The FDA approved the ThinPrep[R] Pap Test[TM], a liquid-based cervical cancer screening test, in 1996 (Johannes 1998) (Cytyc Corporation 2001). Ever since, the ThinPrep Pap test has been rapidly replacing the conventional Pap smear, even though it is about twice as costly as conventional Pap smears (Johannes 1998; Rubin 2002). According to the manufacturer, the Cytyc Corporation of Boxborough, Massachusetts, the test is now used in lieu of a conventional Pap smear in the United States for approximately two-thirds of cervical cancer screenings, a proportion that keeps increasing (Rubin 2002).

Although liquid tests are more effective at detecting precancerous changes and are associated with fewer numbers of ambiguous diagnoses than conventional Pap smears, most of the improvement in test accuracy is in the detection of low-grade lesions that often regress spontaneously (Brown and Garber 1999). Liquid-based technologies have not been shown to be superior to conventional Pap smears at detecting frank cancer and have not been associated with lower mortality from cervical cancer compared with Pap smears. Screening with conventional Pap smears once every three years between the ages of 20 and 75 increases the average woman’s life expectancy by about 96 days (Eddy 1990). According to Brown and Garber (1999), annual screening with the ThinPrep Pap test would prolong the average woman’s life approximately an additional six hours over annual screening with conventional Pap smears. In triennial screening programs, use of the ThinPrep Pap test instead of conventional smears would prolong the average woman’s life about 19 hours (Brown and Garber 1999).

The lower rate of false positive cervical cancer screening tests is one reason for the rapid diffusion of the liquid-based tests, but other factors may also explain their rapid emergence in medical practice. The Cytyc Corporation, the makers of the ThinPrep[R] Pap Test[TM] test (the most commonly used liquid test), actively marketed it to physicians and the general public. The company also encouraged insurance companies to promote themselves to women by including information about their coverage of ThinPrep in advertising campaigns (Johannes 1998).

Articles concerning how physicians learn about new pharmaceutical agents began to appear in the medical literature in the 1950s (Peay and Peay 1994). In recent years, articles have focused on the influences of marketing to physicians on prescription behavior (Avorn, Chen, and Hartley 1982; Manning and Demon 1980) as well as the effect of marketing prescription drugs to the public (Bell, Kravitz, and Wilkes 1999; Wilkes, Bell, and Kravitz 2000; Avorn and Solomon 2000). However, little attention has been given to marketing of laboratory tests used in office-based practice. There is scant information on how office-based physicians choose new diagnostic tests. This paper examines adoption of liquid-based cervical cancer screening tests among family physicians and gynecologists in Maryland. We hypothesized that the efforts of Cytyc Corporation to market the ThinPrep Pap test would be an important determinant of its early adoption by physicians. Additionally, we examined the effects of physician specialty, patient sociodemographics, practice factors, and financial constraints on laboratory decision making on the adoption of liquid-based cervical cancer screening tests.

METHODS

Study Population

The American Medical Association Master File of Physicians was used to create a sampling frame of Maryland family physicians and gynecologists. The selection criteria resulted in a total of 2,025 physicians (1,079 family physicians and 946 gynecologists). Physicians who did not graduate from medical school between 1950 and 1989 were excluded in an effort to restrict the sample to physicians still in practice who had had experience with conventional Pap smears before liquid-based tests were available. Physicians known to be working in federal facilities were also excluded. We randomly selected 250 physicians from each of the two specialty groups using a random number generator. Assuming a 50 percent response rate, this sample size would detect a difference of at least 20 percent in the adoption rates for these groups with a power of .85 (two-tailed alpha of 0.05).

Between July and October 2000, the name of each physician was searched on the web site of the American Medical Association (American Medical Association 2001) and the Yahoo search engine on the Internet for a current Maryland address and telephone number (Yahoo yellow pages 2001).

The medical offices of the physicians were then contacted by telephone to determine if the physician offered routine gynecologic care with screening for cervical cancer. The office staffs of physicians chosen for the study were asked to verify addresses and provide fax numbers. In order to obtain basic information about all physicians in the study, including those who did not eventually respond to the questionnaire, the office staffs were also asked if the physicians use a liquid-based cervical cancer screening test, either the ThinPrep Pap test or AutoCyte (a less commonly used test), conventional Pap smears, or both.

OneTouch Technologies is unveiling the OneTouch System, an electronic data-recording system for inputting resident information at bedside, improving resident care and operational efficiency. At press time OneTouch Technologies was planning to conduct pilot tests with several major long-term care chains.

The OneTouch System includes a computer microchip (iButton) embedded on both a resident’s identification wristband and on the caregiver’s name badge. In addition, the caregiver uses a customized Personal Digital Assistant (PDA) and wand to read the iButtons and record the pertinent resident information.

On the PDA, the OneTouch System provides a preformatted clinical checklist/menu of observations to be made and procedures to be performed and recorded. This enables the caregiver to simply touch an icon on the screen to record preconfigured information without computer keystrokes and in minimal time.

For years, people have been going to the doctor, paying a 810 to 830 copay and going on with their day without thinking about what it truly costs for that doctor’s visit. With the advent of consumer-directed health plans, individuals are beginning to pay closer attention to their health-care expenditures.

Until recently, it has been difficult to determine how much to set aside in dedicated accounts because the cost of doctor’s fees and other healthcare services are typically unavailable to the general public. One national health insurer, Aetna Inc. of Hartford, Conn., is looking to change that scenario.

In August, Aetna began providing members with the prices it negotiates with physicians for hundreds of medical procedures, diagnostic tests and office visits. The program, which is being piloted in Cincinnati, Davton and Springfield, Ohio, Northern Kentucky and Southeast Indiana, aims to let consumers know what they can expect to pay at the doctor’s office before going in for a visit in order to better gauge their out-of-pocket health-care expenses. Aetna members now have online access to a doctor’s discounted rates for up to 25 of the most common office-based services.

This is good news, according to Aetna executives.

“The biggest impediment to effective consumerism in health care has been the unavailability of relevant data on health-care quality and cost,” says Ronald Williams, president of Aetna. “We are taking the lead on opening what is often perceived as the ‘black box’ on physician-specific pricing. As more Americans begin managing their health-care dollars, they are increasingly interested in the ‘price tag’ for the health-care services they receive.”

Aetna is aiming to provide consumers with this information to help them make more informed decisions about their health-care services.

“We have been providing tools to help consumers make health-care related decisions for some time,” says Robin Downey, head of product development at Aetna. “Our members have had access to estimated physician cost information via Aetna Navigator, our password-protected member Web site, and are able to view in-network versus out-of-network rates for physicians in specific geographic areas, along with gauging the cost of chronic conditions, such as asthma and diabetes. With the growth in consumer-directed health plans, we felt it was time to take it to the next level–to begin offering true transparency of health-care costs.”

Aetna held focus groups with network physicians and members, in addition to representatives from local and state physician professional organizations as well as large group practices in Ohio, to guide the creation of the program.

“The physicians we spoke with agreed that patients should understand what their services cost, in addition to the need to make this information easily accessible and understandable,” says Downey. “Throughout the pilot program, we will continue to get feedback from members and physicians so that we can continue to enhance and improve these services.”

A SHROUD STILL SURROUNDS QUALITY

While many health-care consultants and medical providers applaud Aetna’s efforts because it sheds light on the real cost of health care, they agree there are still many challenges ahead, the major one being how to measure quality.

“The consumer is the force that drives cost transparency,” says Harvard Business School professor Regina Herzlinger, a long-time advocate of consumer-directed health care. “As soon as this information becomes more widely available, physicians will need to become more competitive in their pricing, in addition to focusing more attention on how they measure the quality of care provided.”

“For too long, the medical industry has shielded consumers from transparency on cost and quality,” says Stephen Neeleman, CEO of HealthEquity Inc., an administrator of health savings accounts based in American Fort, Utah. “Physicians today need to provide the highest quality for the lowest price. While we’re trying to be more transparent about price, it’s often difficult due to additional fees from treatment facilities, surgeons, anesthesiologists, hospitals, and other costs involved in treating a patient.

“The goal,” says Neeleman, “should be to provide a fair market price for our services and work with patients to determine what makes the most sense for them–such as having a procedure performed on-site at a doctor’s office or at a hospital or clinic.”

Unfortunately, says Hal Heaton, professor of finance and associate director of the Center for Entrepreneurship at Brigham Young University in Provo, Utah, “Health care does not compete like other industries. When was the last time you saw an advertisement by a health-care provider that says, ‘Come to us for the highest quality kidney stone removal at the lowest price?’ Today, health care competes by offering more expensive service because no one pays much attention to the cost. The concept of HSAs opens myriad entrepreneurial opportunities, and will ultimately lead to more specialization and competition based on both cost and quality by health-care providers.”

According to the Institute of Medicine (IOM) in its 2000 report “To Err Is Human: Building a Safer Health System,” at least 44,000 and as many as 98,000 deaths due to “preventable adverse events” occur in hospitals each year. That exceeds automobile accidents, breast cancer and AIDS as a leading cause of death in the United States. The report further states that medication errors account for one in 131 outpatient and one in 854 inpatient deaths, and cites another study that found 2 percent of admissions experience a preventable adverse drug event (ADE). Not all ADEs result in death. However, when it comes to our health or the health of our loved ones, what percentage is acceptable?

Michelle Geurink is an IT analyst at Methodist Medical Center in Peoria, Ill. She also is a trained pharmacist. When she arrived at Methodist in 1999, the organization was implementing a new hospital information system (HIS) for pharmacy, lab, nursing documentation, radiology and order management. As a part of the client services department, Geurink was to make sure the new systems flowed well with IT and the pharmacy. Another Methodist IT analyst, Jennifer Nelson, R.N., was charged with the same task on the nursing side. As a team, they set out to ensure a smooth HIS installation and staff training.

The HIS software included several modules that Client Services intended to roll out one at a time, starting with Nursing Documentation. But when the IOM report came out, Methodist’s executive IT steering committee chose the Meds module because it contained bar coding technology and would address the need to reduce the risk of medication errors and ADEs. Even though studies showed Methodist experienced a statistically tiny number of ADEs compared to the national average (only five in 10,000), they knew they could improve. Instead of lowering their standards, they raised the bar.

By 2001, Geurink and Nelson were attending classes to learn how to build and implement the modules with Methodist’s policies and procedures. They chose the oncology floor as the pilot unit and held a vendor fair so staff could evaluate the new HIS hardware’s placement, and decide whether to go with permanent fixtures or mobile carts. The nurses were given evaluation sheets and asked to state their likes and dislikes. They chose permanent-mounted, all-in-one units that would be installed at the bedside and include a flat-screen monitor/CPU combo, mouse, keyboard and bar code scanner.

While the nurses evaluated the hardware, Geurink and the Methodist pharmacy buyer evaluated their meds. If they weren’t already packaged with unit-dose bar codes, pharmacy would find a company that sold them that way, or purchase them in bulk bottles, print their own unit-dose bar codes and repackage the meds. Today, Methodist always tries to buy meds unit-dose bar coded. Says Geurink, “Every time someone touches them there’s the possibility for human error. And then there’s the cost.” Although Methodist could print their own unit-dose bar codes, it was determined to be more cost-effective to purchase the meds already bar-coded. “I don’t know if we save any money, because, as opposed to a bottle, the unit-dose meds are more expensive, but then you save the labor cost,” says Geurink.

The Little Bang Approach

“When the nurses came in, the first thing we told them was that this was not about saving them time, it was about patient safety,” says Geurink. According to Nelson, the average age of nurses today is 45. That meant some of them needed to learn how to use a mouse and turn on a computer before being taught how to use the bar code system. She says the initial acceptance of the new system by the nurses was not good. “They were so used to having paper, we kind of rocked their world with introducing the equipment in the room–by logging in and scanning–we changed their whole process of delivery of medication.”

Geurink and Nelson trained the first set of nurses to work with the new system and then established a program where each floor’s nurses would train on the system, practice until proficient and then train the next floor in line. They called it the “little bang” approach to training, versus a big bang, where all floors are rolled out simultaneously. The method fostered camaraderie by providing support from within and also gave a sense of ownership to the nurses.

Today, Nelson says the nurses have totally accepted the bar code scanning system, though there are still issues to overcome. Methodist is not yet a paperless hospital, so the nurses are managing two systems, which has its challenges. “It’s hard when some of the physicians still write their notes and orders on paper,” she says. The nurses can, however, do their assessments and chart all their medications online, which is a good thing, because the nurses want more–more technology, more information on the computer and more things done on the computer. “We can’t roll it out fast enough.”

Reiboldy, a medical practice consultant, overviews the changing landscape of health care delivery and shows what doctors can do to cope with the reality of managed care, detailing integration strategies for hospitals, physicians, ancillary services, managed care, and technology. He explains how to identify the operational strengths and weaknesses of a practice, calculate its worth, and how to select a partner. There is information on allowing physician input in hospital-affiliated groups, hospital and physician relations programs, and the prospect of a single-payer system. Sample job descriptions, checklists, and surveys are included.

Gone are the days when physicians could hang their shingles just once and expect to practice in one geographical location their entire careers. Most physicians in the US now expect to relocate for professional reasons, to transfer from place to place within corporation-run health care, or to have other reasons for seeking licenses in more than one state, such as participating in tele- medicine and e-medicine. This guide, which covers osteopathic as well as allopathic physicians, gives states’ licensing requirements, including relevant examinations and fees, requirements for re- registration and CME requirements, endorsement policies for physicians holding an initial license, information on foreign medical graduates, continuing education, national boards, and licensing in the US Air Force, Army and Navy. It includes a list of references and useful web sites.

Featuring localized interface that addresses needs for Spanish-speaking users, eFilm Spanish(TM) allows for viewing, manipulation, and CD/DVD burning of digital medical images. It replicates functionality of downloadable eFilm Workstation v2.1, which includes features for thumbnail views and MPR, spine labeling, and splitting image series. This radiology software application also offers hanging protocol functionality.

MILWAUKEE, Aug. 9 — Merge eMed, a Merge Healthcare company (Nasdaq: MRGE; TSX: MRG) and a leading medical imaging software and services company, today announced the release of eFilm Spanish(TM), a Spanish language version of the company’s widely used eFilm Workstation.

The Spanish version of the software replicates eFilm Workstation 2.1, released by Merge eMed in October 2005. This version included several new features including enhanced thumbnail views and MPR, spine labeling, splitting image series and improved support for CD and DVD burning. eFilm Workstation 2.1 also added improved hanging protocol functionality for organizations using eFilm in conjunction with Merge eMed’s FUSION PACS and RIS/PACS solutions.

“Merge Healthcare is pleased to expand the usability of our eFilm Workstation by localizing the interface for our Spanish speaking customers,” says Robert White, Merge eMed president. “eFilm Workstation was the first radiology software application available via eCommerce at a price point that made the introduction of digital reading easy and accessible for radiologists in the United States, and continues today to be one of the most widely used diagnostic desktop software applications in the world. The introduction of eFilm Spanish replicates this very successful model for a new market of Spanish speaking customers.

“We will continue to leverage widespread use of eFilm Workstation software to further assist our customers with the care they provide patients and their transition from film to filmless workflow environments,” said White.

The Deal: Becton, Dickinson and Company has agreed to acquire the 95 percent stake in Tripath Imaging Inc. that it does not already own for approximately $350 million. Under the terms of the agreement, Becton, Dickinson and Co. will pay $9.25 per share. At that price, the deal would value 100 percent of the company at about $355.7 million. TriPath has agreed to pay a termination fee of $12.25 million under certain conditions if the deal does not close. Certain TriPath executives, including CEO Paul Sohmer, will receive bonus payments if the deal is concluded by the end of the first quarter of 2007 and additional retention bonuses for remaining with the company after the merger. The deal still requires approvals from TriPath shareholders and regulatory agencies.

Discussion: TriPath Imaging develops equipment used for cervical cancer screenings. The company’s products include equipment pre-screening Pap smears, slide preparation systems, and systems for cell collection, preservation, and transportation.

Becton, Dickinson and Co. make medical equipment, including drug delivery systems, infusion therapy devices, and surgical blades. The company is one of the top manufacturers of syringes in the world. Becton, Dickinson also makes diagnostic products, medical data systems, and offers consulting services. TriPath is already working with Becton, Dickinson on developing cancer diagnostic tests. After the deal closes, TriPath will operate as a subsidiary of Becton, Dickinson.

The Medical Group Management Association (MGMA) traditionally provides an exhibit hall at makes others pale in comparison. This year, Oct. 3-6 in beautiful San Francisco, MGMA offers three days of exhibit hall exploration, with the chance to see an impressive array of information technology, to attendees at its annual conference. Suppliers of practice management systems, electronic medical records, scheduling, transcription and voice recognition services, wireless technology, credentialing info tech, financial and claims management systems and document management technologies will be on hand to demonstrate their products and help attendees consider what’s right for their organizations.

To help maximize your MGMA exhibit experience, Health Management Technology offers a showcase of some products you can personally test-drive at the conference. While you are there, stop by HMT Booth 1309 and say hello.

Companion Technologies Booth 523

Companion Technologies develops practice management, electronic medical records and electronic data interchange software.

Companion PM is a fully integrated practice management system that works on Windows, Unix and Linux platforms. Its modular design can be scaled to meet specialty-specific requirements while accommodating changes in practice size and organization. Companion EMR is a Windows-based electronic medical records system that works on PCs, handhelds, laptops and tablets. It provides local and remote access to clinical data and automates prescriptions, labs, encounters, medical histories, patient education, and more.

Companion Technologies also offers group practice and claims management EDI systems that automate billing processes and help reduce errors, maximize reimbursement and improve cash flow. Visit Booth 523 to see which system best fits your data management needs.

Dictaphone Corp. provides solutions that use speech recognition and natural language processing technology–to streamline the clinical documentation process and reduce transcription costs.

EXSpeech offers transcription-assisted speech recognition integrated with Dictaphone’s dictation system. Enterprise Workstation 2.0 is optimized for complete provider control of documentation with voice-driven self-editing of recognized documents. It also incorporates technology that automatically extracts key medical data from text reports for quick look-up and reuse to speed documentation further. The GoMD suite provides PDA-based dictation and charge capture. The ichart solution offers these products on a centrally hosted ASP basis.

We apply the technique of second-harmonic generation (SHG) microscopy to obtain large area submicron resolution image of Type I collagen from rat tail tendon as it is heated from 40°C to 70°C for 0-180 min. The change in the collagen structure as reflected in its SHG image is observed at length scales from submicron to hundreds of microns. We observed that heating the tendon below the temperature of 54°C does not produce any change in the averaged SHG intensity. At the heating temperature of 54°C and above, we find that increasing the heating temperature and time leads to decreasing SHG intensity. As the tendon is heated above 54°C, the regions where the SHG signal vanish and form a tiger-tail like pattern. In addition, a decrease in the SHG signal occurs uniformly throughout the tendon. By comparing the relative SHG intensities in small and large areas, we found that the denaturation process responsible for forming the tiger-tail like pattern occurs at a higher rate than the global denaturation process occurring throughout the tendon. We also measured the fibril spacing and found that it remains constant at 1.61 ± 0.04 micron for all heating temperature and times. The constant fibril density shows that the global denaturation process occurs at a length scale smaller than the size of the fibril. Our results show that second-harmonic generation microscopy is effective in monitoring the thermal damage to collagen and has potential applications in biomedicine.

Collagen, the most abundant protein in mammals, is the main component of connective tissues. It is responsible for the tensile strength in ligaments and tendons, the elasticity for skin, and the transparency and structural support for the cornea. The most prevalent collagen is Type I collagen, which is found in bones, tendons, and scar tissues. The triple helix of Type I collagen molecules are composed of polypeptide chains, each contains the repeated G-X-Y sequence, where G represents glycine, and X and Y usually correspond to usually praline or hydroxyproline (1). They combine to form microfibrils few nanometers in diameter, which then combine to form collagen fibrils that are few hundreds nanometers in diameter. The fibrils further bundles to form collagen fibers that are a few to hundreds of microns in diameter.

Thermally induced conformational changes in collagen have been actively studied, not only because collagen is the most abundant protein of the extracellular matrices, but also due to its relation to the application of several medical procedures. Examples include the use of heating to change cornea curvature, and the use of laser heating to stabilize shoulder joint and to rejuvenate skin (2-4). The response of collagen to heating has been studied using different methods including differential scanning calorimetry (DSC), x-ray diffraction, NMR, and spectroscopy (1,5,6). The denaturation of collagen is complicated among other variables by its polymeric nature and cross-linking. Despite numerous efforts, the precise mechanism of collagen denaturation remains unknown (1).

Among the various methods that can be used to study collagen denaturation, second-harmonic generation (SHG) microscopy is unique in that it is a nonlinear optical technique that has potential to be applied to collagen studies under in vivo conditions (7-13). In short, second-harmonic generation (SHG) is a coherent process in which two photons at the fundamental frequency are converted into one photon at twice the fundamental frequency. Due to the nonlinearity of the process. SHG occurs only in structures that lack inversion symmetry, and it has been demonstrated that Type 1 collagen is efficient in generating second-harmonic signals (7-13).

In this study, we used high resolution SHG microscopy to investigate the thermal denaturation of collagen from rat tail tendon. In particular, we obtain high resolution SHG images of heated collagen fibrils. We attempt to characterize the change in the SHG image as the collagen fibril undergoes thermally induced structural changes.

EXPERIMENTAL PROCEDURE

Sample preparation

Fresh rat tails obtained from the National Taiwan University Hospital were frozen at -80°C until before the experiment. Previous studies have found that freezing and thawing rat tail tendons do not affect their SHG signals (8,10). On the day of the experiment, the rat tails were first allowed to thaw at room temperature before the individual tendon fascicles were removed and placed in phosphate buffer saline (PBS) solutions (product specifications 0.01 M phosphate buffer, 0.0027 M potassium chloride, and 0.137 M sodium chloride, pH 7.4, at 25°C). The fascicles were then placed inside a tube filled with PBS solution and heated for a specific time in a thermal hath that was maintained at a given temperature. The heating temperature and lime were chosen based on a previous study where the SHG signal was found to change significantly between 50°C and 60°C for a heating lime of 10 min (7). After heating, the fascicles were placed on top of a PBS welted tissue paper, which was then placed on top of the glass slide to keep the fascicles moist. Finally a glass coverslip was added and sealed to prevent the tissue moisture from evaporation.