Lab Soft News

Drive-Through Collection of Samples for COVID-19 Testing in Cleveland

The notion of drive-through to collect nasal swabs for COVID-19 testing is a practical and efficient idea and, I think, will ultimately be used across the country. Here's an article about how such a collection process is being organized by two Cleveland hospitals (see: University Hospitals and Cleveland Clinic Partner to Provide Drive-Through COVID-19 Testing). Below is an excerpt from the article:

Cleveland Clinic and University Hospitals (UH) have partnered to provide drive-through COVID-19 testing for patients with a doctor’s order from UH or Cleveland Clinic....Patients without a doctor’s order will not be offered testing at this location. To obtain a medical screening to determine testing necessity, people with symptoms should start with a virtual visit using Cleveland Clinic’s Express Care Online or call their UH or Cleveland Clinic primary care physician. Upon arrival to the drive-through location, patients will stay in their car and present their doctor’s order. They will remain in their car as a sample is collected. Samples collected from this location will be sent to UH and Cleveland Clinic laboratories. Performing testing on-site at local hospitals ensures faster results than sending the samples to the state or outside lab. Results are anticipated to be available within a day. Patients will be tested regardless of their ability to pay; no copays will be charged for the test. Cleveland Clinic and UH are testing in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. 

Several aspects of this program struck me as being interesting. For one, it's an example of two large health systems in the Cleveland market operating in a collaborative way. Secondly, health systems like Cleveland Clinic and University Hospitals, as opposed to public health departments, have their own labs so the turn-around time for results will be about a day. Moreover and in this Cleveland venture, testing will be performed regardless of ability to pay. For those with health insurable, copays will be waived.

A very interesting twist is that Cleveland Clinic has been offering telemedicine services for about five years (see: Cleveland Clinic Launches Web Site to Offer Physician Visits to Ohio Residents). The Clinic was way ahead of the curve in making this service available to Ohio residents. It's value is now being shown in perhaps an unanticipated way -- the ability to generate a physician lab test order for patients prior to their participation in the drive-through line. I think that the COVID-19 pandemic will be a stimulus for other health systems to launch and expand their own virtual care programs.

Some Details about an Emerging Healthcare Service -- Hospital-at-Home (HaH)

One of the new services in healthcare, hospital-at-home (HaH), has caught my attention. I encountered an article providing more details about one company in this business (see: In-Home Healthcare Companies Bring High-Acuity Care, Including Clinical Laboratory Testing, to Patients at their Homes and Workplaces). Below is an excerpt from it:

Whatever name it is given, the high cost of keeping a patient overnight in a hospital is motivating a range of healthcare players to develop innovative ways to provide care to patients—even patients with acute conditions—in their home....One such company is DispatchHealth...which recently brought its “ER-at-Home” in-home healthcare model to cities in Texas, Massachusetts, and Washington State. Focused primarily on seniors with high-acuity medical conditions, Patients or caregivers contact DispatchHealth through their smartphone app, website, or phone call line and the company sends over a home care team consisting of a physician assistant or nurse practitioner, along with an [emergency] medical technician. The team has the ability to perform clinical laboratory studies, infusion, EKGs, and some higher-level procedures, such as the repair of complex lacerations....

....DispatchHealth provides both mobile and virtual healthcare, is in-network with healthcare insurance companies, and has relationships with healthcare systems...“Up to 50% of people who visit the emergency room every day could be treated in a lower cost setting,” said DispatchHealth Chief Executive Officer Mark Prather....In the Spokane market, the company’s six teams and two vehicles can see about seven patients per day for an average of 45 minutes to an hour per visit....DispatchHealth employs more than 200 people and has raised more than $33 million in growth capital financing, according to a company statement. 

It's not clear whether hospital-at-home services like that offered by DispatchHealth can successfully compete against those offered by some of the more innovative health systems (see: Some Details about Hospital-at-Home (HaH) Services for Selected ER Patients). I suspect that at least some of the emerging start-ups may be more nimble and innovative than hospital programs. The company described in the excerpt above seems to be technically innovative.

From a purely financial perspective, health systems are not enthusiastic about long-term inpatient care. They tend to encourage hospital bed turnover. For this reason, they should be promoting their own HaH services. However, most seem to want to stick to the traditional hospital model. As I have pointed out in a previous note (see: Humana's Launches New Venture: Medicare-Centric Primary Care Clinics), health systems are being "bookended" by new entrants to healthcare. Primary care patients are being recruited by "big-box" stores like CVS and Walmart and the sicker, long-term care patient are now being focused on by start-ups like DispatchHealth and Humana. 

Six Health Systems Suffer Financial Losses Following EHR Deployments

I have been blogging for at least seven years about the "numbing costs" of installing a new EHR (see: Who Says a Hospital CIO Can't Get Fired for Picking the Epic EHR?). These costs and sometimes subsequent financial losses are due to the enormous cost of installing such a system, inability to collect on accounts receivable during and even after the transition, and the decreased productivity of physicians and nurses using the new system after system go-live.

There is an inevitable decrease in productivity following the deployment of any new technology because of the unfamiliarity of personal with it. Ideally, this unfamiliarity disappears in short order and productivity rapidly increases if the technology is well designed (see: Lost productivity: the scourge of your EHR cost calculations). A recent article described some current examples of hospitals suffering financial reverses following the deployment of an EHR (see: 6 health systems that blamed Epic, Cerner EHR installs for losing millions). Below is an excerpt from it:

• University of Vermont Health Network said its $151.7 million Epic EHR implementation was partially responsible for its $10 million operating loss in the first quarter of 2020....
• ...[O]fficials at Ector County Health District blamed its Cerner EHR implementation, in part, for financial losses and a bond downgrade....The system's CFO reported that there were issues with its $55 million Cerner implementation that led to challenges with its accounts receivable.
• Centra Health in Lynchburg, Va., posted a loss for the first nine months of 2018, including a $2.7 million operating loss and $18.8 million decrease in net operating income,...[due to] its $65 million Cerner go-live....
• Covenant Health...cited its $83 million Epic EHR implementation for a $60.9 million operating loss in 2018. The hospital reported a 30 percent decrease in productivity after the implementation....
• Vanderbilt University Medical Center reported lower operating income in the first nine months of 2018 after a $214 million EHR roll-out. The year before, the system reported $110 million operating income. It also reported a 9 percent increase in expenses.
• Fairfield Medical Center...reported $22.8 million operating loss for 2018, up from $1.9 million in 2017, and the hospital's CFO...attributed the loss to "the expense of installing and activating a new electronic medical record system"....

A key question in this regard is to what extent physician and nurse productivity bounces back in the months following EHR installation and what is the magnitude of this bounce back. My sense is that health system financial losses and decreased productivity lessens over time but never returns to the pre-EHR installation levels. Then the question arises as to the extent to which other benefits of the EHR deployment such as more effective and efficient billing serve to offset the loss in physician and nurse efficiency. Of interest is that most of these article now and previously about the financial perils of installing an EHR lack any useful comments from the hospital executives themselves. This is not surprising given the negative tone of such articles. I am sure the hospital executives are wary of offending Cerner and Epic leadership with negative comments about their products. However, this does hamper discussion about the root causes of these EHR-associated problems.

Hospital Outpatient Visits Drop for First Time; Long History of Similar Inpatient Declines

It is well documented that hospital inpatient admissions have been declining for the past thirty years (see: The Case of the "Disappearing Hospital Beds"; Implications for Pathologists; Inpatient Admissions Decreasing; Implications for Hospital-Based Labs). Now comes news of a decline in outpatient visits (see: Outpatient Visits to Hospitals Decline Year-to-Year for First Time in 35 Years) Below is an excerpt from the article:

Thanks to the popularity of urgent care clinics and other non-hospital-based ambulatory care providers, the year-over-year growth in the number of hospital outpatient visits has been on the decline for decades....[F]or the first time since 1983, outpatient visits fell below the previous year among more than 6,000 hospitals surveyed by the American Hospital Association (AHA). This is an important event, because anything that affects a hospital’s revenue also affects that hospital’s medical laboratories and everyone connected to it. The decline, according to the AHA, is primarily due to decreasing visits to hospital emergency rooms. ERs provide significant revenue for hospitals. Fewer ER visits means less clinical laboratory test ordering, fewer image study requests, and may mean lower financial revenues overall....[P]atients are increasingly gravitating toward the countless disruptors that tout more convenient, cheaper options for primary care, urgent care, and even emergency care....“We’re pivoting to a new business model in healthcare, with a much more pluralistic delivery system with many, many more consumer options,” [according to an expert on the topic].“Which, of course, is exactly the same thing that’s happening in other parts of the economy. I think it’s very important that especially the major health systems recognize this and realize they have to compete against it.” 

For me, the key question raised by the declining number of inpatient admissions and outpatient visits is the following: What steps can health systems take now to continue to succeed in our competitive and pluralistic healthcare delivery system?  The following ideas come to my mind. The common theme here is the enhancement of the consumer experience. These steps are necessary to staunch the loss of patients to other providers such as CVS, Walmart, and health plans like UnitedHealth (see: UnitedHealth Group Soon to Be Largest Employer of Doctors in the US). 

1. Launch telemedicine programs as one facet of outpatient care (see, for example: Telemedicine Finds Key Target: Working Moms Seeking Pediatric Care; Understanding the Distinction between Virtual Care and Telemedicine. Such visits will have great appeal to both older patients who are less mobile and also for pediatric care, an option that will have appeal for working mothers.
2. Embrace all variety of wellness and patient education programs despite the fact that they are not well reimbursed or not reimbursed at all. They will build loyalty with patients.
3. Increase the number of PCPs on staff including large numbers of advanced practice providers (i.e., APPs; nurse clinicians and physician assistants) so that patients don't need to wait months for an appointment (see: Ranks of NPs and PAs Expanding; Will Increasingly Dominate Primary Care). Such professionals can also be the major players in telemedicine programs.
4. Embrace hospital-at-home programs that are favored by many patients and will reduce the cost of care for many chronically ill patients (see: Some Details about Hospital-at-Home (HaH) Services for Selected ER Patients; Reducing the Cost of Care; Provide Home Care for Sicker Patients with Remote Monitoring).
5. Enhance all types of palliative services to improve the quality of care and reduce the cost of end-of-life care (see: Physicians Less Likely to Die as Patients in the Hospital than Other Patients)
6. Embrace home-based wearable health technologies for healthy patients but which can also be used to monitor sicker patients in hospital-at-home programs (see, for example: The Evolution of "Wearable Health Ecosystems" and Associated Partnerships).
7. Launch programs to improve the health system consumer experience such as valet parking and efficient use of patient portals for making appointments and asking health related questions. Chatbots may eventually be of value in terms of making patient portals more user-friendly (see: Medical Chatbot Improves Patient Response Rate for Flu Shot Reminders).

Why Some Hospital CEOs May Be Opposing Interoperability in Support of Epic

In a recent post, I discussed the opposition to the proposed HHS rule on EHR interoperability on the part of Judith Faulkner, founder and CEO of Epic, and the CEOs of some 60 health systems (see: Faulkner Opposes Proposed HHS Hospital Interoperability Rules; No One Surprised). In this note, I would like to discuss some possible reasons why the CEOs of health systems might oppose such a rule.

• Firstly and as I have long maintained (see: NYT Op-Ed on EHR Interoperability Blames Vendors and Greedy Hospitals), data portability enables healthcare consumers to "shop" hospitals. However, they may not always do so on a voluntary basis. Yearly churn in health plan membership is estimated to be about 25% so some consumers may be forced out of their current health plan due to, for example, a job change (see: Reducing Churn to Increase Value in Health Care: Solutions for Payers, Providers, and Policymakers). The bottom line here is that portability of EHR records is a key element in the improvement of consumer's healthcare experience.
• Secondly, it is asserted by hospitals that interoperability provides health insurance companies an unfair advantage over health systems in negotiating  reimbursement rates between the two parties. I believe, as do many others, that the entire hospital billing system is broken and hospital bills are often indecipherable (see: Two Reasons Why Medical and Hospital Bills Are Such a Mess). The whole hospital reimbursement system needs to be scrapped, allowing us to to start over and create a rational new system. Here's an article from 2006 that discusses this mess (see: The Precarious Pricing System For Hospital Services). I am thus in favor of any change that may disrupt the current hospital billing systems.
• Finally, I was struck by the point raised by Jonathan Bush who favors interoperability as referred to in my recent note (see: Faulkner Opposes Proposed HHS Hospital Interoperability Rules; No One Surprised). He said the following: "... with new data-sharing opportunities, patients can send their medical data to new tech services that can "aggregate data and recognize patterns in a way that health systems can't..." This is one facet of predictive analytics and an exciting new development in healthcare. I don't want to stifle its development in any way. I can envision that consumers will use such "tech services" as a check of a current diagnosis, particularly a serious one.

Bundled Cash Pricing May Provide an Ideal "Transparency" Solution for Many Hospitals

Major changes are now underway in the healthcare industry including the impending CMS price transparency rules that are eliciting marked opposition from various segments of organized medicine  (see: Ohio Healthcare Network Serving Amish and Anabaptist Communities Could Provide Blueprint for Hospital Price Transparency). Below is an excerpt from an article on this topic in Dark Daily:

.... [O]n Jan. 1, 2021, a new Centers for Medicare and Medicaid Services (CMS) final rule (CMS-1717-F2) on price transparency goes into effect. It requires hospitals to publish their standard chargemaster prices, as well as payer-negotiated prices, online for customers to review. A companion proposed rule (CMS‑9915‑P) will, if passed, require health plans and healthcare insurers to disclose covered healthcare costs to customers upon request, including “an estimate of such individual’s cost-sharing liability for covered items or services furnished by a particular provider.” These rules have created a fire storm of controversy. Hospital systems and healthcare organizations like the American Hospital Association (AHA) argue that revealing payer-negotiated rates will undermine health networks’ negotiating power with insurers and increases hospital prices.

....Pomerene [Hospital located in rural Millersburg Ohio] has developed bundled care packages for more than 300 services...for Amish and Anabaptist patients as well as any other self-pay patients who pay their bills in full at the time of service....The initiative came in response to concerns raised by the area’s Amish and Anabaptist communities, which make up roughly 40% of the county’s population. They do not use commercial health insurance. Instead, they pay their medical bills out of pocket....Church members asked Pomerene for guaranteed bundled pricing....In total, nearly one-quarter of the hospital’s patient revenue comes from bundled-service packages, with 3,387 packages provided last year....For competitive reasons, Pomerene does not publicly post its package prices and only prospective cash-paying patients are provided the cost breakdowns. 

I have blogged frequently over the years about the inefficiency and opacity of our current hospital billing systems (see, for example: Two Reasons Why Medical and Hospital Bills Are Such a Mess). I support any CMS initiatives designed to make hospital billing processes more transparent. The opposition to this new program stems, in my opinion, from the need on the part of hospital executives to resist any change to a broken system. For them, this new set of rules can be summarized as an attack on a system that they "understand" despite the fact that many healthcare consumers are being financially destroyed by it (see: 34 Devastating Stories About How People Are Still Crushed By Medical Debt). 

Veteran readers of this blog may remember some of my earlier notes about Bumrungrad International Hospital in Bangkok, Thailand, which was a pioneer in bundled up-front cash payments as part its medical tourism initiative (see: Interview with Bumrungrad Group CEO, Curt Schroeder) Bumrungrad's current web site offers three "Healthy Heart Packages" including various types of surgery based on anticipated risk (see: Packages & Programs 2020).

I suspect that the larger U.S.health systems are holding back on programs of bundled prepayments for various types of "care packages" until one of the industry leaders like Kaiser or Cleveland Clinic move in this direction. After such an initiative, they would then be forced to follow suit because of competitive pressures. The development of appropraite prices for such packages would be relatively simple once the general outlines of the strategy are established. 

Companies Emerge Offering Remote Text-Based Primary Care Consultations

In a recent note, I explored the difference between virtual care and telemedicine (see: Understanding the Distinction between Virtual Care and Telemedicine). Here is the explanation copied from the note:

Simply put, the term virtual care is a way of talking about all the ways patients and doctors can use digital tools to communicate....While telemedicine refers to long-distance [direct and visual] patient care, virtual care is a much broader term that refers to a variety of digital healthcare services.

This made a lot of sense to me when I wrote the note but long-distance care is growing more complex. A recent article described a new example of remote primary care but without the "tele" feature (see: Smartphone Apps Enable Healthcare Consumers to Receive Primary Care without Traditional Office Visits....). Below is an excerpt from it:

Two companies on the forefront of such advances are 98point6 and K Health, and they provide a glimpse of primary care’s future. The two companies have developed smartphone apps that incorporate AI and the ability to interact with real physicians via text messaging....The [98point6] service involves “providing virtual text-based primary care across the entire country, 24/7 of everyday”....It’s text-based delivery of care overlaid with an AI platform on top of it.....98point6 offers the service through individual subscriptions or through deals with employers, health plans, health systems, and other provider organizations. The personal plan costs $20 for the first year and $120 for the second, plus $1 per “visit.”

Here's a cut-and-paste from the K Health landing page:

It’s not a visit—it’s a conversation We’ve redesigned the doctors’ visit and turned it into an ongoing conversation that feels like texting with a friend. Chat with the doctor on call throughout your health episode for a diagnosis, advice, prescriptions and lab test orders. It costs less than a typical copay and there’s no insurance required.

At first glance, this business model made little sense to me, However, on additional reflection, it would seem to be a good option, particularly for younger consumers. Here why it might work:

• Text-messaging requires inexpensive technology for both the physician provider and the consumer. Only a cell phone is necessary. It would seem to be perfect for use by consumers on the road for their work or on vacation. 
• Younger consumers will probably be most comfortable with text-based communication. Lack of video interaction may also be less threatening and intimidating for some consumers.
• Younger consumers who use the service will be less apt to have serious and chronic diseases. Most of them will have only minor ailments and will be looking primarily for drug prescriptions which these texting services can provide.
• In summary, long-distance care seems to be differentiating into low-tech (text messages only) and high-tech (video calls) with broad appeal perhaps to different sets of consumers.

 

Amazon and AWS Help Improve Hospital Efficiency and Reduce Costs

In a recent note, I discussed how Cerner was turning to Amazon/AWS for help in providing assistance with AI technology that an be embedded in its EHR product. One example was the deployment of a chatbot that can be used to interrogate the EHR for critical information that can be difficult to extract, particularly in the form of natural language (see: EHR Vendor Cerner Turns to Amazon Web Services for AI Development). In a recent article about Amazon's healthcare strategy for 2020 (see: 15 things to know about Amazon's healthcare strategy heading into 2020), I was reminded of the relationship between Amazon and Beth Israel Deaconess Medical Center. Here is a brief quote from that article:

In March, [2019], Amazon made a $2 million investment in Boston-based Beth Israel Deaconess Medical Center to test artificial intelligence tools. The two have partnered since 2016 when Beth Israel bought AWS's cloud software and reported significant improvements with operating efficiency.

Here is a quote from another article about the same topic that provides more details about projects that have been initiated in this same program (see: Improving Patient Care with Machine Learning At Beth Israel Deaconess Medical Center)

An initial BIDMC research project used machine learning to optimize the schedules of its 41 operating rooms and align those schedules to improve patient flow in the inpatient setting. Another project has leveraged machine learning to improve operational flow within operating rooms. Now, incoming pre-surgical document packages will be scanned as images and processed with TensorFlow on Amazon SageMaker, hosted in BIDMC’s secure AWS cloud. This machine learning driven process automatically recognizes and inserts consent forms into corresponding electronic health records (EHR), saving hospital staff hours of manual work. BIDMC built a model that scans EHRs to look for key elements like a completed consent form. If a consent form isn’t found, a signal appears on the EHR and nurses follow up with those patients.

The median operating margin for U.S. health systems in 2018 was only 1.8% (see: Operating margins stabilize, but not-for-profit hospitals still vulnerable). Part of the reason for this situation is the nature of our entire health system with its eccentricities and perverse incentives. However, I will also fault some health system executives for these financial challenges. They have tended to focus over the years on optimizing revenue by negotiating with payers rather than vigorously trying to reduce their own cost structures. I am not sure at this point that the use of AI to increase the efficiency of health system operations will have a broad effect. However, this is certainly a trend to watch.

Possible Funding Tension Between Wellness Programs and End-of-Life Care

It is a well known that a large percentage of the total U.S. healthcare spend is devoted to end-of-life care (EOLC) for a small number of patients (see: How We Spend $3,400,000,000,000). To quote the subtitle of the article:..."[M]ore than half of America's healthcare spending goes to five percent of patients." I think that we are approaching the time for an earnest discussion about this disproportionate allocation of healthcare resources and whether some of these resources could and should be reallocated to wellness programs. In my mind, it is out of the question about whether to increase spending for both wellness and EOLC given that the total healthcare expenditure, currently about 18% of the GDP (see: How has U.S. spending on healthcare changed over time?), is more than double that in other developed countries.

In this current note, I want to first raise some of the reasons why expenditures for EOLC have grown so large:

• Organized medicine is generally focused on the treatment of disease rather than the promotion of wellness. Expensive and prolonged end-of-life measures are a consequence of this focus on disease.
• In a parallel manner, the training of physicians and nurses is devoted almost entirely to the diagnosis and treatment of disease, suggesting that this disease treatment orientation among healing professionals will continue in upcoming years.
• In our system, physicians and hospitals are reimbursed almost entirely for the diagnosis and treatment of disease with little devoted to the promotion of wellness. 

By way of contrast, I offer below a bulleted list of forces that are now coming into play such that some percentage of the EOLC resources may be reallocated to wellness:

• Our for-profit health care plans, with an eye toward their own bottom lines, are promoting wellness programs. Corporations are also eager to see this happen.
• More Americans are dying at home of natural causes for the first time since the earliest part of the 20th century (see: More Americans are dying at home. Is that a good thing?). The surely represents a "vote" on the part of consumers against extended and expensive EOLC in hospitals and extended care facilities. 
• Big Tech is a new driver regarding wellness, including Apple, Google, and Amazon. These companies see this market as ripe for innovation and sales of their home-based healthcare devices. As I have commented in previous notes, health plans, Big Tech, and CVS/Walmart are controlling a growing percentage of primary care (see, for example: Walmart Shapes Its Own Primary Care, Unbundling Strategy; CVS Expands Its Healthcare Presence with Its New HealthHUB Stores). They will also thus control some of the referrals to health systems for more complex care and will soon be able to exert more control over the cost of this care.

Higher Quality Healthcare Correlates with Lower Blood Transfusion Rates

In a previous life in the 1970s, I was a blood banker at a large academic hospital. This may sound unbelievable to some of the current Lab Soft News readers but one of our cardiac surgeons in the 1970's would often transfuse six or more units of blood during a CABG (see: Variation in Use of Blood Transfusion in Coronary Artery Bypass Graft Surgery). Although modern blood transfusion can be life-saving, it can sometimes be a substitute for controlling hemorrhage by other and more appropriate means. In other words, less transfusion can often be equated with higher quality care. There is also a financial benefit when a hospital seeks to lower blood utilization rates. This point was reinforced in a recent article (see: Hospitals see improved outcomes, lower costs as blood transfusions drop). Below is an excerpt from it:

Hospitals across the country have been cutting back on their use of blood, saving them money and improving patient outcomes, according to a new study. Premier, the nation's largest group purchasing organization, found that since its last analysis in 2012 blood utilization has been cut nearly in half across the 10 procedures that use the most blood without compromising quality of care. Rates of mortality, complications and readmissions fell in that same timeframe. The GPO's nationwide analysis of 645 hospitals spanning 2011 through the first half of 2016 revealed a 20% decrease in blood utilization across 134 diagnoses that account for the vast majority of red blood cell use. The blood use cuts helped Mercy Health save $6.2 million over that time period, said [a health system executive] "We are conserving a scarce resource and improving patient care," he said....[R]esearchers have found that blood transfusions among cardiac surgery patients have been linked to increased risk of mortality. Transfusions, of which around 40% are unnecessary according to some estimates, can increase the likelihood of allergic reactions, fever, lung injury, immune suppression, iron overload and other harmful side effects. They can also drain a hospital's finances, as each unit of red blood cells costs $218, not accounting for overhead and transportation costs that can inflate the price nearly 5 times.

I hold the opinion that the skill of the physician managing a patient with a low or a rapidly declining hematocrit is critically important and better clinical management tends to result in less blood transfusion. These ideas are reenforced in a passage in Upto Date which is shown below (see: Indications and hemoglobin thresholds for red blood cell transfusion in the adult):

For many decades, the decision to transfuse red blood cells (RBCs) was based upon the "10/30 rule": transfusion was used to maintain a blood hemoglobin concentration above 10 g/dL (100 g/L) and a hematocrit above 30 percent....The 1988 National Institutes of Health Consensus Conference on Perioperative Red Blood Cell Transfusions suggested that no single criterion should be used as an indication for red cell component therapy, and that multiple factors related to the patient's clinical status and oxygen delivery needs should be considered....A common theme of...guidelines [for blood transfusion] is the need to balance the benefit of treating anemia with the desire to avoid unnecessary transfusion, with its associated costs and potential harms. This requires considerable diagnostic skill and acumen on the part of physicians ordering transfusions.