Lab Soft News

Data Brokers Get the Attention of the FTC; Call for Transparency & Accountability

It's long been time to establish some rules for data brokers and the issue now seems to have gotten the attention of the Federal Trade Commission (FTC). The agency recently released a report describing some of the abuses of this business. All of this was summarized in a recent article (see: FTC report examines data brokers). 

In today’s economy, Big Data is big business. And data brokers — companies that collect consumers’ personal information and resell or share that information with others — play a key role....[T]he Federal Trade Commission [has] released a study of nine data brokers. These data brokers collect personal information about consumers from a wide range of sources — including public records, loyalty cards, websites and social media — and provide information for a wide range of purposes — including verifying someone’s identity, marketing products and detecting fraud.

What did the FTC learn about the data broker industry?

• Data brokers collect consumer data from numerous sources, largely without consumers’ knowledge. Some of the information data brokers collect, like bankruptcy information, voting history, consumer purchase data, web browsing activities and warranty registrations are not obtained directly from consumers, and as a result, consumers are largely unaware that data brokers are collecting and using this information.
• Data brokers collect and store billions of data elements, including some on nearly every U.S. consumer. Data brokers hold a vast array of information on individual consumers. For example, one of the nine data brokers has 3,000 data segments for nearly every U.S. consumer.
• Data brokers combine and analyze data about consumers to make potentially sensitive inferences. Data brokers infer consumer interests from the data they collect. Then, they use those interests to make inferences about consumers and place them in categories....

Here's an important point from the executive summary of the FTC report that needs emphasis (see: Data Brokers: A Call for Transparency and Accountability).:

Because these companies generally never interact with consumers, consumers are often unaware of their existence, much less the variety of practices in which they engage. By reporting on the data collection and use practices of these nine data brokers, which represent a cross-section of the industry, this report attempts to shed light on the data broker industry and its practices.

I can't make the point stronger than the title of this FTC report. We need more transparency and accountability on the part of the data brokers. Most consumers are unaware of the intrusive aspect of this industry so there won't be much pressure from them. Stay tuned to see if we get any action from Congress. There's a lot of money and power involved here and it's uncertain if our elected officials view this as a priority, particularly with most of the population unaware of the abuses.

ACA Drives Increased Emergency Room Patient Activity

Some of the consequences of the Affordable Care Act (ACA) are now becoming evident. The Motley Fool, a respected stock market web site, is predicting big profits for hospital emergency rooms as a result of more people with health insurance (see: Will This Obamacare "Emergency" Lead to Big Profits For One Sector?), Below is an excerpt from the article:

Looking back on the first enrollment campaign for the Patient Protection and Affordable Care Act...shows that it was both a bumpy, but ultimately success ride based on initial enrollment estimates. For the open enrollment period, which spanned Oct. 1 through March 31..., more than 8 million people signed up for health insurance between state-run exchanges and Healthcare.gov. This surpassed projections in September from the Department of Health and Human Services whose initial goal was to enroll 7 million people by March 31. Generally speaking, the higher the enrollment number, the fewer uninsured people there are, and the more spread out medical costs should be across all citizens in this country. It remains to be seen if this higher-than-expected enrollment will work to curb premium inflation in 2015, but based on initial proposals from 13 returning insurers from my home state of Washington it would appear that the increases are pretty reasonable, with one insurer actually requesting a premium decline of nearly 7%....

However, one somewhat unexpected consequence of the Affordable Care Act is creating the opportunity for huge profits for hospitals and potentially big bottlenecks for consumers, at least in the early going. This boom is none other than a surge in emergency room visits. According to a survey conducted by the American College of Emergency Physicians..., nearly half of all emergency room doctors have reported an increase in ER visits since the beginning of the year with 86% expecting a rise in visits within the next three years. What's the primary reason for this surge? As FierceHealthcare pointed out this week, it's a combination of two major factors. First, more people are carrying health insurance and taking advantage of that coverage in the form of more hospital visits. Unfortunately, with millions of newly insured persons covered by Medicaid, and a number of physicians simply not accepting Medicaid as a form of payment since the reimbursement rate is sometimes viewed as too low, these individuals in need of medical care are simply turning to emergency departments more often. Secondly, our population is getting older and living longer. Since older adults are considerably more likely to have chronic conditions in need of treatment, emergency rooms are a common stop for the elderly.

I, for one, did not see this increased use of hospital ERs coming. Probably naively, I assumed that, with  routine physician visits covered for more people, the use of ERs for minor problems would decline. However, the article quoted above makes a good point. More people are being covered by Medicaid and many physicians won't accept Medicaid patients because of the low reimbursement rates. Such individuals  then turn to ERs for care as the best alternative. I suspect that ER visits are very lucrative for hospitals -- short visits with lots of high-margin lab and radiology work.

Here's a quote from a Forbes article on this same topic that refers to the same article from Science as the Motley Fool piece (see: Oregon Study Exposes Another ObamaCare Falsehood: Rather Than Reduce Unnecessary ER Use, Medicaid Increases It). Here's an interesting quote from it:

The authors [of the Oregon study] also did a back-of-the-envelope calculation that “Medicaid increases annual spending in the emergency department by about $120 per covered individual.” So if ObamaCare enrolls all 3.9 million individuals that it has so far identified as being eligible for Medicaid and SCHIP [State Children's Health Insurance Program], the law could increase...ER spending by something on the order of half a billion dollars per year. If all 50 states had implemented the law’s Medicaid expansion, the additional ER spending might have hit $1 billion per year.

LIS-FAT Emerges as a Useful Tool for Assessing LIS Functionality

A project launched by the Association for Pathology Informatics (API) called the LIS Functionality Assessment Toolkit (LIS-FAT) seems to be acquiring some momentum. I discussed the project in a previous note (see: Assessing the Functionality of a Laboratory Information System (LIS)). Officially announced at the ASCP annual conference in Chicago on September 20, 2013, LIS-FAT consists of four documents that are available for free download at the API web site. First is a white paper discussing the need to optimize the functionality of LISs in pathology departments, The white paper is accompanied by three appendices. The first of these, Appendix I, is the most important document in the set. It's a compilation of about 850 functionality statements, declarative statements about the various tasks that can and should be accomplished by an LIS. Each of them is assigned a score of 1-4 with the 3's and 4's being the most critical. They have been designed to be used to evaluate a pathology department's current LIS or one under consideration for purchase. Appendix I has been downloaded approximately 3,000 times since it was made available on the web site, indicating that is is proving to be a useful tool.

When the API task force initially developed the LIS-FAT, the major stated goal of the task force was to develop a set of tools that could be used to assess an LIS and, most particularly, help manage the RFP process when buying a new system. Such functionality statements have been included for decades in RFP's developed by individual labs and sent to LIS vendors. One of the goals of the LIS-FAT task force was to make available at no cost a comprehensive list of such statements so that individuals labs could avoid the effort of generating their own similar documents.

Actual events have taken a slightly different turn. Some  LIS vendors have now developed their individual responses to the functionality statements and are making then available to current and prospective clients who inquire about how their product compare on this basis. I was told during informal hallway conversations at the recent Pathology Informatics Summit 2014, the major yearly conference of the API, that many of the LIS vendors welcomed the publication of LIS-FAT and are viewing it as a kind of functionality "standard" in the market. I place functionality in quotes here because LIS-FAT, in its current form, lacks the formality and precision of an IT standard.

The members of the LIS-FAT task force are now considering some possible options in terms of future development of the LIS-FAT. One goal will definitely be to expand the current functionality statements in areas such as genomic testing and lab outreach. Another possible goal will be to consider using the API web site as a central repository for "certified" copies of vendor responses to the functionality statements if the LIS vendors agree that this would be a step forward. The goal here would be for them to "stand behind" the posted responses, guaranteeing them for interested potential buyers. If readers of this blog have other ideas about the future of LIS-FAT, their comments would be most welcome.

Rationale for Many Employers Moving to Private Insurance Exchanges

Readers of this blog may not be familiar with private insurance exchanges. They are a recent innovation and spin-off from the churn of the ACA and health insurance exchanges. A recent program on National Public Radio (NPR) discussed this new type of health insurance available through an employer (see: Employers May Start Paying You To Buy Health Insurance). Below is an excerpt from it:

What if employers started giving workers a chunk of cash to buy health insurance on their own instead of offering them a chance to buy into the company plan?...The idea that employers might drop their health plans and replace them with a "defined contribution" for employees has been around for years. It's one way for employers to control their expenses in the face of the relentlessly rising costs of health care. Now that the Affordable Care Act has made non-company plans more accessible and affordable by creating online marketplaces where people can shop for coverage, the idea is gaining traction....A recent study by S&P Capital IQ predicted that 90 percent of workers who now get their health insurance through a job will be moved to health insurance exchanges by 2020. But a wholesale shift away from employer-sponsored coverage is unlikely. For one thing, under the health law employers with 50 or more workers that don't offer health insurance will likely face a penalty of $2,000 per worker (minus the first 30 workers), beginning in 2015. If employees do drop coverage, it could be a huge change from the way things are now. The employer-paid subsidies to monthly premiums that employees get for employer-sponsored group coverage currently aren't taxed as income to the worker....

Rather than abandoning group coverage altogether, some analysts expect employers to move more assertively into a slightly different health insurance benefit setup: private health insurance exchanges. These online marketplaces, which got their start several years ago as a way to transition retirees from company plans to Medicare, are increasingly being offered to active employees....Once employers have selected a private exchange for their workers, they typically give employees a set dollar amount to shop among sometimes dozens of health plans offered by different insurers. The employer may limit the plan choices available to employees. Since the employer is sponsoring the coverage for the group, workers don't owe income tax on the contributions they receive.....Employers, meanwhile, get what they want: predictable health care costs. With a defined contribution arrangement, the employer can increase or decrease the amount over time depending on business need....While giving employees more plan choices could be a plus for some workers, it could also encourage them to buy less expensive, less comprehensive coverage than they would otherwise have gotten through their employer.

Two points in this article stand out in my mind. The first is that both employees and employers want to maintain the tax-free status of worker health care insurance. The second is that employers want to be able to plan on predicable healthcare insurance costs that also do not rise in cost substantially year after year. The only way that this second scenario can become a reality is if certain major changes occur in our healthcare delivery system. The first, very uncertain at this time, will require the federal government and health insurance companies to push back on pharmaceutical companies regarding the cost of drugs. This will not take place unless and until the politicians are able to wean themselves off the political contributions of the pharmaceutical companies. 

The second change that is actually beginning to occur is a more competitive hospital environment. Many small hospitals are going out of business and others, in order to survive, are aligning themselves with large regional hospitals. The number of surgical procedures occurring in smaller hospitals will decrease each year in favor of larger hospitals that are now competing for these procedures on the basis of price, often fixed. How can larger hospitals provide major surgical procedures on a fixed price basis? They will accomplish this is part by cherry-picking the healthiest patients who are least prone to post-operative complications. They can also offer lower, fixed prices for procedures by wringing the waste out of such procedures by performing them in a repetitive, standardized manner and also through economies of scale. 

Is There Such a Thing as a Healthy Obese Patient?

There have been multiple articles in medical journals as well as in the popular press about "healthy obese people" based on the notion that that overweight people can be very fit. Note however that there is a difference between fit and healthy. Prior to now, I had not really thought about the difference between these two states. A recent article disputed the claim of "healthy obese patients " and below is an excerpt from it (see: There’s No Such Thing As Healthy Obesity, Study Says; Is Healthy Obesity a Myth?)"

Can someone be obese and healthy? A new study and several experts say no. An obese person who has normal blood pressure, normal cholesterol and normal blood sugar levels is still at risk for heart disease, ...researchers ...[recently reported]. In the study of more than 14,000 men and women, aged 30 to 59, those who were obese had more plaque buildup in their arteries, putting them at greater risk for heart disease and stroke than people of normal weight, the researchers found.“People have been trying to work out whether there is a group of people that are obese and healthy,” said Dr. Rishi Puri ... [in] an accompanying journal editorial. Puri noted that even if an obese person has normal blood pressure, cholesterol and blood sugar levels, those measures are likely to change over time and become abnormal, putting the patient at risk for heart disease, stroke and diabetes. He also questioned the need, both in terms of research and patient care, of trying to define healthy obesity....“We have an enormous challenge at a public health and individual level in dealing with obesity-related disorders. Being obese doesn’t just affect the heart. Being obese means you’re more likely to have joint disease, psychiatric disorders and cancers,” Puri said. He added that, over the next couple of decades, obesity and its consequences will be driving health care costs.“Even if we find that these particular obese patients don’t have a higher risk of heart disease in the short-term, what are the many other things obesity does to your body?” Puri said....The researchers looked for buildup of calcium plaque in the heart’s arteries, which is an early sign of heart disease....[They] found that the obese people had a higher prevalence of atherosclerosis of the heart arteries than the people of normal weight.

I have frequently been in the company of individuals who are overweight but seem fit, at least to me, based on their ability to engage in aerobic exercise such a bike riding. The point being made in the article cited above is that obese patients have a greater prevalence of atherosclerotic plaque in their coronary arteries that may, in its early stages, not produce clinical symptoms. Such plaques would not be evident based on their external appearance. Obese patients are also at higher risk for stroke, diabetes, and joint diseases. In my opinion, most physicians don't do an adequate job of helping patients lose weight in part because they are unable to spend the time necessary with such patients to change their ingrained eating and exercise habits. Luckily, there are other options for them with peer support such as WeightWatchers and similar programs. Thus, obesity continues to be a very serious chronic disease even for those who overtly seem fit.

"Liquid Biopsy" Used to Refer to Detection of Any Serum Cancer DNA

I came across the term liquid biopsy in 2010 and posted my first note about the term followed by two more about it (see: Does the New Term "Liquid Biopsy" Make Any Sense?; Rapid Adoption of the Term "Liquid Biopsy" on the Web; Continuing Discussion about the "Liquid Biopsy") Here's a quote from the first of them:

...[The use of the term liquid biopsy]... may offer some benefits. It differentiates between serum biomarkers that are elaborated by circulating tumor cells (CTCs) as opposed to, say, those that are released into the blood stream from a diseased organ or solid tumor. However, it's also possible that all, or perhaps most, serum biomarkers are the result of CTCs.

As a pathologist, I was  influenced the idea that the word biopsy indicate that cells are being obtained and analyzed. In the above  passage, I suggested that the term liquid biopsy should be limited to biomarkers identified in serum that were released by circulating tumor cells. On the basis of a recent article, however, it seems that this distinction is being lost and liquid biopsy is being applied to any cancer serum biomarker (see: The Liquid Biopsy: A Noninvasive Tumor Tracker). It skirts the definitional cell/serum issue by referring to a  liquid biopsy as "a blood test that detects evidence of cancer in the circulation." A biopsy is thus being considered as a type of test. Below is an excerpt from this article but read the whole thing to understand the broader picture.

...{R]esearch published in ...Science Translational Medicine shows how liquid biopsies can provide a noninvasive, ongoing picture of a patient's cancer, offering valuable insight into how best to fight it. Work from [two] different groups shows how liquid biopsies are being used in the lab to identify tumors at a very early stage, monitor them for metastasis, and even pick up signs of early treatment resistance. In the future, instead of extensive imaging and invasive tissue biopsies, liquid biopsies could be used to guide cancer treatment decisions and perhaps even screen for tumors that are not yet visible on imaging....[Researchers have demonstrated] that a liquid biopsy measuring the serum level of circulating tumor (ct)DNA could one day be a very useful tool in cancer decision-making, giving clues about what type of cancer a patient has and whether it has spread. "Mutant DNA fragments are found at relatively high concentrations in the circulation of most patients with metastatic cancer and at lower but detectable concentrations in a substantial fraction of patients with localized cancers," [according to the researchers] .The team found this to be particularly true in cases of breast, colon, pancreas, and gastroesophageal tumors, where "detectable levels of ctDNA were present in 49% to 78% of patients with localized tumors and 86% to 100% of patients with metastatic tumors."...."In addition to offering clues about stage and spread, liquid biopsies can be used to monitor the effects of cancer treatment, give an early warning about possible recurrence, and offer clues to the reasons for treatment resistance"

I fear that this definitional battle has now been lost and that the term liquid biopsy will henceforth be used for any molecular or cellular evidence of a malignant tumor in serum. This evidence can be in the form of circulating tumor cells (CTCs), DNA released from such circulating cancer cells, or DNA that has been released  by the in situ cells of a primary or metastatic cancer. In fact, in many cases, it may not be possible to differentiate between cancer DNA from circulating cells versus in situ cells.

Adoptive T Cell Therapy Shows Promise in Patient with Cholangiocarcinoma

A new form of cancer treatment, adoptive T cell therapy, is showing promise as described in a recent article in Science and later reported by the NYT (see: Patient’s Cells Deployed to Attack Aggressive Cancer). Here's an excerpt from the story:

Doctors have taken an important step toward a long-sought goal: harnessing a person’s own immune system to fight cancer. An article published Thursday in the journal Science describes the treatment of a 43-year-old woman with ...[cholangiocarcinoma] that had spread from her bile duct to her liver and lungs, despite chemotherapy....[The patient] learned in 2009 that she had bile-duct cancer, or cholangiocarcinoma...She had surgery to remove about two-thirds of her liver, but within a few months the disease had turned up in her lungs. She went through one grueling regimen of chemotherapy, then another.....But by last summer, the lung tumors were growing again [despite chemotherapy and T-cell infusions]. By then, the team had sequenced the genome of her cancer, and done extensive studies on her immune system. And it had found what researchers had long hoped for: a mutation in the cancer that was unique to it and not found in normal cells, and a type of [the patient's own] T cell[s] that would attack the mutation. Tests revealed that only 25 percent of the T cells that had been [previously] given to [the patient] were of this specialized type. Again, the team cultured [her] T cells, but this time it used only the ones that would go after the mutation. In October, she received more than 120 billion T cells, 95 percent of which were the highly specific ones. Her tumors quickly began shrinking, and have continued to do so for the past six months, [her physician] said. 

Here's a more detailed explanation of adoptive T cell therapy (see: Adoptive T Cell Therapy):

Adoptive T cell therapy involves the isolation and ex vivo expansion of tumor specific T cells to achieve greater number of T cells than what could be obtained by vaccination alone.  The tumor specific T cells are then infused into patients with cancer in an attempt to give their immune system the ability to overwhelm remaining tumor via T cells which can attack and kill cancer.  There are many forms of adoptive T cell therapy being used for cancer treatment; culturing tumor infiltrating lymphocytes or TIL [tumor infiltrating lymphocytes], isolating and expanding one particular T cell or clone, and even using T cells that have been engineered to potently recognize and attack tumors.  

In the case of the patient above and after previous treatment failures, her physicians did the following: (1) sequenced her tumor; (2) found a mutation of the cancer not shared by the other normal cells in her body; (3) selected a type of her own T cells that would attack the cancer cells and cultured them; (4) injected 120 billion of of these cultured cells back to her in a form of enhanced immunotherapy.

The article pointed out that this whole procedure was a laborious, expensive, and a highly customized form of immunotherapy, clearly not suited to large-scale trials. Moreover, it's likely that some malignant cells remain in her body that, being genetically highly atypical, may develop resistance to T cell therapy, and start growing anew. However, successful experiments such as these will point the way to new forms of cancer immunotherapy in which only the malignant cells are targeted and the cancer treatment does not take such a heavy toll on the patient. 

The Use of Lab Analytic Dashboards in Anatomic Pathology

I have recently developed an interest in lab analytic software and have posted several notes focusing on LIS add-on systems that can be used to improve lab quality, outreach, and workflow in anatomic and clinical pathology (see: Lab Analytics Emerges as Hot Area for Software Development; Leveraging Lab Analytic Data to Include Actionable Details to Improve Quality). For this note, I would like to focus on how lab analytic software can be used to monitor anatomic pathology workflow and operations. For some examples of common AP dashboard metrics, I turned to the Viewics web site listing examples of their anatomic pathology solutions (see: Anatomic Pathology Solutions). Copied from it, here is a list of the out-of-the box analytics offered by the company in this area:

Turnaround Time: Quick Identification and Drill-Down into AP TAT Outliers

Workload Detail: AP Workload in Detail by any Part Type, Location, Priority, etc.

Productivity and Staffing Analyses: Pathologist and Technologist Productivity

Specimen Monitoring: Detailed Breakdown to Identify AP Process Bottlenecks

Overdue Lists: Automated Workdrivers for Pathologists Prioritizing Cases

Grossing Statistics: Daily Accessioned vs Grossed AP Data

Histology Processing: Blocks Processed, Embedded and Cut Volume Data

Cytology Statistics: Cytology Accessioned vs Reviewed Variance Dashboard

Accession vs. Sign Out: Accession vs. Sign Out Activity and Delinquency

When I began to work in pathology, surgical pathology was largely non-automated and viewed as more of an "art" than a science. Clinical pathology (CP), even several decades ago, was highly automated. LIS support for CP was critical and, even then, there were LIS modules designed to periodically generate CP lab management reports such as test turnaround time (TAT). Work flow analysis in surgical pathology was not a common topic of conversation but slide quality issues pertaining to staining and mounting of thin sections have always been a source of concern. It's reassuring that pathologists and the managers of surgical pathology labs can now easily monitor the metrics shown above on their AP dashboard. It's a great start. I can't see how a lab could manage without access to such data.

I need to think more about this but the above list of AP metrics seems to address several kinds of problems. First of all, there are metrics that would identify cases that may be sitting on the desk of a pathologist waiting for special stains (e.g., overdue lists). Secondly, there are workflow problems that can be ameliorated by process changes, new equipment, or the reassignment of personnel (e.g., AP process bottlenecks). Finally, there are personnel productivity issues that may be related to the skill or diligence of personnel (e.g., AP TAT outliers; pathologist overdue lists). I need to give some more thought to how these AP metrics can be translated into actionable items that can then be used to increase the efficiency and effectiveness of a surgical pathology lab.

Pathology Informatics Summit Starts Next Tuesday; It's Not Too Late to Attend

It's not too late to plan to attend the Pathology Informatics Summit 2014. It begins next Tuesday, May 13, and runs through next Friday, May 16, in Pittsburgh at the Wyndham Grand Pittsburgh Downtown. The conference is sponsored by the Association for Pathology Informatics (API). Online registration on the web site is no longer available but walk-in registrations are welcomed. The conference promises to be the most important pathology informatics event of the year. There will be two tracks with lectures by faculty (see: 2014 Schedule; Faculty) and one track with presentations of the best submitted scientific abstracts. A total of twenty-six vendors will display their products in a large hotel ballroom (see: Exhibitors). 

Epic's Achilles Heel; The Development of an "Epic Person"

The Epic Systems culture has long been been a source of fascination for me (see: Epic Systems and Its Corporate Culture; Some Additional Insights into the Epic Corporate Culture; Epic Staffing Guide: Replicating the Epic Culture in Its Hospital Clients). A recent article in a Milwaukee business news web site called BizTimes.com provided some interesting insights about the company. It was a tell-all piece written by Jeff Buchanan, a former Epic employee (see: My Epic journey: An insider’s look at what makes Dane County’s biggest company tick). The portion that caught my attention related to the high caliber of Epic employees and employee turnover. Here is an excerpt from it:

One of the things I liked best about working at Epic is the caliber of employee.Human resources has rigorous hiring standards and I found most co-workers to be intelligent, approachable and reliable. Epic is teeming with talent but every year the company loses many employees it would have preferred to keep. There's no silver-bullet solution to the turnover problem, but one place to start might be hiring more people who have worked in health care and can leverage their experience to connect with end users. One person from my project team who worked as a nurse before Epic hired him demonstrated exceptional rapport with a roomful of practitioners because he'd actually performed the relevant work in a clinical setting. Alas, Epic is unlikely to make this change because it's at odds with the company's hiring philosophy. In a 2002 speech, Faulkner said a new employee that comes straight from college can become an "Epic person" in three years, but it takes twice as long for someone who has worked for another company. Then again this formula, provided it is still Epic's hiring gospel, has served the company well over the years. One indicator of Epic's having become the "it" company in a red-hot industry is the hundreds of thousands of résumés it receives each year. As an employee, though, while it's reassuring to know you work for a prosperous outfit, you also feel replaceable.

All of this was reminiscent for me of the culture of Andersen Consulting, now Accenture. The firm hired the best and the brightest at a young age and then indoctrinated them with the Andersen consulting methodology. I had a connection to the firm on a sabbatical leave about 25 years ago. At that time, the firm had little interest in hiring older personnel with broad work experience. Epic is avidly pursuing a similar strategy -- hiring young recent graduates, paying them very well, and inculcating in them with the Epic dogma and work ethic. You can't argue with success and the company has been remarkably successful in selling EHRs and satisfying most of their clients. However, one usually doesn't hear much from the unhappy ones who leave.

So, in what way is this approach to hiring and indoctrinating personnel an Achilles heel for the company? What is the downside of creating "Epic people" in a relatively short period of time? My view is that such an approach results in employees with a  narrow, homogeneous focus who lack broad professional experience and understanding of the healthcare business. These are people who know most of the answers but have never "walked the walk" in terms of healthcare delivery. They view hospitals and healthcare delivery with a particular type of lens. I believe that this results in EHR and healthcare software that is focused on results and process. Such software will not always optimize the time and talent of healthcare professionals who use the systems, notably physicians and nurses.