this site option.

Unreported Drug Side Effects Discovered by Analysis of Google Big Data

I posted a note nearly six years ago about how the the FDA had created the Sentinel Network to scan the electronic medical records of military personnel and their families to search for unreported drug adverse events (AEs) and assess drug efficacy (see: DOD Will Share Electronic Medical Records with the FDA). Here's a current link on the FDA web site for those interested in viewing the current "deliverables" from the Sentinel Network contracts (see: FDA's Sentinel Initiative - Deliverables from Completed Contracts). I had a hunch even back then that using EHR data might not be productive because these systems have not been designed for medical research (see: The Major Incentive for Mining and Analyzing "Raw Data" in Hospitals). Now comes news about an effort to search for unreported prescription drug effects using the web search queries (see: Unreported Side Effects of Drugs Are Found Using Internet Search Data). Below is an excerpt from the article:

Using data drawn from queries entered into Google, Microsoft and Yahoo search engines, scientists at Microsoft, Stanford and Columbia University have for the first time been able to detect evidence of unreported prescription drug side effects before they were found by the Food and Drug Administration’s warning system. Using automated software tools to examine queries by six million Internet users taken from Web search logs in 2010, the researchers looked for searches relating to an antidepressant, paroxetine, and a cholesterol lowering drug, pravastatin. They were able to find evidence that the combination of the two drugs caused high blood sugar.The study...is based on data-mining techniques similar to those employed by services like Google Flu Trends, which has been used to give early warning of the prevalence of the sickness to the public. The F.D.A. asks physicians to report side effects through a system known as the Adverse Event Reporting System. But its scope is limited by the fact that data is generated only when a physician notices something and reports it. The new approach is a refinement of work done by the laboratory of Russ B. Altman, the chairman of the Stanford bioengineering department. The group had explored whether it was possible to automate the process of discovering “drug-drug” interactions by using software to hunt through the data found in F.D.A. reports. The group reported in May 2011 that it was able to detect the interaction between paroxetine and pravastatin in this way. Its research determined that the patient’s risk of developing hyperglycemia was increased compared with taking either drug individually....The scientists were able to explore 82 million individual searches for drug, symptom and condition information.The researchers first identified individual searches for the terms paroxetine and pravastatin, as well as searches for both terms, in 2010. They then computed the likelihood that users in each group would also search for hyperglycemia as well as roughly 80 of its symptoms — words or phrases like “high blood sugar” or “blurry vision.” They determined that people who searched for both drugs during the 12-month period were significantly more likely to search for terms related to hyperglycemia than were those who searched for just one of the drugs.

People often turn to Dr. Google to search about symptoms they may be experiencing (see: Paging Dr. Google! We Are Waiting for a Second Opinion). Some of them may be drug side effects. Why turn to the web for such research rather than hospital EHR databases? First of all, many patients may not want to "bother" their physician with a report of a non-specific symptom like blurry vision, perhaps assuming that it might be quickly dismissed. They may thus go unrecorded in the EHRs. Many such patients may also be taking multiple drugs and their physicians may be trying to cram a lot of decision-making into a short office visit. But when patients such as these get home to their computer, they may be willing to put general questions to Dr. Google such as whether "he" knows about any untoward reactions with paroxetine and pravastatin.

If you ask me, many researchers are going to ignore EHRs for drug research and go directly to Google if they can "explore 82 million individual searches for drug, symptom and condition information." This will be particularly relevant as researchers become more proficient in the use of Big Data (see: Big Data: The Hottest New Thing in Computing Attracts Big Money; More Discussion about Big Data; Relevance for Healthcare). The key aspect of such Google research is understanding how to interpret search engine queries. Here's a graph of the search term gonorrhea from Google Trends with volume peaking in October, 2010. A correlation with relevant news headlines is also provided.

CIOs and Central IT Departments Have Become Increasingly Less Useful

Here's an interesting article from outside of healthcare about the lack of utility of IT departments and CIOs (see: IT Departments Have Become Completely Useless), See if you agree with him. The use of the word "useless" in the title certainly overstates the case but most of the points in the article are sound. Below is an excerpt from it:

The role of the CIO, the Chief Information Officer, has been debated about as long as the term in itself exists. Rarely before has there been such a misleading description, because in many companies the person assuming the position of CIO was rarely seen as the chief 'Information' Officer....I teach a course at London Business School for the Senior Executive Program. Top executives from all over the world spend three weeks in London to learn about the latest findings in the exciting fields of Strategy, Finance, Marketing, Innovation and Leadership....The first thing on my teaching menu is to have them do a simple word association on their feelings about 'IT'. The responses tend to be crude: 'boring', 'complex', 'costly', 'always too late', 'annoying' are some of the kinder ones....CIO's have lost the edge. The tension between 'business' and IT has been around forever, but instead of getting better, it has gotten worse in the last couple of years. The reason is that digital has become ’normality’, and almost everyone now feels at ease with digital technology. In other words, the natural knowledge advantage of the IT department has eroded. To put it bluntly, since everyone and their dog started carrying around iPads, the IT department really lost their advantage on the 'frontier of technology'. I think the CIO is greatly to blame for this. In many companies the CIOs never fulfilled their roles as such and rather persisted in performing the more comfortable job of Chief Technology Officer (CTO). The reason being that the most of these people had been running IT before it was even called IT....Many IT departments seem stuck in their role as 'suppliers of technology'. Very few have really stepped up to what the CIO job description is really all about: having a solid impact on how companies are dealing with information....But very few (CIOs) had a solid influence on how companies deal with content, build up knowledge, and how they could innovate with information....That's why the CIO rarely had a real seat at the executive management table....But recently, we've seen the rise of a new breed of CXO: the 'CDO' or Chief Digital Officer....This next gen IT hero is the one who really understands digital as a means of innovating the company. His daring mission is to transform the business model of the company.

I have been pondering for many years why chief information officers (CIOs) in healthcare and other industries don't get much respect (i.e., a seat at the table). The answer was actually right in front of me. As the author of the piece asserts, these executives don't have much to do with the value and utilization of information within the enterprise. They function more as "chief information technology officers" and IT does not have the mystical aura of previous times. In fact, the status of hospital CIOs is getting degraded even further these days. Most hospitals are now spending tens or even hundreds of millions on EHRs and directions about how to best deploy the systems come straight from the vendors (see: Are You an Enterprise or Best-of-Breed CIO? Access to Cash May Make the Difference; Some Hospitals Can't Get Past the Final Epic Deployment Step: the "Judy Check"). 

All of this discussion got me wondering about the source of innovation in hospitals and healthcare. Think about your own company or hospital. Which personnel or executives are the sources of disruptive innovation, to use the Clayton Christensen's term? I hark back to a note I wrote four years ago that quoted him from a NYT article (see: Disruptive Innovation and Reform of Our Healthcare System). Here's a quote from the that article:

Disruptive innovators in health care aim to shape a new system that provides a continuum of care focused on each individual patient’s needs, instead of focusing on crises. [Clayton] Christensen and his co-authors argue that by putting the financial interests of hospitals and doctors at the center, the current system gives routine illnesses with proven therapies the same intensive and costly specialized care that more complicated cases require.

Christensen's fertile mind and attention to innovation and reform in our healthcare system is still at work. You want want to scroll down to his critique of ACOs in a recent note (see: ACOs Won't Work According to Clayton Christensen in the WSJ). He is still emphasizing the fact that we are putting the financial interests of hospitals and physicians center stage and not changing the set of incentives as we strive to reform our healthcare system.