We are the world (Musings on sharing TM resources)

Updated: 10 Feb. 2014

February's blog is on transfusion medicine resources, including blogs and twitter. [Like all blogs, please check again as revisions invariably occur.]

The blog's title derives from a 1985 song written by Michael Jackson and Lionel Ritchie for 'USA for Africa.'

The blog's theme was triggered by discovering that CBS had removed the Vein to Vein section of its transfusionmedicine.ca website, a site that Kathy Chambers and I developed for CBS in 2001-2003. CBS assessed that some content had become outdated and some was now well covered by other resources. Both true.

The V2V site went up in 2004, ~10 years ago, a long time in transfusion medicine. It's possible that some elements may be revised based on community needs and re-published on the site, but that's just a maybe.

You can still see snapshots of the V2V site because organizations exist that archive websites. This link is the archived site from Sept. 2012.

[Note: Literature references and other external links are still active but don't work on web archives.] 

But that got me thinking about TM resources and who uses them. As explained in January's blog - 'Mommas don't let your babies grow up to be lab techs' -  in reply to Robina's comment (#2 in Addenda), fewer and fewer medical laboratory technologists read TM journals. The same may be true for physicians and nurses.

About online TM resources, I encourage you to ask and answer these questions for yourselves:

• What resources exist? Who created them and why?
• Who uses them and why? 
• Are they useful in your practice?

Perhaps most importantly, should industrialized nations share resources with those in the developing world? In a way, it's similar to whether we in the West should focus on 'Charity begins at home' and give less or nil in foreign aid to poorer nations. And what's the right balance on that continuum?

What follows is my take and I've selected only a few of many useful online resources. Many more exist and your choices may differ from mine.

Please let me know if I've missed an exceptional resource and specify why.

Criteria I use to assess online TM resources:

• Is content created by credible health professionals, preferably acknowledged experts?
• Are references to scientific literature included?
• Is content current and, if older, still relevant today?
• Even if country specific, is content generalizable to other locales?
• Who's behind the site? [Usually in About Us] 
• Who funds the site? Do they have an agenda? If yes, what is it?
• Does the site follow the entire Swiss HON 'Code of Conduct'?

 A few useful TM resources, in no particular order:

WEBSITES 

CANADA
Canada has many websites that share incredible resources that took much time, expertise, and funding to create. In each case, developers could have hogged the resources, kept them secret on an organization's intranet.

But, like Australia, the UK, and others, they bravely and generously decided to make them public via the Internet so all could see, share, offer feedback on, perhaps even criticize.

For those who know these sites, bear with me. I'll try to feature a few goodies that may be new to you.

1. BC PBCO 

BC's Provincial Blood Coordinating Office was the first PBCO created in Canada (1997). Among other things, that's reflected in them having the vision to snap up the generic domain name, pbco.ca. [Couldn't resist the joke.]

Sorry, PBCO pals!

Seventeen years later, BC PBCO remains a leader in blood utilization management, information management, and quality management, as well as in sharing educational and other resources via its site and TraQ's (see below). For example:

• Central Transfusion Registry (CTR)
• iCHIP: Inherited Coagulopathy and Hemoglobinopathy Information Portal (1st of its kind in NA)
• Utilization management
• RBC Redistribution Manual
• Bits and Bytes (6 educational videos)

2. TraQ
Disclosure: I'm TraQ's content coordinator and webmaster.

TraQ has several unique strengths, including:

• Hosts key BC PBCO resources such as its manuals
• Offers constantly updated transfusion news, including industry news
• Provides links to diverse resources, e.g., 
• Nursing resources 
• Case Studies (Hope to update external links soon)
• Severe Hemolytic Transfusion Reaction Involving a Student
• TM animations and videos

3. ORBCoN

Among its many exceptional resources, ORBCoN hosts

• Bloody Easy series
• Resource Manual for Medical Directors of Transfusion Medicine

AUSTRALIA
Australia has long been a leader in developing and sharing blood safety educational resources. Some examples:

• Blood Matters, including 
• Transfusion Tools
• BloodSafe e-Learning Australia

UK
The UK too has always generously shared its TM resources and they've led in many key areas. For example:

• Serious Hazards of Transfusion, aka SHOT, which began in 1996, is the crème de la crème and THE acknowledged world leader of hemovigilance schemes. 
• Nothing touches it. Compared to SHOT, hemovigilance in Canada and the USA is still in the stone ages. For more, see this review of SHOT and hemovigilance around the globe:
• Bolton-Maggs PHB, Cohen H. Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol 2013.
• Guidelines for the Blood Transfusion Services in the UK
• Also known as the 'Red Book' this UK resource has long been a gem.
• See, for example, Pretransfusion Testing

USA
The best transfusion resources in the USA are the AABB's. I've been a member since 1975 (Yikes!). Please consider that when I criticize the organization. It must be doing something right.

Many of AABB's best resources are restricted to members. But some are available to all, e.g.,

• Regulatory/Government Affairs
• Fact Sheets on Emerging Infectious Diseases

SOCIAL MEDIA
Many of today's 'mature' health professionals diss social media as being sound and fury, signifying nothing, as Shakespeare had Macbeth say about life:

Life's but a walking shadow, a poor player
That struts and frets his hour upon the stage
And then is heard no more: it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing. 

Still, I recommend blogs and Twitter, if they meet criteria as above, as being worthwhile resources for TM professionals.

Social media are democratic, meaning anyone can spout off (I'm a prime example). But health professional bloggers and tweeps shouldn't, and do not, get an audience without earning the respect of peers for the content of the offerings.

Unless they're celebs like Justin Bieber and Katy Perry, who each have over 46 million followers on Twitter. Celebs can be total ______ (fill in the blank with an appropriate word) and still have millions of followers eagerly gobbling up their drivel.

A significant characteristic of social media is that, unlike the websites mentioned above, individual blogs and twitter accounts can be created by anyone for free. The only cost is the time and effort of the people (bloggers and tweeps) who participate and contribute.

BLOGS
1. Musings on transfusion medicine (You are here)
Granted, it's shameless self-promotion to include my own blog. This blog began in 2004 and will have its 10th year anniversary in October. This entry is the 119th individual blog. [As is obvious, I'm long-winded with many rants inside just waiting to be released.]

Many blogs exist (although, not many on TM). Blogs should be taken with a huge grain of salt because they represent one person's biased perspective. Blogs can be thought of as short compositions on a single subject written from the author's personal perspective.

In essence blogs are like newspaper editorials, which represent an individual or group's opinion, e.g., that of the owner, publisher, editor, or editorial board.

Musings on TM represents my opinions alone. A natural tendency is to go against prevailing orthodoxy. To me so much of what people believe, including transfusion professionals, results from speaking to the same people, perhaps a few dozen, day in and day out.

What inevitably results is 'group think'. Spending time in an echo chamber, where you constantly hear your views parrotted back to you, leads to believing your views are conventional wisdom, i.e., Doesn't everyone think that?

In revolt, I'm an iconoclast and this blog provides the medium to oppose what most of us accept as 'truth'.

Still, I hope the blog's ideas are more than a 'nutball sounding off' and represent

• Constructive criticism
• Fresh perspective
• Sound reasoning (Well, mostly...)

If not, the Comments section of the blog (~ Letters to the Editor in newspapers) allows readers to counterbalance my often biased views.

2. A few other transfusion blogs exist but they don't turn my crank using the criteria above. If you know of a good one, please let me know.

TWITTER
Created in 2006, Twitter is a late comer to social media and initially was much ridiculed for its limit of 140 characters and some users tweeting trivialities, e.g., what they ate for breakfast, etc.

But gradually people realized the power of Twitter and saw how it could changed media, politics, business, and more.

I love Twitter for its ability to share news and resources. If you're curious about the world and an information junkie, beware! It's addictive.

1. Cyber Bloodbanker @transfusionnews

Again, forgive the self-promotion. I've 7 Twitter accounts, 4 of them serious (well, relatively so), especially the one above, and 3 spoof accounts strictly for fun. Two are transfusion-related with few followers (only tweet when CBS actions warrant a humorous response):

• Graham Sure @Grahamknowsbest
• Blood Fluids Dot Ca @werefullofit

For transfusion news judged useful or interesting to others, I'll immediately put a link to it on @transfusionnews.

For those new to Twitter, you can register and never tweet, just follow others. Or, if that's too much, a simple approach is to bookmark the account's page and visit it when the mood strikes.

2. Other Twitter accounts
Many of the major TM players tweet and are worth following. Some examples:

• AABB @AABB
• BBTS ‏@BritishBloodTS
• CBS @itsinyoutogive
• CSTM @CanSocTransMed
• Graham Sher (CBS CEO and AABB President) @GrahamSher

LEARNING POINTS

1. Did you notice that most recommended websites were from countries with publicly funded health care and blood systems? Sharing is good.
2. All resources on TM websites in Australia, Canada, and UK are available to anyone with Internet access. In a way, it's a version of foreign aid.
3. Social media is in its infancy but will become ever more powerful as it transmogrifies who controls the message.

FOR FUN

No one says World Wide Web anymore but the web allows us in the West to share resources with those less fortunate around the globe.

Which led me to this month's music choice:

• We are the world (Multiple artists, mainly American - How many do you recognize?)

Also see

• We are the World for Haiti (2010, 25 years later - multiple artists, more international ones. Again, how many do you recognize?)

As always, comments are most welcome.

You don't own me (Musings on TM professionals as industry's poodles)

Updated 1 Nov. 2012

This month's blog is about how much of the TM information we consume is meant to inform, how much is crafted to persuade, and how much info purveyors assume we’re owned by them, i.e., their poodles. The title is from a 1964 Lesley Gore song. 

The blog was stimulated by 3 items:
1. Supposed news from new-medical.net in its 'Insights from industry' section:

• Blood banks: an interview with Celia Tombalakian, Worldwide Group Director, Immunohematology at Johnson & Johnson's Ortho-Clinical Diagnostics, Inc. (OCD) 

2. The article motivated me to visit OCD's 'On Demand' website and register to see its offerings. 

3. Then I was reminded of a recent research paper by OCD staff published in AABB's Transfusion:

• South SF, Casina TS, Li L. Exponential error reduction in pretransfusion testing with automation. Transfusion. 2012 Aug;52(8):81S-87S.

BACKGROUND
Increasingly, I suspect that industry owns the transfusion medicine community. In a way, it's natural given that TM was healthcare but now is business and has been for awhile. Businesses depend on each other to survive. You scratch my back and I’ll scratch yours.

Today's AABB is more and more cosy with commercial interests, which is also natural given the reliance of the former on the latter for advertising revenues and conference support. Plus, as noted in earlier blogs, some AABB luminaries have close ties with industry. It's one big happy family.

The blog’s components  - industry promoting automation via 3 mechanisms - are akin to a full court press in basketball in which industry pressures TM staff from every angle to buy into their false assertions about automation.

The blog's theme is how much industry thinks it owns us and attempts to baffle our brains with BS. 

A common thread in industry’s automation initiative is to create false arguments. For example, manual methods have more processes than automation (true), therefore automated instruments have fewer chances for human errors to occur (true). 

BUT… here’s the logical fallacy (the BS, if you will): Where do most serious TM errors occur? Are they related to manual testing? 

Read and assess for yourself.

1. INTERVIEW
First note where this interview was published: news-medical.net

As with many so-called health sites, news-medical's business model is not immediately apparent without reading the fine print. And let's face it, that's the first thing we do when visiting a website, right?

Part of the 3239 word, 27 point,Terms and Conditions:

News-Medical hereby discloses that a commission or listing fee may be payable by Experts to News-Medical for any fees received by them as a result of an introduction of a client through the Website.  

Unsurprisingly, the site's underlying purpose is to sell stuff.

Besides industry news, news-medical, based in Australia, cheaply repackages health information from several sources, including a heavy reliance on Wikipedia under the Creative Commons Attribution-ShareAlike License.

Below is my summary of a few highlights of OCD’s Celia Tombalakian's interview with news-medical.net in question and answer format, with my comments, aka musings, in italics. Readers are directed to the full interview for exactly what she said. 

The report is selective and my approach is facetious in places. But is it off the mark? You be the judge.

QUESTION: How is the blood banking industry currently being transformed?

CT's ANSWER

CT: Current focus is to improve transfusion safety and efficiency through technology solutions.  

Ah, safety and efficiency, with safety mentioned first. Who can argue?

CT: Over past 20 yrs, the number of highly skilled technologists and scientists entering the global TM workforce has shrunk. 

CT: Therefore, automation is becoming a standard part of blood bank laboratories because it eliminates many of the labor-intensive, time-consuming manual testing that requires specialized skills and significant experience to master.  

Really? Her response implies that automation arose because of staff shortages, which misleads in a chicken and egg sort of way.  

Why has the highly skilled technical and scientific TM workforce shrunk? Many reasons around the globe, inc. poor compensation for education involved (mainly USA), decreased health care funding, leading to regionalization and centralized testing, all facilitated by automation.  Automated instruments continue to be marketed on their ability to decrease absolute numbers of highly skilled staff.

CT: Ultimately, automation can increase a lab’s capacity and help it operate more efficiently, even with a smaller staff. 

A case can be made for how instruments are more reliable than humans, at least for some things. But notice there's no more mention of safety, only efficiency.

QUESTION. Tell us about the new Bloodbanker App and its benefits over traditional blood banking tools.

CT's ANSWER

CT: ORTHO's Pocket Blood Banker app is an educational reference tool that combines genotyping and antibody indexing. Users can quickly determine genotypes based on results with Rh antisera via the Genotype Calculator and learn more about antibodies with the Antibody Index.

CT: Prior to the app, blood bankers used reference tools such as cardboard slide rules. 

You gotta be kidding. Cardboard slide rules? Maybe that's what Ortho supplied customers back in the Jurassic age, but for decades I and many others taught MLS students how to determine Rh genotypes using their ... wait for it ... inbuilt computers, aka brains.

Reminds me of this exquisite Danish humour on computers: Medieval helpdesk

CT: Drawing from a deep understanding of the importance of and need for innovation in blood banking, OCD identified the need for more advanced tools and developed this new technology. The app reinforces our commitment to providing innovative solutions to our customers. 

OMG, classic marketing and branding. We're wise, we're innovative, we're dedicated to helping clients. Please bring us cute babies to kiss. 

QUESTION: Could you introduce Ortho ON DEMAND and how it fits with OCDs overall focus?

CT's ANSWER

CT: ON DEMAND is an innovative virtual engagement platform that enables blood bankers to learn from and connect with experts on topics central to achieving science-driven safety and efficiency in the blood bank. 

Attempt to reinforce Ortho's brand as innovative, Also love 'virtual engagement platform' and 'science driven.' Buzzwords convey modernity and objectivity, respectively. And note re-introduction of the safety and efficiency double whammy.

CT: With OCD’s strong TM history, we understand the importance of supporting industry through education and awareness. 

We're the pros, we understand. Trust us.

CT: Because many of today’s blood bankers work longer hours with fewer financial resources, many laboratories have had to cut costs that previously supported career growth opportunities. Through our new platforms, we hope to help prepare blood bankers to address growing demands for TM expertise. 

Excuse me? Labs have had to cut CE and CPD funding because staff work longer hours with less money? Does not compute. Pure bafflegab.

As for helping a growing demand for expertise, is there a growing demand for expertise? If so, it's to address what automation created in the first place, namely a diminished demand for technical and scientific expertise with fewer positions for TM specialists.

Frankly, automation and apps both contribute to and help alleviate a 'dumbing down' of the profession. I acknowledge that 'dumbing down' is a harsh catch phrase for staffing with less qualified personnel, not that such staff are dumb. I use the term to emphasize that apps do not contribute to developing expertise, but rather exist to alleviate lack of it.

QUESTION. What impact do you think these initiatives will have on blood bankers?

CT's ANSWER

CT: Many of today’s blood bankers struggle to do more with less, working longer hours with fewer financial resources. Concurrently, instrumentation is more complex and the number of transfusions is increasing globally. 

Meaningless bafflegab. Yes, cost constraints force blood bankers to do more with less.  

But instrumentation is more complex? More complex than what? Earlier instruments? Manual testing? Do sales reps' spiels include these words?  "Hey, our instrumentation is more complex. You need better trained dudes to operate it."   

Also, in an age of blood conservation and a kazillion studies on real and unproven potential transfusion dangers, what evidence exists that transfusion numbers have increased? Does not compute.

CT: With reduced resources, many labs cut travel costs to learning events that could better prepare staff to address growing demands for TM expertise. Ortho ON DEMAND addresses this challenge by offering TM professionals free access to education according to their own schedules.

Offering free online education has merit. But it's not exactly true that today's over-worked TM professionals are clamouring to access education on their own schedules. Employers allot no time during work hours. Staff who are under-paid and feel under-appreciated are increasingly less motivated to take time away from families to further their careers.

QUESTION: How do you think the future of blood banks will develop?

CT's ANSWER

CT: While technology has made many routine BB tasks faster and easier, the demand for blood continues to rise and the pace of processing blood continues to accelerate.  

Demand for RBC transfusions (type that automated instruments process in transfusion service labs) is increasing? Where's the evidence? Surely all the efforts on blood management, blood conservation, and improved utilization are having an impact on RBC usage.

Pace of processing blood continues to accelerate? What does this mean? I could speculate but she doesn't explain.  

CT: Hemovigilance and ensuring efficiency is of utmost importance to blood banks in maintaining a safe and accessible blood supply while keeping pace with accelerating demand for blood processing. 

Sounds good but what has hemovigilance to do with OCD's automation and apps? And again the unexplained 'accelerated demand for blood processing.'

CT: The future of blood banks lies in technological solutions that will allow blood bankers to increase safety and efficiency in order to provide the best possible outcomes for patients. 

Motherhood statement. But where is the evidence that automated ABO and Rh group testing and automated antibody screening have improved outcomes for transfused patients? Or that apps that generate Rh genotypes and describe antibodies have made a difference? 

Surely, getting patient identification correct when drawing blood samples and correlating patient identity to crossmatched donor blood when administering blood remain THE hallmarks of safe transfusion practice, the 'right patient, right blood product, at right time' mantra. 

QUESTION: What are OCDs plans for the future? Would you like to comment further?

CT's ANSWER

OCD is the global leader in Transfusion Medicine, stemming from a 70-year history of protecting the safety of the worlds blood supply. We intend to continue our leadership of the market into the future, both with our products and through our service and support of the blood banking community. 

Forgive me, but I'm jaundiced. Although I've known, liked, and respected many Ortho reps, having just read Blood Medicine (aka Blood Feud) about Ortho Biotech and Amgen's marketing of EPO products, protecting patient safety as applied to J & J or any Big Pharma company rings hollow.
Author Q & A

2. WEBSITE

Simply put, Ortho ON DEMAND offers varied worthwhile educational talks by respected TM professionals, but promotes automation. To illustrate, the first 4 talks in its Presentation section are about automation. 

I'm reminded that Ortho and its competitors such as Immucor operate on a razor-blade business model: cheap razors (instruments), with the real money made on expensive blades (reagents).

3. RESEARCH PAPER
This paper by OCD employees further shows how industry treats TM professionals like poodles, hoping to baffle brains with BS. 

• South SF, Casina TS, Li L. Exponential error reduction in pretransfusion testing with automation. Transfusion. 2012 Aug;52(8):81S-87S.

Interestingly, one of the authors, TS Casina, an OCD marketing manager, also penned these 3 articles:

Casina TS. Technologies to improve the future of blood banking. Med Lab Obs 2011 Oct;43(10):32. Excerpt:

• 'As the labor force shrinks, the rapidly evolving field of laboratory medicine is struggling to keep pace with the growing demand for blood and its components. Automation is becoming a standard part of blood bank laboratories because it can help eliminate the labor-intensive, time-consuming manual testing processes that require specialized skills and significant experience to master.'

Casina TS. What's new in transfusion services. Advance for Med Lab Professionals. Posted online 19 Sept. 2012. Excerpt:

• Transfusion of incompatible blood has the greatest potential for severe adverse events and health complications, including death. Fortunately, due to advances in transfusion medicine (TM) practices -improved blood testing, donor screening and the advent of automated systems - the blood transfused to patients is safer today than it's ever been.

Casina TS. References for "transfusion medicine reactions. Advance for Administrators of the Laboratory 2012 Oct;21(10):20. This paper is a reworked version of the one above. Excerpt: 

• A study conducted by Ortho Clinical Diagnostics provides quantitative evidence of how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thereby improve the safety of blood transfusion.  Evaluating the common testing methods above and leveraging failure modes and effects analysis (FMEA) to compare error potentials, the group concluded that automation significantly reduces defect opportunities in pretransfusion testing and could dramatically improve blood transfusion safety.

Can you see how marketing managers use a full court press and recycled material (with the help of willing publishers desperate for articles) to get their message out to industry's poodles, namely us?

Abstract Highlights (Transfusion paper)

BACKGROUND: Human error associated with manual pretransfusion testing is a cause of transfusion-related mortality and morbidity and most human errors can be eliminated by automated systems. 

STUDY DESIGN AND METHODS: Study’s goal was to compare error potentials of commonly used manual (e.g., tiles and tubes) vs automated (e.g., ID-GelStation and AutoVue Innova) group and screen (G and S) methods. G and S processes in 7 TS labs (4 with manual and 3 with automated methods) were analyzed to evaluate error potentials of each method.

Tiles?  Really? Well, they could be large welled plates. But who uses these in routine manual pretransfusion testing?  

RESULTS: Manual methods contained more process steps ranging from 22 to 39; automated methods contained 6 to 8 steps.  

Roughly 4-5 times more steps for manual methods. Authors then use ‘risk priority numbers’ (RPN)  - trust me, you don’t want to go there -  to show manual method RPNs ranged from 5304 to 10,976 vs 129 and 436 for automated methods, conveniently making manual tests away more than 4-5 times as risky as automation.

What the hey! Let's go there. A team (needed to reduce subjectivity) of OCD researchers and staff at 7 TS labs determined how many defects were likely at each process step (defect opportunities) and decided where failures could occur, the likelihood that the failure would be identified, how frequently the failures might occur, and what the effects of those failures (severity) were. The result was a 10 point scale. An example: 

Process Step 16 (tile or plate required tapping and rocking before reading reactions) had 18 defect opportunities. 18 represents 6 wells in the tile or plate in which it was possible to undertap reactants (6 defect opps), forget to tap the plate (6 defect opps), or overtap and splash reactants among wells (6 defect opps) for a total defect opportunity of 18 at that step (6 + 6 + 6 + = 18). The severity was rated 7 out of 10.

Wow! Talk about creative number crunching to get the results you want. The mind boggles....

CONCLUSION: This study provided quantitative evidence on how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thus would improve the safety of blood transfusion.

Oh sure. Is I or is I not your poodle?

MORE MUSINGS
This study’s logical fallacy posits (love that word!) that most, or even many, serious transfusion errors result from manual testing of ABO and Rh groups and manual antibody screening. It's true that manual testing has potential to create more errors than automated testing.

The best evidence of where TM errors occur comes from the UK’s annual SHOT Reports. For example, consider 

• 2011 SHOT Report

I’ll not bore you with too many specifics  - you can read for yourself - but believe me, it’s NOT all about lab staff making technical errors when manually testing. 

'Adverse reactions caused by errors' lists these causes of cumulative cases reviewed 1996-2011 (n=9925):

• Anti-D errors 
• Inappropriate & unnecessary
• Handling & storage errors
• Incorrect blood component transfused (n>3000)

To quote SHOT: Key lesson from 2011 is an emphasis again on the importance of the essential steps of the transfusion process:

• Taking the blood sample from the correct patient 
• Correct laboratory procedures
• Issuing of the correct component
• Identification of the right patient at the bedside at the time of transfusion
• It is clear from the SHOT 2011 data that identification of the correct patient remains a key issue and that this must become a core clinical skill.

BOTTOM LINE
So, what's it all about? Yes, automation can increase efficiency and increase safety by reducing human error. But is automation the TM saviour that industry reps and some TM professionals make it out to be? 

When you examine the arguments of proponents, such as OCD's Celia Tombalakian or the research of OCD employees, their arguments do not stand up to scrutiny. They continually overstate how automated testing can improve safety and propose it as magic it is not. 

Companies have a vested interest in promoting automated testing since the business model of cheap razor (instrument) and expensive blades (reagents) is what makes their industry viable. 

Their multi-media advertisements are relentlessly promoted to TM professionals using flawed arguments that show they think they own us and we are their poodles. 

FOR FUN

Industry's seeming hold on so many TM professionals brings to mind:

• You Don't Own Me (1964 ditty by Lesley Gore; this version in Australia, 1989)

• You Don't Own Me (Same song re-worked for 2012 USA election - thoroughly partisan. ALERT: Depending on your politics, you may be offended.)

• You Don't Own Me (Diane Keaton, Bette Midler, Goldie Hawn in 1996 movie The First Wives Club)

Comments are welcome but due to excess spam this section is removed. Please send comments to me personally.

Goldfinger's filings, a customer's toolkit (Musings on business intelligence)

Updated: 28 Jan. 2017 (Fixed broken links)

This blog's thesis is only slightly tongue in cheek but its title definitively is. The title derives from the ubiquitous toolkits currently found everywhere in transfusion practice, and the 1964 James Bond movie, Goldfinger in which the eponymous character is obsessed with gold, much like private companies are focussed on profits, albeit not usually with the same gleeful fervour as a sinister villain.

As an aside, Goldfinger has special memories for me because I saw the film in Tel Aviv, Israel in 1965. We had to buy tickets ahead of time (none sold at the door) and catch much of the dialogue by reading the French sub-titles (goodness knows why) due to the uproarious cheering of the audience at every Sean Connery feat. We were told that television was only on for a few hours each day and movies were incredibly popular.

By happenstance I came across the SEC Form 10-K Annual report for Immucor, a blood industry supplier of automated instruments and reagents. The Form 10-K reports, which public companies file with the U.S. Securities and Exchange Commission, offer comprehensive business overviews of a registrant's business, such as history, competitors, risk factors, legal proceedings.

Now before your eyes glaze over, if you work in the blood system in any capacity, I highly recommend that you take a peek at these fascinating reports. In a way, it's akin to industrial espionage, i.e., gaining access to information about a company’s plans, products, clients, and trade secrets in order to gain insights and predict their actions, including marketing strategies and sales pitches.

Normally it's competitors who engage in industrial espionage, but if you buy a company's products and services, you can potentially use the information to your advantage. Spying is illegal if the information is private but, since the SEC records are public, it's all above board and fair game.

Donning our sleuth caps, let's examine just a few aspects of the business intelligence that's publicly available in Immucor's July 2010 SEC filing and how it can be used to advantage by potential clients.

The specific information is most relevant to those in the lab but the lessons can be applied to dealing with any sales representative and related marketing, advertising, and selling strategies targetted to your profession.

Immucor's SEC 10-K report merely serves as an example. To all my sales rep friends and colleagues, as they say in the Godfather films, "It's not personal. It's strictly business."

Reality is that companies spend considerable time and effort getting to know potential customers and understand their likes, dislikes, wants and needs. Think of those free wine and cheese parties, dinners, and tour-the-bay cruises you've attended at conferences. They weren't just to create goodwill. Similarly, customers can benefit from knowing how companies think and what tools they will probably use to get you to buy.

Here's a mini-toolkit to get you started. Quoted text is from Immucor's SEC Form 10-K report (23 July 2010).

1. AUTOMATION

"Our strategy is to drive automation in the blood bank."

MUSINGS

Obviously, automation must be strongly promoted, since it is in Immucor's interest to sell its instruments and automated ("capture") reagents. As mentioned in an earlier blog, the latter have one of the highest gross profit margins in the industry, 80.2% in Immucor's 3rd quarter for 2010.

From a client's perspective, profits in the range of 80% may seem excessive. But profits are the primary purpose of private enterprises. From the company's perspective, the higher the profit the more they will be able to

• pay shareholders
• raise additional financing
• survive in hard times
• invest in R&D that can develop new products and lead to continued or increased profits.

However, to drive automation and increase profit, automation must be seen not as a way to increase profits, but as a way for clients to save money while improving safety.

Hence the comapany's sales pitch:

"We believe our customers...benefit from automation. Automation can allow customers to reduce headcount as well as overtime in the blood bank, which can be a benefit given the current shortage of qualified blood bank technologists.

We also believe that automation can improve patient safety, can increase operational efficiency and, for customers such as integrated delivery networks with multiple blood banks, can permit the standardization of best practices.

For Immucor, automation allows us to gain market share and secure a long-term, contractual relationship with our customers."

MUSINGS

On the safety issue, while it may be true (or not), is there published evidence to support a decrease in life-threatening errors and resultant increase in patient safety after Immucor's automated instruments have been introduced in the transfusion service?

Don't ya' love "reduce headcount," an euphemism for eliminate staff, and interesting that it merits first place ahead of "improve patient safety."

About the "current shortage of qualified blood bank technologists", this largely happened because restructuring and regionalization with associated automation led to fewer jobs, which in turn led to closures of medical technology schools. Concurrently, at least in Canada, nurse and physician education programs were also decimated.

In Canada, in response to increased demand, more technologists (nurses and doctors) are now being trained, but a significant number of jobs for technology graduates continue to be part-time.

In a way, automation contributed to a shortage of "qualified blood bank technologists" and now automation is being promoted as a solution to the shortage. Say what?

Fact is that automation allows for less trained staff to perform routine work in the transfusion service and leads to fewer blood bank specialists. Isn't it having it both ways to say that automation now solves the problem that it intrinsically helped create?

In the past, I recall that Immucor promoted its automated instruments to transfusion services as a way to save ~1.5 staff members and to allow remaining staff to concentrate on more 'important stuff' for thinking technologists (i.e., humans) such as identifying antibodies.

In today's economic climate, I imagine that cost saving is still the main mantra of the sales reps, with patient safety tossed in as a 'feel good' justification for eliminating jobs.

With automation, it's worth considering what is actually happening, i.e, a transfer of money from people (staff) residing in a community (people who pay taxes, buy houses, shop and support local businesses, and contribute to community life) to generating profits for a large corporation situated elsewhere. Does this benefit society in the long run? Complicated question but I sometimes wonder.

Obviously those considering automation need to extensively analyse multiple factors between competitors such as

• initial capital costs
• ongoing maintenance and reagent costs
• sensitivity and specificity (as applicable)
• ease of use
• ease of transition and implementation (impact on other processes & procedures)
• redesign of physical layout, etc.
• training requirements, and more

Potential clients should also consider Immucor's huge gross profit margins when negotiating reagent contracts. And it's worth remembering that those long-term contracts for reagents are where the money is. From the NEC submission:

"As of May 31, 2010, we had an instrument backlog of approximately 179 Echos and 43 Galileo/NEOs. This backlog represents instrument orders that have been received but the instruments have either not been installed or the customer validation process has not been completed.

As such, the instruments are not generating recurring reagent revenue at their expected annualized run rates. ....we had not recognized approximately $16.7 million in deferred revenue from instrument sales contracts that had reagent price protection and from extended warranty sales."

Note that Immucor considers extended sales contracts to have built-in reagent price protection. Did they mean protection for themselves or clients or both?.

#2. NEW PRODUCTS

Successful companies must continually innovate to create new products and generate new profits.

" For the fiscal years ended May 31, 2010...we spent approximately $15.4 million...for research and development. Research and development expenses have increased over the past three years due to the acquisition of BioArray...and the subsequent development work on our molecular immunohematology offering."

"In August 2008, we invested in what we believe will be the future of the blood bank – molecular immunohematology....With the goal of improving transfusion medicine, we believe that molecular immunohematology will revolutionize blood bank operations.

In many countries, blood pre-transfusion testing is limited to the prevention of transfusion reactions and not for the prevention of alloimmunization, which occurs when antigens foreign to the patient are inadvertently introduced into the patient’s blood system through transfusions. If alloimmunization occurs, the patient develops new antibodies in response to the foreign antigens, thereby complicating future transfusions.

By using multiplex, cost-effective molecular testing, our molecular technology allows testing to prevent alloimmunization for better patient care."

MUSINGS

In a consumer society, if a real need does not exist, companies try to create one.

So, can we now expect an onslaught of propaganda and industry-funded research to convince us that preventing alloimmunization is where it's at and what we should strive for?

My gut reaction is fuggedaboutit! But the writing is already on the wall:

• Hillyer CD, Shaz BH, Winkler AM, Reid M. Integrating molecular technologies for red blood cell typing and compatibility testing into blood centers and transfusion services. Transfus Med Rev. 2008 Apr;22(2):117-32.

#3. RISKS

Under "Risks", Immucor lists FDA "administrative action", governmental investigations and litigation, fluctuations in foreign currency, and more. Three that stood out:

(i) "A catastrophic event at our Norcross, Georgia facility would prevent us from producing many of our reagent products.

Substantially all our reagent products are produced in our Norcross facility.... and we currently have no plans to develop a third-party reagent manufacturing capability.

Therefore, if a catastrophic event occurred at the Norcross facility, such as a fire or tornado, many of those products could not be produced until the manufacturing portion of the facility was restored and cleared by the FDA.

We maintain a disaster plan to minimize the effects of such a catastrophe, and we have obtained insurance to protect against certain business interruption losses.

However, there can be no assurance that such coverage will be adequate or that such coverage will continue to remain available on acceptable terms, if at all."

MUSINGS: Despite a disaster plan to minimize effects (on clients and the bottom line?) the company's main worry seems to be that its insurance may not cover its losses.

Clients need to include a scenario with a possibly very long delay in obtaining reagents in their disaster plans. Think not only of time to restore production but also time to obtain FDA clearance on a restored facility.

(ii) "Gross margin volatility may negatively impact our profitability."

"Our gross margin may be volatile from period to period due to various factors, including instrument sales, reagent product mix and manufacturing costs....

The higher margins on the Capture reagents used on our instruments may not be enough to offset the lower margins on the instruments themselves...."

MUSINGS: Once again, the importance of Capture reagents to profits is emphasized. Immucor's gross profit margins for these reagents are among the highest in the business. When faced with, "Have I got a deal for you", best to think twice.

(iii) "If customers delay integrating our instruments into their operations, the growth of our business could be negatively impacted."

From time to time in the past, some of our customers have experienced significant delays between the purchase of an instrument and the time at which it has been successfully integrated into the customer’s existing operations and is generating reagent revenue at its expected annualized run rate. 
 
These delays may be due to a number of factors, including staffing and training issues and difficulties interfacing our instruments with the customer’s computer systems.

Because our business operates on a “razor/razorblade” model, such integration delays result in delayed purchases of the reagents used with the instrument.

A number of steps have mitigated these integration delays: improved performance of our field service staff, better instrument instructions, increased use of internet-based remote diagnostic tools, and more efficient scheduling of instrument installations....."

MUSINGS

Potential clients should note the reasons for delayed implementation and acknowledgement of the “razor/razorblade” business model.

A “razor/razorblade” model is the well established business tactic of selling dependent goods for different prices. The one-time product is sold at a discount, while the second dependent one for which repeated purchases are required, is sold at a considerably higher relative price. Think of the practically free razor but expensive replacement razor blades or the low priced video game console and its dependent high priced games.

4. COMPETITORS

"In the U.S. and Canada, Ortho-Clinical Diagnostics (“Ortho”), a Johnson & Johnson company, is our main competitor. In Western Europe, our principal competitors are Bio-Rad Laboratories, Inc. (“Bio-Rad”) and Ortho. Both Ortho and Bio-Rad sell instrumentation as well as reagents. Our principal competitor in Japan is Ortho."

MUSINGS

There is not much competition in transfusion service / immunohematolgy automation, nor for reagents for non-automated testing. Immucor, along with its main US competitor, Ortho-Clinical Diagnostics, is being investigated by the US Department of Justice concerning possible criminal violations of the antitrust laws.

Perhaps not unsurprisingly, both are the subjects of several private civil suits by customers (hospitals) seeking class certification and alleging price fixing.

Anytime you have a market oligopoly, a virtual duopoly, allegations of collusion and price fixing are bound to occur, but they are almost impossible to prove. 

FURTHER BUSINESS INTELLIGENCE
For interest, a few more blood industry companies with SEC Form 10-K reports:

• Johnson & Johnson (1 Mar. 2010) (parent company of Ortho-Clinical Diagnostics)
• Tidbit in report (OCD has many more products besides reagents and automated instruments for pretransfusion blood testing)
• "The Ortho-Clinical Diagnostics franchise achieved sales of $2.0 billion in 2009, a 6.6% increase over the prior year primarily attributable to the recent launch of the VITROS 3600 and 5600 analyzers."
• Bio-Rad Laboratories (26 Feb. 2010)
• Beckman Coulter (22 Feb. 2010)
• Haemonetics (1 June 2010) - One tidbit (and are we surprised?):
• "Our devices use single-use, proprietary consumables, and these consumable sales represent 87% of our total revenues."

BOTTOM LINE
You can discover many useful tidbits in SEC Form 10-K filings. These tidbits can be used to help customers decide on suppliers and to leverage information when negotiating contracts. I hope that this Goldfinger toolkit has given a few ideas.

For fun, here's the theme song from the Bond movie of the same name:

• Goldfinger (by the wonderful Shirley Bassey)

As always, the ideas are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice.