Lab Soft News

Use of the Term "Unpatient" Instead of Healthcare Consumer

I first heard the term "unpatient" used by David Maizenberg who, with Leonard Kish, appears to have coined it in late 2014. They developed a manifesto about access to one's own health data that is available on the web: Health Data Ownership Manifesto. The thinking underlying the idea of the unpatient is that the new generation of healthcare consumers are motivated to collect their personal health data and pursue wellness, thus avoiding diseases when possible (see: The Democratization of Healthcare; Eric Topol's Perspective; "Unpatient" Health Data Ownership Manifesto; An Idea Whose Time Has Come). I have blogged extensively about lifestyle diseases which are often preventable such as obesity, adult-onset diabetes, and cardiovascular disease (see: The Secret to a Healthy Life; Few Americans Would Qualify; Major Transformational and Disruptive Changes That Will Affect Healthcare; Changes in the Cause of U.S. Deaths; Insights into Preventable Diseases). 

I believe that patients should exercise more control over their personal health data (see: Who Owns EHR Data? What constitutes proper data stewardship?) but I also want to briefly discuss the term unpatient from a slightly different perspective. For the more than ten years I have been publishing Lab Soft News, I have been using the awkward term healthcare consumers when I referring to individuals who were not sick or under the direct care of a healthcare professional. I think that the term unpatient is preferable to healthcare consumers because it refers to people generally free of disease but also with a keen interest in preserving their wellness through individual lifestyle choices. 

Whether or not the term unpatient gains favor, the movement toward wellness is irreversible. Major adjustments will be required in order to engage the entire healthcare industry in this pursuit. Our healthcare professionals are generally trained and focused on the diagnosis and treatment of disease and they are compensated for it by the current system. We need to take steps to reward them for the pursuit and preservation of wellness. In other words, we need more attention paid to the needs of unpatients. 

Enlisting a Large Cohort of Citizen Scientists for Precision Medicine Research

Dr. Eric Topol, director of the Scripps Translational Science Institute (STSI), is recognized as a national leader in digital healthcare. I follow him closely on Twitter and his tweets about various aspects of healthcare are always outstanding. He and Scripps have recently been awarded a $120 million grant for a totally new type of research involving "citizen scientists" (see: Scripps Research gets $120 million to change medicine). It is anticipated that the granular biomedical data will be captured and analyzed from one million American volunteers who represent the entire gamut of medical conditions and diseases. Below is an excerpt from the article:

Dr. Eric Topol will co-lead the effort to enroll and engage 1 million Americans in a study that will deeply explore people's health and regularly provide them with information that they can share with their doctors. The $120 million grant from the National Institutes of Health is part of the Obama administration's Precision Medicine Initiative, which will customize patient care through big advances in digital technology.Topol is one of the nation's best known digital medicine advocates. The Scripps Research Institute professor has been pushing medicine to use mobile sensors and smartphone apps to monitor and treat patients. He's also pushed doctors to tie treatment to a broader range of data, ranging from a person's genome to their diet to the air quality in their neighborhood and the microbes in their gut.

Topol's interests are reflected in the NIH's new all-volunteer study, which will last at least five years. People will use mobile and web apps to register and participate. The "citizen scientists" will be able to upload a wide variety of data, including blood pressure, heart rhythm, glucose levels and sleep and exercise patterns....Many people will be asked to give blood and urine samples so scientists can study their biological makeup, especially their genes, proteins and microbes. People who are served by certain health care providers also can have the companies upload their electronic medical records. Blue Cross Blue Shield and Walgreens clinics are among the companies that have agreed to help with the study. The San Diego Blood Bank will help collect blood samples. Apple and Verizon will spread awareness about the campaign. And San Diego's Qualcomm will help with the app's data security.The NIH will crunch this large volume of data to better understand the nature of illness and disease.

Here's a definition from the Wikipedia for citizen scientist (see: Citizen science): A member of the general public who engages in scientific work, often in collaboration with or under the direction of professional scientists and scientific institutions; an amateur scientist. From one perspective, one might suggest the one million American volunteers in the Scripps project are only permitting their personal health data to be analyzed rather than directly engaging in medical research. Therefore, to call them citizen scientists may be a bit of an exaggeration. However, I have come to believe that the term will be truly relevant for them. As this project evolves, I suspect that many of the participants will play an active rather than passive role and help to determine the direction of the project. Patients will thus help to determine the direction of precision medicine.

Needless to say in this age of sophisticated computer hackers, the STSI database will offer an appealing target for mischief (see: Hospital Records Commonly Being Hacked and Sold for a Premium on the Web). I will assume that extreme care will be taken to ensure that it will be secure. Note the involvement of Qualcomm in the project regarding computer security. In order to convince an expected one million "citizen scientists" to allow access to their personal health data, they will need assurances that it will be secure. It may actually end up being more secure than the data in their own home hospital systems.

Researching the Cost of Stellara, a Drug Used to Treat Plaque Psoriasis

Everyone understands that the cost of many drugs has risen to atmospheric levels. The current levels have the potential to bankrupt our healthcare system in short order (see: How Do We Deal With Rising Drug Costs?). Here is a quote from an article proposing some ways for addressing this problem:

According to a recent report by federal health officials, prescription-drug spending rose 12.6% in 2014, the latest year for which data are available, and it is expected to rise 7.3% a year through 2018. Big drug-price increases have triggered congressional investigations, criticism from both Republican and Democratic presidential candidates, and exploration of potential remedies.

I have been noticing numerous advertisements on MSNBC lately for Stellara. It's a prescription monoclonal antibody that targets interleukin 12 and interleukin 23 and is manufactured by Jannsen Pharmaceutical and approved to treat adults 18 years and older with moderate or severe plaque psoriasis that involves large areas or many areas of their body. It's administered as a 45 mg or 90 mg injection under the skin as directed by a physician at weeks 0, 4, and every 12 weeks thereafter. I thought that it might be of interest to the readers of Lab Soft News to research the cost of this drug.

As a quick aside, I have previously posted a number of notes about direct-to-consumer drug advertising (DTC) advertisements (see: Effectiveness of "Direct-to-Consumer" Drug Advertisements; It's Time for the FDA to Prohibit Direct-to-Consumer Advertising by Pharmaceutical Companies; Pressure Mounting to Ban Pharmaceutical Direct-to-Consumer Ads). I personally believe that such advertisements should be banned. DTC television ads are a pure marketing ploy to convince consumers to request treatment by their physicians, often inappropriately. I don't think that they contribute to healthcare consumer well-being.

Spurred on by these DTC adds, I was curious about the cost of Stellara and discovered a web site, GoodRx that provides information about the cost of drugs. Here's a cut-and-past from this web site about its purpose:

Drug prices vary wildly between pharmacies. GoodRx finds the lowest prices and discounts....Collect and compare prices for every FDA-approved prescription drug at more than 70,000 US pharmacies....Show the lowest price at each pharmacy near you.

According to Good Rx, the retail cost of one syringe of 45 mg. of the drug varies from $8,812 to $9,399. The cost of the drug for about the first year, including, the two loading doses, would be about $54,000. Plaque psoriasis is a severely disfiguring disease. I am not suggesting here that it should not be treated. My only point is that the retail cost for this monoclonal antibody is beyond the capacity of consumers to pay for it without insurance. Unfortunately, I do not believe that we will see any legislation in the near future to curb drug costs.

One short term solution to the high cost of drugs like Stellara might be the emergence of biosimilars. Biosimilars are defined as: a biological product that is approved based on a showing that it is highly similar to an FDA-approved biological product, known as a reference product, and has no clinically meaningful differences in terms of safety and effectiveness from the reference product (see: Information on Biosimilars). At least for monoclonal drugs, biosimilars may introduce more competition into the marketplace. 

Hospital Records Commonly Being Hacked and Sold for a Premium on the Web

Hospitals are often the target for ransomware attacks (see: Hospitals and Ransomware; How Should Hospitals Protect Themselves?). In a recent note, I discussed a software product that could theoretically help to protect hospitals from this threat (see: Israeli Software Designed to Protect Hospital Data from Ransomware). It has been suggested by a cybersecurity think tank in a recent article that "some 47%" on Americans have had their medical records hacked in the last year (see: On The Dark Web, Medical Records Are A Hot Commodity). Below is an excerpt from that article:

More than 113 million medical records were hacked in 2015 alone....A newly released report from the Institute for Critical Infrastructure Technology, a cybersecurity think tank, found that some 47% of Americans have had their medical record hacked in the past 12 months....But why are medical records now such a hot commodity for hackers and thieves?....On the dark web, medical records draw a far higher price than credit cards. Hackers are well aware that it's simple enough to cancel a credit card, but to change a social security number is no easy feat. Banks have taken some major steps to crack down on identity theft. But hospitals, which have only transitioned en masse from paper-based to digital systems in the past decade, have far fewer security protections in place. On the dark web, complete medical records typically contain an individual's name, birthdate, social security number, and medical information. These records can sell for as much as (the bitcoin equivalent) of $60 apiece, whereas social security numbers are a mere $15. Stolen credit cards sell for just $1 to $3....[T]hese medical records can be leveraged for a wide variety of nefarious purposes. In some cases, it's about stealing a person's identity and billing them for a surgery or a prescription, and in others it's about opening a new line of credit....Moreover, important information on the patient's medical record will often be deleted, like an allergy to penicillin, or new entries added. In some cases, it's intentional. But it's more often a by-product of the theft.

It appears to me that hospital and healthcare information systems are particularly vulnerable to ransomware and hacking. As I discussed in a previous note about phishing (see: Hospitals and Ransomware; How Should Hospitals Protect Themselves?, part of this vulnerability is attributable to the large number of hospital personnel with access to health records, many of whom may not be that sophisticated about IT. I am not sure if healthcare systems differ from other those in other industries in terms of vulnerabiliy. At the very least, I think that hackers believe that this is the case. 

The article under discussion here indicates that stolen health records are of greater monetary value on the dark web than other records in the sense that the stolen information can be "leveraged" for extra illegal gains. One such strategy is apparently to determine that a patient has some balance on his or her hospital account and then falsely bill the individual for it. At the very least, this same approach would be a means to illegally coax a credit card number from the person. The conclusion that I draw from all of this is that the healthcare industry has a long way to go in terms of making hospital systems immune from hackers and viruses. This means spending more money and hiring the best talent to protect the systems.

Israeli Software Designed to Protect Hospital Data from Ransomware

Ransomware has become an increasingly important threat to hospitals as detailed in one of my recent notes (see: Hospitals and Ransomware; How Should Hospitals Protect Themselves?). An Israeli software company, Votiro, has been said to come up with what appears to be a solution to protect hospitals from ransomware. All of this was detailed in a recent article (see: Israeli system keeps hospital data safe from ransomware). Below is an excerpt from it:

Hospitals are no more vulnerable than anyone else to malware [such as ransomware], because most of it is delivered not through high-tech means that good cyber-defenses could protect against, but by decidedly low-tech phishing methods in which hackers send out scam emails with links or attachments loaded with a malicious payload that, once delivered, can quickly compromise a system. Hospitals, though, have more at stake than many other organizations, since they are accountable to patients, insurance companies, and government regulators....Votiro’s system prevents that malicious payload from getting onto a system in the first place. The company’s system “neutralizes” exploits by dissecting and reconstructing attachments and files that are sent in phishing messages – messages that appear to be legitimate, possibly from managers, friends, or other trusted sources. Unwitting recipients open these attachments and infect their own computers and networks, but Votiro then steps in, keeping those attachments in a special area where they can be checked, the problematic code can be removed and the legitimate data forwarded to the recipient. According to Votiro, it’s the only way to protect systems, as relying on the good judgment of users is not an option....The temptation to click on important-looking attachments is too great, according to this assessment; the best way to protect users from rogue files and attachments is to keep them away from users in the first place.

Hospital computer systems are often contaminated by ransomware using so-called phishing methods whereby hospital employees are persuaded to click on a link or innocently open an email attachment containing a computer virus. As explained in the excerpt above, hospitals cannot rely on the continuous good judgment of their computer users in such matters. The phishing emails are designed so that the recipients mistake them for important information relevant for their jobs and then click on a link or open an attachment to infect the system. 

Votiro's software is said to "neutralize” malware software by dissecting and reconstructing email attachments and files that are embedded in phishing messages. I can't vouch for the quality of the software but the approach seems to be the correct one. Don't allow email into employee's in-boxes that poses even a remote threat of contamination with a virus. I suspect that sanitizing all inbound software has substantial costs in terms of the need for more computing power or delays in the delivery of email but, right now, there seems to be no better solution to this problem.

New CEO at ARUP Recruited from the Pharmaceutical Industry

The recent choice of a new CEO for ARUP Labs was of interest to me (see: ARUP Laboratories Announces New CEO). Below is an excerpt from the announcement:

ARUP Laboratories announced...that Edgar Braendle, MD, PhD, has been named CEO....Prior to joining ARUP, Braendle held multiple leadership roles at Novartis Pharmaceutical Corporation and Schering AG. Most recently, he was senior vice president and global head of Companion Diagnostics at Novartis....Dr. Braendle received his medical degree at RWTH Aachen University in Germany, followed by specialty training in medical oncology, urology, and pharmacology. As an associate professor at the University of Ulm, he led a research laboratory funded by the German Research Foundation and a phase-I clinical trial unit

ARUP is one of the most prestigious reference labs in the country so their choice of a CEO is important for the industry at large. I was interested in Dr. Braendle's resume because of his previous positions at two major pharmaceutical companies, Novartis and Schering. At Schering, he served as global head of Companion Diagnostics. 

It's relevant to this discussion that LabCorp, one of the two dominant reference labs in the country along with Quest, purchased Covance in 2015 (see: LabCorp to Acquire Covance for $6.1B). Covance is the major reference lab supporting clinical trials and contract research. Here are links to some my previous blog notes about Covance (see: Covalence's Execution of a Global Virtual Clinical Lab; Covance Genomics Lab Receives CLIA Certification; Covance Signs Clinical Research Deal with Indiana University School of Medicine). Below is an excerpt from the article above commenting on the Covance purchase by LabCorp:

The acquisition leverages LabCorp's leadership in medical testing and Covalence's leadership in contract research, they said, and the combined firm's technologies will improve patient recruitment for clinical trials, improve efficiency in clinical trials, and deliver data more quickly to drug sponsors, physicians, and patients....The increased scale of its central lab operations and collective data resources are expected to drive greater R&D productivity for its clients, they said.....Managed care revenues will comprise about 32 percent of the combined firm's total revenues, while pharmaceutical and biotechnology business will comprise about 29 percent of revenues. About 22 percent of revenues will derive from commercial customers, 12 percent from Medicare and Medicaid, and 5 percent from private patients. The new firm will have established relationships with all of the top 20 drug firms and an "attractive payor mix," LabCorp and Covance said.

By turning to a former pharmaceutical executive as its CEO, ARUP is signaling the importance in its business model of clinical trials and companion diagnostics. The pharmaceutical industry is a key player in what has been called Big Medicine along with large hospital systems, health insurance, pharmaceutical benefit managers (PBMs), and the dominant healthcare payers like the federal government (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; The Institutionalization of Healthcare; Consequences of Big Medicine?; "Big Medicine" Players Squabble among Themselves). The fact that major reference labs are now tilting more toward work related to the pharmaceutical industry bespeaks an acceleration of this trend.

Avalanche of New Cancer "Products" Will Confront the FDA

Cancer diagnosis and treatment is booming (see: What is cancer immunotherapy?) and the FDA is adapting to these changes with an organizational change. A recent article discussed a recent major organizational shift at the agency (see: Top Officials Aim To Reshape The FDA To Prepare For 'Avalanche' Of Cancer Products). Below is an excerpt from the article:

For 20 years, Richard Pazdur has run the office of the Food and Drug Administration charged with evaluating new cancer drugs, guiding the pharmaceutical industry as the business of oncology went from a relative backwater to the main event....[A]s part of the $1 billion National Cancer Moonshot effort being run by Vice President Joseph Biden, Pazdur was elevated to a new role: running a new Oncology Center of Excellence that will coordinate all of the FDA’s clinical efforts in cancer. Cancer medicines now account for 40% of the drugs under development, but the current revolution–that’s the word most doctors use–going on in cancer care doesn’t just involve drugs. Previously, Pazdur had authority over the pills and antibodies developed by companies like Roche, Merck and Bristol-Myers Squibb. But diagnostic tests, from firms like Illumina and Foundation Medicine, are likely to be just as important. And now companies like Novartis , Juno Therapeutics and Kite Pharmaceuticals are developing genetically engineered cells that hunt down and kill cancer–products that would be reviewed by yet another FDA division....

[P]harmaceutical companies, which a few years ago worried that their drug pipelines had run dry, are now filing drug applications at a dizzying pace....[N]ew technologies like DNA sequencing and 3-D printing, and there is an “avalanche” of new products coming....Not all of these new products will work. Nine in ten cancer drugs that enter human trials don’t make it to market because they are unsafe or ineffective....As with so much in drug regulation, the questions now are bureaucratic–organizational. Pazdur will be replaced as the acting head of the oncology drug division by someone who has yet to be named. The cell therapy and diagnostics divisions will still handle their own approvals. But Pazdur says he wants to share the expertise of the dozens of oncologists who work in the FDA’s drug division with those other groups. It’s not clear exactly how, and there’s no specific timeline, but he talks about thinking about it over the next month.

It's hard to totally grasp the changes that have taken place in the diagnosis and treatment of cancer in recent years. One fascinating statistic, cited in the article above, is that cancer now accounts for 40% of the drugs under development. Part of the incentive for pharmaceutical companies to develop anti-cancer drugs, obviously, is that the price of these new cancer drugs, and therefore company profits, can be overwhelming (see: 5 Freakishly Expensive Cancer Drugs). On the diagnostic side, cancer genomics is leading to scenarios unimagined a few years ago such as the definitive diagnosis of cancer with so-called liquid biopsies, avoiding surgical biopsies (see: Liquid Biopsy Predicts Colon Cancer Recurrence). Genomic analysis of cancer cells can often assess the prognosis of a lesion for the patient and avoid debilitating and unnecessary treatment. I must say that it's encouraging that the FDA is trying to keep one step ahead of all of these changes with the creation of its Oncology Center of Excellence. Obviously, all of the publicity for Vice-President Biden's "moonshot" program provided some of the impetus for these changes at the agency (see: Cancer Moonshot). 

For-Profit IRBs Replacing Volunteer Hospital Boards to Oversee Clinical Trials

As someone who has served on a hospital IRB for a number of years and greatly respected the work of the committee, I was surprised to learn that "commercial boards" are rapidly replacing the volunteer IRBs in hospitals and now dominate the clinical trial process (see: In clinical trials, for-profit review boards are taking over for hospitals. Should they?). Here are some of the details from the article:

Institutional review boards [IRBs] — which review all research that involves human participants — have undergone a quiet revolution in recent years, with many drug companies strongly encouraging researchers to use commercial boards [such as WIRB-Copernicus Group], considered by many more efficient than their nonprofit counterparts. Commercial IRBs now oversee an estimated 70 percent of US clinical trials for drugs and medical devices. The industry has also consolidated, with larger IRBs buying smaller ones, and even private equity firms coming along and buying the companies....But even if the tide has already turned, the debate over commercial review boards ....continues to swirl. The debate could also intensify. Late last month, the National Institutes of Health announced that US-funded trials that are carried out at multiple research centers must begin using a single IRB, with few exemptions possible. Because few universities or hospitals have the capacity to review study protocols and track adverse events for far-flung institutions, the new rule is expected to be a windfall for commercial IRBs. 

The modern history of science is littered with studies in which participants were harmed because researchers failed to take necessary precautions.....But some experts say the risks [of harm in clinical trials] are far greater with commercial review boards, which often have harder-to-spot conflicts of interest and a profit motive. The Food and Drug Administration reported twice as many violations and problems with commercial IRBs as with nonprofit boards from 2008 to 2014, according to preliminary findings in a recent study,....Mark Schreiner, a medical school professor and vice chairman of the IRB at Children’s Hospital of Philadelphia, said he is uncomfortable outsourcing the evaluation of pediatric trials to commercial review boards.“IRBs are hired by the sponsor,” Schreiner said. “They are paid by them. And so if they turn down the study, then I think they’re unlikely to get repeat business.

Here's a brief definition of the work of an IRB (see: Institutional review board):

A committee used in [connection with medical] research in the United States that has been formally designated to approve, monitor, and review biomedical and behavioral research involving humans. They often conduct some form of risk-benefit analysis in an attempt to determine whether or not research should be done. The purpose of the IRB is to assure that appropriate steps are taken to protect the rights and welfare of humans participating as subjects in a research study.

My own view about all of this is that it's a major step backward and another step in the "industrialization" of healthcare and medical research (see: The Significance and Relevance of the "Industrialization" of Healthcare). Here's a quote from this previous note about the prerequisites of industrialization: (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. IRBs are tasked primarily with the protection of the rights of research subjects enrolled in clinical trials. As described perhaps too delicately in the quote above, commercial review boards may be subject to hard-to-spot conflicts of interest and their profit motive. Put more bluntly, there is the serious risk of a compelling financial relationship between the pharmaceutical companies and the commercial IRBs with the research subjects caught in the middle and in peril. The dominant goal of pharmaceutical companies is to successfully complete drug trials, obtain FDA approval, and bring their products to market. Unlike volunteer hospital IRBs, concern for subjects is not their primary concern.

It came as no surprise to me that, according to the article, the NIH is now requiring that a single IRB oversee trials carried out in multiple centers. Also, as noted above, such a rule plays into the hands of the commercial IRBs. Multi-center trials are common for studies for which it is difficult to enroll sufficient subjects from a single hospital. This decision by the NIH makes perfect sense in terms of administrate simplicity for the it given that academic centers have each evolved some of their own IRB rules and bureaucracy. The rule will surely streamline then process of managing and completing multi-center trials. Unfortunately, administrative simplicity will be achieved by creating a duopoly consisting of commercial IRBs and drug companies with the health and well-being of research subjects at risk.

Bundled Payment Web Site Appeals to Self-Pay and HDHP Consumers

Many employers are now providing high deductible heath plans (HDHP) to their employees with lower monthly cost to the companies but with a catch -- the employees need to pay more of the healthcare costs themselves (i.e., the deductible) before the insurance company covers anything. HDHPs have begun to stimulate consumers to shop for lower priced healthcare services. The Dark Daily recently discussed bundled pricing which provides the opportunity for consumers to save money on healthcare (see: More Providers and Payers Use Bundled Pricing to Serve Patients with High Deductibles in a Trend That Has Financial Implications for Clinical Laboratories). Below are some of the details from the article:

With so many people seeking more economical choices for their healthcare needs, providers, hospitals, and health insurers are exploring the options bundled pricing offers. One new twist in the healthcare marketplace is a type of company that specializes in negotiating bundled healthcare options that service the self-pay market. These companies make their offerings available to patients through websites designed specifically to be searched by patients who want to select healthcare providers based on cost and performance. One example of this new type of company is MDSave....Launched in 2012..., the MDSave website offers patients discounts of as much as 60% on medical care, including office visits, surgeries, and X-rays. The self-proclaimed “world’s first healthcare marketplace” does this by collaborating with hospital groups and ambulatory surgical centers to negotiate discounted rates for various services with hospitals and doctors. It then packages those services into a single bundle. On their website, patients can shop for hundreds of procedures, including elective surgeries and routine care. Users also can read reviews and compare pricing for local providers before selecting their best option. Patients then pay up front for needed services, with all fees combined into one bundled price. When a purchase is made through MDSave, the chosen doctor’s office is notified and the patient is contacted to schedule an appointment. The bundled price includes all costs for medical personnel, the facility, and any related services, ensuring there will be no additional medical bills for the patient.that is paid by patients. It may mean negotiating their share of the bundled payment in competition with the hospitals, physicians, radiology labs, and other providers that are part of that same bundled service.

The MDSave web site makes clear the advantage of bundled pricing (see quote below). In case you were wondering, the amount spent obtaining care from an MDSave providers is usually applied to the health insurance deductible but insurance companies will have different eligibility requirements.

An MRI, for example, can include an imaging fee, a radiologist’s fee to read the images, and the hospital’s facility fee. By bundling these costs, MDsave eliminates the multiple bills patients may receive for each fee. In addition, through our relationships with trusted hospitals and doctors, we are able to offer discounted rates, with savings up to 60%.

It occurred to me that some large percentage of consumers who choose HDHPs might not be able to afford the up-front payment required by MDSave. After all, many choose such plans to reduce the monthly cost for health insurance. The company has a solution for this which is described in the following way on the web site (Patient Financing):

MDsave has partnered with Prosper to help patients purchase out-of-pocket expenses associated with procedures. We provide access to simple interest installment loans to ease the financial burden of medical expenses. Prosper offers access to low monthly payments on loans for all MDSave procedures for amounts between $2,000 and $35,000. After receiving funds, call MDsave to get your procedure voucher.

The choice of providers seems to be quite limited at the MDSave web site currently. To seek a "flu shot, colonoscopy, CT scan" (one heterogeneous category offered by the web site), I was directed to a medical center in a small town in Ohio 178 miles from my home. I suspect that prestigious hospitals and clinics will not want to participate in this bundled payment system at the present time but this may change in the future as the competition heats up (see: Anthem Blue Cross of California pilots bundled payments on breast cancer treatment).

The Teleconsultation App: An Unmet Software Need in Hospitals

In a previous note, I raised the question about whether pathologists need to be physically located in close proximity to hospital patients to facilitate consultations with the clinicians caring for patients (see: Do Clinical Pathologists Need to Be Located in Close Proximity to Hospital Patients?). I further suggested that there was a need in hospitals for a teleconsultation app that would make it easy for clinicians to launch a short audio + video conversation with a pathologist. The use of such an app, of course, would not be restricted to pathologists but could be used by any specialist in a hospital including, of course, radiologists. Below is a quote from that note:

...[T]he question at hand is not whether clinical pathologists...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.

Why would a teleconsultation app be necessary for hospital physicians? Would it not be possible for physicians caring for a hospitalized patient to, say, merely make a phone call to the pathologist or even send an instant message? Here is a list of features that I think would make such an app useful in a hospital setting in lieu of a phone conversation or an IM:

• Rapid and easy access to the EHR as well as pathology and radiology reports and images located in the LIS, RIS, or PACS so that the consultant and inquiring clinicians could simultaneously view the same data.
• Some sort of system so that the hospital consultants could enter their availability at any time and also the names of other specialists who could be contacted with a question in their absence.
• A system for assigning the "degree of urgency" of a consultation request so that the requesting physician could break through a "busy" status of a specialist in case of an emergency.

I am particularly interested in this teleconsultation app with regard to inquiries to pathologists and radiologists. I have the impression that pathology and radiology reports may sometimes be ambiguous and prompt questions is the minds of the clinician receiving the report. However, contacting the pathologist and radiologist may be viewed as too time-consuming. The quality of communication might improve with an app to reduce the "friction" of making such an inquiry. In short, I want to break down the barriers that impede optimal communications between clinicians and their diagnostician colleagues.