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An Uneasy Marriage: An Uneasy Marriage: Health Care Technology and Health Care Technology and its Relationship to Qualityits Relationship to Quality
Richard Afable, MDRichard Afable, MDOrange County Orange County
Employee Benefits CouncilEmployee Benefits CouncilJanuary 11, 2007January 11, 2007
AgendaAgenda•• Definition of Quality Health Care Definition of Quality Health Care •• Discussion of TechnologyDiscussion of Technology•• The Marriage of Quality and The Marriage of Quality and
Technology: always beneficial? Technology: always beneficial? •• Lessons learned Lessons learned
What Is Quality?What Is Quality?•• The Institute of Medicine (IOM) defines The Institute of Medicine (IOM) defines
quality healthcare as having six aspectsquality healthcare as having six aspects–– SafeSafe–– Effective Effective –– PatientPatient--CenteredCentered–– TimelyTimely–– EfficientEfficient–– EquitableEquitable
QualityQuality--SafeSafe•• Avoiding injury from care that is Avoiding injury from care that is
intended to helpintended to help•• The IOM, in To Err is Human, estimated The IOM, in To Err is Human, estimated
that nearly 100,000 lives are lost in that nearly 100,000 lives are lost in hospitals annually due to medical errorshospitals annually due to medical errors
•• Healthcare needs to be safe and protect Healthcare needs to be safe and protect patients from needless injuriespatients from needless injuries
QualityQuality--EffectiveEffective•• Avoiding underAvoiding under--use or overuse or over--use of use of
servicesservices•• Patients must be able to receive the Patients must be able to receive the
right service at the right timeright service at the right time
QualityQuality--PatientPatient--CenteredCentered•• Providing respectful, responsive and Providing respectful, responsive and
individualized careindividualized care•• Care processes must be designed from Care processes must be designed from
a patient’s perspective and not from a a patient’s perspective and not from a hospital’s or physician’s viewpointhospital’s or physician’s viewpoint
QualityQuality--TimelyTimely•• Reducing waits and harmful delays in Reducing waits and harmful delays in
carecare•• Hospitals must design processes to Hospitals must design processes to
deliver appropriate care rapidlydeliver appropriate care rapidly–– Heart attack patients need to have their Heart attack patients need to have their
coronary arteries opened within 90 coronary arteries opened within 90 minutes of arriving at the hospital to minutes of arriving at the hospital to preserve functionpreserve function
QualityQuality--EfficientEfficient•• Avoiding waste of equipment, supplies, Avoiding waste of equipment, supplies,
ideas and energyideas and energy•• The cost of healthcare in the US is The cost of healthcare in the US is
skyrocketingskyrocketing•• Must be judicious in the use of scare Must be judicious in the use of scare
resourcesresources
QualityQuality--EquitableEquitable•• Providing equal care regardless of personal Providing equal care regardless of personal
characteristics, gender, ethnicity, geographic characteristics, gender, ethnicity, geographic location and sociolocation and socio--economic statuseconomic status
•• There exists a wide variation of healthcare There exists a wide variation of healthcare utilization depending on where you happen to utilization depending on where you happen to live in the USlive in the US
•• Although there is too much variation even Although there is too much variation even within a communitywithin a community
Ratio to
Surplus/
Benchmark
Deficit
*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
Coronary Artery Bypass Grafting (CABG) per 1,000 Medicare EnrolleesHSA Level Rates (2003)
Area Population Rates
Source: Dartmouth Atlas of Care- www.dartmouthatlas.comAccessed December 21, 2006
TechnologyTechnology
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.
Definition of Technology
Is there a robot in the house? Is there a robot in the house?
Question: Question:
Does new technology always Does new technology always mean better quality?mean better quality?
Start Outcome
Best Clinical Process
Quality AttributesTechnologies (Devices, Pharmaceuticals)
OR RoboticsOR RoboticsAdvantagesAdvantages: Minimally invasive approach to : Minimally invasive approach to
open procedures with less tissue trauma, open procedures with less tissue trauma, bleeding and patient morbidity. Nerve bleeding and patient morbidity. Nerve sparing prostate surgerysparing prostate surgery
Cost: Cost: $1.3M capital; $129K maintenance, $2K $1.3M capital; $129K maintenance, $2K supplies/robot procedure vs. $295 supplies/robot procedure vs. $295 supplies/open proceduresupplies/open procedure
Challenges:Challenges: Changes OR process, long learning Changes OR process, long learning curve, increased surgical time, dedicated curve, increased surgical time, dedicated staffing, OR redesign.staffing, OR redesign.
Results: no data of clear clinical benefit Results: no data of clear clinical benefit
Notes: Market Availability Year: 2003Implementation Year: 2003Full Impact Year: 2005
Drivers &Barriers
Diffusion Curve: Drug Eluting Stents
50% of Consumers Say Most Advanced Hospital Technology Is Critical Factor In Hospital Selection
0%
20%
40%
60%
80%
100%
Most TechAdvanced
MDRecommends
Percentage Saying Factor Very Important
Source: Solucient HealthViewPlus™; 2002
Consumer Demand for TechnologyConsumer Demand for Technology
• 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 StageIT Moves to Center StageFactors driving IT:
• 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 StageIT 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
IT Moves to Center StageIT Moves to Center Stage
IR Readers per room RF Readerper zone
IR IR
IR tag
RF
LON
TALK
Net
wor
k
RFID SystemIR Badge IR/RF Badge
IR/RF tag
Wal
l
Wal
l
Wal
l
Wal
l
CeilingCeilingCeilingCeiling
IRIR IR
RF
IT Impact Projections
Technology ChallengesTechnology Challenges•• Number of new devices / drugs / Number of new devices / drugs /
proceduresprocedures
New Patents by ClassNew Patents by Class
Source: Sg2 private conversation
Class Title 2000 2001 2002 2003
Drug, Bio-Affecting and Body Treating Compositions 6,757 7,316 7,556 6,972Image Analysis 1,245 1,412 1,241 1,626Medical and Laboratory Equipment 673 759 598 700Surgery 5,161 4,932 4,971 6,043X-Ray or Gamma Ray Systems or Devices 379 534 600 452
Technology ChallengesTechnology Challenges•• Number of new devices / drugs / Number of new devices / drugs /
proceduresprocedures•• Different cultural viewsDifferent cultural views
•• PhysicianPhysician•• VendorVendor•• HospitalHospital
The Physician CultureThe Physician Culture•• Physicians are scientistsPhysicians are scientists•• New technologies are tools of their New technologies are tools of their
tradetrade•• Belief and hope that all new Belief and hope that all new
technologies will improve patient caretechnologies will improve patient care•• Belief in the inherent right to try new Belief in the inherent right to try new
technologiestechnologies•• New technology’s ability to increase New technology’s ability to increase
revenuerevenue
Vendor CultureVendor Culture•• Physicians are the true customersPhysicians are the true customers•• Hospitals are the portal to get invoices Hospitals are the portal to get invoices
paidpaid•• There is a right to be in the OR when There is a right to be in the OR when
called upon to provide product called upon to provide product educationeducation
•• Sales are key driverSales are key driver
Hospital CultureHospital Culture•• New technologies are important to the New technologies are important to the
evolution of improved patient care and evolution of improved patient care and strategic plansstrategic plans
•• Not all new technologies are clinically Not all new technologies are clinically and cost effectiveand cost effective
•• Limited financial resources require Limited financial resources require hospitals to make choices on which hospitals to make choices on which technologies to adopttechnologies to adopt
Technology ChallengesTechnology Challenges•• Number of new devices / drugs / Number of new devices / drugs /
proceduresprocedures•• Different cultural viewsDifferent cultural views
•• PhysicianPhysician•• VendorVendor•• HospitalHospital
•• Understanding the total cost of Understanding the total cost of adoptionadoption
Purchase price
Total cost?
What Is the True Cost?
Technology ChallengesTechnology Challenges•• Number of new devices / drugs / Number of new devices / drugs /
proceduresprocedures•• Different cultural viewsDifferent cultural views
•• PhysicianPhysician•• VendorVendor•• HospitalHospital
•• Understanding the total cost of Understanding the total cost of adoptionadoption
•• Individual adoption curveIndividual adoption curve
Diffusion ProcessDiffusion Process
Early Adopters (13.5%)
Early Majority (34%)
Late Majority (34%)
Year2003
Innovators (2.5%)
Laggards (16%)
% D
iffus
ion
of T
echn
olog
y
Source: Everett Rogers Diffusion of Innovations, 1995
tipping point at 10-20% adoption
Trends in Health Care...Trends in Health Care...
Source: Sg2 Analysis, 2004. Presented at Premier’s All Committee Meeting, 14 September 2004.
Innovators (1)Early Adopters (2)Consensus Adopters (3)
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Emboli capture devices for
cerebrovascular diseases
Stereotactic radiosurgery for epilepsy
Endo- vascular coiling
Vagal nerve stimulation
for depression
Magnetic field navigation for
cerebral aneurysms
Brachytherapy for brain cancer
Nitinol stents for cerebro- vasculature
Spinal cord transplantation for spinal cord
injuryGene therapy
for Parkinson’s
d
Deep brain stimulation
for Parkinson’s
Stereotactic radiosurgery
for brain cancer
Stereotactic radiosurgery
for Parkinson’s
Embolic protection devices for
carotid athero-
sclerosis
Stem cell transplan- tation for
MS
Neuroprotective, anti-inflammatory and antioxidant
therapy
Vagal nerve stimulation for
epilepsyLiquid
embolic gel for cerebral
vascular disorders
Neurosciences Devices and Pharmaceuticals Evolution, 2004–2014
...leading us to look at new and emerging technologies.
Technology ChallengesTechnology Challenges•• Number of new devices / drugs / proceduresNumber of new devices / drugs / procedures•• Different cultural viewsDifferent cultural views
•• PhysicianPhysician•• VendorVendor•• HospitalHospital
•• Understanding the total cost of adoptionUnderstanding the total cost of adoption•• Evolutionary vs. revolutionary technologyEvolutionary vs. revolutionary technology•• Individual adoption curveIndividual adoption curve•• Lack of standard approach to technology Lack of standard approach to technology
evaluation (technology assessment)evaluation (technology assessment)
Technology Assessment:Technology Assessment: An evidenceAn evidence--based selection based selection
processprocessDefinitionDefinition -- The evaluation of physicianThe evaluation of physician--
preference supplies and equipment preference supplies and equipment that, once adopted, changes the way that, once adopted, changes the way we practice medicine.we practice medicine.
ElementsElements::•• Clinical effectivenessClinical effectiveness•• Cost effectivenessCost effectiveness•• Reimbursement Reimbursement
Premier Technology Assessment Premier Technology Assessment Member Survey 2005Member Survey 2005
•• Responses from 405 facilitiesResponses from 405 facilities•• 149 (36%) had a Technology Assessment 149 (36%) had a Technology Assessment
CommitteeCommittee•• Most operational 1Most operational 1--5 years (70%)5 years (70%)•• 16% had physicians as a regular member16% had physicians as a regular member•• 88% of the committees responsible for new 88% of the committees responsible for new
technologiestechnologies•• 84% stared their committees were somewhat 84% stared their committees were somewhat
to very successfulto very successful
Lessons LearnedLessons Learned•• Quality of care often isn't dependant on Quality of care often isn't dependant on
the newest technology, it can often be a the newest technology, it can often be a product of doing the things we know product of doing the things we know work for every patientwork for every patient
•• New technologies are coming out at a New technologies are coming out at a very rapid rate. Newer doesn't very rapid rate. Newer doesn't necessarily mean better, but it almost necessarily mean better, but it almost always does more expensive.always does more expensive.
Lessons LearnedLessons Learned•• Our challenge: to evaluate new technology in Our challenge: to evaluate new technology in
the context of what value it brings. the context of what value it brings.
•• Understand the consumer effectUnderstand the consumer effect–– Direct to consumer advertisingDirect to consumer advertising–– Perceptions versus reality Perceptions versus reality –– Accountability for results Accountability for results
•• Shift to Earlier Interventions Drive Delivery System ReconfiguraShift to Earlier Interventions Drive Delivery System Reconfigurationtion
Treatment patterns shift upstream to screening, prevention, and Treatment patterns shift upstream to screening, prevention, and less invasive less invasive surgeries and therapies and to ambulatory and home care settingssurgeries and therapies and to ambulatory and home care settings
•• Patients Embrace The "Bionic Man" ModelPatients Embrace The "Bionic Man" Model
Successful biosynthetic and drug implants target early stage chrSuccessful biosynthetic and drug implants target early stage chronic conditionsonic conditions
•• Cancer Is Tamed But Not ConqueredCancer Is Tamed But Not Conquered
-- Advances in cancer treatments shift the focus from acute to chroAdvances in cancer treatments shift the focus from acute to chronic care nic care management and preventionmanagement and prevention
•• Inpatient Cardiac Services No Longer A Top Revenue GeneratorInpatient Cardiac Services No Longer A Top Revenue Generator
-- Improved medical management of cardiac patients reduces surgicalImproved medical management of cardiac patients reduces surgical interventions, creating fiscal challenges for delivery systemsinterventions, creating fiscal challenges for delivery systems
•• Access to 24x7 Healthcare Becomes A RealityAccess to 24x7 Healthcare Becomes A Reality
-- Open architecture for medical informatics platforms and networkiOpen architecture for medical informatics platforms and networking ng technologies give patients and physicians realtechnologies give patients and physicians real--time data accesstime data access
The Top Ten Technology TrendsThe Top Ten Technology Trends
•• Workforce Shortages Soothed By Technology DeploymentWorkforce Shortages Soothed By Technology Deployment
-- A wide variety of technologies finally deliver productivity A wide variety of technologies finally deliver productivity improvements throughout the healthcare workforceimprovements throughout the healthcare workforce
•• Smarter, Smaller Surgical Devices Drive Volume To MISSmarter, Smaller Surgical Devices Drive Volume To MIS
-- Minimally invasive and noninvasive surgeries replace more than 8Minimally invasive and noninvasive surgeries replace more than 80% of the 0% of the current open surgeriescurrent open surgeries
•• EndEnd--Stage Care Morphs To Long Term ManagementStage Care Morphs To Long Term Management
-- Successful end stage therapies drive up the demand for chronic cSuccessful end stage therapies drive up the demand for chronic care are servicesservices
•• Information Technology Moves to Center Stage Information Technology Moves to Center Stage -- Nearly all medical technologies will transmit something, either Nearly all medical technologies will transmit something, either an image, a an image, a
report, or a point of data and IT will have to capture, send, soreport, or a point of data and IT will have to capture, send, sort, and store rt, and store these streamsthese streams
•• Blockbuster Drugs Wilt As Customized Therapies BlossomBlockbuster Drugs Wilt As Customized Therapies Blossom-- Pharmaceutical companies find markets for blockbuster drugs Pharmaceutical companies find markets for blockbuster drugs
evaporating as genetic testing and imaging define the evaporating as genetic testing and imaging define the nature of disease more preciselynature of disease more precisely
The Top Ten Technology TrendsThe Top Ten Technology Trends
Thank You!Thank You! ItIt’’s been fun. s been fun.
Any question?Any question?
