There is a correlation between having a pet such as a dog or cat and an improved health status. Exactly how this works was the subject of a recent article (See: American Heart Association: Pets, especially dogs, are good for the heart). Below is an excerpt from it:

An animal companion may not just warm your heart, but also help you maintain a healthy heart....Pet ownership, particularly dog ownership, is probably associated with a decreased risk of heart disease," [said the] director of the cardiac care unit at Baylor College of Medicine....[T]here are 78.2 million owned dogs and 86.4 million owned cats in the United States. Thirty-nine percent of U.S. households have at least one dog, while 33 percent have at least one a cat. The AHA's committee reviewed previous research on how pets affect human health, and they found studies that showed owning a pet was associated with fewer heart disease risk factors and increased survival among patients. In particular, owning a dog was shown to reduce cardiovascular risk, perhaps because dog owners are more likely to engage in physical activities just by walking them. One study of over 5,200 adults showed that dog owners were more active than non-dog owners, and were 54 percent more likely to reach recommended levels of physical activity....[A cardiologist said that] "there are plausible psychological, sociological and physiological reasons to believe that pet ownership might actually have a causal role in decreasing cardiovascular risk." [He also] pointed out though if people buy a pet but sit around all day, smoke, eat whatever they want and don't monitor their blood pressure, heart benefits aren't likely."

So walking your dog improves one's health by providing an incentive to walk him around the block a few times a day. This probably won't help if the owner engages in other unhealthy habits. You all know what they are. I also believe that caring for a pet has unique psychological benefits such as relieving stress. These benefits have been shown to be more effective than ACE inhibitors in lowering blood pressure (see: Pet Dog or Cat Controls Blood Pressure Better than ACE Inhibitor):

[A professor of medicine] assessed the effect of social support on heart rate, blood pressure and renin reactivity in response to mental stress in a group of 48 stockbrokers, all of whom were being treated with lisinopril, an angiotensin converting enzyme (ACE) inhibitor used to treat hypertension. She found that in 24 participants selected at random to add a dog or cat to their treatment regimen, these cardiovascular measures remained significantly more stable during stressful situations than in 24 participants in the non-pet-owner group, who served as controls.

The bottom line is that rather than spending money on drugs and surgery for yourself, redirect it to the veterinary bills for your dog and cat. It's a better investment.

Judith Faulkner, founder and CEO of Epic, is warming up to the media according to an interview in Forbes by Zina Moukheiber (see: An Interview With The Most Powerful Woman In Health Care). Here's the reason that she offers in the interview:

I’m recognizing that when we were small, we could stay under the radar, but now it’s harder. I get so many requests for interviews. If I talk to everyone, we can’t do our job with our customers and work on our software. It would be hard to stay focused.

Here's one of the many reactions to the piece by David Shaywitz, also of Forbes (see: Two Quick Reactions To Epic Faulkner Interview: SV Should Show Judy More Love; We Should Shouldn't Let Hospitals Off Hook)

Interoperability issues associated with Epic may reflect tacit preferences of hospital systems.  Tory Wolff and I have discussed the interoperability challenges associated with Epic, and it’s potentially negative impact on the innovation ecosystem (see here and here).  Faukner’s comments don’t particular assuage my concerns, but certainly highlight Epic’s laser-focus on delivering what customers want – and make no mistake, the customer isn’t the patient but the hospital.  This is critical to appreciate.  Thus, while it’s easy (and appropriate) to critique Epic for impeding data sharing, it’s probably also important to remember that if hospitals were all that keen to share data better, I suspect Epic would rapidly find a way to accomplish this. It’s almost as if Epic provides hospitals with plausible deniability.  While it may be convenient to blame EMRs in general, and Epic in particular, for data access challenges, I suspect we also need to dig deeper, and hold hospital systems themselves far more – what’s the word? – accountable.

I couldn't agree with Shaywitz more. In fact, here's a quote from my note of September 14, 2011 (see: Judith Faulkner, EMR Interoperability, and Washington IT Politics)

Now comes a little secret that is not discussed much. Hospital CEOs and CIOs have little interest or enthusiasm for multivendor interoperability, either within their hospitals or hospital systems or across the outside hospital systems that they compete with. Customized interfaces between heterogeneous systems are a pain in the rear-end for the CIOs. They would thus rather have shrink-wrapped integration delivered by a vendor like Epic, the so-called "enterprise solution." Moreover, CEOs don't want to encourage broad patient and clinical data portability because it gives the payers (insurance companies and the federal government) a strategic advantage during negotiations about reimbursement.

So, when the feds raise the topic of interoperable EMR software, most hospital CEOs and CIOs will stand up and cheer. However, when they go out to purchase EMR software, they largely select Epic, particularly the larger ones that can afford it. Faulkner provides the non-interoperable product that they really want. She can also runs political interference for them. She donates generously to the Democratic party, she is tight with the Wisconsin congressional delegation, and takes no prisoners in her political feuds (see: Epic Flexes Its Political Muscle in Wisconsin with Boycott). And she can now try to block any inconvenient initiatives in the arise in the Health Information Technology Policy Committee.

Epic will provide some measure of interoperability to her hospital clients but slowly and most efficiently among Epic client hospitals. This is what her hospital clients want and this is what she will give to them. Here are the (slightly garbled) Epic "rules of the road" in terms of working with other HIT vendors, quoted from the Forbes interview:

We don’t let anyone write on top of our platform, come read our code and study our software. I worry about intellectual property at that point. With our customers, we make sure we have signed agreements. They know they have to respect our software. Customers can do it in a controlled environment, but not the whole world. You’ll see us do more and more of that.

I recently learned about the concept of a lab formulary, an analogue of the pharmacy formulary. The latter is a list of the stock drugs carried by the pharmacy in a hospital. Prescriptions for hospital patients can only be written by physicicans for the drugs listed in the formulary. The comparable notion on the lab side is that only tests contained in the lab formulary can be ordered by physicians. Here is an article that describes the concept in greater detail (see: Constructing A Lab Formulary). Below is an excerpt from it:

Given healthcare's increasing emphasis on cost control and quality measurement, laboratorians need to reconsider their roles within healthcare organizations. A lab that provides what appears to be a commodity service may be at risk of being marginalized at best or outsourced at worst. But a laboratory that plays a highly visible role in promoting high-quality clinical care can strengthen its status within a hospital or healthcare system. One approach worth considering is to think of the laboratory test menu as a "laboratory formulary" analogous to the drug formulary maintained by a hospital pharmacy. Despite what outsiders might think, the role of the hospital pharmacy goes far beyond simply stocking drugs and fulfilling orders. For one thing, it is not feasible to stock every drug in every formulation that a physician might order. For another, it would not be in patients' best interests for pharmacists to fulfill blindly all orders they receive. 

...[T]he appropriate role of the laboratory professional goes far beyond simply maintaining analytic quality and fulfilling laboratory orders. It includes determining what test methodologies will be offered and in what forms, specifically point of care, in-house laboratory and referral laboratory. It also includes redirecting physicians when they order tests that the laboratory knows to be suboptimal....The stereotype of a lab professional, whether technologist, clinical lab scientist or pathologist, is one of an introvert who likes to hide away in the lab... But the stereotype still risks being self-fulfilling....As lab professionals find creative ways...to share diagnostic testing expertise with medical staffs, we, too, will see an increase in professional status. And more importantly, patients will benefit through more efficient and accurate diagnostic testing.

I have not heard any strident calls for the use of a lab formulary so perhaps I am stirring up controversy where none exists. One of the major drivers for the development of pharmacy formularies has been the need to switch physicians to the less expensive generic drugs to contain drug costs. If a particular generic drug is the only option available in a hospital, this goal can be more rapidly achieved. The ire prompted by such a shift from the clinicians is transferred from the pharmacist to the hospital pharmacy committee that maintains the formulary. Since there is no "generic equivalent" to lab tests, such a goal can't be used as an incentive for the development of a lab formulary.

I can envision that one major rationale for the development of a lab formulary: the desire to place some limits on the inappropriate ordering of expensive molecular and genomic tests. However, even the most expensive of these tests may be appropriate under the right circumstances. Rather than a blanket ban on such tests, it would seem more appropriate to publish the clinical criteria for the ordering of such tests and then require the approval of a pathologist when these clinical criteria are not met. In other words, publishing criteria for ordering expensive lab tests, and then enforcing them, would be a suitable substitute for a lab formulary.

I posted a note five days ago about how the cost of healthcare seems to be gradually declining (see: Decrease in Healthcare Costs May Persist as Economy Revives). A reader, Ajit Alles, responded with a comment that decreasing expenditures of health my result in a lower quality of care, which I responded to in another note (see: The Correlation between the Cost of Care and the Health of a Population). He has responded to this second note with the following comment:

As follow-up, I agree that we spend way too much on end of life care, but that won't be reduced without a cultural shift. People expect miracles from medicine based on what they hear on the news and see in TV dramas. We could spend less and get better results, but people have to first start accepting that modern healthcare has limitations, not the least of which is funding. The new push for genomic healthcare is a good example of unrealistic ideas being pushed for profit. If everyone thinks that they are going to get personalized gene targeted healthcare they are dreaming! I know I'm a curmudgeon in this regard, but we first need to have good basic healthcare before we get cadillac genomics....We in for-profit medicine must share the blame for pushing "new and improved" medicine that is unaffordable and only (marginally) benefits the few people who can afford it. I recently heard of a family that wants some genomic test done on their child with cancer. The test looks at sequence variation in multiple genes and provides a "report" of very limited utility since most of the variations have no specific treatment. The test costs about $25000 and is not covered by insurance ....The family can afford to pay for this so it's being done with the encouragement of the oncologist. There are others who peddle proteomics reports to desperate patients. Enough said. This is the road to ruin.

I would like to respond specifically to his suggestion that "[those of us] in for-profit medicine must share the blame for pushing new and improved medicine that is unaffordable and only (marginally) benefits the few people who can afford it." I agree that many providers participate in "for-profit" medicine. However, the nature of the healthcare enterprise is now changing to what has been called "Big Medicine" or "Big Med" (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; The Transition to "Big Med": Need for Emphasis on Standardization and Cost; Health Systems Use Their Regional Dominance to Muscle Insurance Companies). With the rapid decline of private physician practices, many of the key decisions about the future of healthcare will be made by the federal government, large hospital systems, health insurance companies, and Big Pharma. So while we indeed have a for-profit health system in this country, most of the resources will flow from institutions like the federal government and health insurance companies to large institutions like large hospital systems. The great majority of physicians will be hospital employees. I refer to this as the institutionalization of healthcare delivery. We need to better understand the consequences of this shift.

I think that this change will have a major effect on the incentives experienced by physicians. In previous notes, I have made the point that cancer patients receive better care if the treating oncologist is salaried and does not benefit directly from selecting the most expensive treatment. This idea becomes apparent, as one example, in the treatment of ovarian cancer patients where a private oncologist is incentivised to maximize revenue from patient "chair time" whereas salaried academic oncologists seem to be more inclined in select the preferable intraperitoneal infusion of chemotherapeutic agents (see: Patients with a Cancer Should Seek Treatment in Cancer Hospitals). This is the best therapy but complicated and with lengthy patient visits. Here's are a couple of additional articles about how oncologists are compensated for additional reading (see: Will the Sequester Cause Oncologists to Lose Money Prescribing Chemotherapy?; Who Pays Your Oncologist?).

For private oncologists, the so called "oncology concession" goes to their group practice and they themselves directly benefit financially from their clinical decisions (see: The Oncology Concession Under Attack by Health Insurance Companies). For a salaried oncologist, the "oncology concession" goes to the hospital whose executives may choose to pay their oncologists the internist market salary, retaining the difference. The hospital may then choose to reward its executives at a higher level for developing a bigger cancer center (see: Cancer Business Highly Remunerative for Sloan-Kettering Executives).

I believe that health system executives will be more highly compensated and physicians will be less so as a result of institutionalization. After all, it is the executives who are making macro compensation decision and it would be natural for them to reward themselves. Moreover, these same executives will also have critical decision-making power in terms of how "new and improved" medicine is delivered. I believe that most of decisions will be based on how such care is compensated by the various institutional payers.

In a previous note, I discussed the hybrid teleradiology business model (see: Hybrid Model of On-Site and Remote Radiology for Enhanced Patient Workflow). In a nutshell, it works in the following way:

• A radiology department at a 370-bed acute-care hospital in Carmichael, California, utilizes both its on-site radiologists and remote radiology ("nighthawk") consultants to improve the quality of care and workflow.
• Cases are turfed to the outside consultants when the local radiology expertise is unavailable (e.g., neuroradiology), when the local number of radiologists is insufficient to handle the current case load, and during the night and weekends when the local radiology department is not fully staffed.

It occurred to me that this model would be ideal for smaller hospitals today who have deployed a digital pathology system or are interested in doing so. When outside consultation is required for a surgical pathology case, it could be scanned after primary review by the local pathologist. The volume of such cases would thus be small and a high-volume, high-throughput, expensive scanner would not be required. Moreover, such a surgical pathology consultation would require only an outside secondary opinion and thus, given my understanding of today's regulatory environment, would be acceptable to the FDA.

The Digital Pathology Association is planning a webinar next month focusing on the various business models that can be used to deploy digital pathology technology. Are there any readers of this blog who have successfully deployed such a hybrid model and wish to be considered as a faculty member for this upcoming webinar?