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The Frontiers of Science
In health care, cutting-edge technologies will mean, among other things, less cutting
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Business New Haven
10/20/1997
By: BNH
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To discuss cutting-edge technologies and their potential impact in the health care arena, BNH asked representatives of four of the region's leading-edge health care and technology organizations to discuss the issue. We were joined by Raymond J. Huey, director of engineering of the Wallingford-based medical instrument maker Corometrics Medical Systems; Mark L. Andersen, chief information officer for Yale-New Haven Health, Philip F. Nuzzo, vice president of marketing and product development for Novametrix Medical Systems; and Randall Reinhold, M.D., chairman of the Department of Surgery at the Hospital of Saint Raphael in New Haven.
What is technology's changing role in the operating room?
Reinhold: Technology is basically a system that multiplies the effectiveness and power of human beings. Whether that is an energy-transfer in terms of electricity or lasers, there are different ways in which it does it. But basically over time we see everything getting smaller and faster - and different ways to get to awkward places to deliver therapy, whether that's through smaller incisions or drugs that target specific organs. In surgery, the thing that we have learned in the past 15 years most from technology is that it is usually the skin incision that hurts, more than fixing the problem. That is, if you can take your gall bladder out through a tiny incision, you have very little pain.
A gall-bladder operation 30 years ago might have required a three-week hospital stay. Now is that an overnight stay?
Reinhold: Overnight or less, depending on your age. A healthy 40-year-old person would have it done at seven in the morning at be home at seven at night.
Is it a function of technological advances that surgery is far less common? For example, using ultrasound to shrink kidney stones?
Reinhold: That's in part true. I think you see the whole spectrum of surgery moving away from ablation - that is, cutting it off - toward reconstruction. That has been true for 100 years and the ultimate of that will be organ replacement. We do some of that now. But you can imagine 20 years from now when you can do cross-species heart transplant.
As well, we have all these pharmaceutical and biomedical companies, and they're going to continue to come up with compounds to treat things.
Reinhold: Any metabolic illness will eventually give way to medical therapy as opposed to surgical therapy. Gallstones, metastic breast cancer [surgery] is going to give way to therapeutic intervention. We've basically seen what surgery can do. You're looking at its limits, practically speaking.
Nuzzo: You're talking about advances in molecular biology and genetic engineering to develop therapies.
Reinhold: We can do surgery with less pain and a little safer [incrementally], but we don't make any new logarithmic jumps until we get to the issue of putting in new organs. But even that is determined at the cellular level; it's not a technical hurdle. We can put in a heart, that's not the problem.
Ray, please explain what Corometrics does, and what are some of the advances you're thinking about and working on.
Huey: Our core technology is fetal monitoring. We are the first company to develop it. It started with a doctor at Yale-New Haven Hospital, Dr. Edward Hon, in the late 1960s. We use digital signal-processing techniques that give us the ability to count the fetal heart rate non-invasively. One of the things that made Corometrics what it is today is an invention by Dr. Hon of the fetal scalp electrode.
That's a scary-looking thing.
Huey: It looks much worse than it is.
My first son had to have one stuck in his head.
We continue to invent better non-invasive techniques through our ultrasound device, and it [measures] the fetal heart rate as well. The fetal scalp electrode's use has decreased. One, because of the improvement of the ultrasound; and another because of risk of blood-borne pathogens such as HIV. We are currently in a large state of change in the technology we are using. We are about to release monitors dramatically reduced in size. They will use the technology that has been used for wireless LANs that will allow the patient to be much more ambulatory and not tied to the big boxes of fetal monitors that we currently see. Eventually they will lend themselves to monitoring patients in what we call a continuum of care from home to the emergency-room care to the labor area with the same devices. We have the capability to monitor a patient remotely and can see if there is some changing status. The doctor can be paged automatically and can look up on their pager the EKG of the patient. There are also some new types of sensors that are very specific, that are very sensitive. Ultimately they can detect one molecule of any species.
No - a molecule of what?
Huey: Really, of whatever the protein or analyte might be. It's basically the same type of technology your immune system uses.
Before Dr. Hon invented fetal monitors, did physicians monitor babies' heart rates with a stethoscope?
Huey: There was actually a fetal scope. It could be worn on the clinician's head so they could put their head down onto the mom's abdomen and listen to the fetal heart rate and have their hands free.
Mark, how is information technology feeding information back to providers and health care technology companies?
Andersen: Specifically with fetal monitoring? I'm relatively new to Yale-New Haven, but my most recent experience before this was at Columbia Presbyterian in New York. We would display the fetal monitoring system throughout our entire computer network. Physicians across the campus could actively watch the fetal monitor in the delivery room and tell when it was time to go across campus to be on-site. From an IT [information technology] perspective, the issue is getting the information to the right people at the right time. Whether that is a physician or clinician or a businessperson trying to get the patient registered. As health care becomes a more systemic issue, we need to know about patients who are part of the Yale-New Haven family [of facilities], if you will. They may be seen in Bridgeport or in the future in Greenwich [YNHH's management agreement with Greenwich Hospital is pending regulatory approval] or in New Haven. If we have evidence at one site that the patient has an allergy, we need to be able to make sure we disseminate that information if the patient shows up at a different site. With the recent changes in legislation, such as the Health Care Portability Act, it is important for us to be able to track information across our entire system.
More generally, what is your challenge for applying IT throughout a health-care delivery system?
Andersen: Some of it is rather mundane, in terms of bringing together operations that have been very different and disparate and being able to share and integrate that information. We do have this so-called Enterprise Master Person Index that can identify Mark Andersen, wherever he may show up in our system.
How much information can they get about you?
Andersen: That's an important question. In the longer view of the world as the electronic medical record becomes more and more active, [the hospital would be able to access] as much information as we have. Whether that's allergies, your last blood test...
...Shrink appointment...
Andersen: Physician's notes, shrink appointments. There are issues around patient confidentiality that are very critical, no doubt. But what you find, when you look under the confidentiality issue, is that the vast majority of breaches of confidentiality are done by authorized users, not people breaking in. At Columbia Presbyterian we had a database that housed all sorts of clinical information. And when we got VIPs, we would run audits and it was shocking the number of interested physicians, house staffers and nurses [would access the information]. Until we took firm action, it was a problem.
How do individual doctors react to these changes in technology, and how much do you technology guys consult with them?
Reinhold: To the degree in which it is easy and it is quick, [doctors] love it. Something that is free, easy and open, it is great to get out, but doesn't have much confidentiality protection.
As long they don't have to fill out forms to use it I would think they would be happy.
Reinhold: But there are all kinds of issues. I'm a doctor, you're a doctor, and I want to get your X-ray report that was done at a another facility. Am I authorized to get it, and how does the facility know that I'm authorized? Everyone understands the need for the networks, but how to move the information across [them] is very difficult.
In the past would they simply have taken your word on the phone and sent it over?
Reinhold: Most likely.
Andersen: And they would have faxed it over a totally unsecured phone line. Historically there has been very little control. It just becomes more and more of a sensitive issue, as certain exposures get documented in the popular press.
Reinhold: Then, do you rebuild your own intranet or do you go the next generation and broadcast it to the Internet, with the hacking possibilities?
Andersen: Just a couple of years ago Duke [University Medical Center] had their operating schedule, patient name and physician names over the Internet, unknowingly.
Phil, give us the Novametrix overview.
Nuzzo: Novametrix manufactures non-invasive blood-gas monitoring equipment as a base technology. Some of the founders of Novametrix were the founders of Corometrics. It was spun off around 1975. Our first products naturally gravitated toward neonatal patients, the ability to measure, non-invasively, oxygen and carbon dioxide. Most patients in a Neonatal Intensive Care Unit [NICIU] are in for respiratory problems. Since then Novametrix has branched out to anesthesia monitoring, monitoring of blood-gas values, and further into the intensive care units. Recently we added other technologies, such as pulse oximetry and the monitoring of exhaled CO2. We also now can monitor respiratory mechanics, which is the amount and rate and pressures, and so on.
What is pulse oximetry?
That's where the amount of oxygen bound to the hemoglobin is measured, which is very important. Most people say that it is the fifth vital sign now. Recently we've been combining our technologies to yield new parameters at the bedside.
Neonatal intensive care was one area where everyone used to talk about medical costs skyrocketing. How are these technologies affecting costs there?
Nuzzo: You'll have a baby that's the center of attention, and it will be highly monitored in order to treat that patiently correctly. Previously to these skin-surface electrodes, you typically had an umbilical artery line. You would draw blood out and send it to the blood-gas lab. It would be measured on electrodes that we've miniaturized and made available at the skin [surface level]. There's a cost associated with every time you had to get a blood-gas measurement which, with a sick baby, could be every hour. Also, because there is a finite blood supply, you deplete that blood supply and you have to get into the cost of transfusing the baby. If anything, the monitoring has cut down on costs.
We recently quoted a pediatrician claiming that managed care was stifling innovation by individual doctors. Is managed care propelling innovation because of the need for reducing costs, or is it a negative?
Nuzzo: We cannot go forward and develop a product unless we can prove to the medical community - including the managed-care community, but particularly the physicians first - that it does improve patient outcomes and save money. [Otherwise] we won't even embark on it, because it's not worth it. Even if the physician wants that technology, it is very difficult to get it thorough the administration of the hospital. If it's a “nice-to-do,” you can't get “nice-to-dos” in the hospital anymore.
Reinhold: You have to differentiate between the best of managed care - which is a prospective attempt to assure that the patient gets all that they need, and nothing they don't - and what usually occurs, which is managed cost, which merely says do whatever you're going to do, but we're only going to pay you X. Given the pressure at the government and at the employer level to reduce the cost of the health-care benefit, that cost-reduction gets translated irrespective of what may be good medicine. Basically, you have to eat the cost of high technology and new innovation as part of the health-care system - and you can do that for a while. If you look at almost any managed-care plan, they do not have any intentional system of research and development and education.
Andersen: From an IT perspective it's both a blessing and a curse. It is forcing us to do some things, like at least attempting to make sure we reduce the over-utilization of tests. If you just had a chest X-ray a month ago at one hospital, do you need it again at the next one? Probably not. At the same time [managed care] is cutting the costs we can pass on and making us rethink all of our investments and their necessity and appropriateness. Everything is cost-justified.
Huey: The increased awareness of the costs of technology has created new market opportunities, particularly in home care. There is a lot of emphasis in telemedicine and trying to do things remotely, using information technology as well as some pretty inexpensive remote video technologies.
Is our biomedical-biotech cluster here in southern Connecticut unique?
Huey: There is definitely a cluster, but it is not unique. [The medical cluster] seems to be the way that technology is transferred from universities and teaching hospitals [to industry].
Isn't there a very high ratio of
doctors to the population here?
Reinhold: Boston is actually the highest. Remember, when you say “doctor,” a lot of people are in the laboratory and not necessarily practicing physicians.
Andersen: One of the problems in this area, at least from where I sit, is the relative lack of technical education, computer-oriented young people coming up. The computer science and engineering program at Yale is very small, and the other colleges have not focused their efforts [so that] we're seeing any burst of new talent coming up.
Huey: It is a tough market for programmers in Connecticut.
Andersen: I think that is going to have an impact on this community that we all will have to deal with.
How is competition effecting
innovation?
Nuzzo: Competition is fierce in medical electronics. We're seeing a consolidation, with the big guys continually eating up the small guys. It's getting to be that it's difficult to participate unless you are $700 million-plus [in annual sales]. The only way we can stay ahead is to continue to try and innovate and compete with leading-edge technologies that we OEM [sell to Original Equipment Manufacturers] to the big guys. We also have a direct sales force and a big international presence.
Is your business less consolidated abroad?
Nuzzo: I think so. We have better access. [The overseas market is] a little more fragmented. We have earlier access to it because of regulatory issues. About 60 percent of our business is overseas
right now.
Is it a logical extension of consolidation that it will stifle innovation?
Andersen: I think what you see is people like me who are making a lot of buying decisions feeling more comfortable with larger companies sometimes. Sometimes we're willing to make a gamble and go with a smaller company. You have the question of how you get the new technology, like browser-based medical record systems. If we [told potential vendors] that you had to have X number of successful sites of 100 doctors or more, you would eliminate all the newcomers. So we have to balance our decision-making. But it is tough to sell a multi-million-dollar decision from a company that is barely on the map to the board of an organization that wants everything safe and secure.
Is there still competition for more and flashier equipment, as there was a decade or so ago?
Reinhold: I think that the competition benefits everybody. I don't think anybody who thinks about it very long would suggest that either hospital [YNHH or Saint Raphael] having a monopoly in greater New Haven would serve anybody's useful purpose - not any company, not any patient, not any insuring company, not the physicians. Because everyone likes a choice. I think consolidation [is beneficial] up to a point. You see a lot of consolidation in Boston - where maybe 15 teaching hospitals will end up as eight - but they don't create one single monopoly. You don't want Microsoft to have [a monopoly], the gas company, and you don't want one hospital. That having been said, with both of them in the marketplace to stay, they have to adjust what they do and recognize they have different customers. There is a whole other level of customers that Yale Medical School has. It may be research grants, it may be the National Institutes for Health, or medical students. With respect to the hospital competition, it probably makes the price cheaper and the product better.
Nuzzo: At the hospital level, is there a situation where because of cost controls a physician may not be able to order the lab test that he wants?
Reinhold: I don't think it happens on a single-patient basis. It starts to happen on a system basis when you begin to reduce the number of caregivers. We're in a love-hate relationship with technology in America. We all desperately want the hands-on care of the giver when we get sick, be that a nurse, occupational therapist, physician. Yet to the degree that the dollars are limited, we spend it on data-generating technology. The only place you take it out of is your labor costs. Seventy percent of our costs are labor. If RNs costs more than skilled nursing assistants, you reduce the RNs. Everyone says, 'Gee, what happened?' The answer is, 'You wanted us to cut costs, and you wanted the technology.' I don't know the numbers at Yale, but I do know that at Saint Raphael we employ about 15 percent fewer nurses than five years ago.
Andersen: I'm told we also had similar cutbacks.
Looking five or ten years ahead, what do you see as the biggest impact technology will have on your arena?
Andersen: I see a lot more home access [to care]. The patient direct-input sending messages to physicians and providers, and physician consultation done remotely.
Nuzzo: A lot of our long-term planning is based on making smarter monitors. Incorporating rule-based algorithms, neural networks that will tell caregivers, who may be less skilled at the bedside, what to do. The monitor will say, 'You made a medication error,' or 'This probably isn't right; you should consider doing this.' We're already seeing that with some of the R&D that we're doing with our sensor technology, where we put four or five or six sensor technologies together and you can develop algorithms that are pretty good.
Reinhold: Miniaturization, and secondly the transfer to a person-based data system. You heard my beeper go off and I had to get up and go out of the room to the telephone? I believe in five years the information will be available to get the beeper answered and get some kind of image at the same time. When that happens, I think we'll have more access to health care. Right now we're caught in the transition from place-based data as opposed to person-based data.
Huey: How many Star Trek fans are here? You've seen the Borg. Get away from the dark, scary aspects of the Borg, but everyone's plugged in and there is this giant collective consciousness. Person-based monitors will eventually drive the whole medical care to the collective society where all the information is available. Miniaturization is absolutely right; people will be monitored much more frequently because you will have miniaturization and the RF [radio-wave frequency] technology to allow it. I totally agree with the increase in expert systems and the artificial intelligence. We are actively pursuing that. There is quite a technological revolution going on right now, and it will change things dramatically.
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