Technology, technicians, and shortages

Just last night I was having dinner with a couple med school buddies when one proposed that a technician can do a colonscope procedure as well as a GI doctor. He meant the preparing, inserting and scoping around of a person's lower GI tract. One doesn't need an MD-level training to do that he said.

My other friend disagreed: the countless times a GI fellow scopes patients leads to a high level of skill. While the first friend agreed that a physician does need to observe, interpret what they see from the scope and determine a management & treatment plan, he was still convinced that the physical labor can be done for much cheaper, saving patients and more so insurers money on this procedure.

I said this would not come to pass unless there was a crushing shortage of GI docs and too many patients needing to be scoped. Then pressures would compel some solution, which I think is a GI technician who would do scopes, leaving the truly medical aspects of the colonoscopy to the physician.

And then I saw this article in the 26 June 2006 Businessweek titled "The Doctor Is (Plugged) In." It's not as much about new technology allowing doctors to monitor patients remotely as it is how the problem of a shortage of ICU physicians and nurses is being resolved using technology.

The eICU technology, sold by Baltimore's Visicu Inc., lets hospitals leverage the scarce resources of specially trained intensive-care doctors and nurses. A single physician and nurse can support bedside caregivers for more than 100 patients at once. "We classify it as transformational because of what it represents," says Gartner Inc. analyst Vi Shaffer. "How do you do better with less, and how do you improve care when intensive-care specialists and nurses are scarce?"

Both Big Business and the specialty association are behind using technology to deal with specialist shortages.

The Leapfrog Group, a consortium of big employers, says 54,000 people a year could be saved if every U.S. ICU case were co-managed by a specialist. That's impossible without technology: It would take 25,000 specialists to staff
ICUs, and only 6,000 are available. "I've watched eICUs take off just in the past year," says Phillip Dellinger, past president of the Society of Critical Care Medicine. "It inherently makes sense."

Only 7% of American ICU beds are monitored using such technology, and the obvious limiting factor is cost. And this going to remain the limiting factor until prices begin to descend to more affordable levels, despite: "Sentara's Hochman says the system paid for its initial cost ($1.6 million) within six months."

At a time when organizations want to cut the "fat," meaning in one regard cut our layers of management, the eICU adds layers.

Indeed, the real advantage to the eICU is the change it allows in hospital management. Under Sentara's old system, a patient was admitted to a hospital by a nonspecialist doctor. That doctor made rounds in the morning, then went back to the office. For the rest of the day nurses handled whatever came up, alerting doctors when things got urgent.

The eICU system adds two more layers of patient management. An in-hospital team uses shared data to conduct its own daily case reviews. At Norfolk General, Medical Director for Quality of Critical Care William A. Brock rides a Segway through corridors as he directs a dozen doctors, nurses, pharmacists, and other professionals in reviewing each case in Sentara's cardiac ICU, ordering tests, and offering advice to admitting physicians. And from noon to 7 a.m., the eICU team offers specialized support to bedside nurses, who manage cases while patients' personal doctors do other work.

Despite high costs and increasing the layers of patient management, the payoff is there.

In two ICUs, deaths fell 27% the first year Sentara had the system up,
according to a study in the journal Critical Care Medicine. Based on death rates before and after the technology was rolled out systemwide, Sentara estimates that its eICU has saved 460 patients who would have died in traditional care. And the cost per ICU case also fell, by nearly $3,000, or 25%...

Much of the savings came from a dramatic plunge in complications such as hospital-acquired pneumonia and bloodstream infections, which occur more often when patients aren't monitored by experts who understand the meaning of subtle changes in their condition. If not treated immediately, they result in more tests, more treatments, and longer stays in intensive care, which costs about three times as much as the rest of the hospital. The system cut almost a day off the average ICU stay, from 4.4 days to 3.6.

I think it's just a matter of time until every ICU in the country is wired up this way. And it's not just new companies pushing the technology -- it's also patients demanding it. Hospitals may soon have to "factor in a question posed by Charlotte Pipes's sister-in-law, Janet Eiler: 'Patients' families are going to ask: "Why don't you have this?"'"