Lab Soft News

Can the Number of Unnecessary Knee Replacements Be Reduced?

An article that I came across recently suggested that up to one-third of patients undergoing knee replacement continue to experience pain post-operatively and one in five of them regret having had the procedure. The conclusion is that this procedure is perhaps being performed too frequently (see: Up To A Third Of Knee Replacements Pack Pain And Regret). Below is an excerpt from the article:

Most knee replacements are considered successful, and the procedure is known for being safe and cost-effective. Rates of the surgery doubled from 1999 to 2008, with 3.5 million procedures a year expected by 2030....Doctors are increasingly concerned that the procedure is overused and that its benefits have been oversold.....Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while 1 in 5 are dissatisfied with the results. A study published last year in the BMJ found that knee replacement had “minimal effects on quality of life,” especially for patients with less severe arthritis. One-third of patients who undergo knee replacement may not even be appropriate candidates for the procedure, because their arthritis symptoms aren’t severe enough to merit aggressive intervention, according to a 2014 study in Arthritis & Rheumatology. “We do too many knee replacements,” said Dr. James Rickert, president of the Society for Patient Centered Orthopedics, which advocates for affordable health care, in an interview....Although Americans are aging and getting heavier, those factors alone don’t explain the explosive growth in knee replacement.

A key issue regarding knee replacements is what can be done about over-utilization of this type of surgery while at the same time avoiding the stigma of too much intervention and limited freedom of choice for patients. A recent article discussed this issue (see: Reducing unnecessary hip and knee replacements could save billions a year) and below is an excerpt from it:

“With the U.S. currently spending nearly 18% of its gross domestic product on medical care, almost twice as much as other high-income countries, we need to look at every opportunity to reduce costs from services that may be overutilized. Elective joint replacements could represent an area for significant savings,” co-author Jonathan Fielding, M.D., founder and co-director of the Center for Health Advancement, said in a statement. In addition to capping payments, Fielding and his colleagues recommend creating decisions aids to inform patients about alternatives and risks to help them avoid unnecessary hip and knee procedures.

The use of "decision aids" to help inform patients who are contemplating major surgery has been recommended. Here's an example of such a tool for knee replacement developed by HealthWise: Arthritis: Should I Have Knee Replacement Surgery. I navigated through this decision tool and thought that it was informative and clear. Take a good look at it and make up your own mind. However, a patient with severe knee pain may be willing to try almost anything for relief. I will concede that it's hard to advise patients about a choice of surgery compared to, say, physical rehabilitation, because the orientation of some patients may be to fix the problem once and for all" without a deep understanding of the risks of surgery and of a possible suboptimal outcome from it.

eConsult System Designed to Optimize Hospital Specialty Referrals

NYC Health & Hospitals has developed and deployed e-consult software that is both EHR linked and web-based. It has been shown to be a valuable tool for reducing wait time for speciality care appointments and to enable PCPs to improve the quality of care (see: eConsult proves valuable tool for NYC Health+Hospitals in cutting wait times, speeding referrals). Below is an excerpt from it:

The [web-based, EHR integrated] eConsult tool allows primary care providers and specialists to communicate more effectively and co-manage patients when appropriate, as well as allowing them to connect patients to specialty care. The system is integrated through NYC Health + Hospitals' electronic health record systems, which helps with documentation. The eConsult system pilot began in August 2018 with two hospitals....September 2018 marked a milestone of 52,000 referrals reviewed and triaged thus far. The eConsult system helps streamline the referral process by allowing for rapid messaging and responses between providers when a primary care provider's patient has a health concern that would typically be treated by a specialist....Sometimes the communication is simply guidance that will allow the PCP to better treat the patient. Other times, when a specialist visit is necessary, the specialty clinic contacts the patient directly to schedule an appointment....NYC H+H said eConsult has helped to cut wait times for specialty care, showing that for patients referred for an in-person specialty care visit, the median wait time decreased from 50 days before eConsult to 28 days in June 2017.  

Here's another link to a related article about the development of this same software (see: Improving Access to Specialist Expertise via eConsult in a Safety-Net Health System) and below is an excerpt from it about the lessons learned in the process:

• Primary care providers consistently review eConsult responses and follow up with patients as needed.
• Specialty clinic staff schedule only those referrals that have been triaged appropriately.
• Specialists use the eConsult process as an opportunity for ongoing education for referring providers and for co-managing patients.
• Patients expect to be contacted by the specialty clinic if an appointment needs to be made.

There is a long history in the formerly paper-dominant healthcare world in which PCP referrals to medical specialists were largely a one-way street. This process was often inefficient and wasted resources. The e-consult software described here helped to correct this imbalance and enabled a dialogue between the PCPs generating referrals and speciality personnel. As noted in the quotes above, the software also provides guidance that enables the PCP's to better treat their patients and creates an opportunity for training and improved patient co-management. Because of this enhanced communication, median wait time for speciality appointments in the health system was  reduced by almost half since the final software deployment. 

Registration Almost Full for the Second Annual API Digital Pathology Workshop

The second annual API Digital Pathology and AI Workshop will be presented on December 7-8. 2018 (see: Digital Pathology and AI Workshop II). The location 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 over last year's event, now with a maximum of 80 people. Only nine spaces remain open at this time. A waiting list will be created when these places are filled.

Available on the API web site are the schedule and the sponsoring vendors to date for the workshop. Here is a list of the workshop faculty and moderators: Ulysses J. Balis, M.D,; Michael D. Feldman, M.D; Wendy L. Frankel, M.D.; Chris Garcia, M.D.; Stephen M. Hewitt, M.D., Ph.D.;  Keith J. Kaplan, M.D.; Anant Madabhushi, Ph.D. Robert McGonnagle; Liron Pantanowitz, M.D.; Anil Parwani, M.D.;S. Joseph Sirintrapun, M.D.; and J. Mark Tuthill, M.D. Below 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 only one and a half days and takes place on a Friday and Saturday morning. The pathology department at OSU is the first department in the country providing primary surgical pathology diagnoses using digital pathology so a tour of the imaging facility will be highly educational. A dinner is planned for the Friday night for networking and relaxation and is included in the registration fee.  

The second annual API Digital Pathology and AI Workshop will be presented on December 7-8. 2018 (see: Digital Pathology and AI Workshop II). The location 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 over last year's event, now with a maximum of 80 people. Only nine spaces remain open at this time. A waiting list will be created when these places are filled.

Available on the API web site are the schedule and the sponsoring vendors to date for the workshop. Here is a list of the workshop faculty and moderators: Ulysses J. Balis, M.D,; Michael D. Feldman, M.D; Wendy L. Frankel, M.D.; Chris Garcia, M.D.; Stephen M. Hewitt, M.D., Ph.D.;  Keith J. Kaplan, M.D.; Anant Madabhushi, Ph.D. Robert McGonnagle; Liron Pantanowitz, M.D.; Anil Parwani, M.D.;S. Joseph Sirintrapun, M.D.; and J. Mark Tuthill, M.D. Below 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 only one and a half days and takes place on a Friday and Saturday morning. The pathology department at OSU is the first department in the country providing primary surgical pathology diagnoses using digital pathology so a tour of the imaging facility will be highly educational. A dinner is planned for the Friday night for networking and relaxation and is included in the registration fee.  

Who Will Resurrect the "Futurescape of Pathology" Conference?

Hospital-based clinical laboratories are facing threats in various forms including the changing face of ambulatory care. I described this threat in a recent blog note (see: Retail Drug Stores Emerging as Healthcare Hubs for First-Tier Primary Care). The basic problem for pathology is that inpatient admissions are decreasing and new ways to deliver ambulatory care will siphon patients away from hospital ambulatory care settings and hospital-based testing. This is only one challenge facing pathology and the clinical labs. We are in urgent need of a pathology conference with a strategic orientation that can provide answers about how to respond to the changes that are occurring in healthcare delivery and the lab testing market.

The long defunct Futurescape of Pathology conference sponsored the the CAP Foundation was such a strategically-oriented conference. It was launched in 2007 and took place from that year through 2011 with no conference in 2010 (see: Pathology 2.0 - Nine Years Later) Here's a key paragraph from the introductory remarks of Dr. Mary Kass, M.D., at the conference in 2008 to give you a sense of the orientation of the event (see: Futurescape of Pathology 2008 Conference: Welcome and Introductory Comments):

What does the future of pathology look like in an era of personalized medicine? How will personalized medicine impact the way we practice in the next 3 to 5 to 10 years? What is really going on with the biomarker race? What is industry's role in the emergence of this new pathology? And what practical tools can you take away from this conference that will benefit you in your practice? These questions and more will be answered here this weekend. You're going to hear some very exciting, but provoking, information. We hope that you will get involved in the discussion.

Here is the detailed conference schedule from 2011 (see: 2011 Schedule). It's important that you take a look at it. Although it occurred seven years ago, almost all of the topics presented are still vital. As you can also see from this schedule, the conference format was perfect for addressing strategic issues: multiple, relatively short lectures by pathologists, scientists, and vendor representatives commenting on challenging issues. 

Here's my short answer about why I think that the Futurescape conference was discontinued: it was not financially viable. The vast majority of pathologists today have little or no interest in grappling with strategic questions. They are just trying to get through their work for the day. Hence, paid attendance was below expectations. On the other hand, companies in the lab diagnostic space spends millions yearly for strategic advice about the future of pathology and the clinical laboratories. I have some ideas about how a pathology organization could resurrect the conference in a financially viable way. I present them below:

• Plan a conference with a relatively small hotel footprint, limited to perhaps 200 registrants. This will result in a relatively low cost event. One hotel ballroom will suffice.
• Solicit 12-15 vendors in the pathology and clinical lab space who would send representatives to listen to the lectures and help underwrite the conference so it doesn't run at a deficit. I don't personally think its important to have a vendor display area -- the sponsoring vendors would send their representatives mainly to listen. Vendor representatives would also participate in the Q and A sessions so CME would not be provided.
• For the faculty presenting at the two-day meeting, choose, say, 15 of the country's leading experts on the key topical areas in pathology and lab testing. Each of them would speak for 30 minutes to discuss major progress in their specialty and also address how to adapt to the changing environment. Each of them must be comfortable with long-range thinking.
• Intersperse panel discussions between these lectures to weigh the ideas presented and place them in a larger vision of about the future of pathology and lab testing. Vendors should be represented on these panels but they are generally constrained from discussing their future plans/products for competitive reasons.
• Publish a summary white paper after the conference to capture all of the lecture slides and panel discussions. This would also be an asset to build on for subsequent conferences.

Anyone organization out there interested?

Continuing Discussion about Lab Consultations with Test-Ordering Clinicians

I have posted two notes recently about how to improve communications between lab personnel and test-ordering health professionals (see: Need for Improved Communication Channels between Clinical Labs and Users; More on Lab Communication with Test-Ordering Physicians and Nurses). This last one prompted the following comment by Jonathan Horan:

This is really topical right now among the lab. At a lab executives' roundtable I arranged at the AACC this year, the issue of communication came up. We discussed the frustration of family doctors ordering tests that could be duplicate or inappropriate and how the lab might be more proactive in optimizing two ends of the spectrum: the orders transmitted to the lab and the interpretation of the results sent back. Participants felt that there needed to be a sort of "conversation" between the lab and the ordering physician - probably mediated with some combination of middleware/LIMS/EHR. It all came down to communication and how the laboratory is somewhat isolated in its current function, and how improving it is central to becoming part of a value-based care system.

I really like Jonathan's idea of viewing lab communications as conversations that have a dual purpose: helping the test-ordering clinician order the most relevant and appropriate tests and also assisting with the interpretation of the test results. In so doing, the lab client becomes better informed, the quality of patient care is improved, and, often, the cost of lab testing is reduced. The more I think about it, the more I also like Branko Perunovic's idea of memorializing conversations between lab personnel and clinicians in the LIS/EHR (see: More on Lab Communication with Test-Ordering Physicians and Nurses).

You may recognize his lab consultation app as a variant of the "live chat" option which is a common on web sites such as B&H Photo (see far upper right corner of web home page for the live chat option). This comparison of camera sales with lab test ordering is apt because the purchase of a camera can require a high level of technical expertise. At the end of B&H "keyboard" conversations, the entire two-way record is emailed to the customer for later reference. Such a live chat feature as it applies to lab consultations also enables the lab professional to paste links to relevant articles about the question at hand into the record.

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.

Development of a Web-Based Educational Program for the Training of BRCA Carriers

We are in an era regarding genetic and molecular testing when it is often insufficient to simply report certain test results to clinicians and their patients. Sophisticated patient education may then be necessary in order for the patient to understand the implications of certain positive lab results. A perfect example of this is the identification of BRCA carriers. Such patients need to be informed about the implications of their genetic status and their possible responsibility to untested blood relatives. A recent paper discussed the development of a Family Gene Toolkit to achieve such an educational goal (see: Development of a Web-based Family Intervention for BRCA Carriers and Their Biological Relative), Below is an excerpt from this paper:

....Carriers of breast cancer gene (BRCA) mutations are asked to communicate genetic test results to their biological relatives to increase awareness of cancer risk and promote use of genetic services. This process is highly variable from family to family. Interventions that support communication of genetic test results, coping, and offer decision support in families harboring a pathogenic variant may contribute to effective management of hereditary cancer....The aim of this paper was to describe the development of the Family Gene Toolkit, a Web-based intervention targeting BRCA carriers and untested blood relatives, designed to enhance coping, family communication, and decision making. ....The Family Gene Toolkit was developed by a multidisciplinary team as a psycho-educational and skills-building intervention. It includes two live webinar sessions and a follow-up phone call guided by a certified genetic counselor and a master’s prepared oncology nurse. Each live webinar includes two modules (total four modules) presenting information about BRCA mutations, a decision aid for genetic testing, and two skill-building modules for effective coping and family communication.

With regard to the implications of a patient receiving a positive BRCA report, the first issue is whether lab professionals, as opposed to test-ordering clinicians, have a responsiblity for patient education. For me, the obvious answer is that both have a role and this is undeniably the case in large health systems where both lab personnel and clinicians are employees of the organization and have a shared obligation for optimal utilization of lab results. Reports of lab test results such as those relating to molecular diagnostics and genomics may often be so complex that we cannot merely issue a report. We often need to educate patients about the subsequent steps that they need to take in response to positive test results. 

Although delivering written documentation about the implications of certain positive tests results to clinicians and patients such as BRCA are necessary and appropriate, I particularly like the approach described above in connection to the Family Gene Toolkit that involve offering live webinars and a follow-up phone call by a certified genetic counselor and an oncology nurse to patients. It's a means to educate large numbers of patients simultaneously and is both cost-effective and necessary given the scarcity of trained professionals in this area. I do not subscribe to the idea that sole mission of hospital labs is to report test results. We also need to ensure the some degree of followup if and when it is necessary.

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.

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.