Lab Soft News

The Real Star Trek Tricorder May Soon Be Available

Life often seems to imitate art. A recent article described how new healthcare technology is beginning to catch up with devices we have seen in science fiction literatures and TV for years (see: 3 Ways Real Health Care Is Catching Up to Sci-Fi Health Care). The device that caught my eye because it was lab-related was the emergence of what is described as a real Star Trek "tricorder." Below is an excerpt from the article:

At CES 2012, wireless chipmaker Qualcomm, in coordination with the X PRIZE Foundation, launched a $10 million competition to produce the first medical tricorder. The competition asked participants to create a handheld device to diagnose a set of 15 diseases and measure health metrics such as blood pressure, respiratory rate, and body temperature. The proposed device is also expected to accumulate and store data wirelessly over the cloud. Silicon Valley company Scanadu is in the clear lead. The company unveiled a prototype of its tricorder device, known as the Scout, in November 2012. The Scout can instantly scan a wide variety of health parameters, including pulse transit time, heart rate and variability, electrical heart activity, and blood oxygenation. It can also help a doctor diagnose a wide variety of diseases ranging from abdominal cramps to shingles. At...CES 2014, Scanadu finally unveiled its final hardware design for the Scout, which runs on the same operating system used by NASA in the Mars Rover.

Unfortunately, a visit to the web site provides not many more details but rather promises that the Scanadu Scout device can be held up to the forehead and will measure temperature, heath rate, oximetry, heart rate, pulse wave transmit time (PWTT), urinalysis, and stress. It's not exactly clear on the web site but it appears that the urinalysis is performed with a kit called Scanaflo that interacts with a smartphone to measure glucose, protein, leukocytes, nitrates, blood, bilirubin, urobilinogen, specific gravity, and pH. The device will also test for pregnancy.

For me, the most interesting aspect of this whole story was disclosed in a press release by the company (see: Scanadu Secures $10.5 Million in Series A Funding From Relay Ventures, Tony Hsieh and Jerry Yang). Here's an excerpt from it:

In July..., Scanadu closed a crowdfunding campaign on Indiegogo that quickly became the most funded campaign in the platform’s history, raising more than $1.6 million. Those who participated in the campaign will be a crucial part of the company’s road to FDA approval by taking part on a voluntary basis in a usability study for the Scanadu Scout in 2014.

Who would be more motivated to participate in a clinical trial of the Scout device than the crowdfunding small investors supporting the company?

Glaxo Stops Paying Doctors for Helping to Promote Their Drugs

We are now relatively far along the path whereby Big Pharma will stop paying doctors under-the-table for endorsing their drug products overtly or covertly in lectures (see: On the Corrosive Influence of Big Pharma on Academic Physicians; Medical Schools Share Some Blame in Scandals Involving Pharma Payments to Faculty; Details Emerge About Ghost-Written Medical Articles for Wyeth). Here's an excerpt from an article with a concise and accurate title: Glaxo will stop paying doctors to endorse its drugs (see: Glaxo Says It Will Stop Paying Doctors to Promote Drugs):

The British drug maker GlaxoSmithKline will no longer pay doctors to promote its products and will stop tying compensation of sales representatives to the number of prescriptions doctors write, ...effectively ending two common industry practices that critics have long assailed as troublesome conflicts of interest. The announcement appears to be a first for a major drug company...and it comes at a particularly sensitive time for Glaxo. It is the subject of a bribery investigation in China, where authorities contend the company funneled illegal payments to doctors and government officials in an effort to lift drug sales.....For decades, pharmaceutical companies have paid doctors to speak on their behalf at conferences and other meetings of medical professionals, on the assumption that the doctors are most likely to value the advice of trusted peers. But the practice has also been criticized by those who question whether it unduly influences the information doctors give each other and can lead them to prescribe drugs inappropriately to patients. All such payments by pharmaceutical companies are to be made public next year under requirements of the Obama administration’s health care law. Under the plan, which Glaxo said would be completed worldwide by 2016, the company will no longer pay health care professionals to speak on its behalf about its products or the diseases they treat “to audiences who can prescribe or influence prescribing,” .... It will also stop providing financial support directly to doctors to attend medical conferences, a practice that is prohibited in the United States through an industry-imposed ethics code but that still occurs in other countries. In China, the authorities have said Glaxo compensated doctors for travel to conferences and lectures that never took place..... A Glaxo spokesman said that each year the company spends “tens of millions” of dollars globally on the practices that it was ending, but declined to be more specific.

All of this previous mischief on the part of the pharmaceutical companies has spawned a cadre of hyper-vigilant, CME bureaucrats in medical schools. Their task is to ferret out commercial influences in medical conference lectures, armed with complex, lengthy application forms to ensure that the faculty lectures don't favor certain companies. Some medical schools have eliminated all corporate sponsorship of such conferences, a major error in my opinion. I think that we now need to reverse this CME surveillance trend with Big Pharma promising to cut off the emoluments to physicians and the Obamacare Sunshine Act putting the weight of the federal government behind this process (see: Attention Pathologists and Clinical Laboratory Professionals: New ‘Sunshine Act’ Requirements Will Track and Publish Financial Relationships Providers Have with Healthcare Vendors).

I would suggest that we start by simplifying this CME surveillance process. Forget all of the incomprehensible CME forms. Each faculty member participating in conferences should merely launch his or her lecture by disclosing any major conflict-of-interest and stating that the lecture is not inappropriately biased. Unfortunately, I think that this is unlikely to happen for the same reason that governments are unlikely to take any spontaneous actions to reduce their size.

Raising Taxes on Tobacco; Need for a Global Public Health Initiative

The current high smoking rate in China has had a major effect on the health of the population. One measure to reduce the smoking rate would be to increase the tax on tobacco but this poses a dilemma for the Chinese officials. The country received enormous revenue from the manufacture and sales of cigarettes (see: China Eyes Smoking Enhanced Smoking Cessation Programs). Increasingly, governmental officials seem willing to accept the beneficial health trade-off for decreased revenue using higher cigarette taxes as the sharp end of the stick. Here's an excerpt from another article that goes into detail about  increased cigarette taxes and smoking reduction (see: St. Mike’s study finds tripling tobacco tax worldwide could cut smokers by a third):

Aggressive taxation is the key to achieving a World Health Organization goal of reducing the global prevalence of smoking by one-third, new research led by a Toronto scientist shows. A study headed by St. Michael’s Hospital’s Centre for Global Health Research, published ...in the New England Journal of Medicine, found that tripling tobacco taxes around the world could reduce the number of smokers by 433.3 million people and prevent 200 million premature deaths from lung cancer and other smoking-related diseases.“We hope this will spur governments to (recognize) it’s a no-brainer. There is more revenue, fewer deaths and all sorts of benefits for the population,” said Dr. Prabhat Jha....He launched the study to determine how the worldwide prevalence of smoking could be chopped by a third by 2025, a goal set at the World Health Organization’s 2013 Assembly. While the proposal to hike tobacco taxes is a global one, it is particularly targeted at 10 regions representing two-thirds of the world’s 1.3 billion smokers. In descending order, they are: China, India, the European Union, Indonesia, the United States, Russia, Japan, Brazil, Bangladesh and Pakistan. Strong lobbying by the tobacco industry has helped keep taxes lower in those countries, Jha explained. Residents of China consume a staggering two trillion cigarettes annually, out of a world total of about six trillion. ....For example, France tripled cigarette prices by raising taxes at least 5 per cent higher than the inflation rate every year between 1990 and 2005. At the same time, the country managed to halve cigarette consumption and double tobacco revenues.

There's not much more that I can say about this topic. We need to increase taxes on cigarettes around the world. This will obviously have a beneficial effect on health, even in those countries without a sophisticated healthcare delivery system. I really like the idea from France to continuously raise cigarette taxes five percent higher than the inflation rate. I am sure that the politicians will enjoy the increased tax revenue from tobacco sales although they know it will be relatively a short-term gain.

Most Orthopedic Surgeons Don't Know the Cost of Hip Implant Devices

How important is it for physicians to know the cost of a drug or a hip prosthesis that he or she is recommending for a patient. I would personally say that this is very important. One of the major weaknesses of our health delivery system, however, is that consumers are not always sufficiently aware of the price of services being delivered to them. This problem is exacerbated by hospital pricing that has no connection to reality (see: Why the Prices Charged by Hospital for Inpatient Care Are Irrelevant).

Having a discussion about the cost of services between patient and physician is critical. In a recent post, I complained that the cost of labs was commonly the only element of healthcare costs used in research to test whether informing physicians about the cost of services via the EHR makes a difference (see: Displaying the Cost of Lab Tests for Physicians in Their EHRs). In this note, I was really complaining about the fact that lab tests are commonly studied in this regard. I would like to see the research more broadly applied. A recent article indicated that the majority of orthopedic surgeons did not know the cost of a hip replacement prosthesis (see: About 80 percent of hip doctors have no idea how much a hip replacement costs). Below is an excerpt from it:

What will a gallon of milk set you back? How about a new car? You probably have a rough idea. But what about a medical device, the kind that gets implanted during a knee or hip replacement? Chances are you have no clue....But orthopedic surgeons don’t know much about how much their work contributes to that spending. They were able to correctly estimate the cost of a device only 21 percent of the time, according to a survey of 503 physicians at seven major academic medical centers published this week in the journal Health Affairs. Their guesses ranged from 1.8 percent of the actual price to 24.6 times the actual price. (Researchers could not release the actual costs because they signed nondisclosure agreements with the hospitals.)....Unlike pretty much every other consumer industry, health care costs are not transparent, even for the surgeons. Each hospital system and purchasing group negotiates deals with device manufacturers and signs a nondisclosure form, promising not to share the details of those prices with anyone else. That’s because “medical device manufacturers strive to keep their prices confidential so that they can sell the same implant at a different price to different health care institutions,” the study authors write. But costs matter: For a total knee replacement, the actual piece of machinery that gets implanted can cost from $1,797 to $12,093, depending on the negotiated price.....But hospitals don’t tend to pressure surgeons to use the cheaper device, says [an orthopedic surgeon] “They don’t want to offend the doctors. They cater to them however they can, which includes not telling them which devices to use,” he explains.

It's in the best interests of both medical device manufacturers and hospital executives to not make available the negotiated price of medical devices such as hip prostheses. Hence, the caption on this note is a little misleading. The orthopedic surgeons don't know these prices because they are often not informed about them by hospital executives. Hospitals also don't want to nag orthopedic surgeons to use less expensive devices because they want to stay in their good graces -- they generate so much revenue for the hospital. The solution is easy. Physicians, particularly surgeons, need to inform patients about the cost of all medical devices and the differences between them regardless of any non-disclosure forms that the hospital has signed with device manufacturers. This is particularly relevant as many patient's health insurance plans are now associated with co-payment features.

Additional Discussion about Integrated Diagnostic Testing

A recent post raised the topic of integrated diagnostic testing, defined as the combined, correlated strategy of ordering sophisticated laboratory tests and imaging studies simultaneously for patients (see: Quest, University of California to Jointly Develop New Diagnostic Tests). Your immediate reaction to this note may have been that this is nothing new. Physicians have been been ordering clinical lab tests and imaging studies in tandem as long as such studies have been available. However, this new approach is different. We are now entering an era in which radically new types of molecular/genomic tests are available. Needless to say, the variety of sophisticated imaging studies offered also continues to grow. We need to begin to approach integrated diagnostic testing in a much more organized and analytic fashion.

This can't be haphazard or driven by seat-of-the-pants logic diagnostic strategy. We need a new set of rigorously tested algorithms that take into account the disease(s) in a patient's differential diagnosis, diagnostic road maps, and consideration of all of the advantages of newly emerging molecular/genomic tests and imaging studies. We need guidance on exactly what tests and imaging studies to order and how to interpret the results as they are obtained. Such guidance can only serve to stimulate more sophisticated use of the diagnostic tools that physicians now have access to.

I would draw a comparison between integrated diagnostic testing and companion diagnostics. In companion diagnostics, a particular test is mandatory in order to treat a patient with a particular drug (see: More Details About Roche's Companion Diagnostics Strategy; A Closer Look at Companion Diagnostics Strategies; Companion Diagnostics Gains Wider Acceptance in FDA Despite Challenges; Siemens will develop companion diagnostics for Pfizer drugs as part of personalized medicine push). Lab tests are used for gate-keeping. The FDA is putting its weight behind the development of companion diagnostics in order to ensure that some patients are not being treated with an expensive but useless drug. The companion diagnostic must be ordered prior to drug treatment in order to identify those patients who are most likely to benefit from the pharmacological action of the drug. 

Para-EHR Clinical Data Not Being Captured and Keeps Getting Bigger

An interesting question to ask regarding the future of EHRs is how much relevant information about patients that is known by clinicians is not captured by current EHRs. A recent article raised this question and assigned a name to this non-captured, amorphous blob of information -- para-EHR (data) (see: Is the EHR really necessary?). Below is an excerpt from the article:

A ...panel discussion at Partners HealthCare's 10th Annual Connected Health Symposium [concluded] that the important information for a patient's care actually exists outside the electronic medical record. With mHealth becoming the norm instead of the exception, the panelists said EHR vendors will have to find a way to modify their products to focus on data that the patient and his or her care team want, or they'll become obsolete."....The session....focused on what Watson termed the "para-EHR," which he defined as all of the phone calls, texts, e-mails and other doctor-doctor and doctor-patient communications that aren't entered into the EHR. They could include everything from Skype chats between doctors to Post-It notes to data residing on mobile devices and sensors. Watson....estimated that 70 percent of his work with patients is conducted in that informal region outside the EHR. His fellow panelists put that number closer to 90 percent. "The systems that we have today are not geared toward clinical efficiency," said Rasu Shrestha, MD, UPMC's vice president of medical information technology, who said EHRs are instead geared toward billing. He called the para-EHR "this other bucket of information" that more closely resembles the doctor-patient encounter. "Whatever it is today, it's going to get bigger," added Kent Gale....The ability to communicate and capture data in real time through mobile devices and wearable sensors, they said, has made the typical EHR obsolete."When the digital age collided with healthcare, which I think was around 2007, healthcare stumbled heavily," Watson said. Shrestha added: 'We focused on where the money was as we moved from analog to digital." 

In a recent note, I suggested that many EHRs are an efficiency drag on hospitals' key employees, nurses and physicians (see: OIG Says Cut-and-Paste in EHRs Can Lead to Medicare Overcharges). My view is that they have not been designed with efficient clinical workflow in mind. This sentiment was echoed by Rasu Shrestha, MD, UPMC's vice president of medical information technology, in the article above. He suggests that the EHRs that we have today are not geared toward clinical efficiency but rather for efficient billing. The panelists quoted above estimated that some 70-90 percent of physician interactions with patients are not being captured by EHRs. I also suspect some of the data that is actually being captured by EHRs these days is redundant or erroneous due to the cut-and-paste capabilities of the systems (see: OIG Says Cut-and-Paste in EHRs Can Lead to Medicare Overcharges). 

An interesting question raised by this discussion is whether the para-EHR data discussed above (e.g., phone calls, texts, emails) is actually capturable by any currently available system. The answer for the future probably lies in some sort of dedicated physician tablet that will be used for all physician-patient interactions with documentation stored in the cloud. Of course, this approach will require a revamping of EHRs plus some discussion of whether storing all clinical data has some real payoff in the quality of care.

Quest, University of California to Jointly Develop New Diagnostic Tests

As federal support for research in medical schools has diminished due to the sequester and a general belt-tightening, medical schools and their associated hospitals have gotten much more creative in their search for funding and the development of new types of collaboration (see: Big Pharma's Evolving Research Collaboration with Medical Schools; Fund Your Own Seed Research Project at the University of Michigan; Cancer Researcher Turns to Crowdfunding to Support His Research). Some of this innovation now seems to be rubbing off on the diagnostics industry (see: Quest Diagnostics, University to Develop Diagnostic Tools). Below is an excerpt from the article on this topic:

Quest Diagnostics....,shaken by falling prices for its laboratory-testing services, has struck a partnership with the University of California, San Francisco to develop new diagnostic tools that Quest hopes can help jump-start its sagging sales. The agreement is the first broad research partnership Quest has struck with an academic institution—a trend increasingly widespread among health-care companies seeking to boost their innovation. Quest and UCSF will work on identifying genetic mutations and other biological markers that can be used to predict patients' responses to different treatment regimens. They aim to package this genetic data with family history information and tests like magnetic-resonance-imaging scans to help physicians guide their treatment decisions, said [a spokesperson] at Quest. The company hopes such integrated tests can command higher prices than Quest's traditional biopsy and blood-testing services do, he said. Research into new diagnostic tools is booming as health-care companies attempt to tailor treatments to each patient's genetic profile or disease type, a practice known as personalized medicine. The market for diagnostic tests and services related to personalized medicine could grow to $6 billion by 2018 from $2.5 billion today....The pact underscores Quest's efforts to develop more sophisticated product offerings to help offset declines in insurers' reimbursement rates for many of the company's core testing services, which include routine cholesterol tests, cancer biopsies and DNA tests. Reimbursement for such tests is falling because of greater competition from hospitals performing the screens in-house, and efforts by insurers to reduce unnecessary testing....One initial Quest-UCSF project is aimed at identifying patients with a genetic subtype of autism who can benefit from behavioral therapy, and another at developing a test that will predict whether certain patients with brain cancer will respond to a particular drug.

This news, in part, reflects the determination of the major commercial reference labs like Quest and LabCorp to add tests to their menus with higher profit margins. Of special interest to me was that this article was the first to mention, in my experience, the term integrated diagnostic testing in a hospital setting. It relates to the blending of laboratory tests with imaging studies as opposed to the traditional "biopsy and blood testing services." This makes sense from the company's perspective, substituting non-interventional imaging for biopsies in which tissue is examined under the microscope. Quest obviously needed a partner for this research like UCSF with an active patient load and a research-oriented faculty interested in sophisticated diagnostic testing. 

I have posted a number of notes in the past about integrated diagnostic centers (IDCs) staffed by pathologists and radiologists (A Call for the Development of Integrated Diagnostic Centers; Can Existing Breast Clinics Evolve into Integrated Diagnostic Centers?; Plan for the Evolution of Integrated Diagnostic Centers Beyond Breast Clinics; More on Integrated Diagnostic Centers; Trend or Lukewarm Idea?). The business model for the creation of such centers would be to rapidly and efficiently work with patients with undiagnosed tumors. The reason why this could be done more efficiently in such centers, as opposed to physician offices, is that all of the diagnosticians and imaging modalities would be present on-site and computer algorithms could be used to create the fastest and most economical path to a diagnosis for the patient. It seems to me that the major difference between the integrated diagnostic testing proposed by Quest with UCSF and the integrated diagnostic testing that I have described is that the former takes place in hospitals and is managed by clinicians rather than in IDCs that are free standing and managed by pathologists and radiologists.

OIG Says Cut-and-Paste in EHRs Can Lead to Medicare Overcharges

We are fast approaching an impasse regarding the deployment of EHRs in hospitals. Hospitals are spending millions, or sometimes billions, of dollars on systems that are hindering the efficiency of their most critical assets, nurses and physicians. Jacob Reider, the Acting National Coordinator for Health Information Technology, recently commented on the "usability" of EHRs: ...[A]s a physician who has used an EHR in my clinical life since 2001, I worry that some of the usability challenges that we early adopters tolerated “for now” (a decade ago) remain unresolved (see: Usability of EHRs remains a priority for ONC). 

So how do physicians and nurses deal with the incessant demands of EHRs to enter mandatory information or perhaps unnecessary steps that in the past they could have avoided? As I discussed in a previous note, EHRs provide three techniques for documenting patient care in the most efficient manner: (1) document by exception (check one box); (2) enter templated data; and (3) bring forward data (i.e., cut-and-paste) (see: Three Ways to Document a Physician/Patient Visit in an EMR). 

There is a general  distrust of box-checking, templated reports are increasingly viewed with suspicion (see: Distrust of "Templated" Physician Notes in EHRs; Implications for the Future), and now a report by the OIG singles out the cut-and-paste option (i.e., cloning) as potentially fraudulent (see: Report Finds More Flaws in Digitizing Patient Files). Below is an excerpt from the relevant article:

Although the federal government is spending more than $22 billion to encourage hospitals and doctors to adopt electronic health records, it has failed to put safeguards in place to prevent the technology from being used for inflating costs and overbilling, according to a new report by a federal oversight agency. The report, released...by the Office of the Inspector General for the Health and Human Services Department, is the second in two months to warn about flaws in the oversight of the ambitious federal program aimed at converting patient records from paper to electronic....The report was especially critical of the lack of guidelines around the widely used copy-and-paste function, also known as cloning, available in many of the largest electronic health record systems. The technique, which allows information to be quickly copied from one document to another, can reduce the time a doctor spends inputting patient data. But it can also be used to indicate more extensive — and expensive — patient exams or treatment than actually occurred. The result, some critics say, is that hospitals and doctors are overcharging Medicare for the care they are providing.

Here's an excerpt from a previous note about the EHR data entry paradox (see: EMRs and the Data Entry Paradox; Same Concept Not Applicable in the LIS World):

The EMR data entry paradox relates to the fact that the physicians entering clinical data are often pressed for time and do not perceive that they derive any major benefits from this documentation. Because of this, the quality of some of the data may be suspect. Moreover, physicians are accustomed to telling a narrative story in the medical record and often balk at entering structured data which is easier to analyze but may hinder the development of such a narrative. Finally..., physicians and nurses may be under pressure from hospital executives to use EMR documentation to maximize reimbursement.

Here's another quote from my note referenced above (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.

To recap, physicians and nurses are being forced into new behaviors that did not exist before EHRs and that are now viewed with suspicion by the OIG. Some of these new behaviors are actually being encouraged by hospital executives to maximize revenue, analogous to the "facility fee" upcharges used by some hospitals (see: Do facility fees pay for better care or upcharge patients?). 

I personally do not have a clue about where the solution lies to this EHR dilemma. I don't believe that Epic and other EHR vendors will extensively modify their EHR products to better accommodate to the workflow needs of physicians and nurses and increase EHR usability. Perhaps, in time, we will breed a generation of physicians who will become more accustomed to the inefficient design of the EHRs. 

Hybrid Operating Room Now State-of-the-Art; Radiology Meets Surgery

I had not previously encountered the term hybrid operating room before I came across a recent article  (see: Gift to University of Michigan supports creation of a new hybrid operating room). Here are some of the details:

A $7.5 million gift to the University of Michigan will advance research and discovery toward curing aortic disease, and support creation of a new hybrid operating room at the U-M Frankel Cardiovascular Center....The latest advancements in cardiovascular treatment include hybrid procedures in which catheter-based interventions, simultaneous imaging and open chest surgeries are performed in the same operating room. The newest hybrid surgical suite, which is double the size of a regular OR, is the third for the U-M and merges the radiological and surgical techniques that make advanced hybrid procedures possible.....Patients, especially the elderly, recover quicker from less invasive procedures....“Technology is changing how we think about and treat health problems,” says cardiac surgeon G. Michael Deeb, M.D.....“For example if we have a patient with a large aneurysm and cardiovascular disease, we would like to treat those problems simultaneously in order to decrease time on the heart-lung machine. In a hybrid operating room we can perform angioplasty and stent the lesion via transcatheter techniques and then proceed with the open surgery.” 

Here's more information about hybrid operating rooms from the Wikipedia (see: Hybrid operating room):

A hybrid operating room is a surgical theatre that is equipped with advanced medical imaging devices such as fixed C-Arms, CT scanners or MRI scanners. These imaging devices enable minimally-invasive surgery, that is less traumatic for the patient. 

Here's a definition for fixed C-arms (see: U.S. Market for Fixed C-arms to Grow More Than 5% Annually Over Next Five Years):

Fixed C-arms are X-ray systems used in complex angiography, cardiology, and neuroradiology procedures....Fixed C-arm systems are used to guide surgeons performing interventional procedures. Modern flat-panel detector systems provide surgeons with superior image quality when performing complex, time-sensitive procedures.

Here's more information from another article about hybrid operating rooms (see: Two in one: Planning a hybrid operating room):

...[H]ybrid ORs are often the preferred surgical suite configuration among surgeons. In fact, of 335 cardiac surgeons surveyed in 2009 by Steris Corp., 75 percent said they would like a hybrid suite in their hospital. Having a hybrid OR is becoming a standard requirement for leading new and renovated hospitals also because they can serve dual functions.....You can use them as a combined cardiovascular and surgical suite or else swing all the specialized imaging equipment aside and use it as a general operating room.

[I]it's a new breed where the orchestration of teams, workflow, protocols, equipment and space present a new set of challenges. Additionally, the melding of the two distinct functions of radiology and surgery into one OR presents a new mix of physical requirements. For example the sterile and highly flexible environment of a surgical suite must accommodate the large footprints, considerable weight and rigorous stability specifications of radiology lab equipment. Connectivity is also an issue impacting the technological infrastructure. Will the surgical team use the OR to consult with medical staff on site or remotely? Will video feeds from hybrid OR procedures be transmitted to teaching or meeting rooms?

As I was writing this note, a couple of ideas occurred to me. First of all, these new types of ORs are obviously incredibly expensive. Refer to the reference above about funding with a gift of $7.5M. This new technology obviously increases the cost of care and creates an even larger separation between smaller hospitals and the well-endowed larger ones. My other thought is that we are about to enter an era when the concept of "open surgery" will be unknown to medical students. Why would one want to make a large incision in the abdomen when you can approach an organ intravascularly or with a keyhole incision?

Displaying the Cost of Lab Tests for Physicians in Their EHRs

When looking for ways to provide incentives for clinicians to reduce costs through their ordering practice, it always seems that lab tests that come to mind. Here's a report about yet another published study that takes this approach (see: EHR cost data for docs? Big money saver). Below is an excerpt from it:

Annually, healthcare expenditures currently stand at a whopping $2.7 trillion, a number that has industry leaders rushing to take new cost-cutting measures. One of those measures involves displaying the costs of laboratory tests in an electronic health record so docs can see a real-time price comparison of what they’re ordering. And, from a financial savings perspective, it’s working. According to a new Atrius Health study Atrius Health study published in the Journal of General Internal Medicine..., docs who regularly viewed lab test cost data in the EHR both decreased their ordering rates for certain tests and saved up to $107 per 1,000 visits per month. Lab test utilization also decreased by up to 5.6 lab orders per 1,000 visits per month. [The co-author of the study] said these findings have big implications. For a smaller physician practice that typically sees 1,000 patients per month, perhaps not as much, but if you’re talking a large physician practice bringing in 20,000 visits per month, that’s $2,140 per month and more than $25,000 each year. ....Physicians in the intervention group received real-time information on laboratory costs for 27 individual tests when they placed their electronic orders, while the control group did not. Significant decreases in ordering rates were observed in five out of 27 of the high and low cost lab tests. When asked why this proportion wasn’t higher, [another author of the study] said overall they observed a decrease in utilization rates for all 27 tests, but not all were statistically significant. ...."This project is really an attempt at trying to help those 51 percent of doctors who don’t think they have enough information, to try to get them more of that information," he said. What's more, he added, there seems to the general feeling that physicians don't think it's appropriate to consider costs in the workplace, that it's not the role of the physician. 

The authors of this study have discovered that showing the cost of lab tests to physicians in office practices at the time of test orders and via the EHR has saved "up to" the sum of $107 per 1,000 visits per month. This savings doesn't seem to me to be that remarkable. Alternatively, let's  consider other ways that displaying real-time information to physicians via EHRs might reduce costs. For example, how about displaying for physicians the savings of avoiding an MRI or CT scan for a patient or converting patient prescriptions from proprietary drugs to generics. My rough guess for the savings involved in these approaches could be $100 per patient visit rather than per 1,000 patient visits.

An interesting question that comes to mind is why studies like this one happen to focus exclusively on lab test ordering rather than other facets of physician ordering practices where much more significant savings could be realized. My guess is that studies such as this one are relatively easy to perform and then publish. Office physicians order a relatively small menu of lab tests for which the cost is easy to obtain. The authors of such a study then seek a reduction of test ordering in the intervention group after the physicians are shown the cost of such tests. It would also be interesting to determine whether such an experimental effect persists beyond the initial observation period to determine whether the effect is long-lasting. Any intervention usually causes changes in behavior simply on the basis of the intervention. If a longer observation period was introduced and the behavior change went away, there would be no paper to publish.