A trillion base pairs of sequence here, a trillion there. Pretty soon, you’re talking about a lot of information—and it all needs to be managed. That’s the dilemma facing Mayo Clinic and other health care organizations leading the personalized medicine revolution that relies on compiling and analyzing patients’ genetic code to better diagnose, predict, and treat disease.

“We generated 90 trillion base pairs of sequence last year,” says Eric Wieben, PhD, director of Mayo’s Medical Genome Facility in Rochester, Minn. “Gathering big piles of data is the easy part. It’s trying to transform the data into knowledge that’s the hard part.”

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Despite an explosion of research into cancer biomarkers and professional guidelines that urge testing for certain genetic mutations that help detect disease, anticipate its course, or predict response to treatment, many cancer centers are out of sync with oncology testing recommendations.

Payment policies, regulatory oversight, clinician preferences, and varying access to testing technology are among the factors that contribute to discrepancies in cancer care.

So says Jan A. Nowak, MD, PhD. And he is worth hearing out on the subject, as did an audience of hundreds of pathologists, oncologists, and others at this year’s Cancer Biomarkers Conference in Houston.

“Adoption of biomarker cancer testing is not high among cancer centers,” Dr. Nowak told the crowd. “It seems high to us because . . . we go to the meetings and we talk to each other, and we’re doing this stuff. But then there are the people who are not going to the meetings, not talking about it, and not doing it.”

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The constant churn of information technology applications is creating new security and financial risks that health care organizations—including laboratories—must systematically address, IT experts say.

Organizational mergers, acquisitions, and the replacement of lab information systems, electronic health record systems, and other solutions often lead to a “legacy system junkyard” of little-used yet costly applications, according to Steve Davis. He is manager of enterprise archive and decommission at Dignity Health, a San Francisco-based health system with 40 hospitals in California, Arizona, and Nevada, and hundreds of outpatient clinics in 17 states.

In 2013, Davis helped lead an IT application decommissioning project at Dignity Health that resulted in the archiving, purging, or storing of 62 applications, the recovery of more than five terabytes of data, and the decommissioning of 390 servers. That has helped save the health care system $4.5 million—so far. The Dignity Health team plans to retire a total of 192 applications and sees a potential for saving nearly $10 million over five to six years.

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“There are known knowns; there are things that we know that we know,” then-defense secretary Donald Rumsfeld famously said in response to a question at a 2002 news briefing.

“We also know there are known unknowns. . . .” he added. “But there are also unknown unknowns, the ones we don’t know we don’t know.”

Rumsfeld—the principal subject of a new documentary, The Unknown Known, by Oscar-winning director Errol Morris—was addressing the case for war against Iraq. But when it comes to the case for improving the use of laboratory testing, the “known known” is fairly clear.

Overutilization is widely understood as a problem that blights American medicine, with lab testing no exception to the rule.

But there also is a “known unknown” in the world of test utilization—the extent of underuse, its effect on care and costs, and how to deal with it. How often do clinicians fail to order the tests that would improve diagnosis, prognosis, or management? And how can pathologists and their colleagues in the laboratory take action to improve test ordering if they lack the complete patient picture that would allow them to help clinicians spot the instances in which ordering more tests is the right answer?

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A shrinking pool of cash to pay for medical care, the decline of private practice medicine, and recently enacted federal legislation will combine to put the squeeze on medical laboratories. That was the stark and sobering message delivered to the hundreds of administrators, pathologists, and other lab professionals who gathered in New Orleans in late April and early May for the Executive War College.

The bearer of the bad news was Robert L. Michel, editor-in-chief of The Dark Report, which hosts the annual meeting. Michel said the biggest threat facing labs is implementation of the Protecting Access to Medicare Act of 2014. The legislation, signed into law April 1, contains a one-year delay in big Medicare physician pay cuts due to the sustainable growth rate formula. But it also includes major changes to the Medicare clinical laboratory fee schedule that will pose a huge challenge to labs, Michel said.

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