Lab Soft News

Most Hospitals Executives Unenthusiastic About Patient Consumerism

Consumerism is altering the economic landscape. One only need look at the decline in sales at bricks-and-mortar retail stores to grasp the power of consumers and the popularity of web technology (see: The Future Of Retailing: The Technology Revolution Is Now). Meanwhile, despite predictions that consumerism will take hold in healthcare, there is little evidence that healthcare executive are taking this trend seriously (see: Consumerism among Healthcare Patients with High-Deductibles Has Not Yet Altered How Most Hospitals and Healthcare Systems Operate). Below is an excerpt from this article:

...[H]ospitals have been slow to react to...interest by patients in transparency in prices and quality by developing a consumer strategy...."Although the majority of hospitals and health systems recognize the importance of consumerism, most have not put consumerism into action,” ...[a recent] report states.....The authors of the “2016 State of Consumerism in Healthcare” report surveyed executives at more than 100 US hospitals and health systems. They found that:

• 66% of those surveyed said it was important to develop insights into patients’ behaviors and expectations, but less than 25% of healthcare organizations had the tools to gather and analyze patient data, and only 16% had the capability to launch strategies based on consumer insights;

• 79% of respondents said there is a pressing need to understand and enhance patient experience, but only 18% have employed advanced means to do so; and

• Only 29% of respondents consider strategic pricing a high priority, and only 9% have advanced pricing strategies in place.

....[A healthcare executive] advised hospitals and health systems to find new ways to get patients access to healthcare through online scheduling, urgent care clinics, or virtual visits.

Why does consumerism not seem to be a major force in healthcare with executives remaining relatively aloof from the trend? Here are a few personal ideas about what is going on:

• Major health systems often function as quasi-monopolies in their local markets. Furthermore, their power and influence is expanding as they purchase physician practices, leaving fewer private physicians in the market (see: Physicians Continue to Leave Private Practice for Employment).
• Pricing of healthcare services, particularly in hospitals, is hopelessly complicated and lacks tansparency, depriving consumers of the ability to make choices (see: Coding for Hospital Services; One Reason for the High Cost of Healthcare; Some Surgicenters Listing Prices, Reject Insurance, and Require Cash Payment; Transparency in Health Care: What Consumers Need to Know). 
• Healthcare choices are often complicated and based on complex medical science and technology. For example, here are some possible choices relating to hip replacement: inpatient versus outpatient, minimally invasive versus standard approach, type and manufacturer of prosthesis, experience of surgeon, and postoperative rehabilitation regimen. Some patients will research the topic before scheduling the operation but most will defer to the advice of their surgeon.
• Many healthcare consumers, usually those with adequate insurance, are satisfied with the care that they receive and may not engage in "shopping behavior" as it relates to choices. Another way to state this premise is that there is a major difference between a consumer and a patient. The latter is often risk averse when their personal health is at stake.

Taking all of this into consideration, I am not very surprised that most hospital executives assign little priority to consumerism in healthcare. At least for the present, they have "bigger fish to fry" but this may change in the future, at least incrementally.

Telling Daughters About Their Genetic Breast Cancer Risk

We are now in the era of predictive medicine when many of us will have the opportunity to learn about our individual predisposition to develop serious diseases at some point in our lives. This is now a reality for families carrying the BRCA gene (females as well as males) (see: BRCA-Positive Males at Higher Risk for Prostate and Pancreatic Cancer). This topic was discussed in a recent article in the New York Times. An excerpt from the article is listed below (see: When to Tell Daughters About a Genetic Breast Cancer Risk):

As genetic testing has given women and men a trove of information about their health and risk for disease, it has also created a new challenge for parents and medical experts: when to share information with children who may inherit a genetic risk. In genetic medicine, minors typically are not tested for BRCA mutations, which increase the risk of adult-onset breast and ovarian cancers. The worry is that children often lack the maturity to fully understand the implications of a genetic risk, and that they shouldn’t be burdened with the knowledge until they are adults who can participate in the decision to be tested or not. Many experts recommend waiting to test until 25, the age at which screenings such as M.R.I.s and mammograms are encouraged for high-risk women. Sons are also affected by the presence of BRCA and should be tested. A 2015 study of more than 200 girls ages 11 to 19 found that while adolescent girls from families that carry BRCA1 or BRCA2 mutations worry more about the risk of breast cancer, they have similar levels of psychosocial adjustment, and in fact have higher self-esteem, compared to their average-risk peers....[S]ome developmental specialists suggest that adolescents may benefit from learning that a mutation runs in their family because the potential threat is distant, giving them time to develop coping strategies and resilience if they test positive as adults....Dr. Ruth Oratz, a medical oncologist and breast cancer specialist at NYU Langone’s Perlmutter Cancer Center, worries that parents who inform their children about a potential genetic risk do not alleviate anxiety but instead hamper their teenager’s ability to live freely.....Experts recommend using your child’s age, personality and maturity as a guide. Be straightforward and honest but don’t use confusing euphemisms or dump everything on your child at once. 

This same BRCA question was addressed in a related article (see: Is It Time to Reconsider Testing Adolescents for Familial BRCA Mutations?) Here's an excerpt from this article:

Adolescents who were aware of their mother’s BRCA1/2-positive status were more likely to report themselves at higher risk for breast cancer than their peers. The same was true to a lesser extent for individuals with a familial risk of breast cancer but without a mother with a BRCA1/2 mutation. The perceived breast cancer risk also increased with adolescent age. These findings are important because they suggest that genetic testing in adolescents may provide relief from uncertainty, reduce cancer-specific distress for those testing negative, and allow for earlier incorporation of genetic test results into an individual’s genetic identity.

It is not my intention to give advice here about the how and why of genetic testing for children and the stress of such testing. It's clear, though, that this issue will not go away in this modern era of genomics and will only increase as more tests of this kind are developed. Genetic counseling is a rapidly expanding field and obviously recommended for any family with members testing positive for BRCA. Here's some important advice about the inadvisability of BRCA testing in children from the article (see: BRCA1 and BRCA2: Cancer Risk and Genetic Testing):

Professional societies do not recommend that children, even those with a family history suggestive of a harmful BRCA1 or BRCA2 mutation, undergo genetic testing for BRCA1 or BRCA2. This is because no risk-reduction strategies exist for children, and children's risks of developing a cancer type associated with a BRCA1 or BRCA2 mutation are extremely low. After children with a family history suggestive of a harmful BRCA1 or BRCA2 mutation become adults, however, they may want to obtain genetic counseling about whether or not to undergoing genetic testing. 

Telemedicine Used in New Healthcare Settings Like Coaching

I continue to believe that telemedicine will be one of the key elements enabling hospitals to provide services to more consumers at a lower cost. Telemedicine was initially limited to simple, easily diagnosed conditions but is now expanding into areas like chronic care (see: Treatment of Patients with Chronic Diseases: Important for the Future of Telemedicine. Early adopters of telemedicine such as Kaiser Health (see: Kaiser CEO: Telehealth Outpaced In-Person Visits Last Year) and the Cleveland Clinic are now testing new types of care delivery with the technology and a recent article was devoted to this topic (see: How Cleveland Clinic uses telehealth to introduce new dimensions of care). Below is an excerpt from it:

Telehealth may have begun as being most relevant for urgent care, but it has greatly expanded its potential and can be effective across many departments of a hospital. Cleveland Clinic has introduced telehealth across 40 different departments, including neurology, endocrinology, heart and vascular, women’s health and genetics. Any department can be an optimal fit for virtual care, as long as the excitement for telehealth is built into the DNA of providers....Cleveland Clinic has introduced telehealth across many different types of visits, from post-operative care and shared medical appointments, to discharge follow-up and coaching. They see future opportunity for areas like home care and medication reconciliation. The health system thinks beyond the routine visit for a cough or cold, and has experimented with patients in all types of situations. Cleveland Clinic recently began a chronic care and remote patient monitoring pilot, providing video visits to hypertension patients. The pilot involves care coaching and management, combined with remote patient monitoring to assess and track the patients. The pilot relies on data from consumer devices, the platform’s integration with Apple HealthKit, and devices to monitor blood pressure.

In this note, I want to briefly discuss the use of telemedicine in health coaching which is defined in the following way: 

Health coaching is differentiated from [w]ellness coaching in that health coaching is the use of evidence-based skillful conversation, clinical interventions and strategies to actively and safely engage client/patients in health behavior change. Health coaches are certified or credentialed to safely guide clients and patients who may have chronic conditions or those at moderate to high risk for chronic conditions (see: Health coaching).

Health coaching with telemedicine seems to me to provide a solution for the care of patients with chronic diseases. However, one of the criticisms of telemedicine by hospital executives has been that reimbursement is complex and sometimes inadequate (see: Telemedicine Reimbursement). However, health coaching with telemedicine may necessitate a reevaluation of this criticism. Hospitals are currently penalized if their inpatient readmission rate is too high (see: Medicare’s Readmission Penalties Hit New High). It may thus make sense financially for hospitals to focus part of their telemedicine health coaching effort on patients post-discharge who have a high likelihood of readmission such as those with congestive heart failure (see: Hospital Strategies Associated with 30-Day Readmission Rates for Patients with Heart Failure). In so doing, a reduced reimbursement rate for these patents can be ameliorated by the lower readmission rate that is achieved.

"Extinction" for Hospital Data Centers Predicted in Five Years

I have frequently blogged about cloud computing starting nine years ago (see: Finally, A Clear Definition for Cloud Computing). During the course of these nine years, I have also suggested periodically that healthcare IT lags about a decade behind that in most other industries (see: The Potential for "Serverless" Healthcare Computing). It thus seems reasonable that we should now begin to see articles discussing the adoption of cloud computing in healthcare. Along these lines, a recent article predicted that hospital datacenters would be extinct in about five years (see: Hospital datacenters: Extinct in 5 years?). Below is an excerpt from it:

Some enterprising providers and payers, such as the Centers for Medicare and Medicaid Services and Children's Mercy in Kansas City, are...reaping big dividends from hosting data and services in the cloud. The Centers for Medicare & Medicaid Services, for instance, created a cloud-based analytics platform that eliminated $5 million in underutilized infrastructure spending....And Children's Mercy uses Microsoft's Azure Cloud services to host an app and data that literally save lives of at-risk pediatric patients by tracking them after they leave the hospital, according to Richard Stroup, Children's Mercy director of informatics. What's more, Stroup explained that putting the app on Microsoft's cloud also enabled it to make the service available to other Children's hospitals. Seattle Children's was the first to tap into it, and Cincinnati Children's signed on to use it in February. The notion of a widespread migration to the cloud is not entirely new. Nicholas Carr wrote a 2003 Harvard Business Review article titled "IT Doesn't Matter," in fact, that sent a virtual shock wave through the enterprise technology realm — though few in healthcare probably felt it back then — by suggesting that IT is going to be commoditized...."When you're the last man standing with a datacenter, and your competitors are using that capital to generate revenue, the upside of moving to the cloud will become crystal clear," ...[a hospital IT executive] added....[T]he industry is poised for a seismic shift in its thinking about putting health data in the cloud. Carolinas' CIAO...said the system is making big movements into the cloud, and that includes Cerner, Epic, Microsoft 365, among many other apps. BIDMC's [CIO John] Halamka, meanwhile...that healthcare organizations at this point have to plan for a federated approach, even those that are moving to a single EHR.

A good way to launch this note is to list some of the reasons why I think hospital CIOs and other executives have been slow to embrace cloud computing:

• The healthcare industry, in general, tends to be more conservative because it is highly regulated. Moreover, scientific and technical innovations bubble upward from hospital physicians rather than downward from executives who tend to be focused on budgetary and M&A issues. 
• For about the past ten years, hospital executives and physician leaders have been absorbed with the conversion to EHRs rather than other strategic issues. Moreover, the EHR vendors themselves have not enthusiastically endorsed cloud computing although some have offered remote hosting solutions.
• Concerns were raised over the years by hospital CIOs about cloud security and performance of cloud computing but now questions like hacking and ransomware are dominant that could be partly addressed by cloud computing (see: Hospital Records Commonly Being Hacked and Sold for a Premium on the Web; Hospitals and Ransomware; How Should Hospitals Protect Themselves?).

One of the most telling comments from the excerpt above in favor of the conversion to the cloud is the following: When you're the last man standing with a datacenter, and your competitors are using that capital to generate revenue, the upside of moving to the cloud will become crystal clear. I think that hospital executives are becoming increasingly anxious about access to capital. This is partly the result of the new goal for executives of providing services to more patients at a lower cost with less emphasis on bricks and mortar and M&A. One of the ways to accomplish this goal is through telemedicine but most hospitals have not yet adopted the approach as a strategy (see: Telemedicine as a Tool for Physician Visits in Senior and Assisted Living Facilities; Treatment of Patients with Chronic Diseases: Important for the Future of Telemedicine). Another way to free up capital is for health systems to eliminate their datacenters and pursue cloud computing with its highly competitive pricing.

Some Surgicenters Listing Prices, Reject Insurance, and Require Cash Payment

I have been closely tracking various developments in free-standing clinics and surgicenters that may stumulate a more competitive environment for hospitals (see, for example: Tug of War between Hospitals and Surgicenters for Knee Replacements). I recently blogged about how opaque hospital bills have discouraged many patients (see: Coding for Hospital Services; One Reason for the High Cost of Healthcare). I also posted a note about how some hospitals were providing more price transparency (see: Greater Transparency for Hospital Charges Slowly Becoming the Norm).

In order to be more competitive with hospital-based surgeons and to avoid the cost and hassle factor of health insurance paperwork, some surgicenters have begun to operate on a cash-only basis and provide patients with price lists. This idea was raised in a recent article. An excerpt is provided below (see: There's a growing movement of surgery centers and specialists that list their prices and don't take insurance):

When Cheryl Millican found out she needed surgery, her Dallas-based doctor told her it would cost roughly $38,000 out of pocket. Millican, who doesn't have insurance, needed a hysterectomy, a procedure that removes all or part of the uterus. It wasn't an emergency situation, so when a friend told her about a place in Oklahoma [called the Surgery Center of Oklahoma] that could perform the surgery for $8,000 [on a cash basis], she decided to look into it. That included the cost of the procedure itself, an overnight stay, a follow-up appointment, and any other meetings ahead of time....It's happening at a time when high-deductible health plans are on the rise....A number of specialists — oncologists, physical therapists, and even some hospitals — are jumping on board as well....Keith Smith founded the Surgery Center of Oklahoma in 1997....The center would file claims, but insurance companies weren't keen on working with the center because the center was being open about the prices it was charging, he said. After a while, the center and the insurance companies parted ways....Surgery Center lists the prices for more than 200 outpatient procedures on its website, covering everything from plastic surgery to a hip replacement. The site also discloses information about its infection rates, and relies heavily on reviews....But cash-pay providers are gaining traction with self-insured employers, who see it as more cost-effective than paying through traditional insurance....The center now performs 7-8,000 surgeries in a year. 

These surgicenters and clinics are taking a page out of the instruction manual of medical tourism hospitals like Bumrungrad in Bangkok which I discussed ten years ago (see: Medical Tourism Business Model in Thailand Extends to Airport Facilities; Interview with Bumrungrad Group CEO, Curt Schroeder). The business model adopted by these facilities includes offering surgical procedures like total hip replacement for a fixed and low fee and requiring cash payment. I had lost track of Bumrungrad in the intervening years. Here's a link to the hospital web site where it is stated on the home page that it treats 1.1M patients per year.

As noted in the excerpt above, surgicenters that operate on a cash basis are well positioned to offer lower prices because of their lower administrative costs and lack of bad debt. I suspect that there is also some degree of cherry-picking involved in their patient selection which allows them to avoid some post-operative complications. Here are some interesting facts about healthcare administrative costs in the U.S. (see: A Comparison of Hospital Administrative Costs in Eight Nations: U.S. Costs Exceed All Others by Far):

• Administrative costs accounted for 25 percent of hospital spending in the United States, more than twice the proportion seen in Canada and Scotland, which spent the least on administration. Administrative costs were notably higher in the Netherlands (20%) than in other European nation.
• In the U.S., the share of costs devoted to administration were higher in for-profit hospitals (27%) than in nonprofit (25%) or public (23%) hospitals. Teaching hospitals had lower-than-average administrative costs (24%), as did rural facilities.
• U.S. hospital administrative costs rose from 23.5 percent of total hospital costs ($97.8 billion) in 2000 to 25.3 percent ($215.4 billion) in 2011. During that period, the hospital administration share of national gross domestic product (GDP) rose from 0.98 percent to 1.43 percent.
• There was no apparent link between higher administrative costs and better-quality care.

Integrated Clinical Research Databases: A New Way to "Monetize" Clinical Data

I had a conversation with a journalist recently about whether hospital labs and reference labs are selling anonymized lab data to pharmaceutical companies, the most logical buyer of such data. This idea has been percolating for decades in clinical lab and healthcare circles without much (apparent) success. However, even if it were occurring, it would be in the shadows. Hospital and reference lab executives would not relish the blowback from patients if such sales were to become public. Moreover, lab data, in and of itself, would probably not be that useful without the accompanying patient demographic and clinical data.

Having made this point, our conversation turned to the very valuable and recently developed "research databases" in hospitals. The data is extracted from EHRs and contain lab test and imaging results, drug history, clinical data, and patient demographics. EHRs, despite their high cost, are not designed to respond to even relatively simple research questions (see: Hospital EHRs Inadequate for Big Data; Need for Specialized -Omics Systems). Hence the need in order to create research databases by the transfer of data from EHRs to powerful, dedicated computers (see: Mount Sinai's Icahn School of Medicine Pioneers the Use of Big Data to Study Diabetes). 

I blogged in 2014 about the development of a research database at Memorial Sloan Kettering Cancer Center (MSK) in collaboration wiht Quest Diagnostics (see: Memorial Sloan Kettering and Quest Form Strategic Alliance). Here's an excerpt from that note pertaining to the value of cancer genomic data as a component of a hospital research database:

Cancer genomics differs radically different than the other tests that Quest offers to its mainly office-based clinician clients and these differences offers clues to the benefits of the alliance for both parties. First of all, MSK controls a treasure trove of a wide variety of biopsied and resected malignant tumors that can be genetically analyzed. This biorepository is immensely valuable and much different than the standard serum samples that Quest acquires in a huge volume on a daily basis. Moreover, molecular and genomic testing is quickly changing and Quest wants to share some of the new knowledge acquired by the MSL bench and clinical scientists.

Amother very prestigious cancer hospital in the U.S., M.D. Anderson, also set out to develop a research database with IBM as a partner and quickly became immersed in a scandal which is still playing out (see: Scandal at M.D. Anderson -- Operating Loss and Then Watson Deep-Sixed). The reference to IBM's AI initiative, Watson, emphasizes a very important point with relation to clinical research databases. Extracting usable information from these systems requires participation by highly skilled IT professionals who understand big data and deep learning (see: Big Data Coming In Faster Than Biomedical Researchers Can Process It). IBM Watson is also a partner with MSK in their cancer research initiatives (see: IBM Watson, Quest Diagnostics, Memorial Sloan Kettering partner for cancer research). 

So what does all of this have to do with "monetizing" hospital clinical data. These new integrated clinical database have great value for both basic research and for pharmaceutical companies. Just imagine some of the questions that could be potentially answered by such systems. They include the following:

• To which drug(s) are patients with Cancer A responding the best?  
• Considering image analysis of biopsies and imaging studies of patients with Cancer B, which drugs are proving to be the most effective?
• For patients with Cancer C, which basic laboratory tests are most effective in diagnosing the lesion and predicting survival.  

Coding for Hospital Services; One Reason for the High Cost of Healthcare

I have blogged frequently about the irrationality of hospitals bills (see, for example: Two Reasons Why Medical and Hospital Bills Are Such a Mess; High Deductible-Health Plans Causing Hospital Billing Problems; Upcoding Can Result in Greater Healthcare Costs After EMR Deployment). The New York Times recently published a lengthy, well-written article about the relationship between the high cost of care and hospital bills (see: Those IndecipherableMedical Bills? They’re One Reason HealthCare Costs So Much). Read the whole thing -- it's will worth your time. For this note, I want to concentrate on the hospital coding for medical services and how it contributes to the high cost of care as described in the NYT article.  An excerpt is shown below:

There are, of course, many factors that have led to the United States’ record-breaking $3 trillion health care bill: runaway drug prices, excessive testing and sky-high charges for even the most basic medical interventions. But all of those individual price increases have been enabled — indeed, aided and abetted — by the complex system of billing and coding that underlies bills....That system, with its lines of alphanumeric codes and arcane medical abbreviations, has given birth to a gigantic new industry of consultants, armies of back-room experts whom medical providers and insurance companies deploy against each other in an endless war over which medical procedures were undertaken and how much to pay for them. Caught in the crossfire are Americans...left with huge bills and indecipherable explanations in languages they cannot possibly understand....[Billing] codes became an invaluable tool, a common language for epidemiologists and statisticians to track the world’s afflictions. But over the last several decades in the United States, codes gradually took on a bedrock financial function as the basis for medical billing.....Coding systems begot new coding systems, because few hospitals wanted to be paid according to Medicare’s relatively low DRG standards. And because strategic coding meant increased payment, that begot coding specialists and coding courses and coding degrees....Seemingly subtle choices about which code to use can have large financial consequences....The coders who work for hospitals and doctors strive to bring in as much revenue as possible from each service, while coders employed by insurers try to deny claims as overreaching. Coders who audit Medicare charts look for abuse to reclaim money or fraud that needs to be punished with fines. Hospital coders teach doctors — and doctors pay to take courses — to learn how they can “upcode” their charts to a more lucrative level with minimal effort. 

In a nutshell, the coding of medical services by hospital personnel drives the generation of the bill that patients receive. For most of us, these bills are incomprehensible, partly by design. As stated in the excerpt above, "coders who work for hospitals and doctors strive to bring in as much revenue as possible from each service, while coders employed by insurers try to deny claims as overreaching." If you have health insurance, you are partly or even totally protected in that the health insurance company and the hospital each understand the game that is being played. The insurance companies have negotiated to pay a certain percentage of the bill and are aware of the tendency for hospital upcoding and will challenge payment when it occurs. However, the system is rigged for the uninsured, self-pay patients, who may have little recourse when challenging hospital bills.

In a previous note, I suggested that the uninsured patient should approach the hospital billing office at the time of admission and negotiate a discount in exchange for a promise of cash payment (see: Hospitals in California Offer Steep Discounts to Uninsured Patients). In this era of high-deductible health insurance, however, even "insured" patients suffer financial pain from a hospital bill. Uninsured patients patients may thus need a knowledgeable advocate to review a hospital bill for coding errors and upcoding. I can't vouch for the site, but Healthcare Bluebook claims to list “fair” prices for hospital services, defining fair as a small premium above the average fee local providers accept as payment from insurers. Web sites such as this one may offer the names of lower cost providers but consumers need to be aware of potential quality differences across various providers. The lowest cost provider may not be a bargain in many situations  Of course, none of this advice will be of value at the time of an emergency admission to a hospital when time is of the essence.

Expansion of Core Lab Menus by IVD Vendors with New Analyzers

In my mind, three functional domains for lab testing in hospitals have evolved over time. First is the core lab which is optimized for highly automated, routine lab tests, primarily in chemistry and hematology. Second are the specialized and esoteric labs like molecular pathology and the blood bank that are less automated. Third is point-of-care (POC) and STAT/emergency testing with tests performed in decentralized locations rapidly using smaller devices. A recent article from the Dark Report noted that the IVD companies are expanding the menu of tests available on their new, automated platforms (see: Top-5 Diagnostics Trends Identified by Kalorama Will Impact In Vitro Diagnostics Manufacturers, Medical Laboratories in 2017). Below is an excerpt from it:

As healthcare organizations consolidate, IVD companies are looking at core lab markets and automation systems that target big accounts....Two examples of such IVD companies are Abbott Laboratories ...and Siemens Healthineers. Abbott...issued a statement announcing a new diagnostic platform for clinical laboratories, clinicians, and medical institutions called Alinity. It’s a “harmonized” platform of immunoassay, clinical chemistry, point-of-care, hematology, blood and plasma screening, and molecular diagnostics systems. Siemens Healthineers also introduced a new solution to automate core lab testing call Atellica. This is an immunoassay/clinical chemistry solution with patented bi-directional magnetic sample-transport technology that, according to the press release, is 10 times faster than conventional conveyors, is scalable across configurations and locations, and enables simplification of lab operations, streamlined inventory control, and consistent testing results.

This sentence about describing the functionality of the Alinity platform was instructive: a “harmonized” platform of immunoassay, clinical chemistry, point-of-care, hematology, blood and plasma screening, and molecular diagnostics systems. If many lab professionals had their way, there would probably be fewer POC tests available. These tests are more expensive than those in the central labs and are often performed by non-lab professionals. The quote above does not exactly make sense in that point-of-care tests, by definition, cannot be performed in a core lab which is usually distant from patient care sites. However, I think that the claim is being made that the Alinity platform offers flexibility and rapid turn-around-times that are comparable to tests performed on smaller instruments in distributed locations closer to patients.

If the claims being made for the Alinity and Atellica platforms are correct, it may be possible in the near future to reduce POC testing when and where rapid delivery of specimens to the core lab is possible and the lab can be run on a 24-hour basis. Test results, of course, will appear in the EHR database immediately after test completion. I don't think that such a plan would be unacceptable to clinicians if the test TAT is rapid. Of course, patient care sites far removed from the core lab would need to continue to perform STAT or urgent lab tests using POC instruments. 

Comprehensive History of VistA; What's Next for This Early, Highly Functional EHR?

During most of my career in pathology informatics, controversy has been simmering about VistA (Veterans Information Systems and Technology Architecture) which is the EHR developed by VA technocrats in 1985 (see: VistA). I even served on an NIH committee years ago discussing whether VistA should be terminated with the accompanying mandate that the VA turn to a commercial product. My understanding at that time was that VistA had originally been developed as a "skunkworks" operation within the VA. This was easier than the requirements for other EHRs because there was no patient billing module necessary. 

Almost all of the physicians whom I have known who have worked with VistA have admired it in comparison with competing commercial products. However, the days are long gone when a health system, even one as huge as the VA, should be maintaining a home-brew EHR. Attention and time need to be paid to newer technologies that can reduce costs such as telemedicine. Moreover, there has been intense political and lobbying pressure over the years to covert the VA to a commercial EHR. This has often come from members of Congress supporting EHRs developed in their back yards. This pressure won't stop under Trump.

The story gets even more complicated because of long-standing controversy about the integration of VistA with a military EHR which makes perfect sense. However, even the various military branches may not see eye-to-eye on this issue. A comprehensive article was recently published about VistA (see: A 40-year 'conspiracy' at the VA). Below is a short excerpt from it. Read the whole article if you are interested. 

VistA had become a victim of the factors that led to its strength. Its distributed development resulted in a thousand flowers blooming, each one a different species, and in the foggy ruins of time no one could identify the people who wrote the code or how it could be amended. Managing all of those applications across a 167-hospital national system, some said, was a nightmare—more than half of the VA’s $4 billion annual IT budget goes to maintaining existing software. Under its current tentative plans, the VA will continue to update VistA’s interface through 2018. After that, the VA is likely to swap out VistA for a commercial EHR. The speculation is that bid would go to Leidos and Cerner—if their current partnership with the DOD continues to move along on schedule. Some believe the fix is in already, because a number of Leidos IT specialists already work inside the VA. At least two other big EHR vendors, Epic and Allscripts, say they’ll also bid to take over the VA’s EHR duties. This is bitter fruit for many VistA fans. Some still say the system could be fixed for $200 million a year—the cost of a medium-sized hospital system’s EHR installation....

Replacing VistA could be a colossal task—the military is spending $4.3 billion to switch to a Cerner EHR by the end of 2022, and Baker has estimated it could cost the VA $16 billion to rip and replace VistA. To maintain the functions that doctors like about it would require intricately lacing together new and existing software. Pitching all the good old stuff because it’s too old and complex to integrate with a new EHR would be tremendously wasteful and frustrating to doctors. A decision on whether to switch to a commercial system has been set for July 1. Some, including former CIO Baker, think the VA should wait until at least September, at which point the IT world will have a clearer picture of how the military’s implementation of a Cerner EHR is progressing.

An EHR vendor can expect decades of revenue from the government and the military once a foot is inserted in the federal contract door. Hence the attraction of such a contract that will amount to many billions of dollars. There will also be plenty of aggravation and bad press involved. All of this VistA story is curious, however, because federal agencies are typically not known for their skills in innovation. The VA IT specialists developed a great product early but politics and time have combined to make it increasingly obsolete. The story perhaps could have been much different.