We need beds. Discharge every patient you can. Most hospital-based physician will be familiar with this refrain. The problem is that it can lead to premature discharges of some patients, particularly post-op ones who may require closer monitoring and sophisticated nursing care. Revenue-driven surgery and poor planning result in some surgical patients being discharged too early concludes a pair of logistical studies conducted by researchers at the University of Maryland (see: Revenue-driven surgery drives patients home too early). Below is an excerpt from the article:

The studies show a correlation between readmission rates and how full the hospital was at the time of discharge, suggesting that patients went home before they were healthy enough. The researchers recommend better planning and other logistical solutions to avoid these problems ....“Discharge decisions are made with bed-capacity constraints in mind,” [said one of the study authors]. “Patient traffic jams present hospitals and medical teams with major, practical concerns, but they can find better answers than sending the patient home at the earliest possible moment,”[he added]. [The studies] found that patients discharged when the hospital was busiest were 50 percent more likely to return for treatment within three days....Surgeons and hospitals are incentive-driven to perform as many surgical procedures as feasible....“The hospital has to maintain revenue levels to meet its financial obligations. Surgeons are working to save lives and earn a livelihood. It’s what they do....“If the hospital says ‘sorry there are no beds available,’ there’s a lot of tension and pressure from both sides to keep things moving.” These problems are much more likely at large hospitals, which tend to provide more advanced, specialized surgeries not accessible at smaller, community institutions,the researchers say. Patients often have to travel a great distance for the procedures, so hospital delays become expensive for both them and the care providers. The study findings cover surgical discharge data from fiscal year 2007 covering more than 7,800 surgery patients who collectively spent 35,500 nights at the facility....Also, he suggests that hospitals increase the flexibility of where patients go post-surgery. Allowing them to be moved to units with empty beds, for example, could also lessen premature discharges.

All of this makes great sense to me. Now comes the interesting part. How are patients and their relatives supposed to convince a surgeon not to discharge a patient prematurely in the face of pressure from "upstairs". The latter often comes from hospital physician executives. The best argument, echoing the discussion in the excerpt above, is that the patient is not ready to go home and stands a good chance of being readmitted. This is an argument that will resonate with a surgeon if it is likely. A good surgeon, in fact, will have an understanding of which patients will do best at home and which should remain in the hospital for a longer stay. A patient's family should stand their ground and appeal a perceived premature discharge if the facts are on their side. Here's an excerpt from an article relating to premature hospital discharge (see: New Medicare Rules Protect Against Premature Hospital Discharge):

As a result of litigation initiated in 2003, hospitalized Medicare patients will now be better protected against being forced out of a hospital before they can be safely cared for at home or in a nursing home. The new regulations require that patients be given notice of their discharge rights on admission (although it can occur up to two days later) and again at least four hours before discharge. If patients or their families believe the discharge will be premature and not in a patient's best interest, they are entitled to an expedited review of the discharge decision. If they request an expedited review, the patient can remain in the hospital without charge at least until noon of the day following an independent agency's review. The independent review agency is called a Quality Improvement Organization (QIO), and the patient must get in touch with its staff by phone or in writing before the close of business on the day the hospital plans to send the patient home. The QIO demands that the hospital give the patient a detailed, written explanation of her medical condition and the basis for the proposed discharge. 

The need to develop an Accountable Care Organization (ACO) is one of the leading priorities of most hospital executives but there continues to be ambiguity about what an ACO is and what it is designed to accomplish (see: Hospital Executives Search for the Formula for an Accountable Care Organization; The End of Health Insurance Companies by 2020?). A recent article in The Atlantic discusses emerging healthcare models and then provides more details about ACOs (see: The 5 Mega-Trends That Are Changing the Face of Health Care). Below is an excerpt from the article about emerging models with ACOs being one of them. Read the whole article if you have time.

As the sweeping transformation in health care takes hold, several models appear to be taking shape. Each has its strengths and weaknesses and each presents opportunities and risks, but the following three deserve serious analysis and represent different points on the risk spectrum:

• Bundled payments model: calculates total historical payments for the various components of a bundle and then discounts or at least holds constant that amount, placing the responsibility for cost and quality control in the hands of the collective providers.
• Accountable Care Organization (ACO) model: seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
• Capitation model: sends a fixed per-patient prepayment of premium dollars to a provider in return for medical services....

ACOs. For their part, ACOs are hardly proven, but in theory they should achieve results. The overarching idea is to get patients who aren't being treated in a coordinated manner into a system that can deliver care more effectively. The upsides to ACOs are:

• Physicians and other professionals have an opportunity to reap financial benefits of efficiency driven by quality.
• Hospitals that get involved can partially make up for declining volumes associated with higher quality and efficiency.
• Patients currently accessing services in a disjointed manner are likely to have a better overall health care experience in a coordinated system.
• Quality is likely to be enhanced because of coordination and aligned incentives.
• Providers will likely increase collaboration. Existing risk-bearing organizations can increase "membership," and many have already developed at least a portion of the infrastructure and have experience managing risk....

The ACO model, if more broadly accepted, could have a major impact on hospitals, especially because the overall goals here are to reduce unnecessary services and provide better overall health care, which would mean less traditional business for them. A prime issue is that costs--for labor, devices, supplies, equipment, and construction--aren't addressed. And the Affordable Care Act exacerbates this situation by creating additional taxes, such as those levied on device manufacturers and payers, that will be passed through to purchasers.

My general impression is that most hospital executives and, in fact, most healthcare professionals like nurses and physicians, don't have any idea about how to reduce unnecessary services. In fact, most of this group might have a hard time even defining unnecessary services. This is because most were trained and have practiced in an era of plenty where greater delivery of services was praised and elimination of services was criticized. Part of the dilemma lies in the fact that all services industries are highly dependent on labor costs (and new technology in the case of healthcare). Both sets of costs are difficult to ratchet down. In my opinion, part of the solution to the reduction of unnecessary services is engaging patients to take more ownership for their own health. Clearly, most of them need some advice about how to achieve this goal. Healthcare consumer education will thus be one of the major goals. Much of this will be accomplished via the web and social media but we have a long way to go to learn how to do it from both the hospital and consumer perspectives.

A new subdiscipline within oncology is getting increased attention -- survivorship (see: Cancer Survivorship, an Emerging Subdiscipline in Oncology; Cancer Survivorship and the Role of PCPs in Continuing Care of Cancer Patients). As cancer increasingly comes to be viewed as a chronic disease, more attention is being paid to the long-term medical problems of cancer survivors such as the drug damage to normal organs and also new cancers secondary to cancer therapy. Here's an account of second primary malignancy risk due to Revlimid (see: Cancer drug Revlimid (lenalidomide) raises secondary cancer risk). Below is an excerpt from the report:

The U.S. Food and Drug Administration (FDA) is informing the public of an increased risk of second primary malignancies (new types of cancer) in patients with newly-diagnosed multiple myeloma who received Revlimid (lenalidomide). Clinical trials conducted after Revlimid was approved showed that newly-diagnosed patients treated with Revlimid had an increased risk of developing second primary malignancies compared to similar patients who received a placebo. Specifically, these trials showed there was an increased risk of developing acute myelogenous leukemia, myelodysplastic syndromes, and Hodgkin lymphoma. 

Revlimid is used to treat newly-diagnosed multiple myeloma so its target is, obviously, plasma cells and their precursor cells. It's probably no surprise, therefore, that other myelopoietic and lymphopoietic cell lines could be affected by this drug. All of these cells have a high turnover rate in the bone marrow and lymph nodes. Here's an excerpt from the summary of a scientific article published in Sweden to give you some idea of the scope and scale of second primary neoplasms among patients with haematolymphoproliferative malignancies (see: Second primary neoplasms among 53 159 haematolymphoproliferative malignancy patients in Sweden, 1958–1996: a search for common mechanisms):

The Swedish Family-Cancer Database was used to analyse site-specific risk of second primary malignancies following 53,159 haematolymphoproliferative disorders (HLPD) diagnosed between 1958 and 1996....Among 18 960 patients with non-Hodgkin’s lymphoma (NHL), there was over a 3-fold significant increase in cancer of the tongue, small intestine, nose, kidney and nervous system, squamous cell carcinoma (SCC) of the skin, NHL, Hodgkin’s disease (HD) and lymphoid and myeloid leukaemia. Among 5353 patients with HD, there was over a 4-fold significant increase in cancer of the salivary glands, nasopharynx and thyroid, NHL and myeloid leukaemia, and over a 1.6-fold increase in cancer of the stomach, colon, lung, breast, skin (melanoma and SCC), nervous system and soft tissues and lymphoid leukaemia. Among 28 846 patients with myeloma and leukaemia, there was a significant increase in cancer of the skin, nervous system and non-thyroid endocrine glands and all HLPD except for myeloma.

There are at least three explanations for second primary neoplasms among patients with haemato-lymphoproliferative disorders: a genetic predisposition to later malignancies, lifestyle issues, and the lingering effects of treatment for the first  neoplasm. What is certain, however, is that surveillance for secondary neoplasms among these patients needs to be in high-gear. My own view is that such surveillance is best accomplished in specialized cancer centers but I think that many such centers may view their mission as emphasizing treatment over surveillance. However, this attitude is now being modified with greater emphasis on cancer survivorship. This is a welcome change.

The business model for Practice Fusion, a web-based physician office EMR that can be obtained free, has been a source of great interest for me (see: Practice Fusion CEO Calls His Company the Largest EMR Provider; Practice Fusion Supported by Advertising and Owns Anonymized Data). A recent press release from the company caught my eye (see: Practice Fusion Launches API to Democratize Lab Integrations). Here's an excerpt from it:

Practice Fusion, the free Electronic Medical Record (EMR) company,...announced the launch of its new lab API, which allows any laboratory in the country to connect directly to the EMR. The lab API - first of its kind in the health sector - enables rapid deployment of new laboratory connections that would ordinarily take weeks or months to establish, giving over 150,000 medical professionals easy access to their local commercial, hospital and private laboratories....

• Practice Fusion's Lab API allows laboratories to connect to the EMR platform instantly with almost no turnaround time
• Labs can use the API connection to instantly send lab results to Practice Fusion users with standard HL7 data files
• Any commercial laboratory - including clinical, pathology, reference and hospital systems - can send lab results to users directly within the EMR
• Minimal development is required from the lab and Practice Fusion offers free integration support
• Over 150,000 medical providers using the EMR can connect to their national and regional labs of choice at no cost

As many readers of this blog will already know, an application programming interface (API) is a specification for an interface that can be used for communication between two computer systems. The large national reference labs like Quest and Lab Corp have large IT staffs and can quickly churn out interfaces to the most popular office EMRs. Quest, for example, also sells a web-enabled office EMR called Care360. By developing and providing an API, Practice Fusion is facilitating interface development for the smaller regional and esoteric labs, which can then transmit test results to the Practice Fusion EMR for access by physician office clients. If this is, indeed, the first lab API in the health sector, it's a valuable step and a long time in coming. It's also evidence of the high value that clinicians place on access to test results in their EMRs.

I was also fascinated by the choice of words in the press release. The API is said to be a democratizing step. This caught me by surprise -- the use of a political vocabulary with reference to IT. It's possible to chalk this up to an overly enthusiastic ad agency. However, there may also be deeper meaning to it. We live in a era of Big Medicine (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; Hospitals Use Their Medical Schools, Residencies for Later Physician Recruitment; FTC Approves Merger of Express Scripts and Medco). Enabling office-based physicians to rapidly access lab test results could serve as one small antidote to this phenomenon.

Mr. HIStalk recently dropped this little tidbit on us:

The bond rating agency of Dartmouth-Hitchcock (NH), noting the health system’s weak operating performance, blames two factors: reduced state funding and the cost of implementing Epic.

This item reinforces what I have been hearing constantly on the street, particularly from lab colleagues. Many are experiencing embargoes on lab capital spending and LIS enhancements emanating from the hospital C-suite because of the high cost of deployment of their Epic EMRs. In the past, hospital budgetary problems frequently revolved around the high cost of a new hospital building or a low patient census. This Epic EMR twist strikes me as a relatively new phenomenon.

As I am writing this note, I am looking for analogies to this situation in the world of business outside of healthcare. Think, for example, of a medium sized for-profit company with a budget comparable to that of a large hospital or even a hospital chain. When was the last time you heard that such a company had its credit rating under threat because of the cost of some piece of software that it was purchasing? The answer is probably never because most software is not prohibitively expensive. We certainly are well aware of the reported cost of the Epic EMR to the Kaiser health system according to Forbes in a recent article on the web: about $4 billion (see: Epic Systems' Tough Billionaire). This must have caused a bit of a burp in the Kaiser budget.

How are we to explain this struggle by hospitals to purchase the Epic software? One explanation is that it's a mission-critical product that a hospital will acquire at any cost and cannot operate without. Another explanation is that Epic is the EMR pick du jour for executives in larger hospitals and that they are willingly, and grossly, overpaying for the product because of the near-monopoly the company now holds (see: Does Epic Exercise a Near-Monoply for EMRs in Larger U.S. Hospitals?; The Feasibility of Using the Epic EMR as a "Platform" to Extend Its Functionality). Here's another quote from the Forbes article cited above:

At the beginning of each year, [Epic founder and CEO] Faulkner commands her tiny salesforce to select customers based on whether they are fit to work with Epic—making it a privilege. “They don’t need salespeople, customers come to them; they’re like kids showing up at the door asking for Oreo cookies,” says Leo Carpio, a health IT analyst at Caris & Co. At rival Cerner, sales and marketing make up 4% of total expenses.

My problem is that this particular brand of "cookie" is going to cause profound indigestion in ancillary hospital units like pathology and radiology. It's basically a double hit for them -- Epic products like the Beaker LIS can only handle core functions (see: Selecting the "Best" EMR; Problems with the "Greatest Good" Doctrine; ) and then there's insufficient capital available to purchase additional software to manage the absent functionality (see: Details about Epic's Beaker LIS, Supplied by the Company; A Pathologist Describes His Firsthand Experience with a Demo of Epic's Beaker LIS; Assessing the True Cost of Serving as a Beta Test Site for the Beaker LIS). 

The Digital Pathology Association (DPA) in partnership with the Association of Pathology Informatics (API) and CAP Today will host a series of four, one-hour webinars starting tomorrow focusing on the barriers to the adoption of digital pathology. The topics to be addressed during the webinars include: a cultural and strategic perspective, regulatory issues, financial aspects of deployment, and technical issues. Each session will be moderated by Robert McGonnagle, publisher of CAP Today. Each of the four webinars will include several experts in the field who will deliver short and focused presentations, and then will interact with McGonnagle and call-in participants about the major points presented.

These webinars will serve as a bridge between the recent, comprehensive article about regulatory aspects of digital pathology that appeared in CAP Today (see: Digital Pathology and the FDA; WSI Systems Called Class III Devices) and the two most important, national conferences focusing on digital pathology: (1) Pathology Informatics 2012 to be held October 9–12, 2012 in Chicago; and (2) Pathology Visions 2012, the annual conference of the DPA, to be held October 28-31, 2012.

Mark your calendar for 11 AM to 12 Noon EST for the following dates:

• May 9. Cultural and Strategic Barriers to the adoption of Digital Pathology with Dr. Sylvia Asa, Dr. Keith Kaplan, & Dirk Soenksen of Aperio.
• July 25. Financial Barriers to the Adoption of Digital Pathology.
• September 19. Technical Barriers to the Adoption of Digital Pathology.
• November 14. Regulatory Barriers to the Adoption of Digital Pathology.

There will be no charge for participating in these webinars, however advance registration is required (see: Sign up for a free DPA account). The archived version of the webinars will be made available to DPA members only. More details about these events will be published as they become available including the names of the participating faculty members.