In previous notes, I have made a distinction between hospital EMRs and physician office EMRs, the differences being apparent from their names. The December issue of Laboratory Economics contained an article entitled LABS WORKING TO MAKE EMR CONNECTIONS which addressed the very important issue of hospital lab connectivity to office EMRs. This newsletter requires a paid subscription but a sample issue can be downloaded from the home page for review. Take a look at it -- the publication is always topical and provides valuable information for lab professionals. Here is an excerpt from the article cited above:

I think that it can be said with certainty, firstly, that the majority of physician offices or clinics will soon have an EMR and, secondly, that hospital labs will need to deploy what Jondavid Klipp, the publisher of Laboratory Economics, refers to in the article as a "web connectivity" system linked to these physician office-based systems. In previous notes, I have  referred to these systems as lab or web portals. There are three major current categories of necessary clinical lab software: LIS, middleware, and lab portal. I include an anatomic pathology LIS (AP-LIS) as a component of the LIS but it can also be obtained as a standalone system. A fourth functionality category that is rapidly emerging as necessary is a digital imaging system comprised of both software and hardware.

In the Lab Economics survey cited above, it's interesting that "cleaner orders" and "fewer phone calls" ranked higher than the competitive advantage over the large commercial labs in terms of the benefits of lab portal software. I suspect that the competitive advantage was the initial driver for the purchase and then the other key benefits of the software became more obvious to lab personnel.

The following four vendors of lab portal systems will be represented at the 27th annual Lab Infotech Summit to be held on 16-18 March, 2009, at the Venetian Hotel in Las Vegas, two of which are cited above:  Atlas Medical, Blue Iris, CareEvolve, and Cerner. Online registration for the conference is now available at the conference web site. The first 100 registrants for the conference will qualify for a complimentary copy of "The Inovator's Prescription: A Disruptive Solution for Health Care." Dr. Jason Hwang, one of the authors of the book, will be a keynote speaker at the event.

I posted a previous note about how general surgery is becoming a less attractive specialty for new medical school graduates (see: General Surgeons as the Primary Care Docs of the Operating Room). The article quoted drew a parallel between general surgeons and primary care physicians. The reason that general surgery is becoming less attractive is that these specialists often shoulder a heavy burden of the call schedule in hospitals and also end up referring many of the interesting cases to the surgical subspecialists. In that note, I addressed the on-call issue in the following way:

For me, the on-call issue is a distraction that can be solved relatively easily. The hospitals can hire their own surgicalists about which I have previously blogged (see: The Emergence of the Surgicalist) and taking a fair amount of call will be a condition of their employment by the health system. In terms of referral patterns and with a shortage of general surgeons, I envision that the PCPs will refer to the surgical subspecialists. But what happens if there is a shortage of PCPs?

Now comes a new article in the Washington Post that discusses how the shortage of general surgeons  is having a negative effect on healthcare delivery in rural areas (see: Shortage of General Surgeons Endangers Rural Americans). Below is an excerpt from the article with boldface emphasis mine:

Many young physicians are opting for non-surgical specialties, such as radiology or cardiology, in which they can earn as much money as a surgeon with less grueling and unpredictable hours. Many young surgeons, in turn, choose to concentrate in fields such as transplant surgery or plastic surgery, in which they can make more money and don't have to face (usually alone) the wide range of problems a generalist faces. "The shortage of general surgeons is at crisis dimensions," said George F. Sheldon, director of the American College of Surgery's Health Policy Institute. If the trend continues, he said, "the quality of health care will suffer, as the services of a surgeon are unique." In 1980, 945 newly trained general surgeons were certified in the United States. In 2008, the number was essentially the same -- 972 -- even though the population has increased by 79 million. In 1994, there were 7.1 general surgeons per 100,000 people. Today there are five per 100,000.

It occurs to me that a new breed of surgicalist could be developed to provide general surgery services in rural areas of the country. Multiple rural hospitals could join together and hire a salaried surgicalist(s) (i.e., a regional surgicalist) who would be an employee of the hospital network. In order to address the on-call burden, it would probably be necessary to hire two or more of them for any individual network. In addition, it would also be useful to establish telemedicine links across the participating hospitals so that a referring PCP or internist could rapidly obtain a teleconsultation with the regional surgicalist to determine whether surgery was necessary for a particular patient and where the surgery would be performed.

Despite the fact that a hospital surgicalist (or regional surgicalist) is becoming more of a generalist, these specialists will still retain the key advantage over primary care physicians (PCP) of performing procedures and therefore enjoying a salary advantage (see: Two Definitions for the Physician Proceduralist). This may make the idea of developing a position of regional surgicalist more feasible.

For the uninitiated, net neutrality refers to the idea that content providers on the web should not be allowed to pay the cable and phone carrier companies, pipe providers, for an Internet fast lane to deliver information to customers. Google is one of the most prominent and successful content providers, delivering its search-engine results to users and, in the process, its revenue-generating advertisements. Google has been a strong advocate for net neutrality in the past but now seems to be cutting deals with the carriers for preferential fast-lane access. Below is an excerpt from the story from the Wall Street Journal (see: Google Wants Its Own Fast Track on the Web) with boldface emphasis mine:

Google...has approached major cable and phone companies that carry Internet traffic with a proposal to create a fast lane for its own content....Google has traditionally been one of the loudest advocates of equal network access for all content providers. At risk is a principle known as network neutrality: Cable and phone companies that operate the data pipelines are supposed to treat all traffic the same -- nobody is supposed to jump the line. But phone and cable companies argue that Internet content providers should share in their network costs, particularly with Internet traffic growing by more than 50% annually, according to estimates. Carriers say that to keep up with surging traffic, driven mainly by the proliferation of online video, they need to boost revenue to upgrade their networks. Charging companies for fast lanes is one option....But Lawrence Lessig, an Internet law professor at Stanford University and an influential proponent of network neutrality, recently shifted gears by saying at a conference that content providers should be able to pay for faster service.

It should be pointed out that Google has demonstrated a willingness in the past to negotiate with the carriers of Internet traffic in order to provide customers with content. A case-in-point dating back to 2005 was Google's investment in AOL Time Warner (see: Time Warner's AOL and Google to Expand Strategic Alliance). The Google IPO had occurred just previously in 2004 and the company was not the colossus that we know today. That 2005 deal on the part of Google was a critical factor in its continuing growth.

I readily admit to being an avid fan of all of the various products and services provided by Google. I, as well as the majority of you, am also accustomed to lightning-fast Google searches. I would hate to see a degradation of the time required for a web search. Lessig's argument that the content providers should be able to pay for faster service also makes perfect sense to me. By the way, don't expect the content/carrier tensions and competition to subside any time soon. This will continue to be an ongoing battle. Moreover, I have no idea how we will define "content" a year or two from now but I also suspect that it will be greatly different than our concept of today.

I was serving as a pathologist in the Army and based at the 121st Evacuation Hospital in Seoul, Korea, in 1971-1972. On occasion, a representative from U.S. Embassy in Seoul would come to the hospital pharmacy and requisition bottles of barbiturates. The scuttlebutt around the hospital at that time was that these were "spooks" (i.e., CIA operatives) and that the pills were being used in the street to barter for military intelligence from informants. I had forgotten about this distant chapter in my life until I came across a recent article in the Washington Post that made a similar observation (see: Little Blue Pills Among the Ways CIA Wins Friends in Afghanistan). Below is an excerpt from the article with boldface emphasis mine:

The Afghan chieftain looked older than his 60-odd years, and his bearded face bore the creases of a man burdened with duties as tribal patriarch and husband to four younger women. His visitor, a CIA officer, saw an opportunity, and reached into his bag for a small gift. Four blue pills. Viagra....The enticement worked. The officer, who described the encounter, returned four days later to an enthusiastic reception. The grinning chief offered up a bonanza of information about Taliban movements and supply routes -- followed by a request for more pills....In their efforts to win over notoriously fickle warlords and chieftains, the officials say, the agency's operatives have used a variety of personal services. These include pocketknives and tools, medicine or surgeries for ailing family members, toys and school equipment, tooth extractions, travel visas, and, occasionally, pharmaceutical enhancements for aging patriarchs with slumping libidos, the officials said.

I had previously assumed that Afghan warlords held money and political influence in their highest esteem. I now understand that there is one thing that they covet even more. Rather than spending many millions of dollars on ill-fated construction projects in Afghanistan, I have a more modest proposal. The U.S. government should encourage, and perhaps even underwrite, the building of a string of CVS and Walgreens stores in Kabul and in the hinterlands of the country. We should even offer to our special friends a special "warlord or Taliban card" that would qualify them for special attention in these facilities. Special provisions should be made if they leave their cards at home.

In a previous note (see: Informatics as the "Secret Sauce" in the Integration of Pathology and Radiology), I discussed a new Siemens Healthcare integrated diagnostics project at Hospital Clinic in Barcelona. One of the three diseases that will be studied in this initiative is liver fibrosis. In a previous note, I discussed the use of a biomarker to assist in the diagnosis of hepatic fibrosis (see: Serum Biomarkers for Hepatic Fibrosis). This test could potentially be used in collaboration with hepatic MR elastography (see: In a Clinical Trial, Hepatic MR Elastography Delivers Encouraging Results) as a non-invasive approach to this diagnosis. The alternative is a needle biopsy of the liver with its associated risk and morbidity.

It occurred to me that there might be other diseases that could be used to test the theory that serum biomarkers plus medical imaging could be a used to accurately diagnosis disease. In this context, peripheral arterial disease (PAD) immediately comes to mind. PAD affects about 8 million Americans and increases with age such that by 65 about 12 to 20 percent of the population has evidence of the disease. Early diagnosis is important because individuals with PAD have a 4-5 times greater risk of heart attack or stroke. One biomarker that is currently being studies to diagnose PAD is beta-2-microglobulin (B2M) (see: ß2-Microglobulin as a Biomarker in Peripheral Arterial Disease).

Relevant for this discussion of integrated diagnostics for PAD is that the FDA has just approved a contrast agent used in connection with magnetic resonance angiography (MRA) to assess blood flow (see: FDA Approves First Imaging Agent to Enhance Scans of Blood Flow). This agent plus MRA could be used with PAD biomarkers as a new type of integrated diagnostics. Below is an excerpt from the article with boldface emphasis mine:

The U.S. Food and Drug Administration [has]...approved Vasovist Injection..., the first contrast imaging agent for use in patients undergoing magnetic resonance angiography, or MRA, a minimally invasive test for examining blood vessels. Although MRA can be performed without the use of a contrast imaging agent, Vasovist administration provides a clearer image in patients who are suspected of having blockages or other problems with the blood vessels in their abdomen or limbs...."This MRA contrast imaging agent provides clinicians with a much clearer scan of blood vessels, compared to MRA without contrast, even in vessels that are difficult to scan because they twist and turn in the body," said [an FDA spokesman]. When blood vessels are scanned using MRA without any contrast, radiologists are unable to interpret the images about 10 percent to 30 percent of the time. As a result, radiologists have typically used X-rays to detect blood vessel abnormalities. But this is a lengthy procedure and requires sticking a needle into an artery to inject the X-ray dye, a procedure that may result in injury to vessel walls, blood clots, allergic reactions and potential kidney damage. Vasovist is injected into a peripheral vein and no artery is punctured, thus the potential risks are fewer.

I am going to keep an eye out in the future for candidate diseases that may lend themselves to rapid diagnosis by the combination of serum biomarkers and medical imaging, particularly when this approach yields special benefits over current diagnostic methods.

I have posted many notes about the potential benefits of the integration or merger of pathology, lab medicine, and radiology. Robert Michel is presenting a conference on this specific topic in Philadelphia on February 10-11, 2009 (Molecular Summit). A review of the conference program reveals a number of lectures devoted to the topic of informatics which one could describe as the "secret sauce" without which this integration of these medical disciplines could never take place. 

Siemens Healthcare is the corporate underwriter of this conference. The company has been a powerful advocate for the blending of in-vitro and in-vivo diagnostics and has just launched a clinical initiative in a Barcelona hospital (see: SIEMENS HEALTHCARE AND HOSPITAL CLINIC, BARCELONA ENTER AGREEMENT TO USE INTEGRATED LABORATORY DIAGNOSTICS, IMAGING AND INFORMATION TECHNOLOGY SYSTEMS TO ADVANCE PATIENT CARE) with special attention to the diagnostic integration of care in three specified clinical areas: liver fibrosis, fetal medicine and colon cancer.

I want to document here some of the informatics-based processes that will be required in order for diagnostic integration to succeed:

• On the most basic level, pathology and radiology departments have assumed responsibility for their own specialized information systems -- LISs and RISs. The basic management and control of electronic reporting in both departments is obviously the sine qua non of modern medical diagnostics and a prerequisite for the next generation of integrated diagnostics reports. I believe that, in time, LISs and RISs will merged into a common diagnostic report management system, the Diagnostic Information System (DIS).
• All radiology departments maintain their own PACSs, the repository of the images generated in the department. Pathology departments are on the early part of the curve in terms of their own management of digital images. I envision that integrated diagnostics professionals will ultimately be responsible for installing and maintaining an enterprise-wide diagnostic image repository (i.e., PACS) that will include images generated by other specialists in hospitals such as cardiologists and gastroenterologists.
• I have previously referred to the emergence of multi-maker panels, referred to by the FDA as IVDMIAs. Most such panels require the use of computerized algorithms to interpret the clinical significance of the results of the testing. The use of such algorithms have, in part, stimulated the special interest of the FDA in these new and more complex forms of biomarker testing.
• Finally, a whole new type of software will be required if and when in-vitro and in-vivo diagnostics becomes more closely integrated -- rules-based systems that provide recommendations about the cross-referrals between pathology and radiology departments in order to arrive at diagnoses using the most cost-effective, efficient, and effective diagnostic paths.

In previous notes, I have discussed the preceduralist, by which is meant a hospital-based physician who specializes in performing various invasive, skilled procedures such as fluoroscopy, conscious sedation, upper airway endoscopy, and percutaneous tracheostomy (see: The Emergence of the Proceduralist in Hospitals, Cedars-Sinai Medical Center - Hospital innovators 2007). This development is part of the growing specialization of physicians and also the growth of "-ists" such as hospitalist and surgicalist. The latter are hospital employees who assume the previous role of private physicians who admitted their patients to hospitals and provided oversight for their care during the hospital stay (see: The Emergence of the Surgicalist).

I have just become aware of another definition for proceduralist, used almost exclusively in the context of discussions about physician reimbursement (see: On Disparities Between Reimbursement of Primary Care and Proceduralist Physicians). In this latter case, the term refers to any type of medical specialist who performs various "procedures" in contrast with, say, a primary care physician (PCP) whose primary role is to take medical histories, examine patients, treat their patients with drugs, and make referrals. There is a wide income disparity between a PCP and a gastroenterologist who frequently performs endoscopic colonoscopies, a procedure, and profits from the higher reimbursement from third-party payers for such procedures.

It should be relatively easy to understand which definition for a procedurlist is being used from the context of the discussion. Nevertheless, I thought that it would be useful to document these two different uses of the term.

I posted a note on March 18, 2008, plus two follow-up notes, about what I then referred to as the catopsy, which I defined as a classic autopsy extended by the use of medical imaging techniques (see: Reinventing the Autopsy: CT Imaging as a Routine Part of the Procedure, Additional Discussion About Reinventing the Autopsy). At that time, I was unaware that the term virtopsy had already been used to refer to post-mortem imaging that was being performed in various centers. I subsequently published a note about the virtual-autopsy (i.e., virtopsy) (see: Introducing the Virtopsy, a Variant of the Catopsy Theme). My understanding at that time was that the virtopsy consisted of only the imaging component of an autopsy without histopathologic examination of tissue and was, therefore, an extension of the classic autopsy (see: Virtual Autopsy Offers Noninvasive Postmortem Exam).

At the 13th annual APIII conference held in Pittsburgh on October 19-23, I had the privilege of listening to lectures by three individuals who have been pivotal in the emergence of the virtopsy. They were Drs. Stephan Bolliger and Steffen Ross from the Institute for Forensic Medicine, Bern, Switzerland, and Colonel Angela Levy, Uniformed Services University of the Health Sciences, Bethesda, Maryland. These lectures (The Virtopsy Project: Novel Approaches in Post-Mortem Imaging, Drs. Bolliger and Ross; and The Virtual Autopsy and Postmortem Multi-Detector CT Imaging, Col. Levy) can be downloaded from the APIII 2008 web site (Wednesday, 22 October, 10:30 a.m. breakout session). Dr. Bolliger is a pathologist and Drs. Ross and Levy are radiologists. Caution: these two lectures are large PowerPoint files that download slowly but are worth the time and effort.

Having now observed the work being done by Drs. Bolliger, Ross, and Levy, I have personally come to the following conclusions about the virtopsy and the future of forensic pathology:

• The virtopsy now seems to be defined as a combination of classic autopsy techniques plus various imaging modalities. Dr. Ross is even performing post-mortem vascular imaging procedures using injected contrast material. However, the term virtopsy may be somewhat misleading because it refers to both a "real" autopsy and a "virtual" autopsy.
• Dr. Levy is focusing on the description and understanding of post-mortem artifacts as viewed by medical imaging techniques. Such knowledge, of course, is critical in the evolution of the virtopsy and extends the understanding of such artifacts that has been obtained over the years by pathologists.
• Because of the profound amount of new information that is now being added to the classic autopsy gross dissection techniques and microscopic observation of tissue, I personally believe that the forensic autopsy, as routinely performed in the U.S., is on the verge of being obsolete. I believe that most pathologists will come to the same conclusions after reviewing the two lectures referenced above.
• I urge all forensic pathologists to rapidly adopt the medical imaging techniques advocated and now demonstrated as practical by Drs. Bolliger, Ross, and Levy as soon as possible. This will enable a refinement of both standard and forensic autopsies techniques such that much more information can be obtained from the procedures and the information obtained can be better documented.
• Achieving broad adoption of the forensic virtopsy will be very challenging based on the following requirements of the virtopsy: (1) ready access to sophisticated medical imaging devices for most or even many of the procedures; and (2) ready availability of a forensic radiologist such as Dr. Ross to interpret the post-mortem images. Ultimately, I believe that the solution to this problem will be the cross-training of forensic pathologists in both pathology and radiology in order for them to interpret both gross/microscopic pathologic changes as well as the images produced by the various imaging modalities.
• I believe that early adoption of the forensic virtopsy in the better-funded medical examiner offices in urban centers will cause a medico-legal conundrum in other communities. The adoption process will begin to change the standard of practice for the forensic autopsy as interpreted by the courts. In those regions where the practice is not adopted, the defense bar may be able to challenge the validity of classic forensic autopsy findings as inadequate.

A lab professional colleague recounted to me a quote from a recent discussion with an executive of Quest Diagnostics. The Quest executive remarked that logistics was the key core competency of the company. Such a statement actually rings true to me. Just think about it. Quest has developed a courier and shipping system infrastructure that transports fragile biologic specimens from physicians' offices across the U.S. (and also from around the world) to their central lab facilities for rapid processing. However and in spite of this internal perspective, I suspect that the majority of purchasers of the Quest Diagnostics stock view it as an investment in sophisticated healthcare technology. If they are seeking a logistics play, they would buy FedEx or UPS.

I have published a number of notes commenting on the fact that health insurance and hospital executives as well as many clinicians view lab services as a commodity. Below is a quote from only one of them (see: UnitedHealth Threatens to Fine Doctors for Sending Specimens to Quest):

[The attitude of UnitedHealth] is that lab services are generally interchangeable and equal and that only the location and convenience of the patient service center is of paramount importance. The [article quoted] thus continues to telegraph the message that lab testing is a commodity and that all test results are of equal quality, which I do not believe is true.

I have also published a number of notes to the effect that hospital-based labs do not adequately market themselves and the scientific contributions of lab medicine. In a recent note (see: Performance vs. Utility of Clinical Lab Tests: A Marketing Perspective), I made the following point:

I have always held the opinion that the laboratory diagnostics industry, the clinical labs, and lab physicians do not market themselves and their services adequately to test-ordering physicians and to the general public. By way of contrast, I think that radiologists do an admirable marketing job for medical imaging. I am not sure if this latter group is more marketing-oriented or if the new imaging technologies just sell themselves

On its home web page, Quest describes itself in the following way: The world’s leader in diagnostic testing, information, and services. For me personally, there is a major disconnect when a company simultaneously describes itself as the world’s leader in diagnostic testing and also views its core competency as specimen logistics. Put another way, I believe that the major national reference labs view themselves primarily as competing in a commodity market and that they differentiate themselves in this market primarily on the basis of the cost of testing, the efficiency of blood collection, and specimen logistics, rather than underlying science and quality of the lab test results generated. In such a setting, it may be impossible for hospital lab professionals and esoteric reference lab personnel to change the general attitude that lab testing is anything other than a commodity.

Happy Birthday, Lab Soft News. You turn three years old today. The very first blog note was posted on December 21, 2006 (see: Reinventing Pathology: The Autopsy). Interestingly enough, this same theme of "reinventing pathology" has been a persistent one during the course of the last three years.

This will be a brief "state of the blog" note just to bring readers up-to-date. A blog rises and falls and the basis of the interest and enthusiasm of its readers and, on that score, one could conclude that  that the patient is healthy:

• A total of 1,036 notes have been posted on Lab Soft News during the three years and these have stimulated a total of 349 comments. I have come to the conclusion that a blog such as this one is usually not very controversial and thus does not generate much comment traffic.
• Inbound readers currently number, on average, 107 per day. Added to this number are 210 daily email subscribers using Feedblitz, 131 daily RSS subscribers using Feedburner, and 75 daily RSS subscribers using Google Reader. This yields about 523 readers per day. About 80% of them are unique because this is the percentage of subscribers to the blog.
• The reader breakdown by country for the past month is as follows: 73.1%, U.S.; 5.0 %, unknown; 3.2%, Canada; 2.2%, India; 2.2%, Brazil; and 1.7%, U.K. Google Analytics documents that recent readers have come from a total of 48 countries and territories.
• In terms of referring web sites to the blog, 10.2% are from Google and 7.6% are from Yahoo. Confirming these data are those from Google Analytics that shows the following in terms of Traffic Sources: 54.4% direct, 26.0 % referring sites, and 19.4% search engines.
• The average time per reader on the site is 1.25 minutes and readers view, on average, 1.4 pages per visit. This data are reasonable in that most blog readers tend to dwell only on the current material. This is confirmed by the bounce rate of 82.0%, which is the percentage of readers who arrive at a web site entry page and then leave without going any deeper into the site.

Well, that about wraps it up. Stay tuned for another year of interesting news and comments about the lab medicine and pathology world.

I have traced the use of the term cloud as it relates to web-enabled computing in multiple previous notes. Briefly stated, cloud compputing has evolved from a computer architecture consisting of multiple synchronized servers to a broader definition describing a set of Internet services and software accessible with a browser. A recent article in the Wall Street Journal take the term even further afield and defines it in the context of web marketing as an affinity group enabled by, and aggregated, by web sites and services (see: Marketing in the World of the Web). Below is an excerpt from the article with boldface emphasis mine:

From crowds to clouds: Once you get that attention -- once you generate heavy traffic to your site, gather a large league of "friends" on MySpace, or spawn a dedicated following on Twitter -- how do you monetize the crowd? Smart brands are turning their crowds into "clouds": organic, self-forming and often self-governing communities of interest. Companies such as Hewlett-Packard, Frito-Lay and Harley-Davidson use their clouds as feedback loops to get better faster by obtaining good, timely, often brutally honest customer insights. And the members of clouds can become true believers; they don't just watch your commercials, they make them. Right now, few companies are emotionally equipped to wring the best benefits of a cloud, because the most valuable voices out there usually belong to the malcontents. In the old model, customer-service departments aimed to placate or jettison disgruntled customers. In the cloud model, the idea is to cultivate and reward them. That's not an easy transition.

These ideas about an affinity group arising around a set of web services raise a number of interesting questions and possibilities about this blog, Lab Soft News, and its companion conference, Lab InfoTech Summit. For example, is there opportunity or value in trying to convert the readers of this blog into an "organic, self-forming and often self-governing [community] of interest." In order to answer this question, one needs to understand why this blog and conference were created in the first place. That's easy to answer. Pure and simple, the goals of Lab Soft News and Lab InfoTech Summit have always been to create and communicate knowledge about clinical lab software and the clinical lab industry. Professional lab societies such as CAP, ASCP, CLMA, and AACC also pursue similar educational missions as well as other goals such as accreditation, lab inspection, and political lobbying.

Because their educational mission is similar to professional societies, one possible future outcome for pathology and lab medicine blogs is that some of them will merge or blend with the societies and become another educational and teaching vehicle for them. Another scenario is that they will remain independent and expand into "cloud professional communities" that compete with the professional societies. If such "cloud communities" remain relatively small, specialized, and nimble, they may be able to represent the educational goals of lab professionals better than the large societies. Stay tuned for the answer. Self-organizing groups empowered by the web have never existed before so there are no precedents to learn from.

A favorite party game for many of us is to discuss the prices charged by hospitals for our inpatient stays. This is a variant of the apocryphal story of the $40 aspirin. Although somewhat amusing and a good way to keep your guests amused, the prices charged by hospitals are so removed from reality that Elvis sightings might be a better focus for the conversation.

The reasoning behind this statement is established in a podcast interview of Steve Lipstein, CEO of the BJC HealthCare System in St. Louis, by Russ Roberts, the host of Econtalk.The podcast conversation (see: Lipstein on Hospitals) is the most lucid one I have ever heard about the economics of healthcare, due, no doubt, to the high intelligence of both the interviewer and interviewee. Here are the reasons enunciated during the interview why inpatient prices are so fanciful and thus irrelevant:

• A large but variable percentage of inpatient fees are covered by Medicare and Medicaid. The hospital payment schedule to hospitals is established by these governmental bodies themselves and is frequently less than the cost of the care.
• Managed care entities and insurance companies negotiate variable discounts with health systems that are applied against the hospital fee schedules; hospitals keep raising their rates to compensate for the money-losing Medicare/Medicaid patients to achieve, ideally, a 3% operating surplus.
• Other key factors also come into play to account for the spiraling cost of care such as the fact that the patients, the recipients of care, have few incentives to shop for lower cost services or limit the use of expensive procedures. For teaching hospitals, the lower productivity of faculty and inexperienced house officers also needs to be factored into the reimbursement mix.

The conclusion reached by Mr. Lipstein was that, first, the entire healthcare reimbursement system is broken and needs reform. To say that the prices charged for hospital services are independent of market forces and irrelevant is another way of saying that the system is badly broken. Another conclusion is that politicians and bureaucrats probably can't be trusted to reform the system. Most politicians inherently think short-term (i.e., the next election) and want to posture for the voters on evening news and C-SPAN.

If you are an individual who is forced to pay out-of-pocket for hospital services for lack of health insurance, you will be charged the "irrelevant" prices described above unless you negotiate with the hospital to pay the same discounted rates as the private insurance companies. If you are not up to this task, there are strategies for achieving this same goal (see: 10 ways to save on health care costs).

Men who live on their own are less likely than those living with a spouse or a partner to be screened for prostate cancer, even if they have a family history of the disease, a new study finds (see: Screenings: Partners and Prostate Cancer). Below are further details from the article:

This article highlights the question gender relating to the utilization of healthcare services. It is widely understood that women make greater use of such services than men (see: (Gender, psychosocial factors and the use of medical services: a longitudinal analysis). Here a quote from only one article on this topic:

... female gender remained an independent predictor of higher utilization over the 22-year period studied, and psychosocial and health factors measured at the initial interview predicted service use even 19-22 years later. Controlling for factors identified as likely causes of gender-related differences in healthcare utilization, gender remains an important predictor of medical care use before and after removing sex-specific utilization.

It's not necessary to understand for the purposes of this note exactly why women utilize healthcare services more than men. However, it's quite clear that if one were to market the services of a clinical lab, the obvious strategy would be to focus on women who would likely be more responsive to such an appeal. Having said this, it also occurs to me that hospital labs and commercial reference labs view physicians as their primary customers and thus don't feel compelled to market to the general public, female or otherwise. They also don't do a good job in marketing to physicians. I addressed this topic in a previous note (see: Performance vs. Utility of Clinical Lab Tests: A Marketing Perspective) with the relevant excerpt below:

I have always held the opinion that the laboratory diagnostics industry, the clinical labs, and lab physicians do not market themselves and their services adequately to test-ordering physicians and to the general public.

The exception to this rule that clinical labs don't bother to market to the general public are the direct access testing (DAT) web sites including, recently, the personal genomic testing sites that are much in the news. I have posted a number of notes about DAT. My personal belief is that not marketing and emphasizing the value of in-vitro diagnostics to the general public has been a mistake and accounts, in part, for the general lack of appreciation and understanding of the contributions of lab medicine.

Ole Eichhorn has performed a very valuable service in his Daily Scan blog by publishing a long set of perceptive observations about the RSNA (Radiological Society of North America) conference in Chicago (Visiting RSNA). RSNA is one of the largest conferences in the world and attracts about 60,000 registrants annually. His blog note is a gem and I will return to it again because of the many valuable insights it contains. Below is only one of them -- short but powerful.

I have published multiple notes about the implications of the development of "nighthawk-like" outsourced radiology services. Here are four of them: Digital Pathology vs. Digital Radiology: A Broad Divide, NighHawk Radiology Services Enters Software Arena, On-Line Auctions for Radiologist Services Offered by Telerays, On-Line Radiology Auctions and the Explosive Growth of the Specialty). The importance of the rapid maturation of teleradiology into a viable business model can't be overstated. Here are some additional observations:

• Telemedicine has been struggling to find its true niche for three decades or more and is focused today mainly on providing services to underserved, incarcerated, and geographically remote populations. There is nothing wrong with this business model but it is destined to stay as a niche application. Teleradiology, on the other hand, has the potential to serve many if not all of the people in the U.S. (and most will not even know that it is happening). Put more bluntly, teleradiology is quickly becoming ubiquitous and Nighthawk demonstrated the practicality of radiology outsourcing.
• Although the word ecosystem is overworked, Ole is correct in applying it to the emergence of multiple "Nighthawk-like" teleradiology systems. These systems extend beyond mere physical radiology networks and involve both the technical Internet infrastructure as well as sophisticated workflow, reporting software, and collaboration by radiologists positioned around the world. In other words, this heralds a new way for the specialists to practice in the field.
• As Ole also points out, this teleradiology ecosystem has the potential to provide specialized radiologic interpretations to small remote hospitals on a scale never before imagined. I commented on this phenomenon in a previous note (see: On-Line Radiology Auctions and the Explosive Growth of the Specialty) in which I said that, for example, the services of a neuroradiologist are now accessible to patients in small rural hospitals or to multispecialty clinics. This has major quality implications for the U.S. population.
• Recall that this cascade of events has been precipitated by one company, Nighhawk Radiology, with the goal, as the name implies, of providing radiologic interpretive services to hospitals at night and on the weekends when the radiologists on the hospital staffs wanted some relief.

My guest blogger of last Friday, Dr. Tony Killeen, has come up with a practical and up-to-date solution for teaching lab medicine to medical students and pathology residents (see: Using Web 2.0 Tools to Teach a Lab Medicine Course at the University of Minnesota). His answer is to create web sites that accompany and complement a "classic" pathology course or a residency training program. Here's how Tony summarized his idea in his previous blog note:

Arguably the most exciting trend in higher education is the migration from content delivery in a classroom at a fixed time to web-based content delivery that is independent of the physical location of the instructor, the students and independent of time. An essential tool to facilitate this kind of new content delivery is course management software, which allows an instructor to build a course website that includes almost any kind of document: text, images, spreadsheets, databases, wikis, and of course, audiovisual content.

As Tony notes in this blog excerpt, a critical component of a course web site is a set of audiovisual presentations; let's call them electronic lectures presenting new and exciting knowledge about the field. If multiple course and residency training directors in pathology were to create such web sites with audiovisual materials, they could share such content across multiple medical schools and residency training programs, increasing the quality of teaching in all of them. As only one example of electronic grand rounds, Tony highly recommends the University of Washington's Laboratory Medicine Grand Rounds available at iTunesU. I have personally downloaded all of these lectures to my iPod and will listen to each of them.

Links to lab medicine blogs such as Lab Soft News embedded in these lab medicine and pathology teaching and training web sites will serve to enrich the formal didactic content and provide insights into breaking news in the field and outside opinions. Discussion forums for medical students and residents across course web sites can also bring student and resident ideas to bear on the material that is being taught.

Wisconsin, a major focus of GE Healthcare operations, will be facing major job losses as the company responds to the failing economy (see: GE Healthcare plans job cuts as market weakens). Below is an excerpt from the article from a Milwaukee newspaper with boldface emphasis mine:

Dr. Anthony KIlleen, a former colleague of mine at the University of Michigan and now an Associate Professor of Pathology at the University of Minnesota, emailed me about a web site that he had set up to support a lab medicine course that he was teaching. He was requesting permission for an RSS feed of this blog into the web site. I asked him if he would develop a blog note on this topic and he graciously accepted my offer. Boldface emphasis is mine.

Arguably the most exciting trend in higher education is the migration from content delivery in a classroom at a fixed time to web-based content delivery that is independent of the physical location of the instructor, the students and independent of time. An essential tool to facilitate this kind of new content delivery is course management software, which allows an instructor to build a course website that includes almost any kind of document: text, images, spreadsheets, databases, wikis, and of course, audiovisual content. Good course management software eliminates the need for an instructor to have to know anything about html, xml, css, Java, or most of the details of how a website is constructed or functions.

At the University of Minnesota where I teach Laboratory Medicine to second year medical students, I have been using a course management software program called Moodle. This is a popular, open-source product that the University of Minnesota uses to deliver content for hundreds of courses. Educational content for my course includes traditional written material with discussion forums and quizzes, and links to lectures delivered in a variety of formats including Adobe Presenter, MPEG4 movies for downloading to video-capable portable devices such as video iPods, iPhones etc., and MP3 for downloading just the audio content.

Moodle also enables RSS feeds from blogs, including Lab Soft News, to provide students with information about events and activities in this field and fresh content on an almost daily basis. The website thus ties together traditional learning material with contemporary content delivery formats and dynamic content that is updated as new blog entries are created at sources that can be entirely external to the course.  I have been very pleased with the ease of use of Moodle and the positive feedback from students. This is just one example of the application of the concept of Web 2.0, a synthesis of web tools that enhances communication and creativity, and is the direction in which higher education is moving.

::Update on 12/14/2008 @ 9:49 a.m.

Tony Killeen has generously provided us with the link to his clinical pathology course web site for your review.

Because I seek both inspiration and content for Lab Soft News only on the web, I have been forced to become a bit of a web search connoisseur with my favorite search engine being Google. I was therefore interested to learn that Google Search now includes selected magazines (see: Google updates search index with old magazines). Below is an excerpt from the story with boldface emphasis mine:

Google has added a magazine rack to its Internet search engine. As part of its quest to corral more content published on paper, Google... has made digital copies of more than 1 million articles from magazines that hit the newsstands decades ago. For now, the old magazine articles can be found only through Google's search service for finding digital copies of books. But the Mountain View, Calif.-based company plans to eventually include magazine articles in its general search results. Users who want to restrict the scope of their inquiries to magazines can choose that option through the book search's "advanced" function....The list of old magazines already available through Google include past issues of New York Magazine, Popular Mechanics, Popular Science and Ebony. Google has been trying to reel in more content from non-Internet sources for the past four years. The crusade began with agreements to copy books sitting on the shelves of several major libraries — an ambitious project that triggered a copyright battle with publishers and authors that was finally settled in October. Besides books and magazine articles, Google also provides a digital gateway to the archives of several newspapers and millions of old photos from Life magazine.

I, for one, was not very knowledgeable about the process for specifically searching the content of books and now magazines that have been indexed by Google. As noted in the excerpt above, all that you need to do is navigate to the Advanced Search page of Google. At the bottom of this page, you are offered the option of clicking on categories such as the following: News Archive, Scholar, Book, and U.S. Government. The magazine search is included in the book search. If you click on Book, you have a choice of the following categories: Fiction, Non-Fiction, and Random. History of Medicine, that may be relevant for some of the notes included here, is included in the Random Category. The Book page shows the the various covers of the books and magazines that have been indexed, a very useful feature.

As noted above, I only use web search tools to research topics for this blog, as a matter of expediency and personal choice. As a result of this expanded search access to print materials, I will attempt to provide a wider perspective of clinical lab issues when appropriate and relevant. We are very fortunate that our digital universe keeps expanding in this way.

We are evolving from the specialty of medical genetics, with its emphasis on the identification of a specific genetic abnormalities such as Down Syndrome (Trisomy 21), to medical genomics. This latter approach to genetic disease has been defined in a Mayo Clinic publication in the following way:

The application of basic knowledge of the human genome to questions that influence human health. Medical genomics promises a fundamental change in the practice of medicine by: identifying new genes with disease relevance; providing better characterization of subcategories of disease; providing better identification of risk factors; and creating the potential for individualized drug therapies.

Medical genomics is designed to address diseases relating to the entire genome as opposed to medical genetics that had a much more limited horizon and did not address broad areas such as disease risk factors and individualized targeted drug therapies. For me, one of the ironies of medical genomics, as it is now evolving, is that consumers are being exposed to it through consumer-oriented web sites such as 23andMe before the field has sufficiently matured within the formal medical establishment. To a certain extent, I think that this is partly the basis of some of the press buzz about 23andMe and also hostility on the part of physicians to personal genomics.

However, there is now some evidence that sophisticated services relating to genetic testing and medical genomics are beginning to be offered. Generation Health is a case in point. Copied from the company home page, here is a summary of its mission:

• Establishing a framework and rationale for covering and excluding specific genetic tests, based upon clinical validity and utility.
• Prior authorization of all covered tests for eligible employees based upon sound medical criteria.
• Negotiating discounted testing prices and quality/service standards with a contracted network of genetic testing labs.
• Identifying patients, through analysis of medical and prescription claims, who may benefit from genetic testing, and then facilitating their testing.

So Generation Health appears to be one of the first companies to take a stake in the management of genetic testing and, therefore, inevitably, in the management of genomic diseases. In my view, there will be a great need for such services in the long run. It will enjoy a first-mover advantage. The key question is whether the market is ready at this point for such services. There is no question that genetic testing is, and will continue to be, both complex and unnerving for patients and payors. Both of these groups will need all the knowledge and help that they can get.

I must admit at the start of this note that I thought I understood the definition of lifestyle diseases -- in my mind, the term referred to diseases caused by some action, or lack of action, on the part of an individual that caused a disease to develop. Examples of the former, an action taken, would be lung cancer caused by smoking or hepatic cirrhosis caused by excessive ethanol intake. It turns out that I was wrong in my use of the term. The causes of lifestyle diseases are based on the general behavior of populations rather than individuals. Here is the definition from the Wikipedia:

Lifestyle diseases (also called diseases of longevity or diseases of civilization) are diseases that appear to increase in frequency as countries become more industrialized and people live longer. They include Alzheimer's disease, atherosclerosis, asthma, cancer, chronic liver disease or cirrhosis, Chronic Obstructive Pulmonary Disease, Type 2 diabetes, heart disease, nephritis or chronic renal failure, osteoporosis, acne, stroke, depression and obesity.

The reason I was thinking about this topic was that a recent article had caught my attention (see: Molecular imaging that will bring about a revolution in diagnosis and drug discovery). Its categorization of cancer, dementia, and diabetes as lifestyle diseases makes perfect sense now that I understand the correct definition for lifestyle disease (boldface emphasis mine):

Molecular imaging is essential for a better understanding of life, because phenomena in living beings result from interactions between molecules. Masaaki Suzuki, of the Molecular Probe and Drug Design Laboratory, says, “Molecular imaging is the ultimate goal of life science.” Molecular imaging is expected to help in the detection of lifestyle-related diseases, such as cancer, dementia, and diabetes, at an early stage, as well as in developing good new drugs with the fewest side-effects far more quickly. 

Taking the example of cancer as a lifestyle disease, I do understand the idea that a longer life free of, say, infectious diseases, may increase the risk of developing cancer for an individual. Hence the notion that lifestyle diseases being synonymous with diseases of longevity. I also understand that living in an industrialized nation could increase one's exposure to pollutants or food additives that might be carcinogenic. However, I also suspect that some individuals are genetically predisposed to developing malignant neoplasms, partly as a result of having a less efficient or effective DNA repair mechanism, allowing more rogue cells to develop and proliferate. Here's an interesting little article on cancer immunology that includes a reference to the cancer immunosurveillance theory.