Lab Soft News

Partners Healthcare to Self-Insure Its Employees; What Are It's Strategic Goals?

A number of healthcare providers and insurance companies are merging. One previously reported example is the CVS purchase of Aetna (see: Merged CVS and Aetna Will Move Toward a Community-Based Healthcare Model; Analytics May Be the Secret Sauce to Propel CVS-Aetna Forward). Now comes news that Partners HealthCare will self-insure its 100,000 employees (see: Partners HealthCare to Self-Insure 100K Employees). Below is an excerpt from the relevant article:

Partners HealthCare has announced it will self-insure 100,000 of its employees, transitioning coverage from BlueCross BlueShield of Massachusetts to its own Neighborhood Health Plan.... Partners HealthCare chief of human resources...[said] that the change is an effort to control health plan costs and reduce out-of-pocket spending for employees. Currently, Partners HealthCare spends roughly $830 million annually on employee health benefits....Partners expects to save between $10 to $15 million a year by transitioning employees to Neighborhood Health Plan coverage. Partners informed employees that their benefits would not change under the move to Neighborhood Health Plan. Partners will also invest in additional care coordination efforts, while offering enhanced wellness benefits, smoking cessation programs, and related programs for employees.....The move now nearly doubles Neighborhood Health Plan’s commercial membership. Before the transition, Neighborhood Health Plan covered roughly 32,000 Medicaid beneficiaries and 100,000 commercial members. The commercial membership of BCBS of Massachusetts will drop from 2.8 to 2.7 million beneficiaries as Partners begins to transition employees to the new health plan.

On one level, the merger of healthcare providers with insurance companies makes sense. CVS operates MinuteClinics, walk-in retail clinics that are providing an increasing number of visits at the entry level of care. Health insurance companies are also purchasing provider networks (see: UnitedHealth Group Soon to Be Largest Employer of Doctors in the US). The article above reports that Partners HealthCare, one of the most prestigious provider organizations in the country, will now provide health insurance to its 100,000 employees. My recurrent complaint about hospitals and physicians over the years has been that they favor treating disease rather than promoting wellness. Health insurance companies are more profitable if policy holder refrain from using services. Partners may thus now have a powerful motive to promote wellness. The article above provides other reasons for Partners to provide health insurance for its large number of employees: "Partners will...invest in additional care coordination efforts, while offering enhanced wellness benefits, smoking cessation programs, and related programs for employees."

I have blogged ad nauseum about the need for increased attention to wellness and preventive medicine programs like smoking cessation (see, for example: A New Term, Scientific Wellness, Used to Describe Direction of Healthcare). However, let's address the issue of how improved care coordination programs can save money and benefit patients. There's an old adage that a patient with a complex disease needs to keep track of which specialists he has had appointments with and their recommendations because the hospital that employs them won't readily know. This example highlights the importance of care coordination. Below is a good definition of it from NEJM Catalyst (see: What Is Care Coordination?):

Care coordination synchronizes the delivery of a patient’s health care from multiple providers and specialists. The goals of coordinated care are to improve health outcomes by ensuring that care from disparate providers is not delivered in silos, and to help reduce health care costs by eliminating redundant tests and procedures.

Why exactly is enhanced care coordination an important goal for Partners as the corporation provides health insurance for its employees? The quick answer is that it reduces the cost of care by avoiding redundant ordering of procedures and by allowing health professionals to work more efficiently by leveraging their inputs for diagnosis and treatment into an integrated and timely plan. I have no idea to what extent efficient care coordination will reduce the cost of care for Partners but I suspect the it's at least by 25% and perhaps as much as 50%. 

Trump Administration Opposes Public Reporting of Hospital Infection Rates

A recent news article highlighted the news that CMS is proposing a new rule whereby hospitals are not longer required to publicly report their infection rates (see: Trump administration rule could stop public reporting of hospital infections despite death toll). Below is an excerpt from the article:

Federal health regulators will have to stop releasing data on hospital infections — which affect one in 25 hospital patients every day — under a proposal set to take effect in November, according to an analysis by patient safety advocates. The Centers for Medicare and Medicaid Services' (CMS) plan, part of a complex 500-page proposed rule, could halt the public disclosure of the "super bug" MRSA, post-operative sepsis and surgical site infections, as well as accidents and injuries ranging from bedsores to respiratory failure after surgery. If the proposed rule is finalized, CMS' Hospital Compare website won't show the infections or safety measures as to do so, the data would have to be in a program the Trump administration said hospitals should no longer have to report infections and other safety problems to. More than 600,000 hospital patients a year contract an infection and sepsis alone kills about 270,000 people a year.

Leapfrog Group, a hospital rating organization, urged patient safety advocates to contact regulators or sign Leapfrog's letter to CMS protesting the plan. Anew hospital infection report out from Leapfrog Wednesday found the percentage of hospitals reporting to the Leapfrog Hospital Survey and achieving zero infections is way down since 2015.....CMS chief medical officer Kate Goodrich said the agency "is committed to transparency of quality and cost information" and denied that it was proposing to remove the information from Hospital Compare. She also emphasized that the changes are up for public comment. Hospitals apparently hadn't been lobbying for the change, but the American Hospital Association said the amount of data required by different federal programs was burdensome and the change would allow them to focus more on patient safety.  

I don't think that most physicians and scientists would refute the fact that hospital-acquired infections are a major health problem. Some smaller percentage of this group would probably agree that one of the most effective ways to address this problem is the public reporting of such data. This type of reporting puts pressure on those hospitals with unduly high rates to improve their performance or suffer the consequences in terms of decreased admissions. I believe that the American Hospital Association functions more as a business lobbying group than as an advocate for quality and therefore supports this new rule. They take such a position nominally based on their stated opposition to bureaucratic red tape and a burdensome regulatory environment.

On this issue, I come down on the side of the Leapfrog group and oppose this rule change. In what universe is patient safety negotiable. Hospitals work in a competitive environment and don't want to be tarred with unfavorable ratings and thus strive to perform better. In my opinion, the Trump administration is corrupt and always favors less transparency because this is what many business owners want. Such rulings often tend to harm consumers. In all issues relating to patient safety, I come down on the side of increased reporting. This is a central tenet of enhanced consumerism in healthcare.

A New Term, Scientific Wellness, Used to Describe Direction of Healthcare

There has been lots of jargon arising in recent years in relating to the future direction of healthcare. Terms that have been introduced include personalized medicine, precision medicine, personal genomics, and digital health. I want to comment briefly on a recent article that suggested that the term scientific wellness may be useful in this regard (see: The future of personalized health is scientific wellness). Below is an excerpt from it:

The convergence of personalized medicine with digital health and artificial intelligence, systems biology, social networks, big data analytics and precision medicine is on the cusp of enabling an emerging field: scientific wellness. “Over the next 10-15 years there will be a scientific wellness industry in contrast to the disease industry and the market cap will far exceed that of the disease industry,” said Leroy Hood....“The contrast between 20th and 21st Century medicine is striking, 21st is proactive, focused on the individual, disease and it employs personalized data clouds to explore the complexities of human beings.” The idea of scientific wellness is a quantitative approach that includes improving the health of individuals, create personalized treatments, reverse disease transitions and reduce costs — distinct from the current wellness trend focusing primarily on behaviors such as diet and lifestyle.

Precision medicine, much like the future in cyberpunk author William Gibson’s oft-cited quote, is already here — it’s just not evenly distributed yet.....The next phase is not about drugs, it’s about engaging patients, said Peter Bergethon, MD....“Whether AI or wearables, technologies exist and the availability is widescale,” said Derek Cothran, Senior Vice President of Client Strategy and Development at EnvoyHealth. “It’s about taking that more precisely to a patient. We want to take information to patients so they consume it in ways they already consume data.”....“One of the strongest applications of precision medicine might not be in treatment but in the prevention domain,” said Michael Dulin, MD.... Indeed and that’s exactly where the emerging scientific wellness field will figure into the future of healthcare. Scientific wellness is only a matter of time. Provident St. Joseph’s Hood said that 21 Century healthcare will focus on improving wellness for the individual, creating medicine that is preventive, personalized and participatory, and reverses rising cost trends. 

Here are a few comments about the term scientific wellness:

• Clearly, the future of healthcare aligns with the adoption of preventive, personalized, and participatory activities by consumers.These 3 P's have appeared in articles for at least five years but they still make sense and are tacitly encompassed by scientific wellness (see: The "Three P's" And The Future Of Health Care Delivery). 
• I have been commenting on the importance of wellness for a number of years (see: Wellness, Preventive Medicine, and the Classic Disease Model). This idea can't be overemphasized. Consumers need to take more responsibility for their personal wellness and this, in turn, will lower costs (see: Why Preventive Care Lowers Health Care Costs).
• The training of physicians and the orientation of hospitals needs to place greater emphasis on wellness in addition to the treatment of disease (see: Do Physicians and Hospitals Want to Make Us Healthier?). Unfortunately our system provides reimbursement mainly for the treatment of disease so this needs to change.
• I like the idea that there is a quantitative aspect of scientific wellness including the following: (1) improving the health of individuals; (2) creating personalized treatments; (3) reversing disease' and (4) reducing healthcare costs.

Physician-to-PhysicianTeleconsults Boost Survival Rates for Liver Disease

I have blogged in the past about provider-to-provider teleconsults  (see:The Need for More Research in Provider-to-Provider Telemedicine). This type of telemedicine is often overlooked or underreported. A recent article addressed how video consults have improved survival rates for liver disease patients (see: Video consults boost survival rates for liver disease patients by 54 percent). Below is an excerpt from the article:

Patients of primary care physicians who participated in video consultations with liver disease specialists had a 54 percent higher survival rate than patients whose PCPs didn’t leverage the technology, according to a new study by Michigan Medicine. The technology was used by the VA Ann Arbor Healthcare System to link primary care physicians and specialists to discuss patient cases, treatment and recommendations in real time under the Specialty Care Access Network-Extension of Community Healthcare Outcome (SCAN-ECHO) program for chronic liver disease.“Improved survival in patients seen via SCAN‐ECHO suggests that this novel approach may be an effective method to improve access for selected patients with liver disease, particularly in rural and underserved populations where access to specialty care is limited,” conclude the authors of the study published in the journal Hepatology. The clinical effect of this technology on outcomes is as if patients saw a liver disease specialist face to face, according to lead author Grace Su, MD....“Primary care providers really want to do the right thing, but they may not have all the necessary tools,” says Su, who directs the SCAN-ECHO clinics at the Ann Arbor VA. “This research shows an excellent way to impart specialty knowledge to them. The learning is mutual. They are not just learning; they are teaching us.” 

It's not particularly surprising that providing telelinks between primary care providers and medical specialists regarding the treatment of a patient with a complex disease leads to better outcomes. The key question is how such approach and technology could be organized outside of an integrated, national health system system like the VA. Obviously, health insurance companies and Medicare increasingly will provide reimbursement for specialist referrals and for telemedicine visits for primary care (see: Telehealth Services). However, I am not sure to what extent they will provide reimbursement for provider-to-provider telehealth consultations. Such consultations can obviously occur in real-time with the patent in the office of the primary care professional or after the patient leaves.

Because I believe that provider-to-provider teleconsultations will radically improve the quality of care as this report suggests, I have been searching for some sort of practical care model that would work outside of the VA system. How about this? Large health systems could offer such specialized physician services to primary care doctors or nurse clinicians in smaller hospitals in the same state or on a regional basis. Obviously, the participating specialists would be reimbursed for their professional advice according to their normal fee structure but their time would be used more efficiently because they are communicating with another physician. The participating specialists could earmark blocks of time in their calendars for such calls. In this way, some patients with complex diseases could be treated locally but others would need to be referred to the specialist in the larger facility. A major reason for initiating such a formal provider-to-provider teleconsultation service with larger hospitals is for all of the various physician participants to get to know each other better and develop a smooth, working relationship. 

Hospitals Cry Foul Over Anthem's Radiology Reimbursement Policy

In a previous post, I noted that health insurance company Anthem was refusing to pay the hospital rate for outpatient MRIs and CT scans, dictating that their insurance holders receive outpatient imaging services from less expensive free-standing radiology centers (see: Anthem Won't Pay for Outpatient MRIs and CT Scans in Hospitals). Hospitals are fighting back and taking Anthem to court over this policy (see: Hospitals cry foul and sue Anthem over new policies). Below is an excerpt from this article:

County courtrooms are no strangers to contract disputes between local hospitals and insurers. Lately, though, they've had some big cases dropped in their laps as hospitals owned by HCA Healthcare, Sentara Healthcare and Piedmont Healthcare take health insurance giant Anthem to court over its new policies that restrict outpatient imaging and emergency department reimbursement.....The hospitals argue their contracts with Anthem, through its Blue Cross and Blue Shield affiliates, require all parties to agree to such material changes to the policies. They also say the imaging policy isn't really about medical necessity, as Anthem has said, because the insurer allegedly granted exemptions for hospitals that agreed to accept lower rates. The Anthem spokeswoman said the company does not comment on pending litigation.....Some legal experts say the hospitals are standing on solid ground, while others argue Anthem's policies are an important opening salvo to changing healthcare's traditional business model....[T]he underlying issue is the fact that the same services cost more when delivered in inpatient settings than in outpatient settings.....Anthem's cost-shifting strategy aligns with the migration of many healthcare services over the years to cheaper outpatient settings....In every instance, hospitals have resisted the cuts to their revenue....That's what happened when doctors years ago began performing cataract surgeries in outpatient offices, for example.

....[H]ospitals argue that the imaging policy takes away physicians' ability to use their clinical judgment to determine medical necessity, and instead makes it about the site of service.....From the payer standpoint, services covered under hospital-based contracts tend to cost two to three times more than the same ones performed at free-standing clinics, he said.....Part of the reason Anthem's policies in particular are making such a splash is because they're targeting providers themselves. Other carriers have focused on "educating" patients about less-expensive options, a tactic that doesn't get as much attention....UnitedHealthcare...charges higher co-pays for MRI scans performed at hospitals compared with outpatient facilities....Hospitals' legal arguments against Anthem's imaging policy makes material changes to contracts with hospitals without giving proper notice and receiving approval from hospitals.

I have the following observations about this news:

• The hospital strategy of increasing their revenue from profitable lines of business like radiology and the labs to offset losses in others units like ICUs is probably outdated and may not survive various legal challenges such as the one described in this article (see: Identifying the Gap Between Hospital and Free-Standing Prices).
• Hospitals need to directly compete against surgicenters or freestanding radiology centers (see: Tug of War between Hospitals and Surgicenters for Knee Replacements). One of the ways for doing so will be to launch or purchase such businesses (see: How Hospitals Are Rethinking Imaging).
• Meanwhile, health insurance companies like Aetna and UnitedHealthcare are increasingly engaged in direct patient care. I have discussed the merger of CVS with Aetna with the former providing walk-in MinuteClinics in drug stores (see: Details about CVS' MinuteClinic POCT Strategy; Merged CVS and Aetna Will Move Toward a Community-Based Healthcare Model). Meanwhile, UnitedHealthcare has purchased a large physician group so the lines are blurring between health insurance companies and providers (see: UnitedHealth Buys Large Doctors Group as Lines Blur in Health Care).
• The article above points out that health insurance companies have traditionally "educated" their policy holders about how to seek less expensive services (see: CMS Requires Hospitals to Post Prices for Medicare Patients; Useful Step?). Such an approach may now be a thing of the past with direct competition more of the norm for the health insurance companies. 

Deploying Digital Pathology in the Autopsy Service Before Surgical Pathology

I believe that most pathology teaching programs in the U.S. will be feeling a need to launch a digital pathology program soon because pathology house officer and fellow candidates are favoring those programs that are using this new technology. The applicants to these programs understand that they need to begin to master it in order to qualify for positions when they enter the pathology job market. This poses a program for those teaching departments that are not in the process of adopting this technology.

A solution to this dilemma for some departments may be to deploy digital pathology first in their autopsy service. At first glance such a strategy may not make sense. The autopsy services does not generate revenue and there iare few advantages to making the images accompanying an autopsy more portable, at least outside of the specific hospital. Here is a list of why launching a digital pathology program in the autopsy service first is a reasonable option:

• House officers spend their early years in a pathology program performing autopsies so they will gain experience with this new technology soon after entering the program. This enables them to easily adapt to the use of digital pathology in surgical pathology when adopted later. 
• In many programs, the autopsy service often does not have a high priority in terms of capital investment or attention. Making it the test bed for digital pathology puts it more in the spotlight and then hopefully the recipient of more attention.
• Because the number of microscopic images associated with autopsies is relatively small compared to the histopathology workload from surgical specimens, a digital pathology program can be launched without a major investment in hardware and software. Such a new technology and program, however, will allow department leadership to establish a relationship with sdigital pathology vendors with an eye toward future contract and become comfortable with it.
• Review of the microscopic images from an autopsy becomes more flexible and can even be accomplished at home by house officers and staff pathologists.
• Autopsy microscopic slides are a suitable test bed for testing image analysis software as it become available without time and medicolegal challenges.
• Gross autopsy images are common can easily be integrated with the microscopic whole slides images to present an easily accessible total case for subsequent review.
• Microscopic whole slide images can be easily integrated into pathology courses for medical school undergraduates as well into the various hospital teaching and QC conferences.

Can an "Annual Lab Screen" Serve as a Replacement for the Annual Physical Exam

During my career in pathology, there has been a constant litany of complaints from various quarters about excessive ordering of lab tests. And yet, all the while, a complete blood count (CBC) and other lab tests such as electrolytes, lipid panels, and renal panels have been routinely ordered as part of periodic physical exams as a means to screen for diseases that might not be recognized during the physical exam itself. However, the annual physical exam itself has been criticized by many as being unproductive (see: Is the Annual Physical Unnecessary?). The following arguments were marshaled in this article to underscore this point:

By the 1980s, doctors had begun to question which components of the annual physical were worthwhile. Little by little, practices changed. Annual CBCs, urinalyses, TB tine tests, and chest x-rays were found to be useless and were dropped. Pap smears and STD screening were proven worthwhile, but the routine pelvic exam with speculum and bimanual palpation was not. The physical examination of a healthy, asymptomatic adult is unlikely to reveal any significant abnormality (1) that would not have been detected eventually when symptoms developed and (2) whose earlier detection and treatment would reduce morbidity and mortality in the long run.

I will readily concede that a yearly physical may have minimal value in detecting diseases that might otherwise be detected early in a healthy asymptomatic adult. However, many of the routine lab tests ordered as a component of the yearly physical do serve a predictive function. I have blogged before about the use of big data, deep learning, and neural networks in support of predictive diagnostic analytics (see, for example: Should the Work Product of "Non-Explainable" Medical Algorithms Be Ignored; Identifying Patients for Remote Monitoring with Predictive Analytics). We may thus be entering an era when the annual physical exam can no longer be justified when the patient has no significant complaints but an annual lab screen (ALS) comprised of a panel of standard tests coupled with scrutiny by predictive analytic algorithms will constitute a more than adequate substitute.  

Dr. Harvey Kaufman of Quest Diagnostics made the following comment about the potential value of big data and the evolving role of the clinical labs (see: Big Data Analytics in Healthcare – How Laboratories Can Play a Leading Role):

The increasing volume of data from a multitude of sources offers opportunities for improving healthcare. Dr. Kaufman believes clinical laboratories have a key role to play in the analysis and interpretation of that data, thereby providing healthcare professionals with information to guide decision-making. “Historically we’ve been a transactional enterprise,” he says. “Whether in a hospital or reference laboratory, we receive an order, collect the specimen, perform the test, report the results, and that’s the end of our involvement. While we certainly need to continue providing those services, we now also need to go beyond that traditional role and analyze the data in the context of other information about the patient or about the population – that’s what will provide both clinical and economic value. It’s no longer just a matter of what a patient’s cholesterol level is, but also what that level means for that particular patient.”

Another Type of Urgent Care Facility Flourishing for Orthopedic Problems

In a recent note, I discussed how primary care practices and hospital-based ambulatory care are now being forced to compete with both walk-in clinics in retail drug stores and urgent care centers (see: Physicians Are Disappearing from the Front Line of Healthcare). I have just learned about another type of first-line competition for physician and physical medicine practices: walk-in, orthopedic urgent care centers (see: Orthopedic urgent care centers to expand). Below is an excerpt from the relevant article:

A new orthopedic urgent care center operator is expected to start opening centers in Michigan later this year under the Miami-based OrthoNOW franchise as demand for convenience and lower prices sweeps the health care industry....Over the past decade, the number of urgent care centers has exploded in Michigan and nationally as patients seek to avoid a steep emergency room bill or visit more convenient health care settings. Data show there are more than 350 urgent care or walk-in clinics in Michigan, including more than 45 within 20 miles of Detroit, according to Urgent Care Locations LLC.....Most health insurers in Southeast Michigan contract with urgent centers because of their lower cost relative to emergency departments. That steady and reliable reimbursement has helped push the expansion of urgent care. Now, a new breed of urgent cares hopes to convince patients with bumps, bruises, sprains, and even simple broken bones to go to the urgent care rather than the emergency room....[T]he Michigan centers will assess and treat an array of musculoskeletal orthopedic and sports injuries and chronic conditions without appointments. Injuries could affect the foot, ankle, knee, hip, wrist, hand, elbow, shoulder and spine. OrthoNOW also will offer radiology, physical therapy and sports medicine and wellness care.....[The] owner and operator of 1st Choice Urgent Care said his three centers have direct referral relationships with 10 orthopedic surgeons for more serious cases. 

To summarize, a new type of walk-in, urgent care facility is emerging to attend to orthopedic problems including sports injuries and even sinple broken bones. Similar to walk-in retail drug store clinics but unlike many urgent care facilities, these orthopedic centers are staffed by a physician assistant and a medical technician who can also take X-rays but not by a physician. Such orthopedic walk-in facilities represent an expansion of first line health services and one more reason to avoid hospital ERs and primary physician offices. Note also the referral relationship of these centers to orthopedic surgeons for more complex cases.

Health insurance companies are encouraging the use of walk-in urgent care and drug store clinics because they are generally less expensive than hospital ER visits or perhaps even physician office visits. Heres the discussion on the Humana web site pertaining to urgent care center visits by its members (see: Urgent Care FAQs):

When should I visit an urgent care center?

If you have a non-life threatening illness or injury needing immediate treatment, urgent care is a great choice. You’ll receive direct attention from trained clinicians. There are reasons why using an ER for minor and moderate conditions may not be advisable. An ER can be expensive and you may experience long waits for treatment. A primary care physician can be another option. However, your doctor’s office may not be open daily with extended hours, or offer on-site diagnostic tests.

Should the Work Product of "Non-Explainable" Medical Algorithms Be Ignored

I have blogged previously about the use of algorithms in healthcare which will be revolutionary in terms of diagnosing patients and even predicting which diseases they may develop in the future (see, for example: Eric Schmidt Discusses the Potential Value of Predictive Analytics in the ER; An Algorithm Using Medical Record Data Predicts Risk for Parkinson's Disease). A recent article discussed how radical this change will be (see: How Health Care Changes When Algorithms Start Making Diagnoses). Needless to say, some politicians are already making foolish judgements about medical algorithms as quoted in the following excerpt:

...[A] team at Google used data on eye scans from over 125,000 patients to build an algorithm that could detect retinopathy, the number one cause of blindness in some parts of the world, with over 90% accuracy, on par with board-certified ophthalmologists...[T]hese results had the same constraints [as similar other AI studies]; humans could not always fully comprehend why the models made the decisions they made....Earlier this year, France’s minister of state for the digital sector flatly stated that any algorithm that cannot be explained should not be used. But opposing these advances wholesale is not the answer. The benefits of an algorithmic approach to medicine are simply too great to ignore. Earlier detection of ailments like skin cancer or cardiovascular disease could lead to reductions in morbidity thanks to these methods. Poorer economies with limited access to trained physicians may benefit as well, as a host of diseases may be found and treated earlier. Individualized treatment recommendations may also improve, leading to saved lives for some and increased quality of life for many others.

Here's a quote from the Wikipedia about deep learning and neural networks to frame this blog note (see: Deep learning):

Deep learning...is part of a broader family of machine learning methods based on learning data representations, as opposed to task-specific algorithms. Learning can be supervised, semi-supervised or unsupervised. Deep learning architectures such as deep neural networks, deep belief networks and recurrent neural networks have been applied to fields including computer vision, speech recognition, natural language processing, audio recognition, social network filtering, machine translation, bioinformatics and drug design, where they have produced results comparable to and in some cases superior to human experts.

I was struck by the inanity of the observation by France’s minister of state that "any algorithm that cannot be explained should not be used." There have been numerous observations over past years that have saved lives but couldn't be initially explained in scientific terms. Penicillin, a miracle cure in its day, is only one such example (see: Discovery and Development of Penicillin). Algorithms are already in use that can predict the future development of a disease without necessarily understanding all of the factors that came into play in terms of making such a prediction. Predictive algorithms are always tested in the "real world" concerning their validity. Deep learning and neural networks are just another type of scientific tool that will advance medicine and should not be singled out as somehow mysterious and therefore suspect.

Rapid Autopsies: Reformulating the Classic Autopy Toward a Focus on Cancer Research

The non-forensic autopsy is on life support in most hospitals with only about 10% of patients undergoing the procedure nationally (see: The Vanishing Nonforensic Autopsy). However, the rapid autopsy has moved front-and-center for selected cancer patients with the need for rapid tumor tissue harvesting. This specialized type of autopsy was described in a recent article (see: Rapid autopsies could speed cancer research. They’re also fraught for families),. Below is an excerpt from it:

Medical teams have long rushed to save the living. Now, increasingly, they’re rushing to attend to the dead. A small but fast-growing number of hospitals are embracing procedures known as “rapid autopsies,” — conducted in the hours immediately after a patient’s death. The idea is to obtain tissues from tumors before they start significantly degrading. Using genetic analysis technology, doctors can then determine precisely how cancer cells survived every attempt to kill them. But the procedures are forcing doctors and patients to overcome their reluctance to discuss death, and family members to confront the idea of parting with loved ones’ bodies shortly after their death — within six hours, optimally....So far, roughly 10 hospitals conduct the procedures....

The logistics can be complicated. Doctors discuss the procedure with patients, but in most states, it’s the surviving family members who must consent to the procedure. Patients and family members can limit the scope of the autopsy however they wish, though...[a knowledgeable pathologist]  said she “always makes some kind of incision.....[Johns] Hopkins doctors typically broach the subject with patients while they are introducing the prospect of hospice care. But it also helps to have doctors trained in having the conversation....Mass General created a formal rapid autopsy program this year. The hospital now performs roughly two to three procedures weekly, compared with one every three or four weeks in previous years, and is exploring ways to offer them to patients who die outside the hospital. The program will fuel one of the most significant trends in cancer research: the creation of what... [are called]  patient avatars, the cell lines or mouse models derived from a patient’s tumor that can be used to test treatments for patients with similar histories.

The need to sample tumor tissue quickly from cancer patients post-mortem is driven by research on new therapy based on cancer genotyping. Immunotherapy is being tailored to exploit tumor genetic weaknesses. Asking for autopsy permission from family members has never been an easy task but there is now an added time urgency to harvest viable tumor tissue. In earlier times and particularly in teaching hospitals, relatives expected to be asked for autopsy permission. The rationale was often stated in the past as the need to learn from the case. 

Requests for rapid autopsies are now being couched in terms of to the need to increase scientific knowledge by harvesting cancer tissue. As the article cited above states, the hard discussion with a patient about hospice care provides an opportunity to also address the subject of a rapid autopsy in cases where it is deemed appropriate. However, a transfer to hospice care also introduces the challenge of rapidly transporting a deceased patient back to the hospital for the autopsy. Also and as noted above, discussions with a terminal cancer patient provide the opportunity to discuss the creation of patient avatars with the harvested cancer cells used in medical research laboratories. This is analogous to the persistence in research labs of the immortalized cancer cell lines harvested from Henrietta Lacks (see: Henrietta Lacks).