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Medical Breakthroughs That Will Change Healthcare （continued）
Gienna Shaw, for HealthLeaders Magazine, March 8, 2010
What's Next:Wireless devices and telehealth are among the most frequently cited examples of technology that will change how healthcare is delivered. Among the benefits: They speed diagnosis, intervention, and therapy; they produce more data and lead to better outcomes; and they're more efficient.
One wireless device in the pipeline could improve medication compliance. It fits onto a prescription bottle and alerts patients when it's time to take their pills—and reminds them if they forget. In trials now at the Center for Connected Health, the device senses when a patient unscrews the cap on the prescription bottle and sends the information through a secure network to an online site. "I'm using it myself and I find it very helpful," says Joseph C. Kvedar, MD, director of the center, a division of Partners HealthCare in Boston.
"Adherence to medication alone can lower costs," Kvedar says. "It's a powerful tool, and just about every person should have some kind of medication device when we get them to the point where they're affordable and reliable."
As accountable care, bundled payments, and pay-for-performance become more common, improving health outcomes with wireless technology and other tools and devices makes business sense, Kvedar says. Partners is also using such cutting-edge technology to differentiate itself in the marketplace, he adds.
What's Next: The technologies of tomorrow can impact your purchasing decisions today. Hospitals should hold off on investing in hardwired connectivity and save the money—and the disruption, expense, and contamination risk—if you can.
Medical imaging
Imaging is one of the fastest-changing technologies, and experts say there are still more advances ahead. "It's all going to be going down to the molecular level," Ronstrom says. "It's incredibly futuristic what's going to happen with imaging . . . in five years we're going to see major, major changes," says David T. Feinberg, MD, CEO of the four-hospital University of California Los Angeles Hospital System. "Imaging has gone from being diagnostic to therapeutic. Interventional radiology is remarkably helpful in that you don't have to cut people open in the same way you did before."
UCLA was the first organization to offer clinical PET scan services to patients. Today, researchers there are studying the use of PET scans to detect Parkinson's disease, to visualize the success of different cancer treatments, and to determine the effectiveness of chemotherapy.
Minimally or noninvasive approaches such as the ones discussed can reduce complications, including postoperative infection, reduce length of stay, and lower the overall cost of care, studies have shown. They can also save money—an October 2009 study published in the journal Surgical Endoscopy found a difference of more than $15,000 on average for minimally invasive colectomies when compared to open surgery, for example.
What's Next: As minimally-invasive techniques are shown to be safer and more cost-effective, prepare for a wider variety of procedures to move to outpatient settings. And the more procedures a surgeon does outside of the hospital setting, the better the outcomes, including lower infection rates, Wenzel says.
Virtual medicine
Mayo Clinic researchers have been testing a supersensitive fiber-optic probe 2 millimeters in diameter that can be passed through a normal endoscope and can see structures as small as 1 micron, such as single cells or the nucleus within a cell. Probe-based confocal laser endomicroscopy, or pCLE, could eventually reduce colon polyp removal, and data suggest that the virtual biopsy can replace real biopsy in several other conditions, including Barrett's esophagus.
The technology is "highly promising," says Michael B. Wallace MD, MPH, professor and vice chairman of medicine at the 214-licensed-bed Mayo Clinic in Jacksonville, FL. "We also have very promising data using confocal to assess the completeness of removal of very large polyps."
"We remain very optimistic that this technology will have an important role in guiding biopsy to areas that are much more likely to be disease, and in some cases, providing 'virtual biopsy' during procedures in real time so as to guide immediate therapy [instead of waiting several days for actual biopsies then repeating a procedure]," Wallace says.
Dermatologist Babar K. Rao, MD, is particularly enthusiastic about a new device that uses laser imaging to help determine whether a lesion needs biopsy. The VivaScope, made by Rochester, NY-based Lucid, Inc., views skin abnormalities at the cellular level. "In many cases, it can save patients unwanted, unnecessary biopsies, and in some cases it may detect a lesion which otherwise might not have been biopsied."
In this case, virtual medicine is combined with wireless medicine. When a patient has a biopsy, he or she assumes the worst. The patient doesn't want to wait to hear whether he or she has cancer—not even a day. A telemedicine service can send the scope's images via a secure online network to pathologists for those providers who don't have one on staff or who want a second opinion, allowing physicians to deliver results faster than ever before.
What's Next: Don't invest in any device until you find the right person to use it. An inexperienced technician or diagnostician can do more harm than good. For example, when dermoscopy magnification was new, studies showed that when inexperienced people used it, the results were worse than when a physician did an examination with the naked eye, says Rao, who owns a private practice in Manhattan.
Artificial medicine
Heart, liver, lung, pancreas, bladder, ovary: Scientists continue to pursue advances in artificial organs.
"We think that there are going to be a series of products that will become more and more sophisticated," says Aaron Kowalski, PhD, assistant vice president for glucose control research at the Juvenile Diabetes Research Foundation. He also leads JDRF's artificial pancreas project.
The artificial pancreas would help diabetics control their disease, as it reacts to changing glucose levels and delivers the right amount of insulin at the right time. It builds on two already-approved devices—the insulin pump and the continuous glucose monitor, or CGM. But unlike an open-loop system in which the patient is responsible for testing, reading data, and taking corrective action, the automatic closed-loop pancreas would use a control algorithm to read and interpret the information from the device and respond by dispensing insulin when needed.
The device would be particularly helpful at times when patients are most at risk, such as when they are sleeping and more likely to miss a CGM alarm. In such a case, the system would automatically intervene.
What's Next:Although the ultimate goal is to find a cure for any disease or condition, including diabetes, there are a number of near-term advances that will serve as bridges, Kowalski says. "These intermediary steps are important while we fight to get to the end of the disease—to a cure. When you're living with a condition, you want something now . . . even if it's not perfect."
Costs, benefits, and opportunities
Unlike in other industries, where advances in technology reduce costs (self-check-in kiosks at airports, for example), new devices and treatments typically drive up healthcare costs. A new PET scanner is a big investment, UCLA's Feinberg says. It also results in earlier diagnoses and more people getting treatment—and that drives up healthcare costs, as well. Someday colonoscopies will be performed by a pill you swallow, he says. But that means there will be more diagnoses of colon cancer, that those people will need further treatment, and that costs will go up.
On the other hand, says Sacred Heart's Ronstom, "Technology is going to be part of the answer for healthcare costs, because we're going to get quicker diagnosis, earlier intervention, and better safety."
"We had to justify [investing in the smart OR] in every way—not only to the hospital administrators, but to the board and the hospital owners as well," says Thapar. The benefit to patient care is obvious, but other benefits are demonstrable, too, from financial to quality of care to recruitment to marketing. "When you add it up from an accounting perspective," Ronstrom says, "we've done very well."
There's a fundamental question about the dollar value of preventing an error, an infection, a patient fall, or even a death, says Barry Rabner, president and CEO of the 477-licensed-bed Princeton (NJ) HealthCare System. "Every design solution that reduces or eliminates a problem has a cost, and finite resources make design decisions very challenging."
You have to consider cost in the context of the benefit of improved outcomes and of the improvement in people's lives, UCLA's Feinberg says. "Our mission is to train the doctors of the future, to take care of patients, but also to discover tomorrow's cures. That's our core reason for existence . . . These firsts are what we exist for, and they have great societal benefit over the long term."
And then there's the business case: "We can't all afford to be early adopters," says Tom Hanenburg, CEO of the 168-licensed-bed Providence Medford (OR) Medical Center. "But if you're a lagging adopter, you're going out of business."
Technology, pharmacology, and clinical practice reimbursement all change meaningfully over time, and good hospital design requires careful consideration of those factors. Because predicting the future is so difficult, the chances are that you will make predictive errors, and, therefore, you must design as much flexibility into the building as possible, says Rabner, who is currently overseeing construction of a $447 million, 237-staffed-bed hospital to replace University Medical Center at Princeton, the system's aging acute care facility.
"One of our goals in developing the new building was to build in as much flexibility as possible," he says. The trick, he says, has been to put off final equipment decisions as long as possible, but not too long. "Technology continually evolves. All changes are not revolutionary but can have value. You do not want to decide too quickly and lose a useful feature or wait too long and have a building that can't easily accommodate the equipment you have selected," he says.
Every healthcare leader will eventually make a misstep. Many have bought a piece of equipment touted as the latest and greatest must-have item only to see it end up sitting in a back hallway gathering dust, says Hanenburg. "The way to avoid that is to really have some trusted clinical advisors who are willing to also adopt the technology and use it once you buy it," he says. "Identify your core physician leadership—the ones that you trust to guide you well in terms of the technology you're looking at."
Hanenburg says there are several factors to consider when weighing an investment. The first is clinical impact: Will it improve outcomes? The second is whether your physicians want it: Will they adopt it? The third is a little tougher to ascertain: Will insurance companies pay for the procedure and, if not, how long will it take payers to catch up to any given medical advance?
Leaders must take it upon themselves to prepare to answer these and other questions, says Sacred Heart's Ronstrom. "We have to make a personal commitment to staying informed and staying knowledgeable on medical developments," he says. "We need to invest in our organizations so that the staff can stay current with their education, [and] we need to appoint clinical leaders who are really smart about clinical efficacy." Innovation is "the direction we need to go in this country," he says. "The answer for our economy is to make investments in technology, not just walk away from it. This is how this country was built—on our innovation and our discovery."
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发表于 2010-4-17 12:48:02