Lab Soft News

Doctors on Demand Integrates Its Video Visits with Lab Testing

As telemedicine become more of the norm in ambulatory care and extends beyond a narrow range of patient care services (see: A New Perspective on Telemedicine: Patient Visits with Multiple Providers), the need arises to integrate telemedicine with e-prescriptions and lab test orders. A recent HIStalk note alerted me to the fact that Doctors on Demand is integrating its televisits with lab testing orders from the two largest reference labs, Quest and LabCorp (HIStalk News 5/5/17). Below is the item from Mr. HIStalk:

Video visit vendor Doctor On Demand integrates its system with those of lab companies Quest and LabCorp, allowing its doctors to order lab tests and for its patients to choose a lab based on insurance coverage, availability, and location. The company — co-founded by TV psychologist Dr. Phil and his TV producer son – has raised $87 million in three funding rounds, although the largest and most recent was nearly two years ago. Among its investors are Athenahealth’s Jonathan Bush and Virgin’s Sir Richard Branson. It offers medical sessions for $49 along with ongoing psychology and psychiatry counseling.

A couple of items caught my attention when I visited the Doctors on Demand web site. The first is that the company describes the service that is is offering to patients as a video visit. The second point is that the home page lists the "top" conditions seen including cold and flu, allergies, sore throat, eye, skin, sport injuries, UTI's, vomiting, anxiety, depression. These are complaints similar to those prompting visits to any CVS' MinuteClinic. What took me somewhat aback, however, was the inclusion of anxiety and depression in the list. However, this web site may provide the anonymity that a depressed/anxious patient might be seeking. Also and as noted in the excerpt above, Doctors on Demand offers psychology and psychiatry counseling.

Most of the conditions described above as commonly treated by the physicians at Doctors on Demand would not generally require lab testing. However, my guess is that the company desires to extend the range of services it provides to more complex acute cases and patients with chronic diseases (see: Treatment of Patients with Chronic Diseases: Important for the Future of Telemedicine). For me, one of the advantages of televisits is that the patient interacts with a physician without leaving his or her house, a distinct advantage for less mobile patients with chronic diseases. If the goal of Doctors on Demand is to extend its reach to, say, patients with chronic diseases, offering lab tests would be necessary. In summary, on-line telemedicine companies are now competing with walk-in drug store clinics and health systems like Cleveland Clinic that are offering televisits for $49 dollars (see: Cleveland Clinic Express Care Online). Cleveland Clinic is also promoting its Express Care Online for follow-up visits for its own patients. 

Cedars-Sinai Partners with Noteworth to Integrate Patient-Generated Data into the EHR

There was a time when input for the paper medical chart was restricted to healthcare professionals such as physicians and nurses. The contemporary EHR is now in the process of being "opened up" in the sense that patients have access to it for review through patient portals (see: What is a patient portal?) and patient-generated data is being integrated into it (see: Cedars-Sinai Partners With Noteworth to Integrate Patient-Generated Data With Epic EMR). Below is an excerpt from this latter article:

Cedars-Sinai has signed a three-year deal with Noteworth, a healthcare data software as a service (SaaS) company to integrate patient generated data into clinical decision-making....As part of the three-year program, Cedars-Sinai will use Noteworth’s platform to integrate previously unavailable patient-generated data directly into their Epic EMR to help improve patient satisfaction, drive health outcomes and reduce utilization. Noteworth’s interoperable platform enables physicians and care teams to seamlessly collect, analyze and visualize essential patient health data between office visits, allowing for more comprehensive levels of health data clarity for patients outside of the clinic.

To preserve the clinical staff’s existing workflows, Noteworth integrated into Cedars-Sinai’s Epic EMR in a one-month timeframe. Now, when a participating physician wants to know about their patients’ health when they are outside the clinic, they simply place an order from among a wide array of biometric (blood pressure, blood glucose level, weight, etc.) and behavioral data (medication adherence, mood, activity, etc.) directly within the electronic medical record (EMR). Noteworth then curates a set of FDA-approved at-home medical devices matching the data order, delivers it to the patient’s door and provides full support for patient onboarding and continuing device use, all via the Noteworth App (iOS and Android). Once a patient begins taking readings, their fully secured and HIPAA-compliant data is delivered directly back to the EMR in actionable, clinically relevant reports and optional, customizable notifications that care teams can implement.

I don't know if this project between Cedars-Sinai and Noteworth will succeed but the basic idea makes sense to me. Physicians and hospitals value objective and subjective information about the health status of their patients at home, particularly those with chronic conditions such as congestive heart failure (see: Talking to Patients Helps Reduce Hospital Readmissions; Hospitals Deploying Wireless Systems for Monitoring Patients; Home Monitoring of Discharged Patients by Hospitals for Cost Savings; Identifying Patients for Remote Monitoring with Predictive Analytics). Such conditions may predispose to hospital readmissions for which hospitals can suffer financial penalties (see: Medicare’s Readmission Penalties Hit New High).

As I understand the Noteworth business model, the company assumes the burden of delivering remote monitoring devices to the patients when ordered by physicians, instructing the patients on their use, and integrating the inbound clinical data generated by patients into the hospital EHR. It then becomes available for monitoring by the physicians ordering the service. I was not personally familiar with the term "patient onboarding" used in the excerpt above which is defined as patient self-administration of drugs at home (see: Onboarding). I presume that the range of services provided by Noteworth include onboarding training. Below are some more details about the process:

The first 30-, 60- and 90-days, commonly referred to as onboarding, are the most important regarding patient adherence. This is the time when a patient is expected to self-administer medication based upon prescribed regimen. While a patient’s first exposure to a drug delivery device typically consists of training with a health care professional onsite at a medical facility, a patient will most often perform their medication administration alone outside of a health care facility and health care provider supervision.

Warren Buffett Compares Cost of Healthcare in the U.S. to a Corporate Tax

Warren Buffett was quoted in a recent article as comparing the cost of healthcare in the U.S. to a corporate tax (see: Forget Taxes, Warren Buffett Says. The Real Problem Is Health Care). This line of reasoning is important because many executives are lobbying the administration for a lower corporate tax rate. Buffett thinks that they should more appropriately be seeking a lower cost of healthcare in order to be able to operate more competitive globally. I think that he's right and we need a broader discussion of this topic. Below is an excerpt from the article:

“The tax system is not crippling our business around the world.".....Mr. [Warren] Buffett, in a remarkably blunt and pointed remark, implicitly rebuked his fellow chief executives, who have been lobbying the Trump administration and Washington lawmakers to lower corporate taxes. In truth, Mr. Buffett said, a specter much more sinister than corporate taxes is looming over American businesses: health care costs. And chief executives who have been maniacally focused on seeking relief from their tax bills would be smart to shift their attention to these costs, which are swelling and swallowing their profits.....In 1960, corporate taxes in the United States were about 4 percent of G.D.P., which is probably the best way to measure the burden on businesses....Today, it is 1.9 percent. In the meantime, health care costs as a percent of G.D.P. have skyrocketed, significantly diverging with those of other industrial countries. Our health care costs stand at 17.1 percent of G.D.P., up from 13.1 percent in 1995.....

That puts the United States at a material disadvantage far beyond the tax differential. And it harms American companies in particular, since they bear such a big share of those costs. Corporations spend $12,591 on average for coverage of a family of four, up 54 percent since 2005....[T]he United States...[should] enact a sort of universal type of coverage for all citizens — perhaps along the lines of the Medicaid system — with an opt-out provision that would allow the wealthy to still get concierge medicine. Our bloated health care system, Mr. Buffett asserted, is the true barrier to America’s world competitiveness as well as “the single biggest variable where we keep getting more and more out of whack with the rest of the world.”

If and when corporate executives come to realize that the cost of healthcare is a form of corporate tax, what should they then do to help bend the cost curve? One recent article suggested that one solution would be to pursue a series of small steps that, in the aggregate, could make a difference (see: How Small Ideas Are Helping to Bend the Health Care Cost Curve). Here are examples of the small ideas cited in the article:

• Lowering treatment costs by reducing the use of anesthesia providers in routine gastroenterology procedures for low-risk patients.
• Changing the payment policy for emergency transportation or ambulance service. Medicare currently pays vast sums for transporting elderly patients to and from the hospital.
• Shifting care from hospital emergency rooms to retail clinics when appropriate.
• Increasing the use of $4 generic drugs to help rein in runaway prescription drug costs.

There is one way that consumers with high-deductible plans or no health insurance can reduce their healthcare costs -- direct access testing (DAT). Using DAT, consumers order lab tests for themselves on the web, perhaps on the basis of advice from their physicians. Most of these DAT companies use the same national reference labs that provide services to physician offices such as LabCorp (see: FAQs: Walk-in Lab's Questions and Answers). For drawing the necessary blood samples, DAT customers will be directed to the LabCorp's patient service centers. The web-based DAT firms usually use LabCorp to as their performing reference lab.

Creating an Effective Consulting and Education Ecosystem for Digital Pathology

Beginning on May 10, 2017, I posted three sequential notes regarding the deployment of digital pathology platforms (see: "Not Yet" a Common Response by Pathologists to Digital Pathology Adoption; Seeking Funding from Hospital Executives for Digital Pathology Platforms; A Potential and Useful Consulting Role for Digital Pathology Vendors). In response to the last one about the need for consulting support when deploying this new technology, Dr. Karim Sirgi, a pathologist, submitted the following comment:

It is true that digital pathology vendors could play a more active role in "educating" their pathology clients about the many operational and financial benefits associated with digital pathology. However, in order to do so, they need to have on their staff, or as part of their own consultants, "real-life" pathologists who work is settings relevant to such digital pathology deployments....[I have discovered] hollowness in my conversations with most digital pathology equipment vendors ... and found myself in the unusual situation where I had to tell THEM about the unadvertised and underdiscovered features of THEIR products ....

In this note and prompted by Dr. Sirgi's comment, I would like to propose a possible means to provide consulting and educational services for digital pathology with emphasis on optimizing the technology. First, though, I want to list what I don't think will be happening regarding consulting and education in this area:

• Digital pathology vendors will not be able to provide sufficient and adequate consulting and education services for their products because this is not the nature of their business and they often lack the "real world" experience to which Dr. Sirgi refers to above.
• Large healthcare consulting firms will not be entering the pathology market. There's not enough business to attract them and they lack the specialized expertise. 

What I envision possibly, and hopefully, happening is the following to facilitate the rapid acceptance and success of digital pathology:

• The creation of a digital pathology education and consulting ecosystem based on a partnership of (1) digital pathology vendors; (2) pathology departments (i.e., pathologists and support personnel in large health systems already using the technology), and (3) pathology informatics societies like the Association for Pathology Informatics (API) and the Digital Pathology Association (DPA). 
• Participants in this ecosystem will begin to organize tutorials and seminars, frequently in hospital settings, to discuss practical issues including the enhancement of workflow to maximize the benefits of digital pathology systems. The teaching materials used for such events will have been largely developed by the pathology departments that are using the technology.
• Ideally, the pathology departments participating in these tutorials and seminars will be the alpha and beta sites for the digital pathology vendors and will be compensated for their participation with access to the vendors' new hardware and software. This creates a virtuous circle -- a self-propagating advantageous situation in which a successful solution leads to more of a desired result or another success which generates still more desired results or successes in a chain. In other words, these pathology departments will always be working with the latest technology and thus pushing the boundaries in real-world environments.

A Potential and Useful Consulting Role for Digital Pathology Vendors

In two recent notes (see: "Not Yet" a Common Response by Pathologists to Digital Pathology Adoption; Seeking Funding from Hospital Executives for Digital Pathology Platforms), I responded to a comment by a reader, Barry Portugal, about the deployment of digital pathology platforms. However, I have not yet responded to the following portion of his comment: It's my view that digital pathology companies need to step up their efforts to educate pathologists and hospital system executives on the clinical, operational, and financial benefits associated with digital pathology. Today's note, addresses the potential role of digital pathology vendors in advising their clients about how to most effectively deploy their systems.

For my whole career in pathology informatics, I have questioned LIS vendors about why they were not more proactive in providing consultative services to their clients about the "clinical, operational, and financial" benefits of their systems. In many ways, these companies would seem to be ideally positioned to provide such services in that they have comprehensive knowledge of their product. Moreover, they should have also acquired a deep understanding of the operational aspects of pathology departments from client interactions.

For the most part, LIS vendors have always provided support for the use of their software but have never been enthusiastic about going beyond this boundary and providing advice on lab workflow and operational issues. Over the years, such vendors have offered the following explanations for their not being more aggressive in providing LIS consultative services:

• The cost of client support has historically been included in the cost of the software. If additional support were to be provided, clients would expect to receive it at no additional cost.
• LIS vendors viewed themselves as being mainly in the software business and not willing, or able, to extend these services to a different business, lab consulting.
• The companies would experience additional liability if they were to provide consultative advice about pathology and laboratory operations. (N.B.,This always seemed to me to be a weak argument because consulting firms are able to insure themselves against such risks.)

I agree with Barry that digital pathology vendors like Philips and other vendors in the same field like Ventana absolutely need to "educate" their digital pathology clients about "the clinical, operational, and financial benefits associated with digital pathology." I am certain that these companies. and others, will respond that they already engage in educational activities in terms of participation in various relevant conferences. However, I am referring here to on-site, personalized consulting focusing on organizational and workflow changes necessary to extract all of the benefits from a digital pathology platform. In so doing, they can also cultivate champions for the technology who will then proselytize among other departments. Not to do so will unnecessarily prolong the adoption period for the new technology and jeopardize the large R&D investments these companies have already made.

Seeking Funding from Hospital Executives for Digital Pathology Platforms

In response to my note yesterday about pathology naysayers regarding the purchase and deployment of digital platforms (see: "Not Yet" a Common Response by Pathologists to Digital Pathology Adoption), Barry Portugal, a veteran and knowledgeable consultant in pathology and lab medicine, submitted the following comment: 

While I agree that age is certainly a factor to the "not yet" conundrum, it's been my experience that "technology phobia" and capital investment are both more prevalent reasons. It's my view that digital pathology companies need to step up their efforts to educate pathologists and hospital system executives on the clinical, operational, and financial benefits associated with digital pathology.

I agree with Barry that it may be very difficult for pathology departments to acquire funding from hospital executives for a digital pathology program. Hospital execs generally tend to favor projects with a rapid and generous return on investment and often disregard those with a quality orientation. It thus falls to the pathology department leadership to put forward the strongest possible case for digital pathology couched in a convincing set of ROI numbers. In my mind, the two strongest arguments to be made currently for digital pathology are the following:

• Given that whole slide images are highly portable, large health systems have the opportunity to modify their surgical pathology workflow. Glass slides no longer need to be transported to the relevant in-house speciality pathologist or outside consultant. Prior pathology images for current surgical patients can be quickly reviewed. Some multi-hospital systems may even choose to place many, or even most, of their surgical pathologists in one work space to take full advantage of a centralized model.
• For teaching hospitals, the quality of the surgical pathology program is a major factor for residency applicants. I believe that the best candidates will now favor teaching programs with a successful digital pathology program to launch their careers. In short, capital investment in this technology is necessary to retain and attract the best trainees. 

Further and with regard to the financial return for digital pathology projects, one caution I would put forward to departmental leaders is not to promise a rapid return on investment. This is because of the broad organizational changes that will be required to optimize surgical pathology workflow under digital. Also and like many other deployments of emerging technology, digital pathology projects are subject to the S-curve whereby productivity gains are initially slow for early adopters because users are initially unfamiliar with the technology (Innovation and the S-Curve). Efficiency gains then become easier and more rapid as an organization works toward the rapidly ascending portion of the S-curve.

Barry's second point is that "technology phobia" may be inhibiting the deployment of digital pathology. If you were to ask me which departments/units in a hospital are the main "repositories and adopters" of new technology and science, I would respond with the following five: pathology/lab medicine, radiology, cardiology, oncology, and the operating rooms. Thus, if the leaders of a pathology department tend to feel phobic and inhibited by digital pathology, I would suggest that perhaps they are misplaced in the organizational hierarchy and should step aside to allow others to lead the high-tech projects that require major capital investments. 

"Not Yet" a Common Response by Pathologists to Digital Pathology Adoption

In a recent note, I discussed the recent approval by the FDA of the Philips digital pathology platform called Philips IntelliSite Pathology Solution (PIPS) (see: FDA Approves the Philips Digital Pathology WSI Solution for Primary Diagnosis). I know from past experience and from one comment to my note that a sizable number of pathologists continue to respond "not yet" to a call for broader adoption of WSI. This reaction is nominally based on the idea that the technology is not yet ready for "prime time" even in the face of evidence accepted by the FDA that digital images are at least the equivalent of optical images. 

I believe that some, but not all, of these responses by pathology naysayers is based on a reluctance to change routines and learn a new technology and workflow. I believe that many of the opponents of change are pathologists who wish to continue in an uninterrupted way with their current work routines. Their attitudes will probably have considerable influence in the field because many of them are in senior leadership positions and well-positioned to make key decisions about when and how to deploy this new technology.

It's useful to take a step back here and compare the adoption of digital pathology to that of digital imaging in radiology. This latter technology was deployed relatively quickly but had major benefits that precipitated the change. They were the following: (1) the new imaging modalities in radiology were digital from birth; (2) the new modalities were in many ways superior to older imaging technologies and therefore rapidly adopted and ordered by clinicians; and (3) the new modalities generated high profit margins so hospitals executives were eager to provide the capital to radiology departments to quickly adopt the new technologies.

Given that two out of three of these benefits are not relevant to digital pathology, here's what I think are the three major drivers for adopting digital pathology: (1) surgical pathology images become portable, creating new opportunities; (2) pathology images become available for automated image analysis; and (3) these two benefits, in time, will result in reduced costs for the interpretation of pathology images. In order to take advantage of these benefits, we need wider adoption of the WSI technology to achieve economies of scale. At least in my mind and because the FDA approval of PIPS now should bend the technology adoption curve, I believe that the response of "not yet" for WSI is no longer reasonable.

A New Perspective on Telemedicine: Patient Visits with Multiple Providers

A recent article by Ray Dorsey and Eric Topol provided a perspective on telemedicine that I had not encountered before (see: Here’s What Your Future Doctor Visits Could Look Like). It described virtual visits as a data exchange with multiple providers rather than a visit with a single physician as is the normal approach today. Below is the relevant excerpt from the article:

Today’s office visit to a doctor involves a patient, a family member, and a physician 97% of the time. Tomorrow’s visit will engage nurse practitioners, nutritionists, genetic counselors, pharmacists, therapists, social workers, mental health professionals, and exercise coaches. The Internet enables clinicians to connect patients at different times based on need, not travel burden. Just as more clinicians will contact patients, more caregivers including children living in different cities and countries will participate remotely in visits through video conferencing. The nature of visits will also change. Patient-generated data creates the opportunity for the visit to be a true data exchange. Tomorrow’s visit will include objective, high frequency and real-time streaming data, including blood pressure, glucose levels, activity levels, diet, and social engagement metrics. Patients will control the data from novel sensors and grant clinicians access at the patients’ direction. As many visits will be remote, the physical exam will approach a medical selfie. Smartphone attachments, some of which are already cleared by the FDA, will help perform the physical exam, including taking vital signs, listening to heart sounds, and visualizing ear drums with greater clarity that will enable clinicians and patients to see what was previously invisible to them.

Most outpatient visits, as noted above, consist of a face-to-face interaction between a patient and a physician. We need to consider for the future, however, that some visits may include a visit with a health coach (see: Telemedicine Used in New Healthcare Settings Like Coaching) or a pharmacist (see: Hypertension Management Program with Health System and Retail Pharmacists; Pharmacist-Staffed Coagulation Clinics in a Large Health System) or a nutritionist. A virtual visit may thus result in a patient interacting with broader set of providers. Algorithms could be deployed prior to a telemedicine visit to scan a patient's EHR record to determine, for example, whether a patient has a problem that requires help from several members of a health team.

Recall that a virtual patient visit will be scheduled with a physician in one location but interactions with providers in other locations can be scheduled. All of this speaks to the complexity of workflow for a telemedicine visit that needs to be studied. As the excerpt above suggests, our broader deployment of telemedicine will invite us to take a fresh look at how we deliver outpatient care. IT destroys time and distance. A multidisciplinary approach will be the new mantra of healthcare and will be enabled by our new technologies.

FDA Approves the Philips Digital Pathology WSI Solution for Primary Diagnosis

As many of the readers of this blog already know, the Philips platform for digital pathology was recently approved by the FDA for the primary diagnosis of cases using WSI (see: FDA allows marketing of first whole slide imaging system for digital pathology). Primary diagnosis with digital pathology has been a long slog but we have now turned a major corner. Philips presented a webinar yesterday about PIPS (Philips IntelliSite Pathology Solution) which is accessible on-line (see: Philips IntelliSite Pathology Solution now available for primary diagnostic use in the U.S.) Here's the link to the video. The recording is password protected so use the following password: primary_diagnostic_use.

A sizable portion of the presentation is by Dr. Mike Feldman, a pathologist at the University of Pennsylvania, who lead the team that gathered the evidence presented to the FDA to justify the approval by the agency. HIs presentation is smooth and crystal clear. A convincing case has now been made that digital scans and analysis equals that of the predicate device, the microscope. The FDA has also decided that PIPS is a Class II device which is not as high a regulatory barrier as the previously determination as a Class III device. This latter requires pre-market approval (PMA) for changes.

In my mind, the path is now clear for all pathology departments -- an urgent need to deploy this technology which opens up a new set of opportunities and challenges. The major challenges for departments will be modifying their surgical pathology workflow and integrating digital pathology with their LISs. From an automation perspective, surgical pathology will soon be comparable to clinical pathology, at least from the image scanning and analysis perspective. My advice to graduating medical students seeking to pursue a career in pathology is to choose a department for training that will be able to smoothly deploy digital pathology efficiently and broadly.

Some of the Major Criticisms of EHRs; Why Few Changes Anticipated

A recent web article presented a "slide show" of suggestions from readers of Healthcare IT News about how to "fix" EHRs (see: We asked people how to fix EHRs, and boy did they have answers). I have reworked the 19 items in the article and rearranged them into the list below:

Physician interactions with the EHR

• Simplify EHR screens; reduce number of options and clicks.
• Eliminate rigid workflow and increase the efficiency of use, particularly for physicians.
• Incorporate AI and cognitive data tools to generate useful and predictive data.
• Present data in a more meaningful and understandable format; create a homogeneous view of data.
• Strive to optimize physician efficiency rather than generating a bill.

Organizational and vendor EHR issues

• Reduce data requirements mandated by the government.
• Require EHR designers to have worked in clinical setting so that they can better understand system design and workflow.
• Increase clinical data interoperability and data sharing across institutions.
• Develop more effective channels for user feedback to the vendor.
• Develop better hospital training programs.

This is a very good list and reflects most of the major problems associated with EHRs, the health systems that purchase them, EHR vendors, and the federal regulatory environment. Unfortunately, I am not optimistic that any of these will be addressed in more than a cursory manner. EHRs are very complex computer systems and difficult to change without scrapping the whole system. Moreover, one of the major priorities for hospital executives is generating a bill, albeit a very complicated one (see: Coding for Hospital Services; One Reason for the High Cost of Healthcare; Two Reasons Why Medical and Hospital Bills Are Such a Mess). Thus, one of the reasons that EHRs emphasize patient billing is that hospital executives like such a design. In public forums, however, they will usually state that the quality of care is their first priority.

Despite the fact that I envision few major changes to EHRs in the future, the importance of the problem list above will diminish in importance for two reasons. The first is that younger physicians will have better keyboarding skills and interacting with an EHR will be second nature to them. In other words, they will interact with these systems in a more spontaneous and efficient way. The second reason is that the deployment of medical scribes will become even more common and widespread. My blog notes on scribes go back nearly seven years (see: Shift of Hospital EMR Data Entry Tasks from MDs to Scribes; The Emergence of EMR Scribes as a New Category of Hospital Employees; The Explosive Growth of EHR Scribes; Back to the Future).