Lab Soft News

Time to Abandon the Best-of-Breed LIS Label; Emergence of Specialized Lab Software Vendors

I have recently concluded that the term "best-of-breed LIS" has ceased to be useful as products like Epic's Beaker approach the functionality of competing LISs. Beaker still lacks a blood bank module which causes customers to seek one from another vendor. Epic has been assisted in its pursuit of BoB status in part by the publication of the LIS Functionality Assessment Toolkit (LIS-FAT) by the Association for Pathology Informatics (see: The laboratory information system functionality assessment tool: Ensuring optimal software support for your laboratory; Toolkit Components). This detailed list of both mission critical and desirable LIS functions has operated as a roadmap for vendors such as Epic that wanted to improve their LISs to satisfy the EHR market. I think that the best-of-breed label thus no longer provides the ability to differentiate between vendors specializing in the lab market and those that offer an LIS module as a component of a much broader hospital-wide enterprise-wide software suite. I also suggest here that a new label, specialized lab software (SLS) vendor, should he used to refer to the specialized lab software vendors.

I cite Sunquest Information Systems as the best example of a prominent SLS vendor in order to better understand the value that is provided by the company. In recent months, Sunquest and its parent company Roper Technologies have purchased three companies, Data Innovations, Atlas Medical, and GeneInsight, all of which offer highly specialized products. To better understand the degree of specialization offered by these firms, one need only look at Data Innovations (DI) as an example. It's the leading global supplier of instrument interfaces. Such interfaces are a mission-critical component for the Beaker LIS as well as for the instruments sold by the major in-vitro diagnostic companies. As a make-or-buy decision, Epic and the IVD companies have decided that the domain expertise to develop instrument interfaces is such that they turn to DI to supply interfaces to their customers. The IVD companies, of course, have complete mastery over the development of the software/firmware necessary to operate their analyzers. However, their interest, enthusiasm, and market success for middleware, the software that sits between instruments and the LIS inducing interfaces and rules engines, has been limited over the years. 

There is no question that Beaker benefits from certain advantages in the LIS market, notably the desire of hospital executives to seek an "integrated" solution from Epic. On the other hand and as a major SLS vendor, Sunquest may seek to develop pathology and lab software products that may be too specialized or too market-limited for Epic to pursue. The following seven examples come quickly to mind:

• Physician portal and lab outreach software.
• Molecular pathology and cancer genomics software.
• Anatomic pathology automation software.
• Pathology consultation network software.
• Pathology and lab analytics software with emphasis on lab operations.
• Digital pathology software.
• Image analysis software.

What then is the take-home lesson from this discussion for lab professionals who may be in the process of considering the purchase of a new LIS? The pursuit of the maximum functionality from any software purchase is, as always, a key factor in such a process. Computers substitute for labor in in this era of value-based care and software is critical in the automation of most lab tasks. For an EHR/enterprise-wide solution deployment, many of the functionality and financial benefits may lie outside of pathology and the labs. In the final analysis, however, pathology departments will always need to develop a relationship with one or more SLS vendors, both large and small, to provide lab and pathology software and functionalities not offered by their EHR vendor. 

Do Clinical Pathologists Need to Be Located in Close Proximity to Hospital Patients?

A recent article discussed how the clinical pathology labs of the Department of Pathology of the University of Michigan Health System are now moving into new quarters in a former Pfizer research complex that had been purchased by the University of Michigan (see: U-M's North Campus Research Complex renovation plans move forward). Here are some of the relevant details:

In total, approximately 186,000 gross square feet of space will be renovated to provide a space for most of the U-M Health System's clinical pathology activities inside four buildings, renovating another 47,000 square feet of existing space....The new facility will occupy four vacant buildings at the NCRC, less than three miles from the main U-M medical campus. It will give U-M's clinical testing teams facilities that can continue giving patients and doctors high-quality test results they seek, faster and with higher reliability.

One of the most interesting questions prompted by such a move for the UM pathology department is whether moving the CP labs some three miles from the hospital will have a negative effect on patient care and departmental operations. I will put aside for now questions of whether the distant clinical pathology faculty can function optimally from an organizational and academic sense. We are all well aware of the value of having clinical pathologists consult with clinicians about lab test ordering and the interpretation of test results. I have no quibble with this idea. The question arises, however, as to whether such consultations need to take place physically or whether they can be accomplished remotely by simple voice communications via cell phones or more elaborate telepresence.

I recently had a long conversation with a senior employee of one of the largest IT companies in the world with employees scattered across long distances. The normal and customary way for the employees of the company to work is with telepresence. The company has deployed apps such that the company experts in any area can be accessed and integrated into any conversation when the need arises for their input. Clearly there is some skill involved in adroitly managing simultaneous conversations but this is often the case in busy patient care units now.

Therefore, the question at hand is not whether clinical pathologists at the University of Michigan with their labs some three miles distant from the hospital can and should be consulted via telepresence by clinicians when needed. The most important factor is whether the pathology leadership and the hospital executives have an interest in deploying the technology necessary to enable the broad use of telepresence for hospital consultations. By the way, such changes are not solely relevant for clinical pathologists but all consultations that occur daily in an academic medical center, even for physicians who may be a short stroll way from the inpatient beds. In the same way that e-consultation are critical for the future of ambulatory care, telepresence is curtail for increasing the efficiency of inpatient care.

Illumina, the Genomics Giant, Has Expansion Plans in Prenatal Screening

Illumina is the dominant genetic sequencing company that you may never have heard of. I have blogged about some of the company's plans in the past (see: Illumina Launches Company to Develop a Pre-symptomatic Cancer Test; IT Support for Cancer Genomics; Moving to Practical Clinical Solutions). A recent article provides more background about the company and its high-profile CEO (see: Meet The New CEO Of The $22 Billion Genomics Company You've Never Heard Of). Below is an excerpt from it:

Illumina casts a long shadow over the field of genomics, but it lacks the star power of a consumer-focused company like Silicon Valley genetic testing outfit 23andMe. That's because Illumina operates behind the scenes, selling hardware and services to companies and research institutions. But that's about to change if Illumina's new CEO, serial entrepreneur Francis deSouza, has anything to do with it....To date, some 90% of all human genomes ever sequenced were sequenced on Illumina's supercomputers, which range in size from that of a small fax machine to that of an office photocopier. In 2014, one of these machines—the HiSeq X—was the first to sequence the entire human genome for just $1,000, making it exponentially cheaper for researchers to gather genetic information for their studies...."Illumine has come to dominate the sequencing field," says medical geneticist Robert Green, who currently advises the Illumina spin-off Helix (see: Inside Illumina's Plans to Lure Consumers with an App Store for Genomes)....As it pushes ahead with executive changes and new ventures, Illumina is suing a startup called Oxford Nanopore, alleging patent infringement....But deSouza's ambitions reach far beyond the research world. With the help of the company's former CEO, Jay Flatley, he is embarking on an aggressive five-year plan to bring genomics out of research labs and into doctors' offices. This year, to the chagrin of the incumbent competition, the company is placing a bet on noninvasive prenatal testing, which involves screening pregnancies for Down's Syndrome and other common fetal chromosomal anomalies. Illumina is also pursuing its own oncology and forensics tests.

The notion of genetic testing in physician offices has been kicking around for years. I assume that the idea revolves around some sort of point-of-care (POC) device. Office prenatal testing for Down's Syndrome and other common fetal chromosomal anomalies makes a lot of sense. My only reservation to such a plan is that such POC devices need to be foolproof because there is so much riding on the results. The general problem with POC testing in physician offices is that there is frequently staff turnover and some of them may not be highly trained in the use of POC devices. I personally favor central lab control of prenatal screening within health systems. The turnaround time may be slower but I have more confidence in the quality control of such tests.

FDA Tightens Rules for E-Cigarettes and Cigars

I have posted a number of previous notes about e-cigarettes including suggestions that they need to be regulated more tightly (see: GlaxoSmithKline Lobbies Against E-cigarettes; Motivation for Company Clear; E-Cigarette Poison Center Calls Surge; E-Cigarettes Should Be Made Illegal). The sale of these "electronic devices" containing a vial of a highly toxic chemical, nicotine, has largely been unregulated. Now comes news the the FDA is tightening its rules on the product (see: F.D.A. Tightens Rules for E-Cigarettes in a Landmark Move). Below is an excerpt from the article:

The Food and Drug Administration made final sweeping new rules that for the first time extend federal regulatory authority to e-cigarettes, popular nicotine delivery devices that have grown into a multibillion-dollar business with virtually no federal oversight or protections for American consumers.The 499-page regulatory road map has broad implications for public health, the tobacco industry and the nation’s 40 million smokers. The new regulations would ban the sale of e-cigarettes to Americans under 18 and would require that people buying them show photo identification to prove their age, measures already mandated in a number of states. The rules also impose regulations on cigars. The regulations, which will take effect in 90 days, establish oversight of what has been a market free-for-all of products, including vials of liquid nicotine of varying quality and unknown provenance. Producing them has taken years. They stem from a major tobacco-control law Congress passed in 2009. They were first proposed in draft form in 2014....Perhaps the biggest proposed change would require producers of cigars and e-cigarettes to register with the F.D.A., provide the agency with a detailed accounting of their products’ ingredients, and disclose their manufacturing processes and scientific data. Producers would also be subject to F.D.A. inspections and would not be able to market their products as “light” or “mild,” unless the F.D.A. allowed them to. Companies would also be prohibited from giving out free samples.

One of my biggest concerns about e-cigarettes is that the manufacturers have been offering different flavors for "vaping" that have acted as an incentive to entice teenagers to develop a nicotine addiction. Here's more information about this form of addition (see: Is Nicotine Addictive?):

Research has shown how nicotine acts on the brain to produce a number of effects. Of primary importance to its addictive nature are findings that nicotine activates reward pathways...A key brain chemical involved in mediating the desire to consume drugs is the neurotransmitter dopamine, and research has shown that nicotine increases levels of dopamine in the reward circuits. This reaction is similar to that seen with other drugs of abuse and is thought to underlie the pleasurable sensations experienced by many smokers. For many tobacco users, long-term brain changes induced by continued nicotine exposure result in addiction.

Not Too Late to Attend the Pathology Informatics Summit; May 23-26 in Pittsburgh

It's not too late to make plans to attend the Pathology Informatics Summit which will be held in Pittsburgh on May 23-26. The conference is sponsored by the Association for Pathology Informatics. This is the only conference in the U.S. devoted to the very broad scope of pathology informatics ranging from digital pathology to LISs to clinical lab automation. You can review the entire schedule here. Registration on-site is available. The conference format consists of plenary and track lectures by some of the most prominent informaticians in the country, workshops, and "town hall" discussions. 

Most of the vendors supplying IT products and other services for anatomic pathology and the clinical labs will be present in the exhibitor ballroom. This will be your only opportunity to efficiently visit with all of them under one roof. Here's a list of the participants in the conference:

DIAMOND LEVEL

Sunquest Information Systems

PLATINUM LEVEL

Hamamatsu Corporation; Roche Diagnostics/Ventana Medical Systems

GOLD LEVEL

Faxitron; Leica Biosystems; SCC Soft Computer

SILVER LEVEL

American Society for Clinical Pathology; AP Easy; Association for Pathology Informatics; College of American Pathologists; Cortex Medical Management Systems; CytoSavvy; General Data Healthcare; Huron Digital Pathology; Indica Labs; Mikroscan; Milestone Medical; NovoPath; Omnyx; Optra SCAN ; Orchard Software; PathXL; Sakura Finetek USA; Sectra; Technidata; Visiopharm; Voicebrook

What's New about the Status of Google Fiber?

I had lost track of what was going on with Google Fiber but was brought up to date by a recent article (see: Google Fiber is the most audacious part of the whole Alphabet), Below is an excerpt from a long article on this topic. Read the whole piece if you are interested.

Google began digging up dirt and laying fiber optic pipes in Kansas City, Kan., five years ago in April. Its first customers were wired the following year. For the years after, it was unclear..just what Google wanted to accomplish with this first venture outside of its core business. Now it's evident: Google was using Kansas City as a testbed for an audacious project — one to take on broadband providers like Comcast, Time Warner Cable and Verizon, which enjoy long-held duopolies and monopolies across the country, and build out a national service....Google has to figure out how to become a nationwide broadband company. Kansas City may offer a road map....Google Fiber is now up and running in five markets...and has plans under way for 17 more....First, it has to figure out how to become a nationwide broadband company. Kansas City may offer a road map.....In recent months, Google Fiber branched out from the central city to more outlying suburbs. City officials told me Fiber is available to 210,000 households in Kansas City, Mo. — or roughly 80 percent of its population. Former Fiber employees said its pipes easily cover one million households in the entire metro area....People familiar with Fiber say it has hit its initial customer targets in its first three markets — selling broadband to about 30 percent of the homes it has hooked up for service, the industry standard for feasibility. Fiber brought in roughly $100 million in revenue last year, according to sources. Last month, the business embarked on the next wave of its strategy, starting in Kansas City again. It won approval to place special antennas on city light poles that could potentially beam broadband directly into homes, over the air. Fiber wants to start testing out the equipment in November and plans to have a network up and running by the end of 2017. Wireless is a big deal for Alphabet. If it works, it means it can deliver broadband without having to build out or buy fiber networks.

Regarding Google Fiber, one might ask whether it would be a better company to provide Internet access to one's home than Comcast, Time Warner, or Verizon? First of all, Comcast appears by all counts to be one of the most hated companies in America. This seems to be one of the reasons that its proposed merger with Time Warner fell apart partly (see: The Most Hated Merger in America). It thus would be reasonable to assume that almost any company would engender cheers if competing with Comcast and Verizon. Moreover, I personally hold Google in very high regard as do others (see: Google Tops Reputation Rankings for Corporate Responsibility). I would thus be enthusiastic about the direction that Google Fiber is headed. 

There is another key point to consider about Internet access from Google Fiber.The bulk of Google’s $66 billion revenue in 2014 came from its proprietary advertising service, Google AdWords (see: The Business of Google). Given that Google makes most of its money from advertising revenue, it will not necessarily want or need to squeeze its Google Fiber clients like Comcast does. One of the major goals of Google is to give people broader access to the Internet because this increases its advertising revenue. Time will tell if Google Fiber is able to charm its customers. At the very least, we can applaud its efforts to beam broadband into homes.

Using Aggregated EHR Data to Support Medical Research

Kalorama recently published "five things to know" about the EHR market. No item in the list is particularly surprising but one of them got me thinking (see: Kalorama: Five Things To Know About the Electronic Medical Records Market). Below is the list of five:

1. EMR is a $26.5 Billion Market: The market for electronic health and medical records is maturing rapidly, due to the influence of government incentives for the American Recovery and Reinvestment Act of 2009....  
2. Rise of Epic and Allscripts: Epic Systems continues to forge ahead landing sizeable contracts to implement their EHR system. Epic has picked up large and notable clients, including the Providence Network and most recently CVS Caremark Corp.  Allscripts Healthcare Solutions offers its software as a direct license product or as a SaaS product....
3. More Physician EMR Users: The growth rate in physician use of EMR varied from the years 2006 to 2015....At present, EMR usage is advancing – partially due to the threat of penalties from the government in the form of reduced payments from Medicare and other government payers.
4. Vendor Switches Drive Market Growth: Approximately 30 percent of hospitals with EMRs are dissatisfied with their purchase and several have looked into replacing their current vendor. Because the cost of changing systems is so high, many hospitals have resigned themselves to their current EHR system. The main reasons for dissatisfaction with the system they have include lack of key features, a cumbersome and complex interface, poor EHR usability, and bad hardware....
5. Ample Overseas Market:....The Nordic countries have the highest penetration rates but systems are outdated and in need of refreshment to meet the needs of advanced technology.  In China there have been numerous government challenges within the market.  Foreign vendors are concentrating on developing strategic alliances. Japan uses a standardized EMR product with little customization and it relies heavily on local competitors to supply needs. 

The idea of the growth of the international market for EHRs brought to mind the fact that EHRs, either domestically or globally, could and should be as a rich resource of data for medical research. I posted a recent post about how Mt. Sinai's Icahn Medical School was trying to exploit the value of its EHR database using "big data" analytic tools (see: Mount Sinai's Icahn School of Medicine Pioneers the Use of Big Data to Study Diabetes). It needs to be emphasized, however, that there are two barriers to using aggregated EHR databases for medical research. Most hospital executives don't have any particular interest or incentive to do so. They tend to view their EHRs only as a means to support hospital care rather than as a research tool. As a consequence, EHR CEOs are also not inclined to modify their systems to accommodate research. 

I will concede that in years past it was simply not practical to even envision research on millions of aggregated, complex, non-standardized medical records. However, "big data" research efforts may reverse such thinking. There is probably only one way that EHR vendors can be motivated to provide sufficient "granularity" to their databases such that the data can be shared and aggregated across hospitals for medical research. Such a requirement would need to be included in the RFPs generated by hospitals seeking to purchase EHRs. What, then, would be the incentive for hospitals to include such a requirement in their RFPs? For academic hospital systems, the research value of their EHR database alone might provide such an incentive. Another incentive for many hospitals might be the value of selling anonymized patient data to interested parties. This has not been a broadly accepted practice in the past due to patient suspicians but this might change in the future.

Slips, Trips, and Falls in the Elderly as a Major Cause of Mortality and Expense

I have been giving some thought lately to sarcopenia of aging. Below is a description of the condition (see: Sarcopenia With Aging):

From the time you are born to around the time you turn 30, your muscles grow larger and stronger. But at some point in your 30s, you begin to lose muscle mass and function, a condition known as ...sarcopenia with aging. People who are physically inactive can lose as much as 3% to 5% of their muscle mass per decade after age 30....Although there is no generally accepted test or specific level of muscle mass for sarcopenia diagnosis, any loss of muscle mass is of consequence, because loss of muscle means loss of strength and mobility. Sarcopenia typically accelerates around age 75 ...and is a factor in the occurrence of frailty and the likelihood of falls and fractures in older adults.

Slips, trips, and falls are a significant source of morbidity and mortality among the aged due to a decreasing sense of balance and gait but also attributable to muscle weakness and bone fragility as well as other factors (see: Falls and Older Adults).The primary treatment for sarcopenia of aging is physical training to increase muscle strength and endurance using weights or resistance bands. A few drugs are also being investigated for the treatment of sarcopenia but no miracle cures seem to be on the horizon (see: Sarcopenia With Aging): 

Here's some information about the frequency and cost of falls in the elderly (see: Falls in the Elderly):

Annually, 30 to 40% of elderly people living in the community fall; 50% of nursing home residents fall. In the US, falls are the leading cause of accidental death and the 7th leading cause of death in people ≥ 65; 75% of deaths caused by falls occur in the 13% of the population who are ≥65. In 2000, direct medical costs for fall injuries totaled $20 billion. By 2020, the costs are projected to reach $44 billion.

It's possible that modest gains in gait and balance can be achieved with the elderly by interventions (see: Gait and Balance Disorders in Older Adults):

Because most gait and balance disorders in older persons are multifactorial in origin, they usually require several modes of treatment to restore, maintain, or improve functional capacity. In most cases, it is unlikely that gait disorders are reversible; however, modest improvements in gait and balance may be achievable, and interventions may impact important functional outcomes, such as reduction in rates of falls, fear of falling, weight-bearing pain, and overall limitations in mobility. 

Human Longevity Creates a Likeness of a Person from His Genome

I attended the recent Executive War College held is New Orleans. One of the most interesting presentations was by Brad Perkins who is the chief medical officer of Human Longevity Inc (HLI). Details of his talk were summarized recently in the Dark Daily (see: World’s Two Largest Whole Genome Sequencing Programs Give Pathologists and Clinical Laboratory Managers an Intriguing Look at New Diagnostic Opportunities). Here is a quote from that article about the Perkins' presentation:

The first keynote presentation on large-scale whole-human genome sequencing was delivered by Brad Perkins, MD, Chief Medical Officer, at Human Longevity, Inc. (HLI) of San Diego, California....[HLI] was founded by J. Craig Venter, PhD, and two other innovators specifically to research the whole-human genome for the purposes of understanding how to foster wellness and extend the health lifespan of humans...HLI would do this by sequencing tens of thousands of whole-human genomes...HLI has already sequenced 25,000 whole-human genomes. It now has the world’s largest database of human genomes....HLI now has an intriguing capability. “Use of ‘machine learning’ to assess this data now allows us to predict the height, weight, and color of a person’s eyes,” explained Perkins. He then revealed to the audience another unimagined opportunity. “Using the genome, we are able to create an image of that individual’s face,” he added. Perkins then showed a graphic representation of the how one HLI researcher’s face would look. He then put up an actual photo of that researcher’s face. It was an extremely close match!

If a personal image can be developed from a person's DNA easily and relatively inexpensively, the forensic implications of such science will be astonishing. Criminals and terrorists often leave biologic material behind at the crime scene such as blood and saliva. Tissue from terrorists can often be acquired from the debris after bombings. It might also be possible using the same technology to generate images of rapists, for example. Their semen may contain white blood cells including T-lymphocytes (see: The biologic significance of white blood cells in semen). One interesting point and possible limiting factor about all of this, and stressed by Dr. Perkins during his lecture, was that the likeness generated from DNA by HLI is that of the individual at puberty and not later in life. 

One more point about HLI that I picked up from its web site in terms of its solutions: Our discovery team includes: streamlining drug development, discovery of biomarker and companion diagnostics, and rescuing/repurposing drugs from failed clinical trials (see: Products and Services). This latter effort may be under-appreciated but but has major economic and health implications. Thousands of drug candidates have failed clinical trials in the past because of undesirable side effects. It's possible that only some small fraction of the subjects in the clinical trial suffered such side effects but the drug may have been effective for the remainder. It may be possible using HLI's whole genome scanning technology to identify the subjects who suffered the side effects and exclude the others. The rejected drug could then be allowed to enter the market by the FDA if those patients receiving it are prescreened to exclude the adverse reactors. In summary, drugs previously failing a clinical trial may have future significant commercial value as a result of the use of whole genome scans as companion diagnostics. 

Can an Insurance/Health System Joint Venture Emphasize Preventive Care?

I recently posted a note in which I expressed skepticism about whether hospital executives would embrace e-health as a means to encourage patient engagement with a health system. My opinion was based on that fact that such executives historically seem to have had little appetite for preventive care because it was not remunerative (see: Facilitating Engagement of Consumers using E-Health Tools Like Twitter). I subsequently came across an article about the joint venture between Anthem and Aurora Health Care. Executives of the two organizations noted in a press release that health plans and providers, traditionally adversaries, are now finding that they need to work together (see: Anthem hatches another hospital joint venture, this time in Wisconsin). Below is an excerpt from the article:

Roughly 18 months after Anthem rocked the healthcare business community with a new provider-insurance alliance in California, the health insurer has formulated another similar project. Anthem and Aurora Health Care will co-own a new health insurance company. Anthem's Wisconsin subsidiary and Aurora, a 15-hospital system based in Milwaukee, will each own 50% of Wisconsin Collaborative Insurance Co., a newly licensed insurer. The joint venture somewhat resembles Vivify the health insurance product created in September 2014 by Anthem's California subsidiary and seven Southern California health systems, including academic medical centers Cedars-Sinai and UCLA. The latest joint venture is further evidence that health plans and providers, traditionally adversaries, are finding that they need to work together to adapt to the delivery system reforms baked into the Affordable Care Act. Organizations are looking for ways to slow healthcare spending, improve clinical quality and patient satisfaction, and reward hospitals and doctors that do both. While efforts like Anthem and Aurora's company offer fresh takes on the country's healthcare cost and quality problems, executives still have to prove their ideas lead to real-world results....The Wisconsin Collaborative Insurance Co. will offer a commercial health plan called Well Priority to fully insured and self-insured employers. 

Here's a quote from another article that presented the advantages of this new joint venture (see: Anthem and Aurora form joint venture insurance company):

...John Foley, Aurora’s senior vice president of business development and president of the new company, and Larry Schreiber, president of Anthem’s Empire BlueCross BlueShield health plan and the new company’s CEO, outlined the philosophy behind the joint venture.“Today most of our care is sick-care,” Foley said....[We] seek to turn this around by combining Aurora’s delivery system and Anthem’s expertise. By integrating clinical and claims data, professionals will identify gaps in care. This will help WCIC better manage populations around their health.”In other words, the company will focus on patient wellness and preventative care instead of the traditional focus on acute care for sick patients. In theory, the strategy could reduce the number of claims filed with the insurance company, thereby lowering rates.

There is no question that an emphasis on patient wellness and preventative care can reduce insurance claims and therefore the cost of insurance (see: Cleveland Clinic Lowers Health Insurance Costs with Preventive Medicine). In theory, this makes sense as a rationale for the joint venture. There are two reasons why I think this stated goal may be merely public relations fluff to justify the merger and to make more money the only fashioned way: generating billable services from the merged and larger organization:

• I don't view provider health systems or health insurance plans as particularly flexible or innovative organizations. Greater emphasis on preventive medicine will require such ingenuity. I will be interested in watching whether this new joint venture can move in a new and somewhat radical direction.
• There is no question that preventive medicine can reduce the number and size of claims filed. This will help the insurance arm of the new joint venture but reduce the earnings of the provider arm, Aurora. This would seem to inevitably lead to friction between these two units in terms of how to conduct their business and perhaps a breakup of the joint venture.