An Uneasy Marriage: Health Care Technology and its Relationship to Quality Richard Afable, MD Orange County Employee Benefits Council January 11, 2007
Agenda Definition of Quality Health Care Discussion of Technology The Marriage of Quality and Technology: always beneficial? Lessons learned
What Is Quality? The Institute of Medicine (IOM) defines quality healthcare as having six aspects Safe Effective Patient-Centered Timely Efficient Equitable
Quality-Safe Avoiding injury from care that is intended to help The IOM, in To Err is Human, estimated that nearly 100,000 lives are lost in hospitals annually due to medical errors Healthcare needs to be safe and protect patients from needless injuries
Quality-Effective Avoiding under-use use or over-use of services Patients must be able to receive the right service at the right time
Quality-Patient Patient-Centered Providing respectful, responsive and individualized care Care processes must be designed from a patient s perspective and not from a hospital s or physician s viewpoint
Quality-Timely Reducing waits and harmful delays in care Hospitals must design processes to deliver appropriate care rapidly Heart attack patients need to have their coronary arteries opened within 90 minutes of arriving at the hospital to preserve function
Quality-Efficient Avoiding waste of equipment, supplies, ideas and energy The cost of healthcare in the US is skyrocketing Must be judicious in the use of scare resources
Quality-Equitable Providing equal care regardless of personal characteristics, gender, ethnicity, geographic location and socio-economic status There exists a wide variation of healthcare utilization depending on where you happen to live in the US Although there is too much variation even within a community
Coronary Artery Bypass Grafting (CABG) per 1,000 Medicare Enrollees HSA Level Rates (2003) Area Population Rates Ratio to Bench mark *National Average 28,767,985 5.18 - - Mission Viejo, CA 10,504 5.88 1.13 7 Orange, CA 9,429 3.75 0.72-14 Newport Beach, CA 22,956 3.7 0.71-34 Laguna Hills, CA 12,593 3.31 0.64-24 Fountain Valley, CA 13,470 3.3 0.64-25 Anaheim, CA 22,865 3.18 0.61-46 Huntington Beach, CA 11,490 3.18 0.61-23 Santa Ana, CA 13,057 2.59 0.5-34 Source: Dartmouth Atlas of Care- www.dartmouthatlas.com Accessed December 21, 2006 Surplus/ Deficit
Technology
Definition of Technology Technology is the technical means people use to improve their surroundings. It is also a knowledge of using tools and machines to do tasks efficiently. We use technology to control the world in which we live. Technology is people using knowledge, tools, and systems to make their lives easier and better. People use technology to improve their ability to do work. Through technology, people communicate better. Technology allows them to make more and better products. Our buildings are better through the use of technology. We travel in more comfort and speed as a result of technology. Yes, technology is everywhere and can make life better.
Is there a robot in the house?
Question: Does new technology always mean better quality?
Quality Attributes Technologies (Devices, Pharmaceuticals) Start Outcome Best Clinical Process
OR Robotics Advantages: : Minimally invasive approach to open procedures with less tissue trauma, bleeding and patient morbidity. Nerve sparing prostate surgery Cost: $1.3M capital; $129K maintenance, $2K supplies/robot procedure vs. $295 supplies/open procedure Challenges: Changes OR process, long learning curve, increased surgical time, dedicated staffing, OR redesign. Results: no data of clear clinical benefit
Diffusion Curve: Drug Eluting Stents Drivers & Barriers Notes: Market Availability Year: 2003 Implementation Year: 2003 Full Impact Year: 2005
Consumer Demand for Technology 50% of Consumers Say Most Advanced Hospital Technology Is Critical Factor In Hospital Selection 100% 80% Percentage Saying Factor Very Important 60% 40% 20% 0% Source: Solucient HealthViewPlus ; 2002 Most Tech Advanced MD Recommends
IT Moves to Center Stage Factors driving IT: Nearly all medical technologies will transmit something - an image a report a point of data and IT will have to capture, send, sort and store these streams.
IT Moves to Center Stage Virtual visits Remote Patient Management Patient & clinician no longer have to be in proximity for the delivery of care Technology can transport brainpower and information to manage difficult to reach populations ICUs likely to benefit from centralized, round-the-clock management Some workforce shortages will be alleviated through remote management of patients
IT Moves to Center Stage IT drives efficiency: wireless technologies enable information entry, access at the bedside promise an end to lost wheel chairs, infusion pumps or patients provide direct access to clinicians and staff, even off-site Complex choices in planning for IT infrastructure IR Readers per room RF Reader per zone Wall Ceiling IR IR Ceiling Wall IR IR Ceiling Wall IR Ceiling RF RF Wall LONTALK Network IR/RF tag IR tag IR Badge IR/RF Badge RFID System
IT Impact Projections
Technology Challenges Number of new devices / drugs / procedures
New Patents by Class Class Title 2000 2001 2002 2003 Drug, Bio-Affecting and Body Treating Compositions 6,757 7,316 7,556 6,972 Image Analysis 1,245 1,412 1,241 1,626 Medical and Laboratory Equipment 673 759 598 700 Surgery 5,161 4,932 4,971 6,043 X-Ray or Gamma Ray Systems or Devices 379 534 600 452 Source: Sg2 private conversation
Technology Challenges Number of new devices / drugs / procedures Different cultural views Physician Vendor Hospital
The Physician Culture Physicians are scientists New technologies are tools of their trade Belief and hope that all new technologies will improve patient care Belief in the inherent right to try new technologies New technology s ability to increase revenue
Vendor Culture Physicians are the true customers Hospitals are the portal to get invoices paid There is a right to be in the OR when called upon to provide product education Sales are key driver
Hospital Culture New technologies are important to the evolution of improved patient care and strategic plans Not all new technologies are clinically and cost effective Limited financial resources require hospitals to make choices on which technologies to adopt
Technology Challenges Number of new devices / drugs / procedures Different cultural views Physician Vendor Hospital Understanding the total cost of adoption
What Is the True Cost? Purchase price Total cost?
Technology Challenges Number of new devices / drugs / procedures Different cultural views Physician Vendor Hospital Understanding the total cost of adoption Individual adoption curve
Diffusion Process % Diffusion of Technology tipping point at 10-20% adoption Laggards (16%) Late Majority (34%) Early Majority (34%) Early Adopters (13.5%) Innovators (2.5%) 2003 Year Source: Everett Rogers Diffusion of Innovations, 1995
Trends in Health Care......leading us to look at new and emerging technologies. Neurosciences Devices and Pharmaceuticals Evolution, 2004 2014 Innovators (1) Early Adopters (2) Consensus Adopters (3) Brachytherapy for brain cancer Vagal nerve stimulation for epilepsy Deep brain stimulation for Parkinson s Stereotactic radiosurgery for brain cancer Endovascular coiling Embolic protection devices for carotid atherosclerosis Liquid embolic gel for cerebral vascular disorders Stereotactic radiosurgery for epilepsy Vagal nerve stimulation for depression 2004 d 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Sg2 Analysis, 2004. Presented at Premier s All Committee Meeting, 14 September 2004. Nitinol stents for cerebrovasculature Magnetic field navigation for cerebral aneurysms Spinal cord transplantation for spinal cord injury Emboli capture devices for cerebrovascular diseases Stereotactic radiosurgery for Parkinson s Stem cell transplantation for MS Neuroprotective, anti-inflammatory and antioxidant therapy Gene therapy for Parkinson s
Technology Challenges Number of new devices / drugs / procedures Different cultural views Physician Vendor Hospital Understanding the total cost of adoption Evolutionary vs. revolutionary technology Individual adoption curve Lack of standard approach to technology evaluation (technology assessment)
Technology Assessment: An evidence-based selection process Definition - The evaluation of physician- preference supplies and equipment that, once adopted, changes the way we practice medicine. Elements: Clinical effectiveness Cost effectiveness Reimbursement
Premier Technology Assessment Member Survey 2005 Responses from 405 facilities 149 (36%) had a Technology Assessment Committee Most operational 1-51 5 years (70%) 16% had physicians as a regular member 88% of the committees responsible for new technologies 84% stared their committees were somewhat to very successful
Lessons Learned Quality of care often isn't dependant on the newest technology, it can often be a product of doing the things we know work for every patient New technologies are coming out at a very rapid rate. Newer doesn't necessarily mean better, but it almost always does more expensive.
Lessons Learned Our challenge: to evaluate new technology in the context of what value it brings. Understand the consumer effect Direct to consumer advertising Perceptions versus reality Accountability for results
The Top Ten Technology Trends Shift to Earlier Interventions Drive Delivery System Reconfiguration Treatment patterns shift upstream to screening, prevention, and less invasive surgeries and therapies and to ambulatory and home care settings Patients Embrace The "Bionic Man" Model Successful biosynthetic and drug implants target early stage chronic conditions Cancer Is Tamed But Not Conquered - Advances in cancer treatments shift the focus from acute to chronic care management and prevention Inpatient Cardiac Services No Longer A Top Revenue Generator - Improved medical management of cardiac patients reduces surgical interventions, creating fiscal challenges for delivery systems Access to 24x7 Healthcare Becomes A Reality - Open architecture for medical informatics platforms and networking ng technologies give patients and physicians real-time data access
Workforce Shortages Soothed By Technology Deployment - A wide variety of technologies finally deliver productivity improvements throughout the healthcare workforce Smarter, Smaller Surgical Devices Drive Volume To MIS - Minimally invasive and noninvasive surgeries replace more than 80% 8 of the current open surgeries End-Stage Care Morphs To Long Term Management - Successful end stage therapies drive up the demand for chronic care c services The Top Ten Technology Trends Information Technology Moves to Center Stage - Nearly all medical technologies will transmit something, either an image, a report, or a point of data and IT will have to capture, send, sort, and store these streams Blockbuster Drugs Wilt As Customized Therapies Blossom - Pharmaceutical companies find markets for blockbuster drugs evaporating as genetic testing and imaging define the nature of disease more precisely
Thank You! It s s been fun. Any question?