LECTURE

The Impact of Technology on Clinical and IT Systems

Introduction

One of the factors driving change in the health care delivery system is the rapidly evolving technology that emerges from research and development. Emerging technologies create rapid and profound change in the delivery system and may have drastic financial impacts. However, adapting new technologies without a clear understanding of what they can do for and to the system is never a good idea. They must be evaluated for their abilities to enhance the quality of care, along with their capacity to drive new revenue in a procedure-based delivery system. Finally, the cost of new technology is highly correlated with how new it is, and whether it is a stand-alone product with no competition. All of these factors combine to make it essential to do careful business and clinical analyses prior to committing to even the most appealing new technology.

In this module, we will examine two types of new technology: clinical applications and the electronic medical record (EMR).

Clinical Technology

In the realm of clinical technology, there are numerous subgroups. In selected subgroups, we will explore examples of new technology that is in the research and development pipeline.

Cardiovascular

The underlying theme of technology in cardiovascular care is the shift from significantly invasive approaches, such as open cardiac bypass surgery requiring a split sterna surgical approach and the use of a heart lung machine to maintain the patient during surgery, toward minimally invasive or noninvasive techniques. Ultra-wide band radar devices allow the measurement of cardiac output, heart rate, heart rhythm, and patterns of blood flow without any invasion of the body. The device is roughly the size of a deck of cards and can be worn in a shirt pocket without leads or monitor pads. The use of this type of radar-based approach allows noninvasive monitoring without pain or limitation of movement by patients.

Another cardiovascular application is the use of bio-absorbable, drug-eluting stents to open coronary arteries. The old technology required a surgical intervention that involved removing an artery from another part of the body and suturing it to the blocked coronary artery to provide a bridge for blood to flow past the blockage. This generally required hours in the operating room, with a patient on a heart bypass machine, and several days to a week in the intensive care unit after surgery. This has been largely replaced by placing stents or coils in the coronary arteries to hold them open. This is done in the cardiac catheterization lab under sedation or light anesthesia and is accomplished by threading a catheter through the arm or leg vein up to the heart and into the artery. However, historically these types of stents could block up again. The newest technology involves placing a bio-absorbable stent that eventually melts into the arterial wall, along with the drug-eluting aspect, which prevents clot formation. While this is a significant improvement from the patient's perspective, it also comes with a steep premium in cost, at least initially. Cardiac services have traditionally been among the most lucrative services for hospitals and physicians. However, the shift of services from inpatient to outpatient and the marked reductions expected in cardiac surgical volume result in a noticeable decline in patient admission days and overall cardiac revenue for the average hospital. Cardiac surgeons across the country are indicating decreases in volume of 20% to 30% in their patient load.

A brand new emerging technology is autologous cell therapy, in which a patient's own heart muscle cells are cultured from their own adult stem cells and then placed back into the patient's heart muscle. This process is in clinical trials at present, and if it works as expected, patients will have strengthened heart muscle without the fears of tissue rejection from organ transplants. It will also reduce the need for electromechanical pumps or a full heart transplant. This technology could potentially revolutionize cardiac health care.

Oncologic

With the growing rate of cancer diagnoses, oncologic care is an area rife with new technology. One new area with great promise is the use of radioactive trace markers to measure the effects of chemotherapy or radiation on tumor growth. Fluorothymidine is being studied as an imaging probe that measures tumor cell proliferation and response to therapies. The ability to do an early assessment of tumor growth and development should provide better outcomes for patients with cancer and reduced expenses from ineffective therapies.

Another new technology overcomes the problem of the blood-brain barrier, which prevents chemotherapeutic agents from penetrating the brain. The new technology, acoustic-enhanced drug delivery, uses focused ultrasound to reverse the blocking effects of the blood-brain barrier by agitating the brain tissue to enhance its permeability. This also improves the tumor's uptake of the drug, with a quicker and more effective response to the chemotherapy.

Gastrointestinal (GI)

Digestive disorders have been diagnosed for years through endoscopy. However, this process requires sedation of the patient. Video capsule technology appeared in 2001, but its diagnostic capability was limited, since the capsule's movement was not controllable. The newest technology is a robotic capsule that allows the physician to control the movement and orientation of the capsule for better visualization of the GI tract. Once the capsule is positioned properly, it can perform a robotic biopsy or administer a treatment to a specific area with a noninvasive approach.

Diagnostic Imaging

There are numerous technologies that are emerging in the field of diagnostic imaging. Over the last five years, computed tomography (CT) scans have become three dimensional and capable of imaging thinner slices, giving much greater visual resolution. However, increases in CT imaging have prompted rising concerns about radiation exposure. Magnetic resonance imaging (MRI), which creates images through a magnetic field, is a safer option when radiation exposure is a concern. MRIs can also visualize soft tissue in a way that CT scans cannot. A new technology based on the MRI platform is MRI-guided radiation therapy for tumors. In this approach, the MRI imaging system is combined with three gamma ray sources, which function together as a large robot. The patient is positioned between two magnets, and the gamma ray sources rotate around the patient. The higher imaging resolution and real-time visualization of the tumor's shape and location can allow careful coordination of the three beams, protecting healthy tissue for more effective therapy.

These are all examples of clinical technology that are currently being tested and developed. The issues of whether, how, and when to implement new technology depend upon where one wishes to be on the new technology adoption curve. Those who invest early in the process, the "early adopters," may be able to carve out a market and attract new physicians and patients to the new technology and its early promise. The downside is that the new product is generally very costly, especially if it is one of a kind. Early adoption also may not provide enough time in operation to clearly understand the pros and cons of the new technology. The second phase of adoption, defined as the "early majority," involves the emergence of competing vendors that have developed their own versions of the technology. This facilitates wider utilization and more competitive pricing. Differences in the new technology also emerge, offering more options for use. However, an early adopter may have already seized market share, making it harder to attract new business. The third phase, the "late majority," adopt the technology before it becomes obsolete but after it has been thoroughly tested in the market and has become the standard of care. At this point, there are little distinguishing characteristics between vendors, so that price and standardization become the determining factors.

The assessment and evaluation of a new technology always requires a strategic review, a financial analysis, and a carefully done and accurate business plan.

            First, how does the new technology fit into the organization's strategic plan? Will it enhance the achievement of specified goals? What physicians will be stakeholders and users of the new technology? How will it fit with other technology and competing demands for capital resources?

            Second, what does the financial analysis show? What increase in volume is anticipated? What is the potential payor mix? What types of reimbursement are available? Will it add costs for patients on a diagnosis-related group reimbursement plan? What is the contribution margin once the initial capital expenditure is covered, and what is the time frame for a return on investment?

            Third, what does the business plan reveal? Will it attract new physicians and more patients, and from where? Will it enhance elective procedure volume? What is the competitive advantage it brings, or what possible loss of business would it prevent? What market share of the affected patient population is anticipated?

A word of caution: beware of vendors that offer to provide a business and financial analysis to "relieve you of the workload." It is generally not wise to rely on vendor-provided analyses without strong validation of their assumptions from your own internal resources. The wise administrator always does his or her own analysis and review, looking at the new technology with a critical and analytical eye and resisting the temptation to acquire it just because it is new.

The EMR

The Healthcare Insurance Portability and Accountability Act of 1996 mandates that hospitals and health care entities move to an EMR by 2015.  While many hospitals have components of an EMR, not many have the full package implemented and in place, which includes the clinical documentation and the computerized physician order entry modules. There are a large number of vendors competing for the business, and the selection of an EMR product is very difficult.

When preparing for the move to an EMR, there are several steps to take:

1.      Develop clear criteria for success. What does your organization expect the EMR to accomplish for you? How will you know if that is achieved once you implement it? How much of the health care continuum will be included in your EMR (physician offices, hospital entities, outpatient services, etc.)? Many organizations may develop an EMR with the belief that it will save staff time and result in fewer positions and staff costs. In fact, the opposite has been shown to be true. Most EMR implementations take more time than paper and pencil approaches for the data entry. The value of an EMR may well be in its ability to translate data into workable information via reports. If you want to know the number of foley catheters that are in patients for more than two days, a good EMR can generate a report for you. Be sure that your criteria for success are achievable, measurable, and make strategic sense for your organization. Representatives of all stakeholder groups should be involved in developing these criteria.

2.      Use due diligence in selecting your product and vendor. This is a hotly competitive market among vendors of various EMR software products. The vendors will promise a great deal in order to make the final cut and selection. It is essential that you thoroughly evaluate the abilities of each product as it fits your strategic goals, your criteria for success, operations in each affected department, functionality, reporting capability, ease of use, and robustness of the product. A smart way to proceed is to sit through the vendor presentations, take careful notes, and then go talk to hospitals that have used that vendor's product. You need to understand how the product will be used and whether all the components and departments that will use it are integrated (built into the original software platform) or interfaced (requires the build of a software bridge between computer systems). An EMR that does not have an integral surgical suite package would be at a significant disadvantage in the competitive world, for example.

3.      Learn from other hospitals that use the software platform you are considering. You cannot go to too many hospitals to see an EMR in action. It is a mistake to go to only one or two and think that you have seen it all. Multiple visits will show multiple different ways to use the system and the problems that come with it. If you visit, talk to the users in the departments about their feelings regarding the system, how easy it is to use, how it changed their work flow and operations, and what issues they see with it. These visits can help you avoid a very expensive mistake. Having said that, keep in mind that there is no perfect system and that these systems are extremely complex. It is unrealistic to believe the vendor when they tell you that it will be a smooth and organized implementation with no problems, because there are always problems. The vendor's commitment to help and support during and after the implementation is critical to success.

4.      Above all, do not leave any stakeholder group out of the selection and design, especially physicians. Many physicians look with skepticism on the advent of an EMR, and some have likely had less than great experiences with it at other hospitals or in their own practices. It is absolutely imperative that physicians and other key stakeholders, such as staff, are deeply involved in the selection, design, implementation, and monitoring of the EMR system and associated processes. Failure to do this step almost always guarantees a less than optimal result and generally results in a complete failure.

5.      Budget appropriately. The wise health care executive will realize up front that the selection, design, and implementation of an EMR will cost millions of dollars. The software costs alone can run that much, and then one must plan for the hardware costs, data storage expenses, and data entry systems/computers. In addition, the planning and design teams can take months to a year to complete all the implementation planning, and the staff costs for participation can run into high six figure amounts. It is always a good idea to ask the hospitals where you are observing their usage to tell you what their total EMR costs were, at least in ballpark figures.

The EMR requires a huge amount of resource commitment in planning, selection, due diligence, implementation, and ongoing monitoring. This is one of the decisions and change processes that must go correctly, since so much is at stake.

Conclusion

New technology has had, and will continue to have, lasting impacts on the health care delivery system and its individual providers and components. Clinical technology continues to pour out of the research and development pipeline, and new drugs, new procedures, and new therapies will be a part of the health care landscape for decades to come. It is new, exciting, and very expensive. Careful analysis and evaluation is an essential part of selecting what is useful and appropriate for a health care entity and avoiding the high cost flash in the pan that does not meet initial expectations.

Copyright 2011. Grand Canyon University. All Rights Reserved.

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