Lab Soft News

The Health Insurance Marketplace: A Case Study of Incompetence

I posted a couple of notes about heatlhcare.gov in its early days (see, for example: Major Conflict of Interest with QSSI, the Contractor for the Health Insurance Exchange). Although CMS is boasting about a relatively large enrollment, things are far from rosy regarding the quality of this system. Here's an excerpt from an article by David Segal, the "haggler" who responds to requests for help directed to the New York Times (see: The Health Insurance Answer That Took 3 Months):

Our letter comes from a couple named Agler who have been trying for months to sign up for health insurance through Healthcare.gov, also known as the Obamacare website....

Q. ...I signed up for health insurance for my wife and myself through the online marketplace last November. But in January, my wife, Mindy, was denied a benefit from the pharmacy and was told she was not listed on the policy....Numerous calls to the Health Insurance Marketplace have ensued in which it has been established that Mindy’s name was, in fact, on the application I submitted and that for some inexplicable reason her name was not communicated to our insurer, Blue Cross and Blue Shield of Florida. We have been told on successive calls that there is no logical explanation for this, and that our complaint will be “elevated” and “expedited.”....

A. The Haggler does enjoy a bit of goading. So, he contacted Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, which oversees Healthcare.gov....It ultimately took a conference call involving the [the complainant], Florida Blue Cross and C.M.S. [to solve the problem]....When asked for a reckoning, Mr. Albright of C.M.S. said that he could not discuss the matter because doing so would compromise the Aglers’ privacy rights. Fine. Mr. Agler promptly wrote an email to C.M.S. waiving those rights. So. One more time. What happened? “Unfortunately, I can’t discuss individual cases,” Mr. Albright wrote in an email....“Why can’t you discuss the Aglers’ case?”“We do not discuss individual cases,” Mr. Albright responded.“....Perhaps Mr. Albright has since stepped back into the Franz Kafka short story from which he came. Or perhaps he’s a real person, and a dedicated public servant, constrained by a policy that forbids employees from explaining the point of a policy. Or maybe the C.M.S. is just badly in need of better public relations. 

I have had a similar experience with healhcare.gov and a state health insurance company. Here are the basic details:

• Working on behalf of a male relative, we applied for a health policy in late January of this year.
• Simply creating an account on healthcare.gov was frustrating. The first attempt failed due to a software glitch and we had to create another one with a different password. This was a portent of rough seas ahead.
• We were then advised on the web site that the state insurance company was "complete" and we would receive a bill shortly.
• In the latter part of February, about a month later, we called the state insurance company. They said that they had never received our application from healthcare.gov so there was no way that they could bill us.
• We called healthcare.gov again and the representative said that our problem would be escalated. We were told that we would be called back in about a week by a member of the escalation team. A week later, we called again and were told the solution would now take at least a month and we should just sit tight.
• We asked for a case number or trouble ticket number for future reference and were told that there was no such thing. We were told that they were making notes in our file. 
• Calling healthcare.gov repeatedly in subsequent days, about half of the representatives told us that our record did not even exist. The other half found the record immediately but said that there was no progress on the case. 
• We next called the state insurance agency. The representatives said that they could do nothing without their own nine-digit customer account number. 
• Without any resolution for a month on the healthcare.gov side, we decided to work the state insurance side harder and asked them for an escalation of the problem. We had not thought about this earlier because we believed that the problem would get resolved on the federal side
• About eight days later, we received a call from the state health insurance company indicating that the policy was now in force retroactive a week to the time when his previous policy had expired. They offered no explanation about the failure for the completed application to be transferred to them.

Looking at these two episodes, I would describe this as an example of major incompetence regarding healthcare insurance on the part of healthcare.gov and at least one state health insurance company. I don't know where the blame lies. Here are my reasons for this conclusion:

• The  lack of adherence to a standard approach for creating a web account and tracking a problem when errors were encountered.
• Once created, the inability to access that account on a regular basis by the customer service representatives.
• Interactions with poorly trained customer representatives and the inability to solve customer problems in a reasonable time.
• Placing responsibility on the customer to track problem resolution without any acceptable response on the part of the responsible parties.
• Worst of all, near-total opacity in terms of explanations by a government agency about the nature of a problem. In short, no willingness to accept responsibility for system failures.

The problems continue for healthcare.gov (see: Software Bug Takes Down Health Care Site). This latter article also references one Aaron Albright, Director, Media Relations Group at Centers for Medicare & Medicaid Services, mentioned above. Mr. Albright continues to be a font of optimistic news about healthcare.gov on Twitter. I also feel somewhat vindicated that I was unable to get any straight answers about my problem given that a representative of the New York Times had a similar experience.

How Much is Too Much for a New Drug like Sovaldi?

How much is too much for a new drug? One way to understand this question is to assess how much of the previous down-stream healthcare costs are avoided by use of the new drug. This reasoning comes into play in the discussion of of the cost of Sovaldi, a breakthrough drug for the treatment of hepatitis C. (see: How Much Should Hepatitis C Treatment Cost?). Below is an excerpt from it:

A new pill to treat hepatitis C raises difficult questions about fair pricing, not only in the United States and other affluent nations but in developing countries around the world. Hepatitis C, which afflicts some 150 million people globally, often without symptoms for years, can cause fatigue and fever, cirrhosis or liver cancer. The pill, known as Sovaldi, or generically as sofosbuvir, costs $84,000 for a standard 12-week course of treatment....The manufacturer, California-based Gilead Sciences, says private insurers are already covering Sovaldi. The question is whether insurers and public programs like Medicare and Medicaid should have to pay so much for this drug, driving up costs for taxpayers and private policyholders.

Gilead says the price is consistent with the cost of previous treatment regimens...and is reasonable given that the drug can have fewer side effects and cures a higher percentage of patients compared with other drugs. In the long run, the company claims, Sovaldi could save money for insurers by preventing patients from getting sicker and needing costly medical care. However, a panel of experts...concluded that the drug offered “low value” for treating most patients, in large part because of its high price. That judgment was based partly on an assessment of clinical and cost-effectiveness prepared by a nonprofit organization ....It said projected savings from reduced medical costs in later years would not come close to offsetting that cost.

The drug will be sold for much less in many other countries. Gilead plans to license three to five Indian drug makers to produce Sovaldi and expects the price to be perhaps $2,000 for six months of treatment through public hospitals and community clinics in India (compared with $168,000 for six months in the United States)....What can or should be done to reduce the cost in the United States? Some experts suggest providing the drug only to patients with advanced liver disease. Others hope that other new drugs in late stages of clinical testing will be approved, adding competition that could help restrain prices. Still others urge that state Medicaid agencies, which cover a big portion of the infected people, negotiate with Gilead for lower prices or find ways to limit the drug’s use when other good options are available.

For me, the answer to the challenge of the staggering cost for most of the newly approved drugs, as stated in the excerpt above, is for state Medicaid agencies to "negotiate with Gilead for lower prices or find ways to limit the drug’s use when other good options are available." The only reason why such a strategy is not used more often is because of the political lobbying clout of Big Pharma. I think the drug companies would probably earn more in the long run from their new drugs if they reduced the prices and increase the sales volume. Currently, they probably figure that most insurance companies and the state and federal governments will pay the asked price and try to pass the cost through to consumers. It's much easier for Gilead, and beneficial for the stock price of the company, to raise the price of new drugs sky-high and see what the market will bear. This will be a disaster in the long run.

What about the cheap prices in developing countries (see excerpt above) and even in Europe and Canada? My guess is that the various EU bodies and commissions will take a tougher stand than comparable bodies in the U.S. with more emphasis on the cost-benefit equation of new drugs than is possible in the U.S. Here's a quote from an article about this issue (see: Gilead’s Sovaldi gains EC approval for chronic hepatitis C):

In Europe, pricing will come under significant scrutiny in terms of cost:benefit by the likes of the UK’s watchdog the National Institute for Health and Care Excellence (NICE) and its German equivalent the IQWiG. 

::Update on 4/09/2014

See: Express Scripts adds fuel to the fire in fight over Gilead Sciences' Sovaldi

Low-Income, Uninsured Patients Often Excluded from Clinical Trials

A recent article highlighted some of the reasons why low-income people without health insurance are being excluded from the potential benefits of clinical trials (see: Living With Cancer: The Cost of Trials). Below is an excerpt from it. written first-hand by a cancer patient:

A recent CT scan made me realize that the clinical trial extending my life effectively excludes all but the most privileged cancer patients...My oncologist and I had agreed to fudge on frequent testing. But the clinical trial did not. When I registered for the CT, a woman wearing a badge that read “financial navigator” handed me the requisite forms to sign. I explained that the CT should be billed to the Phase I trial, since I was undergoing it so the investigators could measure the efficacy of their drug. Unable to reach the trial administrator by phone, she asked, “Can we put it down as a self-pay since you can change it afterwards?”....The nausea I had felt that day returned some time later when I received a bill for $4,567. Because standard practice of care for recurrent ovarian cancer includes a CT every three months, the trial did not cover the cost of this scan. At registration, I had been thinking in terms of the trial paying or me paying. Instead of saying “self-pay,” I should have handed the “financial navigator” my insurance cards. Adjustments would have to be made with billing services. My mistake at registration revealed the exorbitant price of the CT, which otherwise would have been masked by the incomprehensible maze of paperwork sent by providers. The trial exacts large expenses: it requires that people have periodic scans and does not pay for them. How could patients who are under-insured or not insured at all be included in such a clinical trial? How could people working for the minimum wage afford $18,268 a year for CTs? ....Now I understand why low-income patients are underrepresented in cancer trials, although they bear a disproportionate burden of cancer mortality. For economic status is of course a barrier not only to trials but also, more alarmingly, to detection and treatment.

In a previous note about clinical trials, I reported that the Affordable Care Act (ACA) prohibits health insurance companies from denying their policy holders access to such trials for reasons of cost (see: The Accountable Care Act (ACA) and Clinical Trials). In the note, I also cautioned patients about enrolling in trials without an understanding of both additional expenses that might be incurred as a result of the trial protocol and also the potential benefits of participation. The excerpt above discusses some of the challenges of the payment "negotiations" that ensue for a cancer patient enrolled in a trial. She had health insurance which covered the cost of "standard" diagnostic tests and treatments whereas those extraordinary expenses attributable to the trial research protocol would be covered by the trial budget.

I don't have data to prove it, but I, and the author of the article above, believe that low-income, uninsured people with cancer would probably not be admitted to most clinical trials. Frequently, clinical trials relating to cancer therapy are the most sought after failures of standard therapy. Such patients could certainly not be able to pay an out-of-pocket cost of $4,567 for CT scans not covered by the clinical trial.

There are a number of problems that present themselves if low-income patients are underrepresented in clinical trials. First, most such trials are supported by federal money. Such benefits should be equally accessible. Secondly, lower-income individuals tend to be unhealthier with a higher prevalence of chronic diseases. This is related to factors such as income, access to care, and lifestyle choices. On the basis of such exclusion, the results of the clinical trials are biased toward healthier people who may have a different (i.e., better) response to the treatments being evaluated.

The Significance and Relevance of the "Industrialization" of Healthcare

I have been coming across references in articles to the industrialization of healthcare with increasingly frequency. The most recent was in my note quoting an article suggesting that such industrialization has been increasing (see: Predictions for the Post-EHR IT Era; Business Continuity Challenges). Hence, I thought that it would be useful to gain a better understanding of the term. I turned to an article on this specific topic (see: Health Care Becomes an Industry). Below is an excerpt from it:

The delivery of health care is in the process of “industrialization” in that it is undergoing changes in the organization of work which mirror those that began in other industries a century ago. This process is characterized by [1] an increasing division of labor, [2] standardization of roles and tasks, [3] the rise of a managerial superstructure, and the [4] degradation (or de-skilling) of work. The consolidation of the health care industry, the fragmentation of physician roles, and the increasing numbers of nonphysician clinicians will likely accelerate this process. Although these changes hold the promise of more efficient and effective health care, physicians should be concerned about the resultant loss of autonomy, disruption of continuity of care, and the potential erosion of professional values....As the [20th] century progressed, the work of physicians steadily splintered into narrower disciplines.

The first [medical] specialists focused on particular organ systems or illnesses. Within these disciplines, however, there was still the opportunity for continuity of care. In contrast, the most recent specialties—emergency medicine, intensivists, and hospitalists—focus on a particular stage of care and have fulfilled Taylor’s prediction of the primacy of the system over the individual. These physicians typically work in shifts, and their relationship with the patients they care for begins and ends with their shift. The fragmentation of care is seen not only among physicians, but also in the utilization of nurses and other nonphysician clinicians to perform tasks that were traditionally the responsibility of physicians.....The increased fragmentation of care, particularly the development of process-oriented specialists such as hospitalists, has its critics. Although the stated impetus behind the development of the hospitalist specialty is increased efficiency and quality of care, the benefit (if any) appears to be primarily in the domain of efficiency. Some observers have decried the resultant loss of continuity and argue that such changes are primarily economically driven and may hurt the quality of a patient’s care.

Any physician will be acutely aware of the fact that one of the major effects of the fragmentation of healthcare has been the disruption of the continuity of care. Patients are often asked to supply the "glue" relating to their own care. For example and during a physician visit, they may be asked what other physicians have they seen in the past and what has happened during such visits. The reason is that documentation of these past visits may not be readily available. Healthcare IT can potentially serve as a substitute for this patient-supplied glue (see: Expanding the Definition of the Early Health Model).

Although there have been many gains achieved by the increased number of hospitalists caring for patients in hospitals, one of the challenges of this trend has been a disruption of the continuity of care for patients moving from physician office care to inpatient settings (see: Hospitalists Add to Medicare Costs According to Recent Study). The primary care physician or specialist admitting a patient to the hospital turns over the responsibility for a patient to a hospitalist who is often meeting the patient for the first time.

When nurses and house officers in hospitals change shifts, there is always an effort to brief the incoming staff about the status of the patients for whom they will provide care, particularly the most ill. Sometimes this exchange of information is inadequate because of time constraints. Ideally, EHR's could or should serve as a substitute for these briefings. However and because of EHR design and organizational issues, summarizing a patient's current condition from the EHR is challenging (see: Para-EHR Clinical Data Not Being Captured and Keeps Getting Bigger; Are electronic health records already too cluttered?).

In many ways, "first generation" EHRs have failed to optimize clinical care and failed to counteract the increasing fragmentation of healthcare delivery (see: Predictions for the Post-EHR IT Era; Business Continuity Challenges). This is due, in part, to the fact that the EHRs have been primarily designed to optimize billing and charge capture and not clinical care delivery. Here's a quote from my note from four years ago that makes this point (see: Upcoding Can Result in Greater Healthcare Costs After EMR Deployment):

In an ideal world and in an ideal healthcare system, all of the incentives support the efficient use of resources to deliver top-notch care. In our real world, one of the primary drivers for EMR deployments over the last several decades has been billing optimization, which is to say increasing revenue from payers for services rendered to patients. Algorithms within automated billing systems analyze the billing codes assigned to patients and suggest different ones that are still justifiable but which result in greater reimbursement for the provider. This is called "upcoding" and is the norm for all of the financial modules that are components of EMR systems.

Improving Blood Transfusion; Hemoglobin Level an Inadequate Metric

This is a guest blog note by Dr. David Jadwin, a pathologist and founder of Columbia Analytics, a company that provides external medical chart reviews. He is particularly active in the assessment of hospital blood transfusion practices and an advocate of external chart review. --BAF

Although not required to have a specific transfusion committee, hospitals are required to review hospital blood use to ensure that transfusions meet appropriateness criteria established by the medical staff.  When hospitals perform such blood use reviews, they are often cursory and frequently fail to recognize the 30 to 50 percent of non-beneficial transfusions that occur in nearly every hospital. There are many reasons that internal chart review is not effective. These include lack of subject matter expertise, uncompensated physician review time, inappropriate criteria, and reviewer bias that occurs when physicians review the work of physicians they know and with whom they may have economic, political, social, and referral relationships.

The fact that our country spends $800 billion dollars for unnecessary healthcare services and that medical error is perhaps the third leading cause of death in the US highlights the failure of internal review to ensure high quality patient care. While some hospitals have made modest gains in reducing blood use, few, if any, have reduced blood use by the percentage necessary to achieve "bloodless" healthcare. That's because they focus on the wrong metric, the percent reduction in blood use, rather than the percent of avoidable transfusions accompanied by more than 20 other metrics that measure the effectiveness of patient blood management. Unless a standardized, objective, comprehensive, and independent (external) review is performed, hospitals and physicians will probably not recognize the extent to which non-beneficial transfusions occur.

Hospitals persist in using single laboratory values as benchmarks for appropriate use of blood such as the hemoglobin level. This despite the fact that such decisions are too complex to be based on a single lab test (see: Red blood cell transfusion: a clinical practice guideline from the AABB) We routinely find transfusion orders that meet the hospital-approved hemoglobin level of <8 gm/dL for packed red blood cells in a stable non-bleeding patient. Decisions to transfuse blood are not simple and it's not possible to create specific rules that every physician can employ.

Transfusion medicine requires physicians who have specific complex knowledge and decision-making skills and particularly those who feel comfortable not transfusing patients. It is perhaps for this reason that AABB has recently proposed standards to specifically credential physicians for transfusion medicine just as physicians currently are credentialed for conscious sedation privileges. 

A hospital system-wide, state-wide or even national review process will be required to improve blood use across the country. An external review process can ensure that every chart, every physician, and every hospital is reviewed in a standard manner and create transparency about blood transfusion practices that currently doesn’t exist. Since blood represents one of the highest supply costs for hospitals and 30 percent or more (perhaps even 70 percent) of transfusions are non-beneficial, then 100 percent chart review capable of identifying all inappropriate events is necessary. Technology currently permits cost-effective review of all hospital blood transfusions and educational feedback to physicians to improve hospital blood use. 

ICD-10: An Opportunity to Provide Lab Results in Patient-Facing Apps

Below is a guest blog by Bob Rudy who recently launched a company called RARE-data = Solutions. Bob is a veteran hand in the healthcare software field and particularly in the PACS field. He has made available on slideshare a detailed PowerPoint deck about the ICD-10 to ICD-9 cross-reference whitebook he has developed. Here's a link to a document describing ICD-10 in detail published by the WHO. Here are more details about his ICD-10 solution: "The design of my ICD-10 solution has been constructed so it can be used worldwide by researchers to collect ICD-9 & 10 data with one application. It will be sold as a "Right to Use License" to anyone without restrictions for embedding inside other applications and cloud services."

Time is of the essence for better healthcare IT solutions if we are truly going to engage patients in their treatments. In order to move forward from here, we need a platform from which all of us can light the way for improving treatment of illnesses. Up to the present time, we have relied on a patient's input or condition in case of an accident as the start of treatment. Going forward into 2014, health treatment processes are about to change in a major way. Beginning October 1, 2014, healthcare in the United States will be based on the International Classification of Diseases Version 10. This new version replaces the International Classification of Diseases Version 9 which has been in use here for decades.

The Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems has two elements -- CM and PCS. ICD-10-CM is composed of 69,000 codes compared to the 17,000 in ICD-9-CM. As one can easily appreciate, the new ICD-10 presents a major hurdle in the education of practitioners. To get a handle on this task for ICD-10-CM, I thought it would be a good idea in 2009 to consider whether ICD-9-CM and ICD-10-CM could be combined into one document. 

Four years later, I have succeeded in developing an "ICD-10-CM thesaurus" described in the introduction above. One question that arose in this context is whether the thesaurus could be applied to patient-facing applications such as those relating to drug prescriptions. This now appears to be feasible. With the formation of collaborating groups such as CommonWell, there is now the possibility that patients can gain greater access to information about their health (see: CommonWell wants to 'open this up'). With pharmacies filling countless prescriptions generated by physicians, it is in their best interest to develop patient-facing apps linked to these prescriptions as a reminder about dosages, drug side effects, and drug-drug interactions.

Prescriptions are issued based on a patient's condition at the time of treatment and can change over time. ICD-10-CM will be able to provide a more precise description of one's specific medical condition and enable better health outcomes. The not-for-profit organization CommonWell provides an opportunity for the clinical laboratories to join in an effort to provide lab results in patient-facing applications so that patients can have access to the same lab report that physicians use on a daily basis. Putting the patient at the center of treatment plans should be everyone's objective as we move forward.

The Recent Choice of Epic by MinuteClinic; What Happened to Allscripts?

In a recent note, I discussed a newly announced deal between Epic and CVS's MinuteClinic for the deployment of EHRs in their walk-in clinics (see: Epic EHRs Added to In-Store MinuteClinics; the Pursuit of Connectivity). The Medial Quack reminded me that MinuteClinic had announced a previous EHR arrangement with Allscripts in February of 2012 (see: CVS Flip Flops With Medical Records Choice For Minute Clinics, Selecting Epic; CVS Caremark's MinuteClinic to Deploy Allscripts EHR Nationally). She also commented that the prior electronic medical record used by MinuteClinic was their home-brew version that based on e-ClinicalWorks. 

I am not surprised that CVS/MinuteClinic has been trying to move away from home-brew software in favor of a commercial EHR. Hospitals, clinics, and physician offices learned this lesson decades ago. You need to have a company that can support your software rather than your internal IT department for both economic and regulatory reasons. Internal IT personnel often favor home brew software development, preferably poorly documented, because it provides a long-term employment contract for them.

I don't know why the previous contract between MinuteClinic and Allscripts was canceled but this does not stop me from speculating about the cause. It's possible that the Epic arrangement may also blow up, perhaps for the same reason that the Allscripts deal went away. Here's some reasons why Epic and CVS/MinuteClinic may not have a harmonious relationship; some of these same reasons may apply retrospectively to Allscripts:

1. Epic has mastered client control in order to enhance their software deployment success record. They have learned that if their hospital clients modify their software, they often break it or stress it. A large national business-savvy corporate client like CVS may be harder to dominate in this way. My guess is that MinuteClinic will be much more satisfied, in the long run, with a smaller EHR vendor with a system designed for simple healthcare delivery and based in the cloud.
2. The ambulatory care records of a MinuteClinic will be rudimentary compared to most physician office practices and hospital ambulatory care settings. CVS may ultimately balk at the inherent work-flow inefficiencies and complexity of the Epic ambulatory care software.
3. Epic executives prefer to use consulting firms approved by them as key interfaces between them and their clients, allowing the company to grow faster and optimize new software releases and products. I don't know who or what will function as the "interface" between CVS/MinuteClinic and Epic. My guess is that the CVS/MinuteClinic internal IT department is managing the Epic software deployment. If so, this may place additional strain on the relationship.

An old adage is that culture always trumps strategy. I view CVS/MinuteClinic and Epic as having different cultures with the former representing a go-go, growth-oriented company and the latter an insulated, inward-looking healthcare IT company. There is a wide gulf between the two. Based in part on the apparent failure of the previous Allscripts venture, I would guess the chance for success with Epic will be slim. If it doesn't work out, it will probably take at least two years for the announcement.

CAP Today Article Provides Highlights about the Pathology Informatics Summit 2014

The new issue of CAP Today contains an article describing some of the featured speakers at the Pathology Informatics Summit that will take place on May 13-16, 2014, in Pittsburgh (see: With lab informatics, better to give than to receive). Below is an excerpt from the article referencing one of them, Dr. Mike Becich, who is chairman of the bioinformatics department at the University of Pittsburgh Medical School. Link to the article itself to read about some of the other speakers at the conference.

The roles of pathology informatics, biomedical informatics, and data analytics in the laboratory will be the subject of a talk by Michael J. Becich, MD, PhD [at the PI Summit].... “I’m calling for pathologists to realize that the age of computational pathology is upon us,” Dr. Becich says. What does he mean by “computational pathology”? “It’s the analytics of lab data,” he says, “combining different types of data sources on a patient generated by the laboratory and perhaps other health care sources, and really deeply interrogating genome data, imaging data, and what I’ll just loosely call phenotype data—the age at which you got a disease, the other diseases you have, your family history, all the things that EMRs are supposed to intelligently manage but, sadly, don’t.” Those are what computational pathologists want to use to add value to personalized medicine through big data, he says. “And the solution to that, for me, is not just pathology informatics, but computational pathology. It’s not just about delivering the data and getting it in the hands of the clinician. It’s about analyzing that data and the complex variations in that data.”

Unfortunately, Dr. Becich adds, far too few pathologists are trained in computational pathology. “What we want,” he says, “are pathologists who don’t just crank out tests in a laboratory, but who can manage large, complex databases; do deep interrogation against those databases to take data and turn it into knowledge; and master complex software tools that enable this deep discovery of data. This kind of pathologist is one part computer software savvy physician, one part molecular genomicist, and one part pathology informatician, deeply familiar with the lab information system.”In his view, training is the principal challenge. “There are no computational pathology fellowships anywhere in the country,” he points out. “We’ve trained about six or seven here at Pitt, but we’ve done it by cobbling together resources for people who were largely doing the interface between genomics and informatics. And those people are wildly successful and highly sought after, and are successful both in small business as well as in pathology. If I had 50 people like them right now, I could find them all jobs immediately. So how do we scale up the training?”

The 2014 PI Summit will begin with four workshops on May 13, 2014. They are: (1) A Comprehensive Review of Pathology Informatics; (2) HIMA Imaging Science; (3) Informatics-Driven Molecular Pathology; and (4) Digital Pathology 101 Workshop. There is no extra cost beyond the general registration fee for these workshops.

The main conference begins on Wednesday, May 14, and continues until noon on Friday, May 16. It is organized into two tracks, the first devoted to clinical pathology informatics and the second to surgical pathology informatics. The latter track will provide a number of lectures on digital pathology. There is also a third track for the best scientific abstracts that are submitted as well as lectures on proffered topics.

Over the course of three days, the main conference will feature 25 lectures presented in these two tracks as well as the plenary lectures. All of the track lectures and plenary lectures will be delivered by national leaders in pathology informatics. The PI Summit 2014 web site provides a number of useful features: (1) the schedule for the entire conference; a list of the 41 participating faculty members with brief biosketches; an on-line registration form, and on-line hotel reservations. The web site also lists the vendors that have committed to participate with many more anticipated when the conference begins. This is the only conference in the country devoted exclusively to pathology informatics, an increasing important specialty area in this era of healthcare reform and emphasis on cost-containment.

Repurposing Abandoned Hospitals in New Jersey as Medical Malls

Seeking profits, developers are converting abandoned hospitals in New Jersey into medical malls. This turns out to be a good news, bad news story as described in a recent article (see: Repurposing Closed Hospitals as For-Profit Medical Malls). Below is an excerpt from it:

New Jersey has been losing hospitals for more than two decades....But in recent years, a few developers have purchased some of these abandoned structures, reopening them as private medical complexes that offer many of the services the hospitals once provided. For struggling cities like Paterson, N.J., the new use removes blight from the streets, restores health care services, creates jobs and provides a tax boost when a for-profit company replaces a nonprofit institution. Since 2008, developers have bought hospitals in Paterson, Jersey City, Hammonton and Trenton, converting the buildings into so-called medical malls that house an array of services like urgent care centers, doctors’ offices and dialysis centers. Critics worry that these new medical complexes are no substitute for the hospitals they’ve replaced and may siphon off paying patients from them. Unlike a hospital, individual providers in a private medical complex are not required to provide charity care, nor do these complexes have nonprofit missions to serve a community’s health needs, although some tenants are nonprofits. Nevertheless, these buildings are often ideal for medical uses — an emergency department can be repurposed as an urgent care center. Existing operating rooms can be used for outpatient surgical centers. And an inpatient floor is a natural fit for a subacute care facility. Added to that, the new use is certainly preferable to a deteriorating structure that contributes to urban decay....An urgent care center, for example, is not an emergency room that can admit patients. While a nonprofit hospital is required to serve a community’s health needs, a developer’s primary goal is to fill space with tenants who can pay the rent. So a primary care doctor or a pediatrician might not be as lucrative a tenant as a radiologist....But for communities with a high mix of uninsured patients, the services available at a medical mall are inaccessible to a sizable portion of the population. So the remaining hospitals absorb more uninsured patients, while they lose paying patients to a medical mall.

First of all, the charity care provided by non-profit hospitals as a requirement for their tax-free status turns out often to be a myth (see: Non-Profit Hospitals Drift from Their Mission Despite Subsidies; Can U.S. Hospitals Become More Oriented to Health Outcomes?; Cities Begin to Question Non-Profit Status, Tax Breaks of Their Hospitals). The care provided on this a basis is often minor compared to most of their business and even this percentage is unreliable because it's often accounted for on the basis of the inflated "retail cost" of care. Giant health systems like the the University of Pittsburgh Medical Center are anything but non-profit. Here are a few details about it (see: University of Pittsburgh Medical Center). 

The University of Pittsburgh Medical Center (UPMC) is a $10 billion integrated global nonprofit health enterprise that has more than 62,000 employees, 22 hospitals with more than 4,700 licensed beds, 400 clinical locations including outpatient sites and doctors’ offices, a 2.2 million-member health insurance division, as well as commercial and international ventures.

Healthcare is one of the major drivers of the U.S. economy. According to the World Bank, in the U.S. it now comprises 17.9% of the GDP. In many urban centers with large numbers of unemployed and uninsured, the standard business model for hospitals is no longer viable. If developers can convert abandoned hospital buildings to medical malls, this shift should be welcomed. Here's an interesting quote about the cause of many hospital closures and rural "medical deserts" (see: Hospital closures will leave 'medical deserts').

The [hospital] closures are for a variety of reasons, including demographic shifts, politics and the economy,...and reimbursement cuts to hospitals due to healthcare reform....The issue is not just the lack of geographical access, but the fact that residents of "medical deserts" in rural areas are less likely to have good health insurance....

Epic EHRs Added to In-Store MinuteClinics; the Pursuit of Connectivity

Walk-in clinics located in CVS and Walgreens stores offer a wide range of basic services such as vaccinations and the treatment of minor ailments. Some are even some offering lab tests (see: Lab Testing Now Being Offered in Walgreens California Stores). Although there are other players in this business, I think that these two companies dominate the field. They offer the convenience of multiple locations and effective marketing. Since their inception, one of the weaknesses of walk-in clinics in general has been their rudimentary electronic records. This gap now seems to be closing, at least for the CVS MinuteClinics (see: CVS-Epic deal will add EHRs to Minute Clinic in run-up to major expansion). Below is an excerpt from an article on this topic:

Just as CVS Caremark is poised to expand its MinuteClinic system, it’s inked a deal with Epic Systems to provide ambulatory electronic health record support for the clinics. The EHR/EMR  giant will replace the homegrown EHR system CVS developed....It reflects a growing maturity of the MinuteClinic concept as it moves beyond flu vaccinations and blood pressure readings to provide more non-emergency care, and it is one of the healthcare industry trends to reduce healthcare costs by providing alternatives to hospitals or the doctor’s office. The clinics are equipped to provide vaccines, do some lab tests and provide several non-emergency care services....Dr. Nancy Gagliano, MinuteClinic’s chief medical officer, said Epic’s support of national interoperability standards, analytics and customization helped cement the deal. CVS currently has more than 800 MinuteClinic locations and expects that to almost double to 1,500 locations....“We need a robust IT system, an EHR that will effectively interconnect with our affiliated partners,” as well as health information exchanges, [Gagliano] said. “We’re going to have over 1,500 clinics in just over a couple of years. We see 4 million patients a year and we’ll see 10 million patients a year in the near future. So we need a big company to support the volume that we’ll have.”

It will be a while before people should expect to see Epic’s EHRs in action. It will take about 12 months to train staff and set up “specialized interfaces” and another year to roll out the EHR network across MinuteClinic locations. A couple of components of the EHR network CVS is installing are Care Everywhere, which works as a health information exchange between Epic customers; and Care Elsewhere, which makes interoperability possible between Epic systems and other non-Epic providers or health information exchanges....CVS just joined the CommonWell Health Alliance — a group of health IT companies to improve the way healthcare data is shared. At the time of its launch last year, the alliance was perceived...as an attempt to better compete with Epic....In the announcement last week at HIMSS, a statement said that CVS is joining CommonWell as a contributing member, and would work with RelayHealth to embed these services natively into its pharmacy system.” It will also help providers securely access prescription information to improve patient safety. “Through the Alliance, pharmacies and health care providers will be able to better connect with the broader health ecosystem.”

These deals and alliances with Epic, RelayHealth, and CommonWell on the part of the CVS MinuteClinics are all about the integration of information and access to prescription data for patients. I suspect that the long-term plan for CVS is to position their clinics as the most basic rung in the U.S. healthcare delivery system. As such, they need to provide clinical and drug information up the line and also get access to the medical records of other providers. This yields both integration and legitimacy.

So what's in this deal for Epic. A huge number of patient records, obviously. Here's a quote from above: [CVS is] going to have over 1,500 clinics in just over a couple of years. We see 4 million patients a year and we’ll see 10 million patients a year in the near future. Although Epic will continue to connect its hospital clients with health information exchanges (HIEs) when available, I also believe that Epic's goal is to become a de facto HIE for their large client base (see: Connectivity and Hospital-Based EMRs; The EMR as an Operating System?; A Reader Comments on Epic Interoperability and Care Everywhere; Surescripts May Capture the Health Information Network (HIN) Business; Sharing Medical Records across Hospitals with Epic's Care Everywhere; Judith Faulkner, EMR Interoperability, and Washington IT Politics). In this context, providing support for the MinuteClinics makes perfect sense.