Lab Soft News

Should Virtualists Be Recognized as a New Type of Medical Specialist?

An article published in the JAMA Network by Nochomovitz and Sharma suggested that we should recognize a new type of medical specialist, the virtualist (see: Is It Time for a New Medical Specialty? The Medical Virtualist). These physicians would limit their practice to telemedicine, which is to say treating patients on a virtual basis. This is an appropriate suggestion from a credentialing viewpoint given that a number of new sub-specialties have emerged in recent times such as general surgical oncology, interventional radiology, electrophysiology, and pathology informatics. Below is an excerpt from the article:

Early telehealth focused on minor ailments such as coughs, colds, and rashes, but now telehealth is being used in broader applications, such as communicating imaging and laboratory results, changing medication, and most significantly managing more complex chronic disease. The coordination of virtual care with home visits, remote monitoring, and simultaneous family engagement is changing the perception and reality of virtual health care. Commercialization is well under way with numerous start-ups and more established companies....We propose the concept of a new specialty representing the medical virtualist. This term could be used to describe physicians who will spend the majority or all of their time caring for patients using a virtual medium.....Contemporary care is multidisciplinary, including nurses, medical students, nurse practitioners, physician assistants, pharmacists, social workers, nutritionists, counselors, and educators. All require formal training in virtual encounters to ensure a similar quality outcome as is expected for in-person care. It is possible that there could be a need for physicians across multiple disciplines to become full-time medical virtualists with subspecialty differentiation. ....Medical virtualists will need specific core competencies and curricula that are beginning to develop at some institutions. In addition to the medical training for a specific discipline, the curriculum for certification should include knowledge of legal and clinical limitations of virtual care, competencies in virtual examination using the patient or families, “virtual visit presence training,” inclusion of on-site clinical measurements, as well as continuing education. 

I have been a strong advocate for telemedicine in Lab Soft News and consider this approach to healthcare delivery to be one of the best ways to reduce the cost of care while serving a broader group of patients. I also think that the creation of a new specialty group of virtualists is a good idea and probably inevitable. Physicians and nurses will continue to practice telemedicine and will learn their craft whether or not they have some sort of speciality recognition. I do have a couple of comments on this article:

• It's extremely important that medical virtualists have telemedicine practices and thus serve as role models for their colleagues. However and in addition, most virtualists will probably oversee a team of other health professionals engaged in the same pursuits. Nochomovitz and Sharma refer to this when they say that contemporary care is multidisciplinary. Because telemedicne is now entering a period of explosive growth, the pioneers in the field also need to have broad managerial skills in order to manage teams and proselytize others about the benefits.
• I mentioned above that pathology informatics is a subspecialty of pathology that emerged over the last several decades to meet the need of pathology for specialists in information technology. The proposal for the accreditation of medical virtualists flows from the same sort of logic: new technology enables physicians to diagnose and treat patients at a distance. I thus find it perplexing that information technology is not listed as one of the proposed core competencies of the virtualists. One might think that this was a minor oversight but the virtualist needs to have a deep understanding of the technologies that enable telemedicine visits of all types. With an IT skillset, he or she will be able to better shape the technology to adequately support all types of patient-physician encounters.

Mayo Clinic Develops a Lab Test for Inflammatory Demyelinating Diseases

The spectrum of inflammatory demyelinating diseases (IDD) includes neuromyelitis optica, acute disseminated encephalomyelitis, optic neuritis, and transverse myelitis, all of which need to be differentiated from multiple sclerosis (MS). Mayo Clinic scientists have developed a test for an antibody to myelin oligodendrocyte glycoprotein (MOG) which can help to differentiate the former set of diseases from the latter disease (see: Mayo Clinic develops neuro test that distinguishes demyelinating diseases from MS). Below is an excerpt from the article announcing its availability:

Mayo Clinic has launched a first-in-the-U.S. clinical test that will help patients who recently have been diagnosed with an inflammatory demyelinating disease (IDD) but may be unsure of the exact disorder. Neurologic-related diseases commonly affect the brain, optic nerves and the spinal cord, and this new test can distinguish other IDDs such as neuromyelitis optica, acute disseminated encephalomyelitis, optic neuritis, and transverse myelitis from multiple sclerosis (MS). The test uses live cells to identify patients who are positive for an antibody to myelin oligodendrocyte glycoprotein (or “MOG,” for short)....[A Mayo spokesperson said the following:] "we have learned that if patients test positive for MOG antibodies, it generally indicates that it’s not classical MS,”....“And, more important, some MS treatments have been reported to worsen the disease of patients diagnosed with an IDD that is not classical MS.”

“While many IDDs that mimic multiple sclerosis are rare, correct and early diagnosis allows for early immunotherapy with immunosuppressants, rather than disease-modifying agents that are commonly used in treating MS,”....The researchers also found that persistence of the MOG antibody is associated with disease relapses, thus warranting relapse-preventing immunotherapy. “We’ve learned that if patients are positive for MOG antibodies, and they have an attack (such as optic neuritis), and they persistently remain positive [for the MOG antibodies] when tested six to 12 months later, they have a higher likelihood for a relapse,” says Andrew McKeon...., a clinical biochemist and co-director of Mayo’s Neuroimmunology Laboratory.

It thus appears that the availability of the MOG test may help to clear up some of the ambiguity in diagnosis of demyelinating diseases. Here is the current set of criteria that are used for the diagnosis of multiple sclerosis (MS) (see: MS Diagnosing Tools):

Criteria for a diagnosis of MS

At this time, there are no symptoms, physical findings or laboratory tests that can — by themselves — determine if a person has MS....In order to make a diagnosis of MS, the physician must:

*  Find evidence of damage in at least two separate areas of the central nervous system (CNS), which includes the brain, spinal cord and optic nerves AND

*  Find evidence that the damage occurred at two different points in time AND

*  Rule out all other possible diagnoses.

In 2001, the International Panel on the Diagnosis of Multiple Sclerosis updated the criteria to include specific guidelines for using magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) analysis, and visual evoked potentials (EP) to speed the diagnostic process. These tests can be used to look for a second area of damage in a person who has experienced only one relapse.... — referred to as a clinically-isolated syndrome (CIS). A person with CIS may or may not go on to develop MS. 

Could Apple Be Trying to Develop a "Patient Portal" for the iPhone?

Apple has periodically experimented with various products for the healthcare market because it accounts for such a large percentage of the economy. There even has been periodic speculation that the company thus might try to compete in the EHR space (see: Could Amazon or Apple actually make a dent in the EHR market?). Here's a quote from this article:

"It will be an uphill battle [for Apple in the EHR market], especially if they try to compete in the larger segments of the market," said Bryan Fiekers, Senior Director of Research Services at HIMSS Analytics.....John Moore, founder and managing partner of Chilmark Research, added that many enterprise technology titans have struggled to tackle the healthcare IT conundrum. “Think Microsoft, Google and IBM with very mixed success,” Moore said. ....It’s worth pausing to note that what has thus far been reported is based on unnamed sources — meaning neither Apple nor Amazon has formally revealed any intentions to build an EHR. 

Now I turn to another recent article on a similar topic, which is to say speculation about whether Apple may be trying to turn its iPhone into a type of "companion" to a patient's medical record (see: Apple is quietly working on turning your iPhone into the one-stop shop for all your medical info). Below is an excerpt from it:

CNBC has learned that a secretive team within Apple's growing health unit has been in talks with developers, hospitals and other industry groups about bringing clinical data, such as detailed lab results and allergy lists, to the iPhone, according to a half-dozen people familiar with the team. And from there, users could choose to share it with third parties, like hospitals and health developers.....Such a move would represent a deviation in strategy from Apple's previous efforts in health care, the people said, which have focused on fitness and wellness. Apple's HealthKit, for instance, is primarily used to store things like step counting and sleep. There's also a feature called "health records," which includes the option to import documents that include summaries of care, but that is a limited snapshot of medical information....

...[Patients] who do have access [to their EHRs] through so-called "patient portals" sometimes find that the user experience is poor and the information is limited. This problem is often referred to as the "interoperability crisis" — and it is hurting patients, health experts have said. The lack of data-sharing between health providers leads to unnecessary mistakes and missed diagnoses....As health care goes digital, the promise has always been to give patients and the doctors they trust full access to their health information.... Apple in recent months has been involved with discussions with health IT industry groups that are looking for ways to make this goal a reality....The company has also hired some of the top developers involved with FHIR, an increasingly popular protocol for exchanging electronic health records.

This discussion suggests that Apple may be considering the following idea: rather than replicate the EHR and compete with entrenched vendors like Epic and Cerner, it way want to develop an app for the iPhone that replicates, but improves, the patient portal (see, for example: Patients Often Lukewarm about Patient Portals; Problems with Training?). In this way, Apple will not be forced to compete directly with established EHR vendors for whom the patient portal has been a bit of an afterthought. The focus for EHR vendors remains on satisfying hospital executives, doctors, and nurses rather than patients. Apple also holds the advantage of being known and valued by consumers.

Another advantage held by the Apple is the ability to integrate and display data generated by health wearables (see: 39 essential fitness apps and devices that work with Apple Health). As noted above, the major challenge for Apple, if they wish to get into the patient portal business, will be obtaining access to hospital data from the health systems and their EHR vendors. This will partly be an interoperability problem (see, for example: Hospitals Need to Pressure Their EHR Vendors to Improve Software Functionality) but also a data access problem. However, much of patient care and health data will be moving in a centrifugal direction away from hospital control and hospital executives could do worse than collaborating with Apple.

Detroit and Wayne County Sue Drug Makers Over Opioid Crisis

I have blogged about the opioid crisis which is enveloping the entire country (see: Pharmaceutical Companies and PBMs Helped to Create Our Opioid Crisis). The Sackler family, owners of Purdue Pharma, have been much in the news with assertions by some media that the company, when marketing OxyContin, conspired to downplay its addictive qualities (see: THE SECRETIVE FAMILY MAKING BILLIONS FROM THE OPIOID CRISIS; The Family That Built an Empire of Pain). It should therefore not come as a surprise that some governmental bodies such as Detroit/Wayne County are suing drug manufacturers for having caused the chaos and deaths due to opioid addictions (see: Oakland, Wayne sue drug makers over opioid crisis). Below is an excerpt from this article:

Oakland and Wayne counties are suing several pharmaceutical makers over what they call "deceptive marketing practices" amid a rising number of opioid deaths....Oakland County Executive L. Brooks Patterson and Wayne County Executive Warren Evans announced a joint federal lawsuit against drug makers...."The opioid industry has taken a page out of big tobacco's playbook," Patterson said Thursday...."They utilized misleading information, marketing campaigns, and studies to convince the public that their product was safe. They put profits over people and now people are paying the price, some with their lives." Their suit...alleges several drug makers intentionally misled doctors and patients about their products' appropriate uses, risks and safety while downplaying the risks of addiction....The lawsuit seeks to stop drug companies from making further false or misleading statements about opioids and stop them from not reporting suspicious drug orders. It also seeks legal costs and damages....Caitlin Carroll, a spokeswoman for the Pharmaceutical Research and Manufacturers of America...said the group cannot comment on legal matters relating to specific member companies.

Note the reference in this excerpt to the analogy between the "opioid industry" and the "tobacco industry." And like the tobacco industry in the past, the opioid manufacturers are now subject to myriad lawsuits including various class actions (see: Are Pharmaceutical Companies to Blame for the Opioid Epidemic?). Here is a quote from this article which suggests that it's unwise to draw too many parallels between the opioid and tobacco cases because those addicted to the drugs are said to have caused their own problems:

But the situation differs in significant ways from the tobacco example, and proving the pharmaceutical companies are responsible will be difficult. Individual plaintiffs who have sued pharmaceutical companies over how opioids have been marketed have rarely been successful....Courts have made clear that they believe that individual victims are largely responsible for their addiction. People who die of overdoses are often using the pills not as they were prescribed, but are obtaining the pills on the black market. They are disregarding doctors’ prescriptions and taking more than is safe. 

It's going to take some time for all of this to play out and I suspect that the plaintiff's attorneys in these cases will try to develop a strategy that works well in the courtroom. Meanwhile, there may be a no safe harbor for many healthcare organizations. Even the Joint Commission is being sued  for failure tp set up standards that could have avoided the opioid crisis (see: ‘This is just the beginning’: Scope of opioid lawsuits widens to include hospital accreditor).

Roche to Acquire Viewics, an Analytics Software Company

I have posted numerous notes about analytics software (see, for example: Lab Analytics Emerges as Hot Area for Software Development; Relevance of Lifestyle Analytics for Healthcare Organizations; Leveraging Lab Analytic Data to Include Actionable Details to Improve Quality; Much of the Future for Pathology and Lab Medicine Rests with Analytics). Roche Diagnostics is now acquiring a lab analytics vendor, Viewics (see: Media Release). Below is an excerpt from the press release from Roche:

* Roche to acquire Viewics, Inc. to provide data-driven lab business analytics and add further digital capabilities along the laboratory value chain

* The Viewics solution allows for efficient integration of big data from a variety of IT systems in the laboratory and beyond, pioneering a new way in extracting, cleansing, transforming and augmenting data.

* Executive, financial, operational, technical, and laboratory roles gain comprehensive insights, enabling data-driven decisions that improve laboratory processes and performance.

* Viewics, Inc. will become an integral part of Roche and add further digital capabilities on top of Roche Diagnostics’ Integrated Core Lab offering.

....This acquisition allows Roche to expand its leading position in the Integrated Core Lab with business analytics capabilities, enabling laboratories to make faster data-driven informed decisions on their operations and processes. The cloud-based solution is secure, infrastructure-agnostic, interactive, and accessible from multiple devices (e.g. smart phones, tablets, desktop computers).....The Viewics solution offers automated data extraction, cleansing, and augmentation architecture and resolves many of the typical problems that laboratory IT staff encounter when using generic business intelligence solutions, traditional data warehousing, or extraction methodologies.

The major IVD companies have been involved with the lab software in various ways and at various times. For example, Abbott Informatics, one of the corporate underwriters of this blog, owns StarLIMS. All of the major IVD companies also provide middleware to their customers which is software positioned between analyzers and the LIS (see: Beyond connectivity: middleware’s shifting shape). By and large, the IVDs have stayed away from LIS development or the purchase of a major LIS vendor, largely focusing on data generation rather than data management or analysis. I have also suggested that IVD vendors should consider aligning themselves with LIS vendors to offer "integrated diagnostic solutions" (see: Development of an "Integrated Diagnostic Solution" in Response to EHR Market Pressure). I think that this would allow them to compete more effectively with EHR vendors like Epic and their LIS module, Beaker.

For me, the Roche purchase of Viewics does not raise a question about the value and future of lab analytics for which the future is bright. However, there is one question in my mind: what's next for Roche? There is one important clue in the press release cited above. It states: Viewics...will become an integral part of Roche and add further digital capabilities on top of Roche Diagnostics’ Integrated Core Lab offering. So, at least for the present, Roche seems content to remain within the "IVD space" which is to say within its Integrated Core Lab Offering. This then prompts the question of how all of the useful "comprehensive insights" to be derived from the use of the Viewics software are going to be reported to the lab managers and to test-ordering clinicians.  

MSK-IMPACT: New Tumor Profiling Genetic Test Approved by the FDA

Memorial Sloan Kettering Cancer Center has developed the first tumor-profiling laboratory developed test (LDT) approved by the FDA. It's called MSK-IMPACT. Below are some details about the test from a recent article (see: FDA Authorizes MSK-IMPACT Test for Analyzing Patient Tumor):

The FDA’s authorization of MSK-IMPACT sets a precedent for future authorization of tests developed by both academic and commercial labs....The test was developed by Memorial Sloan Kettering’s Department of Pathology to look for genetic mutations and other alterations in patients’ tumors.....MSK-IMPACT, which stands for integrated mutation profiling of actionable cancer targets, has been used to analyze the tumors of people with advanced cancer being treated at MSK since January 2014.....When the test was first developed, it looked for alterations in 341 cancer-associated genes. Today, it looks for alterations in 468 genes. These alterations may be seen in both common and rare cancers.... It is now the first tumor-profiling laboratory-developed test to receive authorization through the FDA....To date, more than 20,000 MSK patients with advanced cancers have had their tumors sequenced. The resulting data have helped guide therapy while also providing a wealth of new information that is driving new investigations in the laboratory.....According to a study published earlier this year...which looked at the first 10,336 patients to have their tumors sequenced with MSK-IMPACT, nearly 37% had at least one actionable mutation. This means that drugs targeting these mutations were available. Based on those testing results, the paper reported, 11% of patients — about 1,000 people — were able to participate in clinical trials of treatments that directly targeted the genetic alterations in their tumors....One of these abnormalities, known as   instability (MSI), occurs due to a defect in a process called DNA mismatch repair....Earlier this year, the FDA approved the immunotherapy drug pembrolizumab...for the treatment of tumors with MSI, regardless of where the tumors appear in the body.

To my mind, tumor profiling tests are extremely valuable in that they show the best way to seek out the genetic weakness of tumors. MSK-IMPACT fits the bill in this regard, revealing alternations in 468 cancer-associated genes. Changes in any of these genes in the tumor enable the treating oncologist to choose the optimal drug(s) for treatment of the lesion, taking advantage of its intrinsic genetic weaknesses. With increasing frequency, the approach will be immunotherapy agents, sometimes in combination. The timing of the use of such drugs is now becoming more important (see: Timing and Sequence Critical for Immunotherapy Combination). You may have a different opinion of LDTs (see: To Regulate or Not? The Lab Developed Test Saga Continues), but I am confident that a tumor-profiling test like MSK-IMPACT developed at a prestigious cancer hospital like MSK would be designed to assist their oncologists in optimally treating  their patents.

Feasibility of the Delivery of Lab Specimen and Units of Blood by Drone

The use of drones for delivery of various types of goods has been in the news lately (see: Here’s everything you need to know about Amazon’s drone delivery project, Prime Air). However, the use case that caught my attention was the delivery of clinical lab specimens (see: Johns Hopkins’ Test Drone Travels 161 Miles to Set Record for Delivery Distance of Clinical Laboratory Specimens), Below is an excerpt from this article:

....Johns Hopkins University Medicine (JHUM) has set a record in America for the longest distance drone delivery of viable medical specimens. In a project to demonstrate the viability of using drones to transport medical laboratory specimens, the Johns Hopkins University team flew a drone with specimens more than 161 miles across the Arizona desert. The goal is to bring autonomous medical delivery drones a step closer to transforming how specimens get transported across long distances.... In conducting its most recent study, Johns Hopkins researchers obtained paired chemistry and hematology samples from 21 adults.... A temperature-controlled specimen transport container designed by the Johns Hopkins University research team ensured the blood samples remained cooled and were viable for testing after the three-hour drone flight in the Arizona heat....The test flight adds to the growing evidence that unmanned aircraft may be the most effective way to quickly transport blood and other medical samples to clinical laboratories....Another major player in medical drone delivery is Zipline, a Silicon Valley-based drone delivery company that since October 2016 has flown more than 14,000 flights in Rwanda, delivering 2,600 units of blood.

It seems to me that the most relevant case for drone delivery of lab specimens and units of blood would occur in rural areas of the U.S. and also in less developed countries where there might be a lack of paved roads and commercial airline flights. My reading about drones suggests that other issues that might limit the practicality of drone delivery include range restrictions due to battery limitations and cargo weight. Here's additional information about the success of Zipline in Rwanda (see: Condom drops and airborne meds: 6 ways drones could change health care):

...California-based Zipline [has] started flying commercial drones from its distribution center in Muhanga, Rwanda, to nearly two dozen hospitals in the country. Health workers at remote clinics can order supplies via text. And Zipline promises to air drop the delivery in as soon as 15 minutes, cutting time on trips that once took hours to complete by car. Zipline, which has already completed more than 350 flights, claims on its website that its Muhanga facility will become Rwanda’s busiest airport sometime this summer.

Down Syndrome Disappearing in Iceland; Similar Events Will Become More Common

We are now living in an era when infants born with genetic disorders such as Down Syndrome will disappear in some societies (see: "What kind of society do you want to live in?": Inside the country where Down syndrome is disappearing). Below is an excerpt from this article explaining this process. Read the whole article if you are so motivated. 

With the rise of prenatal screening tests across Europe and the United States, the number of babies born with Down syndrome has significantly decreased, but few countries have come as close to eradicating Down syndrome births as Iceland. Since prenatal screening tests were introduced in Iceland in the early 2000s, the vast majority of women -- close to 100 percent -- who received a positive test for Down syndrome terminated their pregnancy. While the tests are optional, the government states that all expectant mothers must be informed about availability of screening tests, which reveal the likelihood of a child being born with Down syndrome. Around 80 to 85 percent of pregnant women choose to take the prenatal screening test....Using an ultrasound, blood test and the mother's age, the test, called the Combination Test [or Quadruple Test in England], determines whether the fetus will have a chromosome abnormality, the most common of which results in Down syndrome....Other countries aren't lagging too far behind in Down syndrome termination rates. According to the most recent data available, the United States has an estimated termination rate for Down syndrome of 67 percent (1995-2011); in France it's 77 percent (2015); and Denmark, 98 percent (2015). The law in Iceland permits abortion after 16 weeks if the fetus has a deformity -- and Down syndrome is included in this category

Here is more information from the Mayo Clinic web site about prenatal cell-free DNA screening (see: Prenatal cell-free DNA screening):

Prenatal cell-free DNA (cfDNA) screening, also known as noninvasive prenatal screening, is a method to screen for certain chromosomal abnormalities in a developing baby. During prenatal cell-free DNA screening, DNA from the mother and fetus is extracted from a maternal blood sample and screened for the increased chance for specific chromosome problems, such as Down syndrome, trisomy 13 and trisomy 18. This screening can also provide information about fetal sex and rhesus (Rh) blood type. Prenatal cell-free DNA screening is recommended for women who are at least 10 weeks pregnant and have adequate counseling regarding the options, benefits and limits of first and second trimester screening. 

It's not my goal in this short note to discuss the ethical or moral issues surrounding the termination of pregnancies due to, for example, a fetus with genetic disorder such as Down Syndrome. To restate the obvious and in this era of increasingly sophisticated DNA testing, articles such as the one cited above will appear with increasing frequency across a wide range of genetic disorders. To some, the situation in Iceland calls to mind the practice of "negative eugenics" (see: Eugenics). To quote one sentence from this Wikipedia article: ...[E]ugenics is no longer ex post facto regulation of the living but instead preemptive action on the unborn. At the very least, we need more public and wide-ranging discussion of prenatal cfDNA testing as part of the larger discussion of the future of genomic testing. 

The Need for More Research in Provider-to-Provider Telemedicine

A recent article in Dark Daily provided me with a useful way to better understand the field of telemedicine by dividing it into three segments (see: Telemedicine Gaining Momentum in US as Large Employers Look for Ways to Decrease Costs; Trend Has Implications for Pathology Groups and Medical Laboratories). Below is an excerpt from it:

[A recent article] divides telemedicine technology into three distinct segments:

1. Provider-to-provider

2. Remote patient monitoring

3. Patient-to-provider

In an article...[written[ for MedCityNews (see: Telemedicine: Take a lesson from retail to improve patient adoption),...[the author] calls provider-to-provider telemedicine the “most evolved to-date” segment of the telehealth trend. She highlights ICU stroke care with remote consults and monitoring as an example of its “success,” and notes a large potential for growth in remote patient monitoring (RPM).....However,...[she] also notes consumer acceptance of patient-to-provider telemedicine has fallen short of industry expectations. While virtual office visits...grab headlines,...“several factors” are hindering adoption. “Reimbursement is not yet universal,”....“but consumers are growing used to paying more out-of-pocket with high-deductible plans. Physicians have long resisted change in how they practice, and many remain lukewarm at best about telemedicine.

I have blogged extensively about telemedicine and remote monitoring (see, for example: Telemedicine and Home Monitoring Will Promote Healthcare Transformation) but have largely ignored provider-to-provider interactions except for my discussions about virtual critical care (see: Centralized Cardiac Monitoring Center Developed by Cleveland Clinic). The excerpt above, cites ICU stroke care and remote consults as a key area for the development of provider-to-provide interactions. Here is an article on that topic for reference: Remote Evaluation of the Patient With Acute Stroke.

I think that provider-to-provider remote consultation is going to be very helpful for increasing the quality of care in rural hospitals. We are on the cusp of understanding how such consultations needs to be structured for optimal quality and efficiency. An article published in 2013 examined some aspects of this process (see: Provider-to-Provider Electronic Communication in the Era of Meaningful Use: A Review of the Evidence). Here is a relevant paragraph from the introduction to the article referring to the types of communication that are required for provider-to-provider communication:

Coordination of care within a practice, during transitions of care, and between primary and specialty care teams requires more than data exchange; it requires effective communication among healthcare providers. In clinical terms, data exchange, communication, and care coordination are related, but they represent distinct concepts. Data exchange refers to transfer of information between settings, independent of the individuals involved, whereas communication is the multistep process that enables information exchange between two people. Care coordination, as defined by O'Malley, is “integration of care in consultation with patients, their families and caregivers across all of a patient's conditions, needs, clinicians and settings.”

The study ends with the following conclusion: the principal findings of the literature review underline the paucity of quantitative data surrounding provider-to-provider communication. It looks like the advocates for provider-to-provider communication as a key component of telemedicine have their future work cut out for them.

The Case of the "Disappearing Hospital Beds"; Implications for Pathologists

I have posted a number of previous notes about the greater emphasis being placed on ambulatory care and bedless hospitals (see, for example: Hospitals Investing Capital in Variety of Outpatient Facilities: IT Serves as the Glue; Some Additional Ideas About the Bedless Hospitals of the Future). I had not come across hard numbers about this phenomenon until now. A recent article discussed the case of the "disappearing hospital beds" (see: The case of the disappearing hospital beds). Below is an excerpt from it:

Healthcare is leaving the traditional four walls of hospitals. As patients, payers, and providers seek to reduce costs and improve quality, they are relying less on inpatient stays and more on outpatient services. A growing reliance on outpatient services could drive healthcare costs down as costly inpatient services are increasingly reserved for patients who truly need them. Hospital beds have been on their way out for a while. Over the past 20 years, the general trend to provide more value and less volume has driven down the number hospital beds available to patients nationwide. There were a total of 901,056 hospital beds across the country in 1994....That number fell to 786,874 by 2014. Inpatient admissions ticked upwards slightly during that time, but admission rates per 1,000 visits dropped from 118 to 103.7. Around 2.3 million more patients were treated at hospitals in 2014 than in 1994, but they spent 26.7 million fewer days in the hospital.

Meanwhile, utilization of outpatient services has increased. There were a little less than 383 million outpatient visits in 1994 and more than 693 million in 2014. The number of outpatient surgeries performed each year increased from 13.2 million in 1994 to 17.4 million in 2014. The number of outpatient surgery centers serving patients has increased by 407 from 2009 to 2014, from 5,039 to 5,446. As a smaller percentage of patients require shorter inpatient stays, hospitals are removing their beds.....The University of Pittsburgh reduced its beds in service across its network of hospitals by 8.4% from 2013 to 2014....While some providers remove beds, others aren’t offering inpatient services at all. In 2014, Montefiore Health System opened a massive 12-story ambulatory surgical hospital without any inpatient beds.....[The] MetroHealth System [recently] opened the Brecksville Health and Surgery Center in Ohio. The facility will feature an always-open emergency department, laboratory and imaging services, and primary care services, but it will not offer inpatient services....In one review of relevant studies,...researchers determined outpatient surgeries were associated with cost savings averaging 16.6% to 57.6%, with most of the savings in nursing and room costs.

The professional services rendered by pathologists in hospitals consist of the interpretation of tissue biopsies and surgically resected tissues and the management of clinical laboratories. Let's call this set of services pathology diagnostics for the sake of this discussion. I believe that the following set of changes will have a major effect on the volume of pathology diagnostics: (1) the shift to outpatient services including outpatient surgery; (2) increased adoption of telemedicine and home monitoring (see: Telemedicine and Home Monitoring Will Promote Healthcare Transformation); (3) value-based care driving more surveillance and a reduction of lab testing driven, in part through the deployment of "laboratory expert systems" (see: Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital); (4) increased home lab testing and "wearables"; (5) adoption of predictive analytics and big data that will squeeze more useful information from generic lab tests; (5) increased competition from national reference labs as more retail drug stores install walk-in clinics and patient service centers for national reference labs.

In terms of the most significant and impending effect on the volume of pathology diagnostics, I would suggest we look at the increase in outpatient services and outpatient surgeries as noted above. Historically, far fewer tests are ordered for outpatients than inpatients. This is due, in part, to the fact that outpatients are less sick and that inpatients undergo more complex surgeries. However, part of the growth in the number of outpatient surgeries has been based on the fact that new techniques and technologies allow more complex cases to be performed on this basis (see: Tug of War between Hospitals and Surgicenters for Knee Replacements). As outpatient services expand, I predict that the number of tests per patient visit may increase but not to the former inpatient levels. In short, I think that the total volumed of pathology diagnostics will decline in upcoming years.