Lab Soft News

Dissent Roils the AMA; Some Possible Reasons for the Problems

Winds of change are sweeping through the executive offices of the AMA. A recent article provided some details about what's happening in this major medical organization (see: Dissent roils the AMA, the nation’s largest doctor’s group). Below is an excerpt from it. You may also want to read: Trump’s Health Secretary Pick Leaves Nation’s Doctors Divided. 

...[M]edicine is a house more divided than ever. The AMA still has more clout....than the scores of medical specialty societies and splinter groups that sort doctors by political leanings. But it counts fewer than 25 percent of practicing physicians as members, down from 75 percent in the 1950s. And the association infuriated many doctors recently with its quick endorsement of President-elect Donald Trump’s choice for secretary of health and human services — Representative Tom Price, an orthopedic surgeon-turned-congressman who’s led the charge to overturn Obamacare. Just two weeks earlier, the AMA’s House of Delegates had reaffirmed the association’s support for coverage expansions under Obamacare....Just hours after Trump named Price as his pick to head HHS, the AMA’s board of trustees put out a strong statement of support. Controversy erupted immediately. Within days, more than 700 AMA members had signed a letter protesting that endorsement as “divisive.” A separate petition accusing the AMA of disregarding patients’ needs drew 5,500 physician signatures. Dr. Patrice Harris, board chair of the AMA, found herself in the hot seat. In a recent phone interview, Harris said the organization’s endorsement of Price doesn’t signal that the AMA has backed off its support for Obamacare....The association has spent $347 million lobbying since 1998 — more than any other company or group except the US Chamber of Commerce and the National Association of Realtors, according to the Center for Responsive Politics. Still, scholars agree that the association’s clout has declined over the last 30 years as specialty societies rose in prominence, health care costs soared, managed care became more prevalent, and physicians’ allegiance to the organization diminished.

One of the major problems for the AMA is that physicians are increasingly leaving private practice to work for hospitals. Private practitioners are the core supporters of the organization. Here are some of the reasons cited by physicians for the declining popularity of private practice from a 2012 study (see: More Data on Physicians Leaving Private Practice; Discussion of Findings):

• The majority (87 percent) of physicians surveyed cited the cost and expense of running a business as a chief concern.
• Most doctors (65 percent) joining health systems said they expect to make the same or less compensation than in private practice.
• Sixty-one percent cited business operations as a main reason for seeking hospital employment rather than remaining independent.
• More than half of doctors (53 percent) cited electronic medical record requirements as a main reason for leaving private practice.

Accenture reported in July 2015 that the number of independent physicians in the U.S. has declined over the past several years from 57% in 2000 to 49% in 2005. The firm predicted that in 2016 this number will drop to 33% and represents a 10% decline from Accenture's 2012 report (see: Many U.S. Doctors Will Leave Private Practice for Hospital Employment). The majority of physicians are now health system employees. As such, they will undoubted turn to their speciality medical societies for professional and scientific information but must cede most financial and economic decisions to the executives of their hospital employers.

I believe that the membership and political influence of the AMA will inexorably decline. Like labor unions, these organization are roadkill for major structural and economic forces that are outside of their control. It seems to me that that there are two strategies that the AMA could pursue in order to retain some of its former influence and prestige. One would be to align its strategy and interests with those of large health systems but they already have their own lobbying organizations. The second would be to develop professional societies or merge with existing ones that appeal to physicians. This latter approach would probably not be attractive to current speciality societies who would see little gain in such an approach and who also relish being independent.

Tug of War between Hospitals and Surgicenters for Knee Replacements

In blog note posted last June, I raised the issue of outpatient knee replacements and the competition for these procedures that exists between hospitals and surgicenters started by orthopedic surgeons (see: Joint Replacement in Ambulatory Care Clincs; A Major Financial Threat to Hospitals). In that note, I suggested that surgicenters are often able be able to perform these procedures less expensively and suggested the following reasons for this difference:

• Such clinics [i.e., surgicenters] enjoy the advantages of cherry-picking the healthier and lower-weight patients who can tolerate short clinic stays.
• Because free-standing clinics are highly specialized, they can invest in the latest technologies and surgical techniques and focus on refining their techniques.
• Free-standing clinics do not have to bear the cost of maintaining money-losing units such a critical care units as is the case of general hospitals.
• As much smaller business units, these clinics are often more nimble and innovative than the often sluggish community hospitals.

The issue is continuing to brew as discussed in a recent article (see: Tug of war emerging between hospitals, surgery centers over knee replacements). Below is an excerpt from it:

Medicare, which spends several billions of dollars a year on knee replacements for its beneficiaries..., is contemplating whether it will help pay for knee replacement surgeries outside the hospital, either in free-standing surgery centers or outpatient facilities. The issue is sowing deep discord in the medical world, and the debate is as much about money as medicine. Some physicians are concerned that moving the surgeries out of hospitals will land vulnerable patients in the emergency room with uncontrolled pain, blood clots or other complications. But proponents of the change say it can give patients more choice and potentially better care, as well as save Medicare hundreds of millions of dollars....The final decision, which could come within a year, would also act as a test of sorts for Donald Trump and his new administration. They will weigh whether to limit government controls..., or to bend to pressure from hospitals and doctors, many of whom oppose the change.....Demand for total knee replacements is growing -- 660,000 are performed each year in the United States. That number is likely to jump to two million annually by 2030, making this complex and expensive operation one of surgery's biggest potential growth markets. Even if the policy change is made, Medicare would still pay for patients to get traditional inpatient surgery. But with the agency also paying for the bulk of outpatient procedures, there would be a huge shift in money -- out of hospitals and into surgery centers. Medicare could save hundreds of millions of dollars if it no longer needed to pay for multiple-day stays at the hospital. 

The federal government is anxious to reduce Medicare costs. Shifting some percentage of Medicare patients to lower cost surgicenters would be one way to achieve this goal. Many of the surgicenters have demonstrated high quality results with their patients which will make such a policy change easier for Medicare officials. The argument that surgicenter patents will clog emergency departments with postoperative complications seems dubious to me. However and as stated above, the surgicenters may be cherry-picking their patients for the younger and healthier to achieve their good results. All Medicare needs to do to respond to the claim of clogged ED's is to publish criteria that reimbursement for patients undergoing outpatient procedures be limited to the more robust and younger ones. This is already occurring but the Medicare rule will make it official. Such a rule would also act as an incentive for hospitals to begin competing in this growing space.

Hospital executives needs to develop more expertise in managing patients on an outpatient basis, particularly for outpatient surgery. I have previously discussed some of the evolving new business models for hospitals such as bedless facilities (see: The Design of Bedless Hospitals Continue to Evolve Based on Cost and Technology; The Future of Healthcare: Virtual Physician Visits & Bedless Hospitals; Some Additional Ideas About the Bedless Hospitals of the Future). 

BRCA-Positive Males at Higher Risk for Prostate and Pancreatic Cancer

Here is a brief description about BRCA gene mutations and the manner in which they predispose to  various cancers (see: BRCA mutation):

A BRCA mutation is a mutation in either of the BRCA1 and BRCA2 genes, which are tumor suppressor genes....Harmful mutations in these genes may produce a hereditary breast-ovarian cancer syndrome in affected persons. Only 5-10% of breast cancer cases in women are attributed to BRCA1 and BRCA2 mutations..., but the impact on women with the gene mutation is more profound. Women with harmful mutations in either BRCA1 or BRCA2 have a risk of breast cancer that is about five times the normal risk, and a risk of ovarian cancer that is about ten to thirty times normal. The risk of breast and ovarian cancer is higher for women with a high-risk BRCA1 mutation than with a BRCA2 mutation. 

Most of the attention regarding BRCA mutations has been focused on women but men who inherit the BRCA1 or BRC2 gene are also at greater risk for prostate and pancreatic cancers as well as malignant melanoma (see: Familial Pancreatic Adenocarcinoma; Genetics of Prostate Cancer; Skin Cancer Risk in BRCA1/2 Mutation Carriers). Here are more details about men and BRCA from a 2012 article (see: Males With Mutated BRCA1 Breast Cancer Gene Have Higher Prostate Cancer Risk):

Men who carry the mutated BRCA1 gene have a four times greater chance of developing prostate cancer than other males....Men with the mutated BRCA1 gene are also more susceptible to the very aggressive form of prostate cancer....In Great Britain, more than 50% of prostate cancer cases are diagnosed in males over the age of 70 years, making age the main risk factor. In...[one] study,...out of 913 men who underwent screening, three-quarters of the ones carrying the mutated BRCA1 gene had a prostate cancer diagnosis before reaching 64 years of age, indicating clearly that the presence of the faulty gene might serve as an early warning for individuals with a higher risk of developing the disease at a younger age.

Here is more information about the association of BRCA2 and familial pancreatic adenocarcinoma from the first link above:

Familial pancreatic cancer (FPC) designates kindreds that contain at least two first degree relatives with pancreatic ductal adenocarcinoma. Studies of FPC have focused on discovery of genetic etiology and on management of those at genetically high risk. Over a decade of research reveals that a half dozen known hereditary syndromes or genes are associated with increased risk of developing pancreatic cancer, the most prominent of which are BRCA2 and CDKN2A. 

The lesson from all of this is quite clear. Men with BRCA-positive female relatives also need to be tested. If positive, they may need to undergo screening for prostate and pancreatic cancers and perhaps other neoplasms. If male patients test BRCA-positive, it's important that their female relatives also be tested for the gene. 

Third Annual API/Sunquest Webinar Series Focusing on Pathology Informatics

The Association for Pathology Informatics (API) and Sunquest Information Systems are collaborating for the third consecutive year in the development of a webinar series devoted to pathology informatics. Below is a list of the 2017 lecture titles with dates and participating faculty:

• Jan. 26: The Shifting Value Equation Between Hospital Labs and Reference Labs (Dr. Brian Jackson)
• Feb. 14: Consumerism in Diagnostics: Retail Testing and the Future of Providers (Panel discusion moderated by Robert McGonnagle)
• Mar. 21: Primary Diagnosis Using Digital Pathology: Are We There Yet? (Dr. Liron Pantanowitz)
• Apr. 25: An End-to-End LIS Solution for Clinical Pathology (Manish Muzumdar)
• May 11: HIT from the Regulatory Point of View (Dr. Walter Henricks)

To register for any of these webinars, navigate to this link: API Webinar Series. Click on one or more of the presentations to register. You will receive an email reminder prior to the lecture. This web page will be expanded with a short description of each lecture. Video recordings of seventeen of the previous webinars in this multi-year series are also available on-line (Sunquest and API Webinar Series). On this page, click the "view recording" link next to each lecture and the video of the presentation will launch. 

The API is the sponsor of the most important pathology informatics conference in the country -- Pathology Informatics Summit 2017. It will take place in Pittsburgh on May 22-25, 2017 (Pathology Informatics Summit 2017). The conference web site provides comprehensive information including a tab for submitting an abstract for the meeting with a deadline of March 5, 2017. The API will also provide travel awards up to $1,200 to pathology residents and is now accepting applications for these grants. 

Possible New Strategic Initiatives for Best-of-Breed LIS Vendors

The best-of-breed (BoB) LIS vendors have learned from the market that Epic with its Beaker product can be an aggressive competitor. Beaker functionality has improved recently, aided partly by the availability of a comprehensive list of necessary and desirable LIS functionalities (see: LIS-FAT Emerges as a Useful Tool for Assessing LIS Functionality). Epic also continues to enjoy the competitive advantage in the market of being familiar to hospital executives. All of this raises the question about the future direction of BoB LISs. I began to discuss this topic in my recent note about the emergence off MIMS -- molecular information management systems (see: MIMS as a Specialized LIS System; Best-of-Breed Vendors Need to Take Heed). 

I believe that the BoB LIS vendors need to focus increasingly on specialized clinical lab software in order to compete more efficiently with Epic and Beaker (see: Time to Abandon the Best-of-Breed LIS Label; Emergence of Specialized Lab Software Vendors). For me, there are four emerging categories of specialized lab software. They are: (1) molecular and genomic; (2) predictive analytics (see: Future of Healthcare Changes Inextricably Bound to Information Technology; Identifying Patients for Remote Monitoring with Predictive Analytics; Relevance of Lifestyle Analytics for Healthcare Organizations), (3) integrated diagnostics (see: Revisiting Integrated Diagnostics and the Integrated Diagnostic Report), and (4) automation middleware. I have discussed these first three in previous notes so I will concentrate here on the last of them.

In the computer world, middleware is the software that acts as a bridge between an operating system or database and applications, especially on a network. In the clinical labs, the term middleware is usually reserved for software located between an analyzer and the LIS which performs functions not provided by the analyzers. I began a discussion of middleware in a note ten years ago (see: The Appeal of Lab "Middleware"). Here is an excerpt from it:

It is absolutely correct that various IVD vendors have entered the lab software market before with only limited success. It is also correct to say that their core business is selling analyzers and reagents. I have heard IVD vendors in the past say that they are in the information management business as opposed to the information creation business, but not necessarily understanding all of the implications of total lab information management. One of the litmus tests for the IVD vendors entering the middleware market will be whether their middleware products will be able to interact with information from their competitor's analyzers.

The future direction for the larger clinical labs should be toward a totally automated solution. This goal will never be achieved as long as individual IVD manufacturers continue to develop their own middleware that is incompatible with that of their competitors. I believe that the LIS vendors should take a leadership role in the development of automation software for all CP and AP automated lines and analyzers. To achieve this goal, some type of collaborative understanding needs to be developed between LIS and IVD vendors. The reason for the need for such an agreement is that it's unlikely that the IVD vendors can compete in the market with their own LISs nor can the LIS vendors manufacture IVD equipment (see: Five Alternative IVD + Software Business Models). 

MIMS as a Specialized LIS System; Best-of-Breed Vendors Need to Take Heed

The best-of-breed LIS vendors have only been partly successful during the last decade in providing adequate support for molecular and genetic labs. This was due, in part, to the rapidly changing technology/science deployed in these labs. I became aware of the fact that the informaticians supporting these labs were a breed apart when I heard them referring to their systems as LIMSs rather than LISs. LIMS, laboratory management information systems, was the preferred term for the systems used in "scientific and industrial" labs as opposed to the LISs in hospital labs. These informaticians tended to have a closer relationship to companies like Luminex than to IVD vendors such as Roche or Siemens.

I recently read an article in the Dark Daily suggesting that the information systems used to support molecular and genetic labs are being referred to as Molecular Information Management Systems (MIMS) rather than LIS modules (see: Molecular Information Management Systems (MIMS) Are Newest Tools to Help Clinical Laboratories Perform and Report Molecular and Genetic Test Results). Below is an excerpt from this article:

Steady improvements to next-generation genetic sequencing, lab-on-a-chip technologies, and lab automation are triggering substantial increases in the volume of data generated at medical laboratories and pathology groups....However, over the past decade, the volume of data generated by molecular and genetic testing has outpaced the organization, reporting, and interfacing features of popular LISs....Particularly in the past 10 years, advances in molecular diagnostics and genetic testing outpaced the capabilities of traditional laboratory information systems. And, because during most of this time, it was typically a handful of medical laboratories that performed advanced molecular and genetic testing, this market was not big enough to justify IT companies developing more sophisticated LIS products to serve what was, at that time, a small market segment. Consequently, for the past 15 years, clinical labs that developed and performed sophisticated molecular and genetic tests often found it necessary to create their own software code to support their unique menus of tests....Meanwhile, what has changed in the molecular and genetic testing marketplace during the past 48 months is the availability of more multi-analyte assays, load-and-walk-away analyzers, and automation that enable pathology groups and community hospital labs to establish and offer a growing menu of molecular assays and genetic tests.

....To meet the demand for laboratory information systems that competently and capably manage the high volume of data generated by the current generation of molecular and genetic tests, most LIS providers and vendors are scrambling to add capabilities to their traditional LIS products. ....[M]edical labs performing molecular and genetic tests are turning to new best-of-breed solutions known as Molecular Information Management Systems (MIMS) to help streamline and manage laboratory workflows, reporting, billing, and other essential aspects of daily operation. These software products are designed to enable labs to handle the growing volume of molecular and genetic data that powers personalized medicine. By design, they have capabilities that go beyond the traditional LIS products, mostly because of the often huge volumes of raw data they must collect, store, and analyze. In addition, best-of-breed MIMS software must do more than help manage data within the clinical laboratory environment. 

To a large extent, the best-of-breed (BOB) LIS vendors have also been outperformed by smaller lab software companies in providing analytics software (see: Leveraging Lab Analytic Data to Include Actionable Details to Improve Quality; Lab Analytics Emerges as Hot Area for Software Development; Using Lab Analytics Software to Manage Customers Relationships in the Clinical Labs). I believe that the next major trend in clinical lab software will be predictive analytics (see: Identifying Patients for Remote Monitoring with Predictive Analytics; Relevance of Lifestyle Analytics for Healthcare Organizations) and big data/deep learning (see: Allscripts Launches a Subsidiary, 2bPrecise, Focusing on Genomic Testing). Like the just described MIMS scenario, I don't think that the the LIS vendors will lead the pack in these new areas. One of the dominant goals of predictive analytics software will be is the analysis of LIS data supplemented by clinical data from the EHR to generate patient diagnoses. As noted in a recent blog note I believe that in perhaps five years, the role of pathologists, radiologists, and clinicians will be primarily the management of lab, radiology, and hospitals predictive analytic systems rather than generating most of the diagnoses themselves (see: Radiologists and Pathologists as Information Specialists; Merger of the Specialties?). 

Hepatitis C Treatment Continues to Amaze; Need to Screen Baby Boomers

Regarding the treatment of hepatitis C, I confess that I have been distracted in recent months by the controversy surrounding the cost of treatment and not paid sufficient attention to the incredible  success with the treatment (see: Hep C Treatment Prognosis Continues to Amaze). Below is a quote from this article:

Rapid advances in the treatment of hepatitis C have clinicians seeing outcomes they never thought possible, and experts are optimistic that more complex and challenging patients will respond to therapy. However, treatment choice can be tricky. And caveats are emerging, including reports that direct-acting antivirals used for the treatment of hepatitis C might increase the risk for hepatitis B reactivation and liver cancer in some patients. But the big picture is one of clinical success. "We know that 95% to 100% of patients treated for hepatitis C can be cured. It's pretty amazing," said Tram Tran, MD....Unlike most viruses, this is a virus we can cure"...."The key is to keep screening, especially the baby-boomer generation,"....[another expert commented]. Baby boomers should have at least one hepatitis C test, he said, citing an emergency department study that showed high rates of unrecognized disease in patients born from 1946 to 1965....

There is thus a pressing need to screen Baby Boomers for hepatitis C. It's not exactly clear why this cohort has such a high incidence of hepatitis C. Here is a brief discussion about this problem (see: Hepatitis C: The Forgotten Virus):

No one is 100% sure why Baby Boomers (born 1945–1965) are at higher risk [for hepatitis C infection]. Since the Hep C virus was only discovered in 1989, it’s likely that most Boomers were infected before that time and may only be showing symptoms now. In fact, donated blood was not screened for Hep C until 1992. According to the CDC, many Baby Boomers were infected in the 70’s and 80’s when infection control standards were not what they are today.

To finish, a quick summary of the cost of treatment (see: Pros and Cons of New Hepatitis C Drugs):

The newer hepatitis C drugs are super-expensive. Harvoni rings in at $1,125 per pill, or $94,500 for a 12-week course of treatment, and other new medications are nearly as pricey. Insurers are scrambling to figure out how to pay for treatment without breaking the bank. Many say they will only cover costly therapies for the sickest patients. In comparison, the cost [for] 11 out of 12 cancer drugs the FDA approved in 2012 for cancer chemotherapy was over $100,000 for a one-year treatment course. 

Perhaps a Step Closer to Artificial Blood for Transfusion

I started my career as a blood banker in 1973 and switched to pathology informatics in 1982. For this period of nine years, the idea of "artificial blood" was very hot, funded largely by the military. Obviously, the military has a keen interest in a blood substitute with long shelf life, no requirement for crossmatching, and no fear of disease transmission. Fast forward to the present time when the hope of a practical blood substitute has yet to be fulfilled. A recent article provided an interesting perspective on this topic (see: Another Step Closer to Artificial Blood). Below is an excerpt from it:

Researchers have created an artificial red blood cell that effectively picks up oxygen in the lungs and delivers it to tissues throughout the body. This artificial blood can be freeze-dried, making it easier for combat medics and paramedics to keep on hand for emergencies, said senior researcher Dr. Allan Doctor....It's a dried powder that looks like paprika, basically ....It can be stored in an IV plastic bag that a medic would carry, either in their ambulance or in a backpack, for a year or more. When they need to use it, they spike the bag with sterile water, mix it, and it's ready to inject right then and there. The artificial blood cell, which is about one-fiftieth the size of a normal red blood cell, is made from purified human hemoglobin proteins that have been coated with a synthetic polymer....The hunt for an artificial blood substitute has been underway for more than 80 years, but the closest prior attempts have failed in two major ways....Earlier versions could capture oxygen in the lungs, but then would not effectively release the oxygen after traveling out to tissues and organs....There also was an unintended reaction between "naked" hemoglobin and nitric oxide, a substance released by the lining of blood vessels that allows the vessels to relax and open up....The polymer coating also keeps the hemoglobin from reacting with nitric oxide in the bloodstream, thus preventing dangerous constriction of the blood vessels....There's also one more benefit -- because the polymer coating is "immune silent," the artificial blood can be used in anyone regardless of blood type....Lab tests involving mice and rats have proven that the artificial red blood cells can effectively deliver oxygen to needy tissues....Besides emergency settings, the artificial blood also could be used to help keep donated organs alive on route to a recipient.... 

The research on artificial blood continues unabated. What's interesting to me about the article about Doctor's research is that he has apparently come to the conclusion that it's extremely difficult to duplicate the function of human hemoglobin in terms of oxygen capture and release. He has thus wrapped hemoglobin with a synthetic polymer to prevent undesirable reactions between the "naked hemoglobin molecule" and the nitric oxide released by the lining of blood vessels. However, Doctor has bigger ideas in mind for his research than a blood substitute, although that would be a great gift for transfusion medicine. Here is an excerpt from his lab's home page:

[T[he long term goal of the studies in my lab is to define the role of red blood cells (RBCs) in the spread of vascular dysfunction during oxidative stress, as exemplified by the development of secondary lung injury. Impaired pulmonary vascular control occurs early in respiratory failure complicating systemic inflammation. This pulmonary vascular dysregulation is characterized by loss of coupling between regional vascular tone and oxygen gradients (e.g. ventilation – perfusion mismatching). While nitric oxide (NO) signaling has been implicated, there is no clear mechanism linking remote inflammation to downstream lung injury. New data suggest that NO groups circulate and signal remotely through serial NO-thiol transfer reactions.

Radiologists and Pathologists as Information Specialists; Merger of the Specialties?

In a recent article available on-line on the JAMA Network entitled Adapting to Artificial Intelligence: Radiologists and Pathologists as Information Specialists (see: Radiologists and Pathologists as Information Specialists), the authors Saurabh Jha and Eric Topol conclude that both pathologists and radiologists function as "information specialists" and therefore should consider merging their specialities. Below is an excerpt from the article:

Radiologists are more aptly considered “information specialists” specializing in medical imaging. This is similar to pathologists, who are also information specialists. Pathologists and radiologists are fundamentally similar because both extract medical information from images. Pathologists have embraced machines and technologies. Some tasks once performed manually by pathologists have been automated, such as cell counts, typing and screening of blood, and Papanicolaou tests, leaving pathologists with more complex tasks. Artificial intelligence can perform the more complex tasks of pathologists and, in some instances, with superior accuracy....Because pathology and radiology have a similar past and a common destiny, perhaps these specialties should be merged into a single entity, the “information specialist,” whose responsibility will not be so much to extract information from images and histology but to manage the information extracted by artificial intelligence in the clinical context of the patient. The information specialist would not spend time inferring conditions between competing shadows on radiographs, scroll through hundreds of images looking for pulmonary embolus on CT, or examine slides for “orphan Annie”–shaped nuclei. Artificial intelligence could perform many such tasks. The information specialist would interpret the important data, advise on the added value of another diagnostic test, such as the need for additional imaging, anatomical pathology, or a laboratory test, and integrate information to guide clinicians. Radiologists and pathologists will still be the physician’s physician. Together, the information specialist and artificial intelligence could manage individuals and populations.

Th ideas and conclusions of Jha and Topol coincide with my own, In a blog note posted here ten years ago, I called for a merger of pathology and radiology, perhaps into a new medical speciality of diagnostic medicine (see: Ten Reasons for Merging Pathology/Lab Medicine with Radiology). I have been subsequently told that the VA system merged some of their pathology and radiology departments even earlier than this, promoted by efficiency and staffing concerns. Here are more notes from Lab Soft News about this topic: More On Convergence of Pathology, Lab Medicine, and Radiology; EHRs Pose a Major Threat to Fields of Pathology & Radiology Informatics; Development of Integrated Diagnostic Servers by Pathology and Radiology. More recently, Dell Medical School in Austin had merged these two departments (see: World-Class Innovator Comes to Dell Med to Rethink Medical Diagnostics). Here is a quote from this latter article:

R. Nick Bryan, M.D. is the new director of diagnostics for the Dell Medical School at The University of Texas at Austin. He will oversee diagnostic activities for Dell Medical School, encompassing the traditional departments of radiology, pathology and laboratory medicine. Doing so will merge key components of diagnostic examinations that determine the health status of patients. Dell Med’s innovative approach will help ensure that these skills are taught and used in a more integrated way.

I suspect that if you were to ask most pathologists and radiologists to specify their primary professional task, the majority would probably choose the diagnosis of disease rather than the management of diagnostic information. One exception to this rule would be clinical pathologists who generally do not personally create most of the information from the clinical labs. The raison d'être of surgical pathologists and radiologists has thus always been the interpretation of images. Jha and Topol, however, suggest that we are now at a critical inflection point in both surgical pathology and radiology. Artificial intelligence (AI), image recognition software, and deep learning using big data (see: Allscripts Launches a Subsidiary, 2bPrecise, Focusing on Genomic Testing) have taken us to the point where most diagnostic reports will soon be generated by computers.

As an increasing number of reports are created by computers, pathologists and radiologists will begin to serve primarily as managers of information and must decide exactly which cases require human, professional intervention and interpretation. Most of us tend to view our careers and our medical specialties through the rear view mirror. More than a decade of discussion about the role of pathologists and radiologists in this information era should be sufficient to prompt a more serious discussion of what the future holds in store for medical diagnosticians. I personally believe that it lies in the creation of Departments of Diagnostic Medicine.

American Well Offers Remote Physical Monitoring for Telemedicine Visits

Routine telemedicine visits at the present time are usually restricted to low-intensity patients with the exception of telemedicine as it relates to "remote ICUs" (see: Remote ICUs). Here is a description of remote ICUs from this article:

Telemedicine is most commonly used in one-on-one scenarios between a physician and a patient or between two physicians. Increasingly, however, remote ICU’s are being implemented to help extend the range of intensivists, as well as allow them to monitor multiple patients in multiple facilities. By utilizing advanced medical imaging, video conferencing, and computer software technology, specialists can effectively monitor a larger group of intensive care patients, and consult with on-site nurses and physicians when hands-on care becomes necessary. Remote ICUs have resulted in a number of positive outcomes, including decreased patient mortality, shorter ICU stays, and rapid return on investment for hospitals.

Because the technology has existed for years for sophisticated remote monitoring of critical care patients, I am convinced that it is only a matter of time before it becomes cost-effective to assess vital signs and more during "routine" patient televisits. I use the word routine here to indicate that the range of ambulatory patients who can be served by telemedicine is about to greatly expand. A recent article discussed how American Well, a major vendor of telemedicine software, is incorporating remote examination tools in collaboration with TytoCare (see: American Well taps TytoCare to incorporate connected health tools into video visits). Below is an excerpt from this article:

Telemedicine provider American Well has teamed up with Israel-based medical device maker TytoCare to combine video telehealth visits with remote examinations. With the partnership, TytoCare’s examination platform will be integrated into American Well’s telehealth platform. In turn, TytoCare’s customers will have access to the network of healthcare providers who use American Well’s platform. Patients will be able to replicate an in-office visit at home by using TytoCare’s platform to examine the skin, heart, lungs, abdomen, ears, throat and skin. Then, they can share the examination with a clinician prior to or during a telemedicine visit. TytoCare, which recently received FDA clearance for its digital stethoscope, offers several FDA Class 1 devices: a connected otoscope for ear examinations, a high-resolution camera, and a thermometer that is placed on the forehead for a reading. The devices pair with smartphones to capture, store and share data via a cloud-based telehealth platform with video conferencing...."Our partnership with Tyto Care arms remote telehealth physicians with the physical examination they traditionally needed to safely diagnose, treat and follow medical conditions while the patient remains in their home,” American Well CEO Dr. Roy Schoenberg said in a statement.

There will obviously be significant patient training necessary for the TytoCare kit to be used to record heart sounds and murmurs, uploading them to the cloud, and then making them available during a telemedicine visit by a physician. Much sooner, however, will be the use of such technology using the product called TytoClinic. Increasingly, nurse practitioners (NPs) are working independently in their own practices (see: What's an NP?). I envision NPs providing independent services to a wide range of patients as part of large health systems. When they encounter patients with problems beyond their expertise, they can use such TytoClinic kits, combined with the American Well software, to consult with a physician. Such a workflow will enable health systems to serve far more patients and also triage those with the more serious problems.