Lab Soft News

Citrix Has Become a Barrier to Improvements in Healthcare Software

Bruce Friedman — 2009-11-06T08:38:53-05:00

In my opinion, many EMR and LIS systems have become outdated in terms of their architecture (see: Possible Adverse Consequences of Increased Federal Investment in HIT). I have attributed this in the past to the fact that hospital and lab executives keep purchasing them so there is no rush by the vendors to convert them to a more modern design. A recent note by Mr. HIStalk on the use of Citrix in the healthcare industry provides another view of this problem. Here is his note:

...[S]omeone lists the five companies Dell should take over, all of them in healthcare IT. They are Allscripts, Quality Systems (NextGen), CSC, Cognizant, and Citrix Systems. Citrix isn’t technically a healthcare IT vendor, but [healthcare is] probably [the company's] biggest vertical since the industry is dominated by 1970s time capsule applications that won’t run efficiently and securely without it....Actually I use Citrix a fair amount at work and it’s pretty cool – poorly architected fat client apps run a heck of a lot better over wireless or VPN when you’re only painting screens and not slinging massive data packets back and forth.

His observation is very interesting and hits the mark. I am reminded of a LIS vendor many years ago which was reluctant to admit that the use of Citrix was absolutely essential in order for its product to function adequately. The company did not want current clients to understand its fat-client problem nor potential clients to add the cost of the Citrix software to the total cost of ownership (TCO). This need for Citrix as companion software for many LISs and EMRs also places an additional work burden on the lab and hospital IT support staff. As noted above by Mr HIStalk, the success of Citrix in the vertical healthcare market is a function of the inadequate design of the EMRs and LISs that we continue to buy and operate. Citrix is cool but there is a big price to be paid in order to see it work on a daily basis.

Preventive Medicine Emerging as a New Clinical Practice Opportunity

Bruce Friedman — 2009-11-05T11:10:56-05:00

I have posted a number of previous notes about preventive medicine and also commented about how most physicians tend to focus on the treatment of disease (disease model) rather than health promotion and preventive medicine. Below is an excerpt from an article which suggests that healthcare personnel should place more emphasis on "health" (see: Making health care about health):

As a young cardiologist, Steve Devries noticed a disturbing pattern: His patched-up heart patients kept returning for repairs. It happened so often that Devries decided there must be another way to advance patients' health. Today, his thriving Chicago practice focuses exclusively on preventing disease, and Devries is far more likely to counsel patients about diet, sleep habits and exercise than to prescribe high-tech scans or cholesterol-lowering drugs. Motivated by a growing sense that America's health care system is broken, doctors such as Devries and public health experts are turning to preventive medicine for a potential fix. And lawmakers, eager to curb rising health care costs, are paying close attention. Every serious proposal for health reform includes measures to promote healthier lifestyles and minimize the burden of disease.... Extensive research documents the potential impact. In an April article in PLoS Medicine..., researchers estimated that 191,000 fewer deaths would occur each year in the U.S. if people got more physical activity; 216,000 deaths forestalled if people were a normal weight instead of overweight or obese; and 467,000 deaths averted if people gave up smoking....A recent report in the Archives of Internal Medicine underscores the point by finding that people who live in "healthy" neighborhoods -- areas with plentiful opportunities for physical activity and eating well -- had a 38 percent lower rate of Type 2 diabetes than those in "unhealthy" neighborhoods.

I am very enthused about the idea of increasing the number of physicians specializing exclusively in preventive medicine. I hope that health insurance companies jump on this trend and provide some sort of physician and consumer incentives to enhance the status of preventive medicine. I suspect that the patients who patronize these specialists will fall into two groups: those who already are health and fitness converts and want to pursue even higher level goals and those who have had some health health problem, or even catastrophe, and need help in digging themselves out. As to the "healthy" neighborhoods described above, my guess is that they are populated by individuals with more education who are already predisposed to healthy living. Education has been shown to be the most powerful predictors of good health (see: Education Level A Leading Factor In Good Health, Longevity, According To Health Economists). Researchers have discovered that the correlation between health and education goes beyond a pure understadnding of health maintenance. It may, in fact, have something to do with investing in oneself for the future.

New Lecture Posted on Integrated Diagnostics

Bruce Friedman — 2009-11-03T13:42:20-05:00

I delivered a lecture/discussion yesterday about integrated diagnostics to a mixed audience of pathologists and radiologists at the University of California San Francisco (UCSF). This is a topic that I have covered in previous notes. Part of the discussion also touched on the development of integrated diagnostic centers and the relationship of the virtopsy/catopsy to these new concepts. The potential patient referral patterns into these integrated diagnostic centers was touched upon, a topic ripe for discussion that I plan to address in subsequent notes.

Flash Drive "Awareness" Bracelets Distributed to Students

Bruce Friedman — 2009-11-02T08:00:00-05:00

Here's a good idea -- flexible "awareness" bracelets are being distributed to public school students in Michigan for storage of their home work, for logging into school computers, and whatever (see: Dexter students sport rubber bracelets as part of technology upgrades). Below is an excerpt from the story:

Using money from a school bond, the Dexter [Michigan] school district recently upgraded its technology, including replacing old PCs with Macs. And giving students a small rubber bracelet was part of those upgrades. Students from fifth through 12th grade each received a bracelet that's a two-gigabyte USB flash drive with two primary functions. It's formatted for both Macs and PCs, so students can take files from one computer to another. But more importantly, the drives will log students in to the computers when they plug them in....However, if students forget their flash drive bracelets at home, it leads to bigger issues [such as not being able to log-on to computers]. If lost, students can replace the drives $7. As with many changes, the school is still taking a wait-and-see approach to see how the bracelets work out. If the flash drives are successful, school administrators will decide whether to buy new ones for incoming students or reuse the ones from departing students.

Logos can be embossed on these flash-drive bracelets, hence the "awareness tag". I don't think that this type of gimmick would have much appeal for adults. most of whom are studiously trying to avoid the various "awareness" campaigns. My need for a flash drive is only sporadic so I keep a pile of them on my desk. I have avoided attaching one to my key chain, which is already too bulky. Still a great idea. One problem is that kids will need to come up with a new excuse when they can't deliver their homework. The "dog ate it" just won't do anymore.

G.E. Jumps into the Hospital Connectivity Space

Bruce Friedman — 2009-10-30T08:02:09-04:00

As someone who spent a lot of time in the past thinking about community health information networks (CHINs), the recent news about G.E. entering the HIE (health information exchange) space made me laugh out loud. The amount of money lost on healthcare connectivity endeavors such as CHINs and regional health information exchanges, a later incarnation of the same concept, has been enormous (see: A Quick Look at CalRHIO). So here we go for one more bite at the apple (see: G.E.’s Bid to Connect Computerized Health Records).

There are all sorts of obstacles to moving the nation’s health care system, choking on paper records, into the computer age. The cost and complexity of making the transition are daunting, though the government’s $19 billion in incentives for doctors and hospitals to adopt electronic health records should help. But the hoped-for benefits of digital health records ...will not really materialize unless information flows seamlessly and securely among labs, clinics, hospitals, doctors’ offices and patients. General Electric’s big health care division is introducing on Thursday a new unit, eHealth, to pursue the business opportunity presented by this challenge. The main target for G.E.’s new business unit is in providing the technology and expertise to build regional and statewide Health Information Exchanges [HIEs], as these planned data-sharing hubs are now being called. An initial $564 million grant from federal government to the states will provide seed money to get things started. Over the last two decades, there have been efforts to set up such health information-sharing networks. They were first called Community Health Information Networks and later Regional Health Information Organizations. Mostly, they failed. Hospitals and physician groups had no incentive to make the investment to share patient information, since they were not paid for doing so. But to qualify for incentive payments from the government, doctors and hospitals need to adopt electronic health records that share information across networks....G.E. said it was investing $90 million to get the new eHealth unit going. Its offerings include software for securely storing and sharing patient information, a Web portal that can pull patient information from various sources and present it to doctor, and a Web-based personal health record, called LifeSensor. It was built by a G.E. partner, InterComponentWare. So is G.E. going head-to-head in the emerging field of personal health records — controlled by individuals, not a doctor, hospital or insurer — with the likes of Google and Microsoft?

I do take issue with the statement above that hospitals lacked an incentive to share patient information and paying them for doing so will provide sufficient motivation. My view has always been that hospital executives view patient information as proprietary and providing some small payment for them to pursue a connectivity goal will be insufficient. The problem is that they will never state their true objection but rather moan about the complexity of medical information and the challenges of clinical data exchange. Incidentally, hospitals have had no problem sharing financial information because this is how they are reimbursed (see: CCHIT Certification and "Meaningful Use" of EMRs).

I have covered both the Microsoft and Google forays into the PHR development and, of late, Google's partial withdrawal from this field. I have come to the personal conclusion that the Google executives have decided either that they have bigger fish to fry (e.g., the cell phone market with Android) and/or the healthcare market poses too many risks and too little profit for a technically innovative and adroit company (see: Google Health Running Out of Steam, According to Experts). For Microsoft, working several years behind the curve and having power lunches with hospital executives probably feels just about right (see: Microsoft's Cell Phone Operating System Lacks Key Functionality). I suspect that G.E. decided to hold its nose and jump into the HIE fray. After all, McKesson, a serious competitor, has had success linking physician offices and office EMRs with its RelayHealth product (see: Developing an Electronic Medical Record Ecosystem (Network).

Another Saga of "Blame the Vendor" Leaks Out of the UK

Bruce Friedman — 2009-10-29T08:25:43-04:00

There are days when I am sure that Neal Patterson, CEO of Cerner, regrets the little pas de deux that his company has been engaged in with the British government and its NHS for years. Mr. HIStalk alerts us to another chapter to this continuing saga with its "blame the EMR vendor" theme:

Speaking of Cerner, St. Bartholomew’s Hospital in London faces fines of $650,000 per month for lengthy patient backlogs that it blames on the “dreadful” Cerner Millennium. I doubt it’s that simple, but blaming the computer is always convenient.

Here's an excerpt from the source (see: Barts faces fine over IT failures):

St Bartholomew’s Hospital in London faces being fined £400,000 a month for missing patient care targets as a result of the troubled NHS IT programme....Tory MP Richard Bacon, a member of the Commons public accounts committee, which scrutinises public spending, said the £12.7bn NHS IT programme had led to Barts developing a backlog of thousands of patients waiting for treatment....He said the Cerner Millennium system had caused “havoc” wherever it had been deployed in the NHS. The hospital was failing to meet a Department of Health target that no one should wait more than 18 weeks to receive hospital treatment from the time they are referred by a GP.

I have covered the issue of "blame the vendor" in a previous notes (see: Do Hospital Executives Use Their IT Vendors as Scapegoats?). My guess is that there's plenty of blame to go around with the NHS' EMR program and that their electronic medical record problems are multifactorial (see: NHS Computer Czar "Outed" by his Mum). I also believe that any large-scale IT project mounted by the NHS will inevitably end in chaos, with or without Millennium in the mix. You have a mixture of a creaking government bureaucracy, hospital personnel who may not be motivated to put in a day's work, and a host of grand-standing politicians playing to the crowd. Did you note the name of the Tory MP quoted above -- it's BACON. From what I know about the usual wait for hospital admission in the U.K., 18 weeks seems like good performance. Comparable in some ways to Canada (see: The Fundamental Flaws in the Canadian Healthcare Delivery System). Does everyone understand the irony of the British government fining a hospital $650,000 per month that it itself owns and manages. The government hospital executives will surely ask for a larger operating budget to cover their recurring fines? Another alternative is to withhold payments to Cerner. Blame the vendor.

Are You a Primary Care Pathologist, Asks Dr. Henderson

Bruce Friedman — 2009-10-28T09:03:00-04:00

A new pathology blogger has appeared on the scene -- Dr. Gregory Henderson. He calls himself a primary care pathologist and his first blog note is about this very topic (see: You Might Be A Primary Care Pathologist). Here are the criteria he lists to determine whether one falls into this category:

If you have ever taken phone calls from patients to help explain their diagnosis, you might be a primary care pathologist.
If you have ever scrubbed into a surgical procedure to help the surgeon identify key areas to sample for frozen section, you might be a primary care pathologist.
If you have ever manned a booth at a community health fair that educates women about Pap and HPV testing, you might be a primary care pathologist.
If you have spent an enormous time over the past 3 months helping your hospital prepare for the impending H1N1 epidemic, you might be a primary care pathologist.
If you look around your lunch table most days and see physicians of other specialties and no other pathologists, you might be a primary care pathologist.
If your pattern of practice looks anything like any of the pathologists on this CAP website, you might be a primary care pathologist.

I need to confess that my first reaction, on reading his inaugural note, was to flinch a bit. After all, the notion of "primary-care-anything" seems to be quickly losing its luster in our rush to become uber-specialists, particularly those who can bill for a procedure. However, and after reading his list, I have changed my mind. There is a tendency for one's first blog note to focus on a topic that one really cares about. It goes to the nature of this obsession -- the need to communicate one's ideas on a broader scale. There is the ring of authenticity and sincerity about his list that any pathologist will be proud of. I wish him the best of luck in his future blogging career. I am sure that he will provide us all with better insights into the valuable services that individuals like him provide to their communities. Oh, and the fact that Dr. Henderson refers to Lab Soft News on his home page as one of his favorite blogs had no influence on these remarks.

Microsoft's Cell Phone Operating System Lacks Key Functionality

Bruce Friedman — 2009-10-27T08:10:22-04:00

If I say PC and operating system, some of you will probably respond associatively: Windows and Microsoft. If I say cell phone and operating system, most of you will probably stare at me. That's really not a problem. The critical differentiating feature for cell phone operating systems is not it's name but rather what it can do for you. In previous notes, I have presented the idea that the smartphone is the next PC and will have great relevance for healthcare, pathology, and lab medicine. What users should now be looking for in their cell phones is nearly the same, or better, functionality than their PC.

My Palm Pre browses the web so efficiently that I can read email and search the web without any sense of being inconvenienced. Despite its best efforts and having been in the cell phone OS business for a long time, Microsoft still can't seem to get this right. Some of the details were revealed in a NYT review of a Windows Mobile phone (see: Another Try for a Windows Phone, but It’s Still Clunky). Below is an excerpt from the article:

If you’ve never heard of a Windows Mobile phone, or never particularly cared what kind of software runs on your phone, prepare yourself. In the coming months, Microsoft will release a steady drumbeat of ads intended to make you want a device powered by its software....Windows phones have been around for years, mostly competing with BlackBerrys for the allegiance of business users. But while BlackBerry crossed over into the consumer realm with more user-friendly phones, Windows Mobile remained in its corporate cube, because of devices that could be so frustrating to use that few people would choose one without a corporate mandate....For much of the last year, Microsoft has been saying that its new mobile software upgrade would significantly simplify the user experience. And the upgrade does simplify things, but not much. Instead of poking around with a stylus, Windows now features icons that are big enough to hit with your fingertip. That helps you navigate the phone’s software menu and interact with various programs, but when it comes to the one application smartphone owners use the most — Web browsing — it falls far short....But unlike the iPhone or the Palm Pre, a Windows phone still lacks a multitouch screen, so you can’t pinch and pull the display to a chosen size. Instead, you press buttons and sliders in a scheme that sorely lacks precision....Likewise, instead of simply connecting you to a free Wi-Fi hot spot, Windows forces you into a three-step decision tree that would make a technician’s heart sing, but would strike fear into the heart of just about anyone else who just wants to log on.

There's a lot that's wonderful about the current crop of smartphones. Although I am very fond of my Pre cell phone from Palm, I recently purchased an iPod touch, which is an MP3 player that lacks cell phone capabilities. However, it can connect to the internet effortlessly using W-Fi so I can still place VOIP calls anywhere in the world using a Skype application that I have downloaded and installed. It is quite a remarkable device.

For me, the greatest feature of my Pre is being able to effortlessly surf the web with the essential enabling element being hand-gestures such a "pinch" or "pull" interpreted by the device's touch screen as a zoom-in and zoom-out. Similarly with the Pre, I can change applications, still keeping all of them resident, with a finger-sweeping gesture on the screen to the right or left. The review of Windows Mobile above provides further evidence for me that Microsoft is still wandering in the wilderness. Fortunately for us, there are cell phone OS developers who understand the web and the need on the part of users for a friendly user interface in order to surf it.

American Academy of Family Physicians Cozies Up to Coke

Bruce Friedman — 2009-10-26T08:40:28-04:00

I sometimes think that many prestigious U.S. organizations have badly lost their way recently. Another possibility is that it's business as usual for all of them and the web provides us with insights into business deals previously gone unnoticed. Here's only one example. A major factor into our obesity epidemic is the sugar-loaded soft drinks. Our politicians are so concerned about this that they want to tax the sugar beverages to restrict usage and, uh, generate new tax revenue (see: Federal Tax on Soda Pop Proposed: Can This Be Justified?). We now learn that one professional physician society has established a tight (i.e., six-figure) relationship with Coke in order to provide "nutritional" information on its web site. Here's the news (see: Looking for health advice? Dr. Coca-Cola will see you now):

When the American Academy of Family Physicians [AAFP] announced it had received a substantial grant to enhance educational information about nutrition on its FamilyDoctor.org site, you’d think health experts would have been happy. But the money was earmarked to focus on the role of beverages and sweeteners in a healthy diet. And it came from the world’s largest beverage maker, the Coca-Cola Co....“We urge the AAFP to regain its credibility by rejecting the deal with Coca-Cola,” [a recent letter from physician critics] stated. “If the AAFP declines to do that, we urge your organization to reassert its support for the public health (and its own independence) by supporting a warning label on caloric sugar-sweetened beverages and a federal tax on soft drinks to support health promotion or health insurance programs.” The letter noted that soda is “the only food or beverage that has been demonstrated to promote overweight and obesity.” ...But the signatories warned that the six-figure grant from Coca-Cola will prevent the doctors group from “criticizing sugar-sweetened beverages in the strongest language.”....In 2003, the American Academy of Pediatric Dentists took a $1 million payment from Coca-Cola. Before the payment, the dentists' group acknowledged the connection between sugary drinks and dental disease. But after the payment, the president of the AAPD told reporters that the ‘scientific evidence is certainly not clear’ on the role soft drinks play.

I think that there is a need to try to explain how a professional physician society could accept a grant from a company such as Coca-Cola. Surely every physician member in the group would immediately understand that this was a big mistake. I suspect that the short answer is money but this response begs for a more in-depth explanation. Here's one for your consideration. Physician professional societies have two major sources of income. The first is membership dues but this does not amount to serious money. Dues are intentionally set low to encourage greater membership. The second source of revenue are the meetings sponsored by the society. Unfortunately, the net revenue generated by medical conferences is headed south. This is a result of the feeble economy and also a more punitive environment regarding conference sponsorship, particularly regarding various types of payments from pharmaceutical companies.

But wait! Why would physician professional societies need a robust revenue stream? The physician leaders of societies work on an unpaid basis. Well, partly to offset the losses from their print medical journals, which are dinosaurs and will soon disappear, and also to develop their web sites devoted to healthy living and good nutrition. Also keep in mind that many such societies, particularly the largest, have hired executive directors who have salaries in the high six figures and a large cadre of well-paid staff members. As a result, the leaders of such societies are increasingly on the hunt for companies that are willing to write big checks for the endorsement of some of their (frequently) unhealthy or unnecessary products. Hence the embarrassing news about the AAFP noted above.

Health Promotion Goes Mainstream at NBC-Universal

Bruce Friedman — 2009-10-23T09:21:18-04:00

I, like many other people, am concerned about the toll that the chronic disease epidemic, including problems such as diabetes, is taking on the U.S. population (see: Seeking Solutions to the Chronic Disease Epidemic). Furthermore, I am convinced that many of the complications and side-effects of these chronic diseases could be avoided if people took better care of themselves. Needless to say, a similar case can be made for the so-called "lifestyle" diseases. So, what is the best way to raise the consciousness of the majority of Americans about these issues? A recent note in the WSJ Health Blog gave me an idea (see: GE Continues Health Push — By Selling Ads). Below is an excerpt from it:

Earlier this year, GE’s CEO made a big speech about how the company planned to expand its health care business. We figured that meant selling more electronic health records systems, CT scanners and the like. Turns out, it also means selling health-themed ads on NBC, the TV network owned by GE. NBC Universal said last week that it was launching something called “Healthy at NBCU” as a companion to GE’s company-wide “healthy imagination initiative.” As part of the program, Campbell Soup will pay to sponsor two health series on the TODAY show, where the company will run ads for its “heart healthy” soups. Ad sales are down for lots of media companies, but advertisers are still willing to pay to tie themselves to a cause, like the environment — or healthy living. Advertiser spending on cause sponsorships in the U.S. is expected to rise slightly to $1.57 billion this year, this morning’s WSJ reports. NBCU has already made similar pushes to bring in marketing from companies who want to tie themselves to environmental causes and women’s issues. Since the end of 2007 the company has brought in incremental revenue “heading toward” $100 million from its health, environment and women’s packages, on top of what it gets from selling regular ads, according to the WSJ.

I now believe that probably the best way to effectively educate the majority of Americans about healthy living is through the main-stream media such as NBC-Universal. If corporations are enthusiastic about sponsoring health-themed TV series, I am all for the idea. If we can educate the population while improving sponsor recognition, so be it. I recently watched one of the celebrity physicians, Mehmet Oz, on his TV show, scrub suit and all. He is both charismatic and a believable spokesperson. His answers to health questions were short, to the point, and accurate. He is also very popular, I am sure, with women, who have much more of an interest in personal health issues than men.

FDA Convenes Advisory Committee to Discuss Whole Slide Imaging

Bruce Friedman — 2009-10-22T08:59:20-04:00

The FDA's Hematology and Pathology Devices Advisory Committee will be convening today and tomorrow to discuss discuss, and make recommendations, about what they describe as "public health issues" related to the use of digital whole slide imaging (WSI) systems that are now being used to replace conventional light microscopy for diagnostic surgical pathology. The meeting will be open to the public. Within the scope of this meeting, digital pathology is defined as the conversion of images that can be observed by conventional light microscopy on histologic glass slides into digital whole slide images via digital scanners. These latter images are then viewed with a computer monitor to render pathologic diagnosis of the lesion of interest. Finally, this process involves digitally archiving and retrieving these images for access at some later time. The committee will not be discussing computer-assisted image analysis or remote real-time microscopy at this time.

The FDA background briefing for this meeting as a PDF file and downloaded from the FDA web site makes interesting reading for those interested in digital pathology. Below is more detail extracted from this briefing paper about what the FDA hopes to achieve by this meeting. Obviously, the major thrust will be the establishment of a set of principles for evaluating the accuracy and reproducibility of pathologists using this tool including both objective and subjective perspectives.

FDA hopes to gather information about how to evaluate and compare the performance characteristics of both the light microscope‐the reference method‐‐and the digital WSI method. As background for the panel discussions, there will be presentations to cover the principles of light microscopy and the possible criteria and studies for analyzing the accuracy and reproducibility of the diagnostic performance of pathologists using the light microscope for examination of human tissue specimens, the principles of digital WSI, and the criteria and studies for the evaluation of the diagnostic accuracy and reproducibility of pathologists using digital WI for examination of human tissue specimens. There will be a discussion of the objective and subjective aspects of reading direct images from a microscope and from a digital screen.

Some Laboratory Managers Getting Carried Away by Lean/Six Sigma Projects

Bruce Friedman — 2009-10-21T08:34:10-04:00

Don't get me wrong. I am just as enthused as the next person about correcting lab errors and work product defects. The bone that I have to pick with some of the Lean/Six Sigma experts is that this approach to lab management seems to becoming the answer to all lab problems. Some aspects of Lean/Six Sigma have always seemed to me to be vaguely ominous -- turning lab professionals into automatons who paste tape outlines on benches so that the scotch tape dispenser does not wander around the lab. All of my concerns came to the surface when I read a recent article in the Wall Street Journal (see: How Labor Is Liberated). Here is the excerpt from the article that caught my eye:

"Jean-François Zobrist ...captured his leadership philosophy with a distinction. There are, he said, two kinds of companies: 'Comment' in French, or 'how' companies, and 'pourquoi,' or 'why' companies. 'How' companies spend their time telling workers how to do their jobs—where to place the machinery, when to come to work and when to leave, and so on.The second is that it becomes difficult, if not impossible, to change any of the myriad rules about how to get things done. You want to move that cart to a different spot on the shop floor? You need clearance from your manager, who may have to ask his manager, and so on, creating a never-ending 'chain of comment.' The result, as Zobrist put it, is that it becomes impossible to get the work done without disobeying somebody in the chain of command. A pourquoi company is different. It replaces all the myriad 'hows' with a single question: Why are you doing what you're doing? The answer is always the same: to keep the customers happy. As long as what you do satisfies that commandment, Zobrist doesn't worry about how you do it. Freedom at FAVI meant replacing the chain of comment with a single pourquoi." This has two consequences. The first is that you end up judging employees by everything except what counts, which is whether the job gets done and the customer is happy.

So, for me, lab personnel who spend most of their time worrying about "how" or "comment" questions may be too involved with improving daily work processes and perhaps avoiding some of the more challenging "why" or "pourquoi" questions. I am sure that lab executives who specialize in Lean/Six Sigma can readily point to customer feedback to buttress their claims that they are pursuing goals that please their customers. For a change of pace, however, how about responding to this question: Is your laboratory sufficiently innovative in addressing the questions of tomorrow that many clients may not even be asking about? In order to begin to explore some of these strategic "why" questions, it might help to begin with consideration of the four rapidly developing fields that I think will pose the greatest challenges for labs in the upcoming years: (1) molecular diagnostics; (2) information technology; (3) digital pathology; and (4) ultra-fast histology processing. Here's another "why" question. Is your lab a regional or national leader in these four areas?

Health Insurers Emerge as Major Foes of Healthcare Reform

Bruce Friedman — 2009-10-20T09:35:14-04:00

Both Big Pharma and the hospital industry stand to profit greatly from healthcare reform. New customers for drugs and services will undoubtedly emerge from this legislation. So who will be getting the short end of the stick? It turns out that this may be the health insurance companies that will now face unwanted competition, perhaps in the form of a public insurance option. They may also be forced to insure some customers whom they would have rejected in the past, thus reducing their profits. Did someone say competition? That's unfair! This is America. Here are some of the details from a recent article in the Washington Post (see: Health Insurers Emerge as Obama's Top Foe in Reform Effort):

For months, President Obama and his administration waged their fight for a health-care overhaul without a clear opponent, even courting the industry executives and interest groups that helped kill reform efforts 15 years ago. But attacks on the leading Democratic reform plan this week by the insurance lobby left little doubt that two of the most powerful institutions involved in the debate -- the White House and the nation's insurance companies -- have abandoned any real hope of forging a compromise. What was a tenuous truce has turned quickly into an all-out battle, with both sides ratcheting up the hostilities...."The insurance industry has decided to lead the charge against health reform, and everyone recognizes their motives: profits," said White House deputy communications director Dan Pfeiffer. "We are going to make sure they can't sink this effort at the last minute."...The insurers, however, showed no sign of being chastened. America's Health Insurance Plans, an industry trade group, opened a fresh line of attack with a multistate advertising campaign warning that senior citizens enrolled in private Medicare plans could lose benefits under the legislation...."We want to begin to build an awareness of the potential implications to seniors," said AHIP President Karen Ignagni. She declined to say how much money would be spent on the commercials airing in six states, but one advertising analyst said the industry has enough cash to pose a serious threat....The insurance sector and health maintenance organizations spent more than $116 million on lobbying in the first six months of this year, according to an analysis by the nonpartisan Center for Responsive Politics.

So stay tuned to see who triumphs in this quest for meaningful reform of our healthcare system. To add some spice to the conversation, we now have an estimate of the amount of money being spent on political lobbying by the health insurance and HMO organizations during the first six months of this year -- $116 million dollars. I really have no idea what the final product from Congress will look like but continue to hope for the best. In a previous note, I was very pessimistic about any sort of change (see: American Attitude toward Reform Through the Eyes of David Brooks). Here a quote from it:

I would personally like to see some fundamental changes in our healthcare system, particularly modifications of the current fee-for-service approach that rewards unnecessary and inappropriate procedures. Such an approach is wasteful and can also harm patients. I now don't believe that such a change is going to happen. There's just too much money flowing into lobbying efforts from special interest groups representing insurance companies, big pharma, hospitals, and physicians to maintain the status quo.

Physicians Using an iPhone Application to Triage Their Patients

Bruce Friedman — 2009-10-19T09:24:53-04:00

John Moore, who blogs over at Chilmark Research has discovered an iPhone application that reinforces my belief that smartphones may soon rival the stethoscope as an essential healthcare delivery tool (see: iTriage: A Business Model Gaining Traction). iTriage assists physicians in referring their office patients to regional hospital emergency rooms when necessary. I have posted previous notes about the myriad healthcare applications that can potentially be deployed on smartphones and this is certainly a good example of the potential of these devices. Below is an excerpt from his note:

iTriage is a slick iPhone app.... Since its launch in April 2009, iTriage has maintained an enviable position as one of the top downloaded apps in the iPhone AppStore, currently in the top 10% of all apps downloaded....The parent company’s (Healthagen) business model is to solicit providers, mostly large integrated delivery networks (IDNs) to become premier sponsors who pay an annual subscription fee...to Healthagen to have their facility listed along with some brief marketing content, including the ability to upload videos, as to why one would want to go to their facility (typically ER) versus others. Thus, Healthagen is tapping into the marketing budgets of IDNs....On October 5th, HCA announced that they would become a premier sponsor as well for their facilities in South Florida. What is particularly cool about this announcement is that in addition to the standard promotional marketing content that one may find in iTriage on a given HCA facility, HCA will also be providing real-time information on expected wait-times in ER, right there in the palm of your hand on your iPhone and in a recent upgrade of the software, a Blackberry as well. (In November, they’ll release versions for Android and PalmPre.) This is all part of a larger push by HCA, which includes posting wait-times on billboards in this region to drive consumers seeking medical attention to their facilities as a significant percentage of those admitted to ER wind up being admitted for more extensive care.

I am not surprised that the executives at HCA immediately understood the value of iTriage for their hospitals. What a clever way to market their emergency departments to community physicians! Adding expected wait-times will provide added valuable information for healthcare consumers who download the application. I pointed out in a previous note how emergency departments are an important portal for inpatient admissions to hospitals (see: Hospital Admission of Patients with Chronic Disease from the Emergency Department). Here is a quote from that note:

In 2005-2006, hospital admissions through EDs accounted for approximately 60% of acute care hospitalizations in Canada (excluding hospitalizations in Quebec and those among women admitted for childbirth and infants born in hospital). These patients accounted for 65% of in-patient days, 11% of which were alternate level of care (ALC) days.

We have only scratched the surface of smartphone applications that are directed to both physicians and healthcare consumers. For example, it would be relatively easy to adapt content currently on the web concerning the interpretation of lab tests for smartphones (see: The Mobile Web and the Future of eHealth). Here is a quote from this blog note:

...[I]t's now time, in my opinion, to begin to adapt [the content of] consumer-oriented web sites about the significance and interpretation of lab tests to the mobile web. One good example of such a site is Lab Tests Online. Such modification would allow, for example, patients who have just completed a physician visit to use their cell phones to query [their smartphones to] obtain a better understanding of their test results.

Storing Cell Phone Data in the Cloud Can Be Risky

Bruce Friedman — 2009-10-16T08:55:46-04:00

It will come as no surprise to IT enthusiasts that storing their data in "the cloud" does present some risks. A problem associated with the Sidekick smartphone was highlighted in a recent article (see: T-Mobile: Missing Sidekick data "almost certainly has been lost"). Below is an excerpt from it:

The Sidekick was one of the first phones to keep all your e-mail, contacts, events, and photos in an online "cloud"; cool, right? But in the wake of a critical server outage more than a week ago, frustrated Sidekick users are learning the hard way that when things go wrong, cloud computing isn't all it's cracked up to be. In what's shaping up to be one of the worst tech train wrecks of 2009, T-Mobile and Microsoft (owner of Sidekick developer Danger) admitted Saturday that any contact, events, or to-do lists that haven't already been restored following a massive server meltdown earlier this month are probably gone forever....Meanwhile, it's still not clear what caused the server outage—which left Sidekick users without any data access at all for days on end—in the first place (although there are some theories floating around)....T-Mobile has already told Sidekick users that it will give them a month's worth of data for free in the wake of the outage, and the carrier also posted a F.A.Q. on how to restore your Sidekick contacts from vCard files, Outlook, or a SIM card. But many Sidekick users looked to be out of luck Monday, with who-knows-how-many contacts, calendar events, to-dos, and e-mails vanishing into the ether. Indeed, more than a few angry users on T-Mobile's message boards were already grumbling about lawsuits. In the end, though, nothing (short of a miracle on T-Mobile and/or Microsoft's part) will bring the lost data back, and that brings us to the moral of the story: Backup your data, especially the stuff that's floating up in a cloud somewhere....That's especially important when it comes to free, in-the-cloud e-mail account like Gmail and Yahoo! Mail—both have methods for quickly exporting all your contacts and events to a local file....

Here is an update on this story in the form of an excerpt of a letter posted on the T-Mobile web site from Ros Ho of Microsoft (see: Microsoft Confirms Data Recovery for Sidekick Users):

On behalf of Microsoft, I want to apologize for the recent problems with the Sidekick service and give you an update on the steps we have taken to resolve these problems. We are pleased to report that we have recovered most, if not all, customer data for those Sidekick customers whose data was affected by the recent outage. We plan to begin restoring users’ personal data as soon as possible, starting with personal contacts, after we have validated the data and our restoration plan. We will then continue to work around the clock to restore data to all affected users, including calendar, notes, tasks, photographs and high scores, as quickly as possible.

So, from all of this we learn that the servers in the cloud are fallible. A good rule-of-thumb is to always backup your data no matter where it is stored. At first blush, such a strategy may seem impractical when radiology or pathology PACS image files are stored in the cloud because the reason for utilizing cloud storage in the first place is because of insufficient data storage capacity locally. Well, the obvious answer to this question is to contract for both primary and less expensive secondary storage in the cloud (see: Does cloud storage need backup?). If there is a failure at either point, file restoration is possible. I have no advice if there is failure at both points.

My thanks to Robert Michelle of the Dark Report and Dark Daily for suggesting this topic to me.

Differences Increasingly Blurred Between PCs and Smartphones

Bruce Friedman — 2009-10-15T08:31:52-04:00

Smartphones are rapidly becoming the new PCs (see: Smartphones as the New PCs; Connecting to Healthcare Professionals and Consumers). This trend is now accelerating, if the rumor mill is correct that Dell, historically one of the major PC manufacturers, may bring a version of the Android smartphone to market with AT&T (see: Dell May Bring Android Smartphones To AT&T). Below is an excerpt from this article:

The lines between smartphones and laptops are increasingly blurring as hardware and mobile data networks rapidly improve, analyst says. Dell may be successful in its foray into the U.S. smartphone market if it manages expectations, but it may have difficulties standing out from the crowd, according to an industry analyst. The computer maker is reportedly close to announcing a deal to bring Android-powered smartphones to AT&T. This comes after years of speculation that it would enter the mobile space, and a few months after it unveiled Android-powered smartphones for China Mobile. AT&T and Dell have not confirmed the report....Computer makers such as Acer have already taken the smartphone plunge, while Nokia, the world's leading handset maker, recently introduced a 3G netbook....[An analyst] said Dell's first handset will not outsell Apple's iPhone, but could potentially match the sales of the Palm Pre, which analysts estimate has sold more than 700,000 units since its summer release. The first Dell smartphone will reportedly be an upgraded version of the Mini 3i smartphone that will hit China soon. It features a large touchscreen with an iPhone-like user interface....The computer maker has a recognized brand name and strong direct-to-consumer sales channels that may woo mid-tier smartphone buyers.... It also should not be difficult for Dell to create or outsource the design of an attractive Android-based handset. Additionally, Dell may not want to compete against the BlackBerry in the corporate realm because Android is not yet enterprise-friendly, although that is expected to change with future software updates.

The interest on the part of Dell in the smartphone market is additional evidence that these devices are rapidly becoming the new PCs. Partnering with Google, the developer of the Android smartphone operating system, also makes sense. I am not surprised at the statement above that "Android is not yet enterprise-friendly." The Google approach to software has always been to release early versions and then improve it based on the input from users and experience in the field. Probably only Google could get away with such a strategy because of its strong relationship with the user-community and the fact that most Google products have generally been free. Dell's well known strength is its understanding of the needs of corporate users and, as noted above, its target of mid-tier buyers. This is in sharp contrast to Apple and its iPhone with its appeal to the hip twenty-somethings who are willing to pay a premium price for Apple products. The problem for Dell with such a strategy, also as noted above, is that both BlackBerry and the Palm Pre are strong players in this same space.

But We Already Have Mammologists -- Physicians Staffing Our Numerous Breast Clinics

Bruce Friedman — 2009-10-14T09:43:47-04:00

In a recent op-ed piece in the New York Times, the authors lamented about the fact that we do not have enough medical specialists focusing on diseases of the breast, referring to such specialists as mammologists. This void, according to the authors, results in diagnosis delays and more severe bouts with the disease for women with the disease (see: Wanted: Mammologists). Below is an excerpt from it:

Delayed diagnosis of breast cancer — measured from the first health care consultation for a breast complaint to a diagnosis of cancer — is the most common and the second most costly medical claim against American doctors. Moreover, the length of delays in breast cancer diagnosis in cases that lead to malpractice litigation has been increasing in recent years. According to a study by the Physician Insurers Association of America, in 1990 the average delay was 12.7 months; in 1995 it was 14 months. The most recent data, from 2002, showed the average delay had risen to 16.3 months. Why are there such long delays, even for women who get regular examinations? The insurers association identifies five causes: a misreading of the mammogram, a false negative mammogram, findings that fail to impress the doctor, the doctor’s failure to refer the patient to a specialist and poor communication between providers. Four of these five are preventable human errors (a false negative mammogram is a machine failure) and two — failure to make a referral and poor communication — are products of the way we organize health care. The breast is something of an orphan in our health care system. We have cardiologists, nephrologists, hepatologists, proctologists and neurologists — but we have no “mammologists.” How did the breast get lost?

I have been a strong advocate in Lab Soft News of integrated diagnostic centers (IDCs) in which clinicians, radiologists, and pathologists would work collaboratively to diagnose patients referred to the center. I have suggested that these clinics would have multiple advantages over our current approach to diagnosis, describing such advantages in a shorthand fashion as faster, better, and quicker. These benefits flow from having a multi-disciplinary diagnostic team under one roof. In effect, such a center serves to minimize or reduce the causes of error cited in the article above.

In order to jump-start the development of IDCs, I have advocated that the numerous and highly successful breast clinics currently scattered around the country be converted to "integrated diagnostic centers" focusing on breast disease by adding pathologists to the radiologists who currently comprise the majority of physicians staffing of such clinics. Considering these breast clinics and in response to the op-ed piece above, it can thus be claimed that we already have a large cadre of diagnostic mammologists delivering care in this country. They are the radiologists working in these breast clinics and the pathologists who specialize in diseases of the breast. I suggest here that surgical pathologists be more tightly integrated into the existing breast clinics. In so doing, we can shorten the "time-to-diagnosis" of breast masses to several days in most cases.

This very concept has been promoted by Dr. Ron Weinstein and colleagues (Virtual slide telepathology enables an innovative telehealth rapid breast care clinic). Ron is one of the fathers of telepathology and telemedicine in this country. Although his telepathology model is certainly a viable one, I recommend that pathologists work on-site in the busiest of the IDCs. The op-ed piece above did alert me to one issue that I have neglected in my previous discussions about integrated breast diagnostic centers. These is a need for medical specialists working in them who are capable of performing biopsies in order to pursue the very rapid diagnosis that should be one of the primary goals of these facilities.

Reaction to Note on Flaws in the Canadian Healthcare Delivery System

Bruce Friedman — 2009-10-13T09:22:17-04:00

In a recent note, I discussed some flaws in the Canadian healthcare delivery system and how it possibly could be reformed (see: The Fundamental Flaws in the Canadian Healthcare Delivery System), quoting the work of Nadeem Esmail, an economist from the Fraser Institute. The piece has stimulated two Canadian physician readers to submit comments, which I now elevate to the level of this note:

(Dr. EM) [Nadeem Esmail] removed data from some OECD slides to enhance his point: the country with the largest %GDP health spending is the USA -- by far. In 2003, USA= 16%GDP, Canada= 10%. Other than that, the overall message is correct. In particular, Canadian doctors are truly more pessimistic than other doctors, as shown here. His solution is good, rational and should be well accepted by hospital admins, doctors and patients alike. But it will not happen, because Canadian politicians handle health care (35% of all public expenditure) like a sleeping dragon: action only if absolutely necessary. Unlike Obama, we in Canada hope there's no change
(Dr. Murray Treloar) As a Canadian doc, I can say that these comments resonate. However, it must be recognized that the Fraser Institute is a conservative (read Republican) 'think tank' and can be relied on for right-leaning analyses. What the US and Canada need is evidence based debate, not ideological ramblings. Neither system is sustainable.

I did state in my first bullet point that Nadeem had stated unequivocally during his presentation that he was only comparing those OECD countries that offer universal health coverage in his comparison slides. No one disputes the fact that the U.S. spends more per capita on healthcare as a percentage of the GDP than the U.S. I also suspect that, on average, U.S. physicians work many more hours per week than the physicians in other countries so that the hourly compensation for some may not actually be that different than their peers. For those U.S. physicians who perform procedures, I am sure that their income dwarfs that of comparable physicians in other countries.

I must admit that I did not know anything about the political orientation of the the Fraser Institute when I posted the note. I did have the distinct impression that Nadeem was not a staunch liberal because of his willingness to criticize Canada's universal health system. However, I think that it will be more productive to discuss healthcare reform from the perspective of incentives rather than political labels. Here are some examples what I consider to be major flaws in the current U.S. healthcare delivery system in terms of incentives:

Physicians have an incentive to provide too many procedures because they are rewarded financially on this basis rather than on treatment effectiveness.
Healthcare consumers with insurance have an incentive to consume far too many services because they do not pay out-of-pocket for them. They also have few incentives to take better care of themselves.
Health insurance executives have an incentive to demand ever-increasing compensation, including lucrative stock options, while minimizing costs by cherry-picking customers and denying claims to existing clients on the basis of preexisting conditions.
Health insurance executives have few incentives to simplify their billing procedures in order to lower administrative costs and, in fact, have an incentive to make them more complicated as a basis for denying claims on technicalities.
Health system executives have an incentive to take advantage of their non-profit status by allocating only a small portion of their budgets to uncompensated care while simultaneously expanding their facilities to compete with regional competitors.

Forbes.com Puts Some Numbers to the Epic Systems Success Story

Bruce Friedman — 2009-10-12T08:20:29-04:00

I have a special and continuing interest in the corporate culture of Epic Systems, one of the most successful hospital EMR companies. Because its founder and CEO, Judith Faulkner, does not allow interviews and the company is privately held, hard facts about it can be hard to acquire. However, a recent story in Forbes.com about Epic (see; Wired Medicine's Silent Giant) provides much new information and analysis, all of which rings true to me. Below is an excerpt from it:

...[T]he hottest company in the electronic medical records industry is a secretive Wisconsin outfit called Epic Systems. It does little marketing or advertising, shuns acquisitions, never issues press releases and tries to stay out of the headlines....Yet with a reputation for customer service and software that is more user-friendly than most, Epic has snagged contracts with famous places like the Cleveland Clinic and University of Chicago Medical Center, the big HMO Kaiser Permanente and Group Health Cooperative in Seattle. Epic has recently been winning about 40% of the new contracts for electronic records systems at major hospitals--far ahead of its competitors....In 2008, Epic won 24 big-hospital contracts, versus 12 for McKesson ... and 10 for Siemens....A contract to install medical records software at a 400-bed hospital might be worth $20 to $30 million over several years....Epic had $600 million in revenue last year, up from $500 million in 2007. It does not disclose its profits. The company focuses exclusively on larger hospitals and health systems--it has just 180 customers--allowing it to get business by word of mouth without much marketing....Computer programmer Judith Faulkner founded Epic in 1979 with three part-time employees and is still chief executive....[S]he is known for her liberal politics and buying quirky artwork for headquarters, according to local newspaper reports....Epic has a reputation for relatively high prices and high levels of service to ensure software is installed on time with as few snafus as possible...The fact that Epic is private is also viewed as an advantage by some hospitals....Installing medical records can take a year or more, and hospitals don't want a vendor that will be distracted every three months with earnings reports. Drexel University medical computing expert Scot Silverstein is a harsh critic of most medical records systems, which he says are confusing, glitch-prone and hard to use. But he gives Epic some grudging respect. "It is not terrible. Epic has the advantage of having been around for a long time, and they have been steadily improving the quality of their product. It is much simpler in its appearance to end users than some of the competing products. The user is not presented with a massively complex set of screens." ....Epic, of course, was unavailable for comment [on this article].

I found it interesting that Epic's privately-held status is put forth in the article as an advantage by health system clients because the company does not need to "dress up' quarterly earnings or court financial analysts. It would be more worrisome for me, as in the case of Kaiser Permanente, to have spent a king's ransom ("The Kaiser project will cost $4.2 billion by the time the final updates are completed in 2013.") on an EMR provided by a company micro-managed on a daily basis by a single individual. Perhaps plans have been made for Judith Faulkner's succession and the hospitals hold the system source code to ostensibly protect their institutions, but I very much doubt it.

For me, here's one of the paradoxes of the Epic success story. As noted above, Epic only sells to large health systems. These, of course, are the very organizations with the largest numbers of talented IT professionals. One of the secrets of the Epic success is that the company has a "take it or leave it" approach to its software products. In other words, the company does not allow local hospital IT personnel to modify the product -- only install and maintain it. The result of this arrangement is a "not terrible" EMR product, referred to by me in a previous note in a more charitable way as vanilla (see: Some Additional Insights into the Epic Corporate Culture). There are probably few other segments of the global IT industry where the most successful company in an industry would provide a product requiring a multi-billion dollar investment that is described as "not terrible."

The Fundamental Flaws in the Canadian Healthcare Delivery System

Bruce Friedman — 2009-10-09T08:36:10-04:00

I recently attended the Executive Edge conference in Toronto that focused on various aspects of clinical lab management in Canada. For me, one of the most impressive lectures was delivered by Nadeem Esmail, Director of Health System Performance Studies at The Fraser Institute (see: Demographics, New Technologies, and Health Care). He presented a critique of the Canadian healthcare delivery system from the perspective of an economist and healthcare analyst. Given that the U.S. is now enmeshed in a prolonged debate about how to improve our own system, I thought that it would be useful to present the key points of his analysis of a system admired by many in the U.S.:

Canada lags behind most other countries with similar universal healthcare systems in terms of capital expenditures for expensive diagnostic and therapeutic devices such as MRI, CT, and PET scanners as well as lithotriptors (see, for example, slides 4, 6, 7, and 8).
Canadian physicians, when polled, express the belief that their ability to deliver care has gotten worse in the past five years (slide 13). If the physicians concede this, I suspect most patients would hold the same opinion.
Wait-times in Canada for MRI studies for 1994 to 2008 have have varied from eight to ten weeks (slide 37). I don't know the comparable figure for the U.S. as a whole but I suspect that its about one quarter to one third of that in Canada. One of the debates here is whether we have too many MRI devices with some then underutilized.
These problems in Canada cannot be attributed to any lag in per capita spending. Slide 40 shows age-adjusted health spending as a percentage of GDP in the 28 OCED (Organization for Economic and Co-operative Development) countries. Canada ranks second from the top, next to Iceland in terms of its spending for healthcare.

Nadeem explained the essence of the Canadian healthcare problem in the following way:

Canadian politicians at the provincial and national level, much like their colleagues south of the border, are most interested in getting re-elected. Laboratory analyzers and radiology imaging devices don't vote but nurses and other hospital employees do have this privilege. Healthcare expenditures by the government are thus primarily directed toward salary increases, particularly to workers represented by politically strong labor unions. Nadeem illustrated this fact by saying that a hospital cook in Vancouver makes more than a chef working in the finest restaurant.
This problem is compounded by the fact that hospital executives work with what Nadeem called "soft" budgets. They generally receive the same budget allocation for their hospital as the previous year plus some modest percentage increase in good years. They thus "sit" on their resources and resist large capital expenditures that might be necessary to stay abreast of new technology. Canadian patients have little recourse but to utilize the hospitals in their neighborhood because the healthcare delivery system is a national monopoly. Of course, they can always play the "medical tourism card" if the queues are too long in Canada or they absolutely require more sophisticated imaging technology quickly.
Nadeem favors conversion to "activity-based" healthcare funding model such as that used in Switzerland. Hospital budgets there are based on the number of patients treated during the year, which focuses the attention of hospital executives on delivering quality care and competing with other hospitals. In other words, the Swiss system tends to be more patient-centric rather than budget-centric. The federal funds to support the universal healthcare system are allocated to the health insurance companies which, in turn, favor those hospitals that provide the highest quality care.

Despite HIPAA, the Privacy of Our Health Records Is Largely a Myth

Bruce Friedman — 2009-10-08T08:40:38-04:00

Most of us, perhaps too glibly, assume that our medical records, both in hardcopy and electronic formats, remain a bastion of privacy and can be securely anonymized and and thus protected from prying eyes. Mr. HIStalk comments wisely on this topic in a recent blog post:

I think that [HIT vendors selling hospital clients' ‘de-identified’ clinical data] conveniently [hide] behind the concept of “anonymization” as an absolute; a simple technique of magically rendering highly sensitive personal data untraceable. Sounds good to a lay person, right? It even sounds technically reasonable as long as you’re thinking of someone having only one data element (just your birth date) instead of multiples (your birth date and ZIP code) and one database (a prescription file) instead of multiples containing joinable fields (prescriptions plus driver’s license records plus a grocery store loyalty card database). It’s like security in general: rarely absolute, secure only if there’s not enough incentive for someone to go to the trouble to crack the code.

I stated rather bluntly in a previous note (see: On the Privacy of Health Information: The Horse Is Already Out of the Barn) that the privacy of medical records is largely a myth and that we should get accustomed to the idea. I specifically cited an article in the Washington Post describing how pharmacy benefit managers (PBMs) sell data about individuals to health insurance companies in order for them to assess financial risk of insurance applicants (see: Prescription Data Used To Assess Consumers). The lede to this this article stated the problem succinctly: "Health and life insurance companies have access to a powerful new tool for evaluating whether to cover individual consumers: a health "credit report" drawn from databases containing prescription drug records on more than 200 million Americans." In other words, health insurance companies can acquire from the PBMs a report of your health status based on the type and doses of the drugs that are prescribed for you by your physician. The PBMs assert that the disclosure of such information is legal because the consumers authorize the release of such information to health insurance companies.

I am not saying that we should let down out guard or even think about abandoning HIPAA. There are too many people feeding at the HIPAA trough -- to do so would postpone our economic recovery for at least another year. I just want to reinforce Mr. HIStalk's major point, which is that no privacy or anonymization system is absolute. If someone with a computer, a few dollars, and some computer savvy wants to learn all of the details about your health status, there is little that can be done to protect your data. The situation is not going to get better in the future as "protected" health information is replicated to an increasing number of applications and databases including personal health records (PHRs), for which I am a strong advocate. Let's face facts. When the pharmaceutical companies pull out their checkbooks, nothing or no one is protected. Even the AMA, supposedly chartered to protect its physician members, is susceptible to the lure of cold, hard cash (see: AMA Discloses Masterfile Physician Data to Pharmaceutical Companies).