Lab Soft News

Upload Your DNA to a Web Site to Generate Risk Scores for Five Diseases

I have posted a few notes about predictive diagnostic algorithms (see: An Algorithm Using Medical Record Data Predicts Risk for Parkinson's Disease; Should the Work Product of "Non-Explainable" Medical Algorithms Be Ignored) and disease risk scores (see: Genetic Risk Scores: Ready for Inclusion in the Medical Record?). Using AI techniques, researchers at Massachusetts General are developing a web site that will display a risk score for five common diseases after consumers upload their DNA to the site (see: Clues to Your Health Are Hidden at 6.6 Million Spots in Your DNA). The algorithm takes into account millions of alterations in the DNA rather than a few focal changes. Below is an excerpt from the article about this news:

...[R]esearchers are now building a website that will allow anyone to upload genetic data from a company like 23andMe or Ancestry.com. Users will receive risk scores for heart disease, breast cancer, Type 2 diabetes, chronic inflammatory bowel disease and atrial fibrillation....Dr. Sekar Kathiresan, senior author of the new paper and director of the Center for Genomic Medicine at Massachusetts General Hospital, said his team had validated the heart risk calculation in multiple populations. But DNA is not destiny, Dr. Kathiresan stressed. A healthy lifestyle and cholesterol-lowering medications can substantially reduce risk of heart attack, even in those who have inherited a genetic predisposition. The new tool also can find people at the low end of the risk range for the five diseases. This should prove useful to certain patients: for example, a woman who is trying to decide when she should start having regular mammograms, or a 40-year-old man with a slightly high cholesterol level who wants to know if he should take a statin....

“It carries great hope, but also comes with a lot of questions,”....“Who should get tested? How should the results be provided? ...[W]ill the results actually lead people to make decisions that improve their health? People may need genetic counseling before and after getting these sorts of risk scores....Patients may not appreciate the consequences of learning they have a high likelihood of having a heart attack or breast cancer or one of the other diseases the test assesses.....But medical experts said this sort of risk assessment is the wave of the future....The study began because there was general agreement among researchers that many common diseases are linked not to one mutation, but rather to thousands or millions of mutations....In recent years, scientists have cataloged more than 6 million tiny changes in DNA that slightly affect the chances that people will get various diseases.....But it should be possible, scientists felt, to combine data on all the small DNA changes to construct an individual risk score. To do that, the researchers needed a new algorithm that would weigh the significance of the variations in the genes....The investigators found that their algorithm did predict the odds of being diagnosed with one of the five diseases.

I personally believe that predictive analytic web sites such as the one described above will provide significant public health benefits. But, as always, there will be downside risks. The most obvious is that some individuals informed about having a risk for a particular disease such as IBD may obsess about this possibility. On the more positive side, the five diseases listed above (heart disease, breast cancer, Type 2 diabetes, chronic inflammatory bowel disease and atrial fibrillation) constitute a large percentage of the chronic disease burden in the U.S. If the users of the above mentioned web site take serious measures to forestall the onset of a particular disease (e.g., weight loss for type 2 diabetes), the consequences can be very significant.

I have already personally gained substantial benefit from having my DNA analyzed by 23andMe in terms of my learning about an inherited disease for which I am a carrier and also support for my hobby of genealology. Hoever, the vast majority of our population will not have the means or an interest in obtaining disease risk scores using AI technology. However, the future for predictive diagnostic analytics is now becoming quite clear. We will initially see a number of web sites such as the one described above that will perform such services for a fee. In the long run, such predictive analytics will be performed in our health system labs and then offered as a routine health test. Appropriate and necessary monitoring for the appearance of particular disease(s) will then be performed in that health system.

Ten Suggestions for Young People from Warren Buffett

In a recent tweet, Warren Buffett, the "sage of Omaha," posted the following ten points that he described as advice to young people:

• Read and write more.
• Stay healthy and fit.
• Networking is about giving.
• Practice public speaking.
• Stay teachable.
• Find a mentor.
• Keep in touch with friends.
• You are not your job.
• Know when to leave.
• Don’t spend what you don’t have.

A very useful list and one that I have personally tried to adhere to. For me, the hardest one to achieve has been to "know when to leave" because this has never exactly been obvious for me. Perhaps he is referring here mainly to investments rather than, say, a job. Also, I very much like the idea of "staying teachable."

Surprise Free Gift: Free Tuition at NYU Medical School

In a surprise movie, NYU School of medicine recently announced that it will cover the tuition of all its students going forward (see: Surprise Gift: Free Tuition for All N.Y.U. Medical Students).This sets a very high bar for the top-ranked medical schools in the country. Undoubtedly, this news will force many of them to follow suit although not all may be able to tap into a comparable philanthropic pool than what is available in New York City. Below is an excerpt from the article:

The New York University School of Medicine announced...that it would cover the tuition of all its students, regardless of merit or need, citing concerns about the “overwhelming financial debt” facing graduates. N.Y.U.’s initiative comes at a time when affordability has become an increasingly urgent issue in higher education, with some graduates struggling with thousands of dollars in debt.... In the field of medicine, schools have become worried that students saddled with steep debt are increasingly pursuing top-paying specialties rather than careers in family medicine, pediatrics and research....But N.Y.U.’s plan...in an unexpected ending to the annual “White Coat Ceremony” for new students and their families, goes beyond that, and may spur other top medical schools to follow suit. In a statement, N.Y.U. said that it would be the only top-ranked medical school in the nation to offer full-tuition scholarships to all students. The plan, effective immediately, covers all current and future students. Annual tuition is roughly $55,000. There are 93 first-year students, and another 350 students who have up to three years left before obtaining their degrees....The plan does not cover room and board or fees, which together are an additional $27,000, on average. About 62 percent of N.Y.U.’s School of Medicine graduates leave with some debt; the average debt incurred by members of the class of 2017 was $184,000.....At UCLA’s David Geffen School of Medicine, a $100 million fund announced several years ago pays for the entire cost of medical school for all four years, including tuition, fees, books and living expenses for roughly 20 percent of its students. But that program is based on merit, not need. Meanwhile, a small medical school affiliated with Case Western Reserve University at the Cleveland Clinic covers the tuition and fees for its five-year program focusing on research.

As noted above, medical students at NYU are still responsible for their room and board which, because of the location, is a stiff $27,000 per years. NYU is already ranked third in the nation in one poll. The quality of the students it accepts will inexorably rise with this news. Some articles have posited that NYU graduating medical students will now be less apt to select more remunerative specialities because they will carrying less debt, making it easier to pay off their loans. I find this idea somewhat dubious. The choice of a medical speciality is a complex decision based on factors such as one's personal skill set, interests, and anticipated work hours. This does not detract in any way from the very positive aspect of this NYU announcement.

The Quest for a Fail-Safe Patient Identification Solution in the U.S.

A recent article on the challenges posed by mistakes in patient identification was rather pessimistic about the amount of progress that has been made in the field (see: Fail-safe patient ID matching remains just out of reach patient-id). This boils down to the challenge of ensuring that the EHR record of "Mary Smith" who is admitted today is uncorrupted by data from a different "Mary Smith" who was admitted to the hospital yesterday. Below is an excerpt from the article. It's long so read the whole thing if you are interested.

[D]igital technologies—electronic health records in particular—have greatly exacerbated the challenge of ensuring that clinicians not only accurately identify patients but match them to their medical records. There's a lot more data flowing around and between health systems now than ever before. At a time when healthcare organizations are looking for every advantage to cut costs while improving quality and safety, patient matching is a challenge that can cause problems on a lot of levels. When a hospital has a patient's correct health record, it not only provides better care but it can cut down on the costly inefficiency of having multiple records for one patient or a single— erroneous—record for one patient. Estimates of patient-matching accuracy vary, but most say that it hovers around 90%. The problems posed by the remaining 10% are costly, both in terms of safety and money....

[H]ealth systems are searching for a combination of digital and manual fixes. They're using tools that run probabilistic matching on records, and they're also training patient access staff to match records by hand. Most health systems use a combination of demographic information and internally assigned patient identifiers to match patients to their records. At Geisinger Health, for instance, staff use a master patient index database that spans the entire enterprise to match patients to their records. Every day, several people work to keep the master patient index data “clean” so it can probabilistically match patients correctly more than 90% of the time....Just because a patient has a name matching one of the clinic's records doesn't mean that patient is the one who's in the records.... Some health systems are layering software on top of their EHRs to address the problem, at least internally.....In early 2018, Apple launched a new version of its Health app that allows patients of certain health systems to download their health records onto their iPhones. It's one big step toward making patients the agents of interoperability.

Here is a definition for the enterprise master patient index:

An enterprise master patient index (EMPI) is a database that is used to maintain consistent and accurate information about each patient registered by a healthcare organization. It may link several smaller MPIs together, such as those from outpatient clinics and rehabilitation facilities. An EMPI can also aggregate patient data contained in separate systems within one facility.

The search for as solution to the patient ID problem has been exacerbated by the broad adoption of EHRs with a single system spanning a large health system and scores of people responsible for the correct patient ID when entering data. I have blogged about the Apple initiative, mentioned in the first excerpt, that enables patients to view their EHR records with their iPhones (see: Apple Getting Traction with Its App to Access EHR Records with iPhones). Unfortunately, I don't think that making patients the "agents of interoperability" for monitoring the quality of their own records is a practical solution to this problem. Too few patients will use such a system and its not practical to ask them to scan their entire record and determine if any of the entries possibly belong to another patient. The sole solution to the problem is the adoption of universal health identifier such as that being used in countries like Australia but there is little chance of such a system being adopted in the U.S. One reason is that there is too much distrust of the government at this time, exacerbated by the political rhetoric of Donald Trump.

Ohio Medicaid Department Directed to Quit Its PBM Contracts

It seems like this has been a long time coming but at least one set of state officials is taking action regarding the excess profits and business model of their pharmacy benefit managers (PBMs) (see: Ohio Medicaid to try out transparent PBM pricing model). Below are some details from the article:

Ohio's Medicaid department is directing its managed-care organizations to quit their contracts with pharmacy benefit managers because of opaque pricing practices officials said cost the state millions of dollars. The state's five managed-care plans must strike up new contracts with companies able to manage pharmacy services using a more transparent pricing model by Jan. 1, 2019. The decision comes after an analysis commissioned by the Medicaid department found that the two largest PBMs operating in the state — CVS Caremark and OptumRx — billed managed-care plans $223.7 million more for prescription drugs than they paid pharmacy providers in one year under a practice known as "spread pricing." Pharmacy benefit managers are middlemen that administer pharmacy benefits and negotiate prescription drug rebates from manufacturers on behalf of insurers and self-insured employers. They also negotiate discounts from pharmacy networks that dispense drugs to patients. Most PBMs engage in spread pricing, where the PBM pockets the difference between what it bills to the payer for medications and what it pays the pharmacy to dispense those drugs. PBMs keep that figure close to the vest. But the report commissioned by the Ohio Medicaid department found that the spread totaled 8.8% between the two PBMs in the state. Ohio Medicaid wants to move to a pass-through pricing model, in which the managed-care plan pays the actual discounted pharmacy price that the PBM negotiated with the retail pharmacy network. Under that model, PBMs wouldn't be able to keep the difference as revenue. Managed-care plans would be required to pay higher administrative fees to the PBM, however. 

All of this is a continuation of the controversy that has long been simmering about the excessive PBM profits. Here's another quote that adds to the discussion (see: The Hidden Monopolies That Raise Drug Prices):

Americans pay the highest health-care prices in the world, including the highest for drugs, medical devices, and other health-care services and products. Our fragmented system produces many opportunities for excessive charges. But one lesser-known reason for those high prices is the stranglehold that a few giant intermediaries have secured over distribution. The antitrust laws are supposed to provide protection against just this kind of concentrated economic power. But in one area after another in today’s economy, federal antitrust authorities and the courts have failed to intervene. In this case, PBMs are sucking money out of the health-care system—and our wallets—with hardly any public awareness of what they are doing.

One more aspect of this story relates to the discounts offered by pharmaceutical companies on some drugs. In 2011, Caremark Rx, now owned by CVS, was the nation's second-largest PBM. It was the subject of a class action lawsuit in Tennessee which alleged that Caremark kept discounts from drug manufacturers instead of sharing them with its member benefit plans (see: Pharmacy benefit management). My only question at this point is why has it taken so long to try to correct the "PBM problem." Part of the reason is that some of the PBMs were kicking back money to the health plans in exchange for not being viewed with too critical an eye.

Need for More "Disruptive" CEOs of Health Systems; What Does This Mean?

Some critics of the current health system CEOs assert that some of them are unprepared for what lies ahead in the field. Their primary expertise is often in revenue management and M&A. For most hospitals, however, revenue is shrinking (see: Why Major Hospitals Are Losing Money By The Millions) and many potential mergers have already been achieved. Inpatient stays have also been shrinking  (see: Trends in Hospital Inpatient Stays in the United States, 2005-2014) and threats to outpatient revenues are presented by walk-in retail clinics, urgent care clinics, and UnitedHealth as a major physician employer (see: 30,000 Strong and Counting, UnitedHealth Gathers a Doctor Army). A recent article suggested that more "disruptive" healthcare CEOs are needed (see: As healthcare changes, systems need to broaden search to find disruptive CEOs). Below is an excerpt from the article: 

Four years ago, Dr. Rod Hochman, CEO of Providence Health & Services, hired Aaron Martin away from Amazon to head strategy and innovation. Martin's team has spun out several new products to better engage consumers between episodes of care, then found venture capitalists to turn them into businesses. One is Xealth, which enables physicians to “prescribe” a wide range of nonmedical products or services for patients directly through the electronic health record, including apps, articles, Lyft rides and health-assisting products. Martin said what Hochman hired him to do—build deep digital engagement with consumers—is taken for granted in other industries but is brand new in healthcare. Still, he doesn't think he would ever feel comfortable moving into the Providence CEO role himself. Instead, he urges more healthcare CEOs to learn from Hochman....With healthcare changing rapidly, hospital CEO positions turning over at a high rate, and baby boomer senior executives eyeing retirement, some hospitals and health systems realize their next leaders will need a different set of experiences and skills to successfully navigate that new world. For example, these leaders may have to figure out how to run a “health village” rather than an acute-care hospital....The traditional route to the C-suite—long years of progressively more responsible positions running inpatient hospital operations—may no longer be the best preparation, though hospital experience remains desirable.....Yet many health systems and their boards haven't fully embraced the emerging paradigm and are still hiring leaders to put heads in beds, some observers say. Meanwhile, the most innovative people, who may be exactly what these systems need, are reluctant to join slow-to-change, risk-averse organizations.

First of all, I wanted to get a better understanding of the term digital engagement which is one of strategic goals of many hospital boards. Here are some suggestions about what it might look like in the health sector:

• Blogging.
• Using platforms like Twitter or Facebook.
• Adoption of social media channels on Flickr, YouTube, Twitter or many others to interact with stakeholders and customers.
• Making contact with third parties who run forums and sites and establishing two-way partnerships with them.
• [Allowing customers to provide] feedback, leave comments or vote/rate things online using simple digital tools.

As one example of digital engagement in healthcare, systems can market themselves by a presence on Twitter. However, this is not so simple. I blogged more than two years ago about how Cleveland Clinic uses Twitter to enhance its reputation among physicians and consumers (see: Facilitating Engagement of Consumers using E-Health Tools Like Twitter). What is so impressive for me about Cleveland Clinic's presence on Twitter, which continues to this day, is that their tweets tend not to be overt messages asserting that the system delivers better care. Rather, it addresses topics such as new surgical techniques or details about the treatment of various diseases which have been pioneered there. In other words, it's a quality and value message relayed via tweets. 

For me, the essence of creating a digital engagement campaign by a health system is that the personnel managing such a campaign understand the medium and its subtleties (see: Why Twitter Engagement Is Essential for Brands Today). For example, if I were a health system CEO, I would launch, as only one example, a series of consumer-related lectures on various topics relating to consumer health. I would then publicize them on Facebook and Twitter. I would also post selected video clips of the talks on the various social media. Although such talks would be classified as consumer health education, they would buttress the reputation of the sponsoring health system among consumers as being innovative and forward-looking and with an understanding of digital marketing.  

Successfully Screening for Lung Cancer Based on Predictive Analytics

I have blogged a number of times about predictive analytics (see, for example: Identifying Patients for Remote Monitoring with Predictive Analytics; Eric Schmidt Discusses the Potential Value of Predictive Analytics in the ER). Much of the hype about this technology and set of products is largely theoretical at this time but great potential looms in the future. I therefore was very interested in a recent article that provided a very pragmatic perspective on the topic (see: Big data and predictive analytics pull in smokers for lung screening). Below is an excerpt from it:

Virginia-based Chesapeake Regional Healthcare sought to motivate smokers and former smokers to "Get Off their Butts" and get screened with its Lung Cancer Screening Trigger Campaign, which they started in 2015. By leveraging SaaS-based big data analytics and marketing technology, Chesapeake Regional Healthcare was able to identify, target and educate certain populations at risk or eligible for lung screenings with this personalized outreach program. As a result, the healthcare organization was able to get 5.21 percent of new patients and 9.17 percent of all patients it targeted to get lung screenings. "Chesapeake Regional Healthcare was looking to drive more volume into our Lung Cancer Screening program, and only certain people need or qualify for a lung screening – targeting and predictive analytics are perfect for this type of campaign," said Sarah Liebrum, manager of marketing and communications at Chesapeake Regional Healthcare. So the health system turned to Tea Leaves Health, a developer of cloud-based analytics technology that Liebrum said "offers self-reported smoker data as well as some modeling that allows us to predict who is likely to need this screening."

To get right to the point, a healthcare system "was able to identify, target and educate certain populations at risk or eligible for lung screening with...[a] personalized outreach program." A very high percentages of patients it contacted scheduled lung screenings with a large number of cases of lung cancer identified. Campaigns like this take the theoretical advantages of predictive analytics to a practical level. I suspect that many patients who were long-time smokers were not inclined to ignore a letter from their hospital indicating that a "computer study" indicated that they were at a high risk of lung cancer and should schedule a diagnostic screening. Even if the male recipients of such a letter were still inclined to ignore the advice, the letter was probably opened and read by their wives.

I believe that one of the reasons why this example of predictive analytics was so successful was that the participating health system, Chesapeake Regional Healthcare: (a) could pursue an admirable public health objective, screen for lung cancer; and (b) simultaneously generate revenue-producing activities in terms of diagnostic procures and, for some patients, surgery and disease treatment. In short, health screening is more apt to be supported by health systems if it produces subsequent business and revenue for them.

Announcing the Second Annual API Digital Pathology and AI Workshop

On December 8-9, 2017, the Association for Pathology Informatics offered for the first time a workshop on digital pathology at Henry Ford Hospital in Detroit, Michigan. This conference was somewhat unusual in that it was located in a hospital rather than a hotel or conference center. A tour of the automated lines in the pathology department of Henry Ford was included. Navigate to the above link to review the faculty and lectures that were offered at that time. It was very well received and highly successful with all seats filled.

The second workshop in this series is now being offered on December 7-8. 2018, but with inclusion of AI as it applies to surgical pathology (see: Digital Pathology and AI Workshop II). The location for this second workshop in the series will be Ohio State University College of Medicine in Columbus, Ohio. You can register for the workshop here. The capacity for the workshop has been doubled, now with a maximum of 80 people. Please consider registering early to secure a spot. Available on the API web site are the schedule and the sponsoring vendors to date for the workshop. Here is a quote from the workshop summary page on the API web site describing the workshop in more detail:

This workshop will focus on the practical issues surrounding the deployment of digital pathology and AI in a hospital setting. Ten lectures by national experts will be punctuated by Q and A sessions including industry representatives and a guided tour of the Ohio State University's Department of Pathology. Topics covered will include the fundamentals of digital pathology, the integration of the technology with LISs, the enhancement of AP workflow, the development of an RFP for purchasing digital pathology equipment, and current perspectives about AI within pathology.

This workshop has been planned with busy surgical pathologists and departmental leadership in mind. It lasts 1.5 days and takes place on a Friday and Saturday morning. Ten lectures by national experts are packed into this time frame as well as a tour of the digital pathology unit in the James Cancer Hosital. The pathology department at OSU is the first department providing primary surgical pathology diagnoses using digital pathology in the U.S. so a tour of the imaging facility will be highly educational. A dinner on Friday night for networking and relaxation is included in the registration fee.  

During an EHR Crash, Don't Disturb the Worker Bees

In response to my blog note yesterday suggesting the need for frequent updates during major EHR crashes (see: Hospital Computer Crashs Show EHR Vulnerabilities; Need for Better Explanations), a reader of Lab Soft News submitted the following comment:

I suspect those who desire frequent updates have never lived on the "IT" side of one of these crashes. Interrupting the staff who are working to resolve the issue will only delay the resolution. It is not practical to have them stop "frequently" to give their leadership updates, unless that is considered a higher priority than restoring the system.

I personally lived on the IT side of the equation for 24 years as the director of an LIS in a major health system. During that time, I was involved in a number of system crashes, all for relatively short periods of time. During each of them, physicians and nurses were deprived of rapid and easy access to critical lab test results and patient care suffered. In my note referenced above, I did not discuss exactly "who" would be responsible for developing frequent bulletins about progress in the resolution of the nature of an EHR crash, the remedies that were being undertaken, and when service would be restored.

In the case of the crash at Sutter Health, the "who" would be obvious in terms of communication with affected hospital personnel and patients. With a system-wide EHR crash that persists for more than 24 hours, I assume that the CIO of the health system and all of his her deputies will be on-site, observing and communicating continuously with EHR personnel as well as representatives of the EHR vendor. It seems to me logical that responsibility would fall to such EHR leadership to closely observe the situation and then to collaborate with the health system public relations and patient communications personnel in developing the necessary and relevant communications that I recommended in my note.

Restoring service during an EHR crash will always be the first priority and no mission-critical IT personnel should be distracted from their continuing effort to resolve the problem. I think that it would be highly unlikely that the CIO of a major health system would be pivotal in resolving the cause of such a crash. If this were indeed the case, a mere 24-hour EHR crash would be considered a miracle.

Hospital Computer Crashs Show EHR Vulnerabilities; Need for Better Explanations

A recent EHR crash at Sutter Health was managed in about the same (ineffective) way as most of the other similar health system disruptions. Sutter disclosed little about what was happening during and after the crash. The outage was discussed in a recent article (see: How a Major Computer Crash Showed the Vulnerabilities of EHRs). Below is an excerpt from it:

The...[recent] communications outage at Sutter Health, the largest health system in northern California, which cut off access to electronic health records (EHRs), highlighted the frequency of such outages and the need for backup plans and drills nationwide (see: Sutter Health fixes systemwide computer failure, launches investigation). The outage started at about 10:30 PM May 14 and lasted more than 24 hours, until Sutter announced systems were up and running at 2 AM May 16. During the shutdown, some elective surgeries were rescheduled, some procedures were delayed, and some patients were discharged. The 24-hospital health system executed its downtime plan and reverted to paper-based charts.....Sutter spokesperson Dean Fryer told the San Francisco Chronicle that the cause for activation of the system was not a fire or data breach but did not disclose details. Fryer told Medscape Medical News he would have no further comment beyond the May 16 update.

First of all, let me speculate about why I think that health systems tend not to be forthcoming about their EHR disruptions. First and early in the process, the cause of the crash may be unknown as it is investigated. However, this does not explain the lack of information after the cause has been diagnosed but before the problem is corrected. Secondly, hospital officials do not want to unduly alarm patients by discussing problems of this kind in detail. However and drawing an analogy to delayed airplane flights, consumers and patients can be more alarmed by the lack of information than by releasing accurate updates about the problem. Thirdly, I suspect that hospital executives may be restricted by EHR contracts from explicit explanations about failures. Fourthly, the health system may believe that the release of any significant information will reflect poorly on the quality of the health system itself.

It's important to note that hospital EHR crashes are common. Here's a comment on this point from an article on the topic (see: Electronic medical records: preparing for the inevitable crash):

All ...[major hospitals] use electronic medical record (EMR) systems, and all were left scrambling to function when their system crashed. If multiple hospitals use the same system, the scale of the problem is even larger when an outage occurs. “A computer system lets you do and control more things at once,” says Dean Sittig, a professor in the School of Biomedical Informatics at the University of Texas Health Science Center at Houston. “But when it goes down, you can have bigger accidents.” Sittig and two colleagues recently completed a study, as yet unpublished, of how often EMR systems fail. They found that not only are system crashes common, they are pretty much inevitable. The public is probably unaware of this, suggests Sittig, because news of a crash tends to escape a hospital’s walls only when a ticked-off patient calls a reporter.

The solution to this problem, at least to me, is obvious. Hospitals need to create and publish a standard operating procedure (SOP) for communicating with their staff and patients at the time of any significant EHR disruption. Such an SOP would require frequent updates and include an explanation of the possible cause of the crash, what efforts are being taken to correct the problem, what services have been lost, what steps are being taken to provide the lost services in some other way, and when the lost services will be restored. I suspect that healthcare systems would never adopt such a policy of their own accord so the various regulatory organizations might need to compel them to do so. Until such an approach is adopted, we will continue to remain in the dark about these increasingly common events.