If the AMA does not publicly display that it understands the urgency of more widespread IT adoption in medicine (which apparently it does not), what hope is there of persuading AMA members to adopt IT?

Britain’s equivalent of the AMA — the BMA — is at least showing an interest in the topic of IT in calling for a boycott of the planned nationwide EMR system.

In May, we wrote about the end of primary care. But we were not allowing for what, to many doctors (though not to the more “with-IT” rest of the world) is an innovative use of basic IT; in this case, to compete with the “boutique” primary care providers. In any event, doctors must learn to use IT to broker the best care for their patients, as cost and convenience drive more US states to allow pharmacists and other non-physicians to prescribe some drugs, despite concerns about a potential adverse impact on care quality.

Further evidence of the trend to consumerism and hospital price competition can be found in Wisconsin, where heart X-ray scans are on sale for as low as US$49.95. (But wait! Call in the next 30 minutes, and we’ll throw in a FREE tetanus shot!)

Methodist Hospital shows how to market surgery to consumers via the Internet. They had better not market surgeries about to go out of style, such as the traditional hysterectomy, which may be about to receive a beating from an ultrasound alternative.

Fast becoming in style are robot assisted surgeries, including a new spinal surgery robotic assistant. One wonders whether the surgeon who extols the virtues of robot-assisted surgery will be quite so thrilled when, as a result of increasing robot autonomy, the tables are turned and robot-assisted surgery becomes surgeon-assisted robot surgery and, ultimately, simply robotic surgery.

There can be no doubt that robots will become autonomous. There are hints that Sony’s QRIO android is about to get a supercomputer-sized external brain, for that very purpose, and a spin-off of US military robotics research could be robotic wheelchairs to semi-autonomously ferry patients around a hospital.

A 113-bed hospital with two operating tables, digital x-ray, and other state-of-the-art equipment goes on the road in North Carolina. It sounds futuristic, but not nearly so much as a commercially available “wearable hospital” the US military has bought for some of its troops, raising telemedicine to a new level by not requiring that monitoring equipment be installed in homes and that patients be at home or any other specific place, and by enabling continuous as opposed to periodic monitoring of vital signs.

An Oregon hospital has adopted an open floor OR plan to make technology more affordable, by making dollars that would have been spent on room build-outs available for new technologies instead.

AMA Does Not Get IT

While British doctors, for good or ill, are addressing the issue of EMRs (see next article), American doctors are ignoring it, judging by a report by Neil Versel in iHealthBeat. While news and initiatives on e-prescribing, EMRs, and other health IT swirl all around them, they — or at least their representative, the American Medical Association — evidently feel that the malpractice issue is more important and will be solved by getting rid of the lawyers rather than by using IT to help reduce the malpractice.

The annual AMA meeting in June “was memorable for its scant attention to information technology,” writes Versel. “Rather than being a forum to advance the medical profession, the AMA meeting turned into a carnival of lawyer-bashing.” While acknowledging that anger and frustration over malpractice lawsuits is real, he suggests “it might be more constructive for physicians to pressure malpractice underwriters to reduce rates if they take steps to prevent errors and ensure quality,” such as using electronic drug interaction checking, EMRs, and computerized physician order entry (CPOE).

And while delegates adopted a resolution to lobby for incentives to adopt technologies in their practices, they rejected a proposal from the American Academy of Pediatrics asking the AMA to seek tax credits or similar incentives to invest in IT. Based upon its objections, it would seem that the AMA is uninformed about government and industry-backed standards initiatives.

Finally, it is instructive, to put it wryly, that at a conference devoted to electronic patient records, the AMA’s booth was “hawking clinical guidelines-on paper. As noted medical informaticist and AMA member Dr. Allen Wenner of Columbia, S.C., described it, ‘It’s like they went to an auto show and were
handing out buggy whips.'”

Reference: Versel, Neil (2004). “AMA Meeting Leaves IT in the Dust.” iHealthBeat, June 21.

Reactionary British Docs

Britain’s equivalent of the AMA — the BMA — is at least showing an interest in the topic of IT in calling for a boycott of the planned nationwide EMR system.

The British Medical Association’s family doctors committee says it has “no confidence” in the British government’s US11 billion plan to create a nationwide electronic medical record system, and has recommended a physician boycott. It seems they are concerned about the plan’s timetable, the confidentiality of patient records, and that they were not consulted.

Reference: Unknown (2004). “British Docs Oppose Patient Records System.” iHealthBeat, June 21.

Technology: Primary Care’s Savior?

“A combination of e-mail, the telephone and patient feedback could easily help shape the future of primary care,” writes Mark Hollmer in the Boston Business Journal, reporting on a startup medical practice founded by Harvard physicians. It is a sweeping conclusion, but it may well point in the direction of truth. For US$40 a month patients can access their electronic medical records and email or call the doctors.

The doctors will all use wireless tablet PCs and e-prescription services, and will offer after-hours preventive-care seminars for patients. Patient committees will work with the doctors to help improve how the practice operates over time, and “clinical partners” (“ideally, registered nurses”) specializing in disease prevention programs or nutrition will help patients navigate through the health system.

The idea, said one of the founders, is to “get patients involved to help … create this radically new model as to how to deliver health care.”

Reference: Hollmer, Mark (2004). “Renaissance to unveil experimental health care model: Practice will use technology to deliver patient care.” Boston Business Journal, June 18.

Physician Disintermediation in Prescribing

The states of California, Arizona, and Hawaii allow naturopaths to prescribe some regular pharmaceuticals,  and Alaska may be next. Washington state has a pilot program allowing pharmacists to prescribe birth-control pills and patches to women, in addition to administering vaccinations and dispensing prescription smoking-cessation products. “This year,” writes Jane Spencer in the Wall Street Journal, “eight state legislatures dealt with bills that would let women get prescription emergency contraception, known as the morning-after pill, directly from a pharmacist — without seeing a doctor.” Louisiana has enacted legislation allowing psychologists to prescribe psychiatric drugs such as antidepressants and anti-anxiety medications, provided they get additional training in medicine and psychopharmacology. New Mexico passed similar legislation in 2002. Some states are “considering bills that would expand prescriptive rights for groups including nurse anesthetists, and optometrists,” adds Spencer.

Cost and convenience are the drivers, and insurance companies and some major drug makers support the trends. Predictably, however, it is “generating fierce opposition from physicians’ groups,” who claim it undermines standards and may lower the quality of care, and demand at least some control over the prescribing process. “Even some pharmacists,” says Jennings, “are hesitant, citing the potential for errors and adverse drug interactions,” and they and other nonphysician prescribers could see their malpractice insurance costs rise.

The cost savings, however, are compelling to at least one health insurer, which now pays pharmacists US$20 for emergency contraception prescriptions, compared to $250 if the patient went to an emergency room for the same drug. Allowing pharmacies to dispense the morning-after pill could also help prevent unwanted pregnancies and reduce abortions, since some women may not be able to get a doctor’s appointment within the 72 hours in which the pill would be effective, whereas pharmacies are open on evenings and weekends.

One thing is for sure: An already complex US healthcare system is growing more complex as a result of these various state initiatives.

Reference: Spencer, Jane (2004). “Getting Drugs Without the Doctor: States Extend Prescription-Writing Powers To a Growing Range of Nonphysicians.” Wall Street Journal,June 1.

Blue Light Special: Heart Scans

“Bargain-basement” heart X-ray scans are on sale at some Wisconsin hospitals. Prices are typically in the US$150 to $250 range, writes Joe Manning in the Milwaukee Journal Sentinel, but some go for as low as $49.95.

Manning points to a number of factors behind the trend, including consumerism as patients are forced to shoulder more of the burden of costs, and loss-leader marketing to attract patients for more expensive procedures. The low-price scans may make sense for people who don’t have risk factors for heart disease, one patient — who happens to run a hospital system — told him, adding that price competition “is cropping up in areas where health insurance doesn’t cover costs, such as cosmetic and vision-improvement surgeries.”

“As a result of the screenings,” said one hospital executive, “we’ve already had patients who required additional diagnostics or procedures such as angiography, cardiac catheterization, and one patient requiring open-heart surgery.” However, some hospitals “don’t believe screening scans are appropriate,” while others argue the benefits of inexpensive, fast, and painless “early warning . . . of developing heart disease.”

(Psst: For the $49.95 scan, call the Milwaukee Heart Hospital and ask for “X-Ray Ed.”)

Reference: Manning, Joe (2004). “Low-price heart scans: Good for consumers or a lure for more care?” Milwaukee Journal Sentinel, May 31.

Advertising Surgery on the Internet

The inventors of the METRx minimally invasive microdiscectomy procedure for a herniated disc, which usually allows patients to go home within a few hours of the procedure and return to normal work within a couple of weeks, have webcast the procedure via the Methodist Healthcare website. During the live webcast, one of the surgeons narrated the surgery and answered questions emailed from viewers.

The webcast (which is now archived on the website) was designed to market to, and educate, consumers, and it also served to educate surgeons as well.

Reference: Watson, Mark (2004). “Methodist puts spinal surgery on the Internet.” Commercial Appeal, June 17.
Ultrasound in Place of Surgery

An Israeli medical imaging firm is seeking US Food and Drug Administration approval for its ExAblate 2000 MRI/ultrasound treatment that breaks up fibrous clumps in the uterus as an alternative to hysterectomies and other surgical treatments. The procedure has already been approved in Europe and Israel, and is being studied as a possible treatment for breast tumors.

An MRI scan locates the clumps and directs ultrasound waves to destroy them. The detritus is flushed from the body naturally. Though very successful in trials, side effects included nerve injury, leg pain, bowel symptoms, bladder symptoms, and skin injury.

According to the National Uterine Fibroids Foundation, fibroids are the main cause of all hysterectomies, which is a major invasive procedure. However, the ExAblate 2000 treatment may need to be repeated as more fibroids grow.

Reference: Heavey, Susan (2004). “Experts to Review New Ultrasound Fibroid Therapy.” Reuters via Yahoo News, June 2.
Spinal Surgery Robot

The US Food and Drug Administration (FDA) has approved a miniature robot claimed to enable “fail-proof” spinal surgery. The US$100,000, soft-drink-can-sized robot from Israel improves accuracy during complicated back surgery. It further minimizes risk by reducing surgery time and invasiveness, which expedites recovery and minimizes associated risks such as infection and blood loss.

SpineAssist, as it is called, attaches to the patient’s body and shows the surgeon the exact positioning needed for tools and implants, down to the millimeter. “It conceives a plan for locating the spinal implants, but neither replaces the surgeon nor performs any operations. After examining and approving the recommendation, the surgeon inserts surgical instruments through the arm of the robot, thereby minimizing the danger of damaging vital organs,” a company executive told a Jerusalem Post reporter.

The US$100,000 system has been installed in Israel and at the Cleveland Clinic.

More than half a million spinal operations are performed annually in the US alone, and the number is growing by eight percent a year. The company says its technology can also be applied to brain and knee surgeries, and it is working on a miniature version that will fit inside a patient’s spinal cord.

Reference: Siegel-Itzkovich, Judy (2004). “Health Scan: Robot aids spinal surgery.” Jerusalem Post, June 27.

Reference: Unknown (2004). “FDA Approves Israeli Spinal Repair Robot.” Reuters via Yahoo News, June 9.
Future of Surgery Already Here

More and more types of surgery are being performed with the help of surgical robotics, which give the surgeon greater precision while reducing risk and discomfort for the patient. A surgeon at Good Samaritan Hospital wrote in an article for the Cincinnati Business Courier: “I truly believe that in the not-too-distant future, the da Vinci [the leading surgical robot] will become the standard operating method for cardiothoracic, urological, vascular, and general surgeries at Good Samaritan,” and predicted the hospital would eventually need a second da Vinci to handle the growing case load.

The benefits of surgical robotics, he noted, also will become widespread as more surgeons become proficient in the technology’s use. At Good Samaritan, they do so in the hospital’s Minimally Invasive Surgery Training Center, using computer-simulated patients instead of animal models or human cadavers. “What was once considered surgery of the future is today reality,” he writes, adding for good measure: “Tomorrow’s technology is here.”

Reference: Smith, J. Michael (2004). “Surgical robots revolutionize hospital OR.” Cincinnati Business Courier, June 18.
Android Gets a Brain

Sony is reported to be working on a project to connect its Qrio humanoid robot via high-speed network to a teraflop computer grid, to give Qrio the “mental capacity,” as it were, to make its own decisions. However, details are scant.

Reference: Unknown (2004). “Sony QRIO Robot gets Tera Flop Brain.” i4u.com, June 21.

Robot Patrol

Robots costing from US$200,000 to $500,000 are being tested by the US military as patrolling guards. They include remote-controlled full- and ATV-sized vehicles equipped with radar, video cameras, an infrared scanner, weapons, and a mini-robot that can search under vehicles and inside buildings.

“The vehicles can be programmed to patrol specific areas and then alert an operator by radio if they find something suspicious. They have loudspeakers and microphones for questioning intruders and the operator can pick from a variety of languages,” writes Bill Kaczor for the Associated Press.

Operating the robots is literally child’s play — anyone who plays games on “PlayStation or X-Box, that type of thing, it’s right up their alley,” a soldier testing the robots told Kaczor.

Reference: Kaczor, Bill (2004). “Air Force testing robot vehicles to protect bases and forward units.” Associated Press via San Francisco Chronicle, June 23.

Hospitals2Go

Two 53-foot tractor-trailers constitute a 1,000-square-foot mobile hospital designed to respond to terrorist attacks or other disasters. The US$1.5 million facility, paid for by a US Department of Homeland Security grant, has an operating room that can handle two simultaneous surgeries, 13 acute and general care beds, a digital X-ray machine; and a dental chair. An attached tent adds 100 exterior beds.

Reference: Funk, Tim (2004). “Hospital on Wheels Can Roll With the Disasters.” Charlotte Observer, June 17.

LifeShirt

The US Army Research Institute of Environmental Medicine has ordered a number of US$500 LifeShirts with embedded sensors that monitor and transmit the wearer’s blood pressure, oxygen in the blood, temperature, movement, and other pulmonary, cardiac, posture, and activity vital signs, reports Dani Dodge in the Ventura County Star. The shirt contains about as much monitoring equipment as a hospital room, and is is especially useful for soldiers, firefighters, and others who must work in hazardous environments often wearing bulky and hot protective clothing but who become “so pumped up on adrenaline, they aren’t aware of their own bodies’ signals.”

The shirt has obvious benefits, too, for ordinary people, enabling their vital signs to be monitored all the time, wherever they are. It has also been used in a clinical study of sleep apnea drugs, allowing patients’ respiration to be monitored remotely, so they could sleep in their own homes instead of in an expensive sleep lab. It has been used by the Walter Reed Army Hospital, Italian climbers scaling Mount Everest, and a race car driver.

The US Army’s purchase will enable Army medics to remotely locate soldiers, assess their health status, and triage for medical attention as needed. Soldiers in Iraq could be monitored for heat stress and dehydration, among many other things.

Reference: Dodge, Dani (2004). “LifeShirts could save lives: Ventura firm sells monitoring devices to Army.” Ventura County Star, June 21.

Future of Surgery

Providence St. Vincent Medical Center in Portland, Oregon, boasts a digital surgical suite containing an array of high-end technologies in “a single-room arrangement expected to increase operation efficacy and even lower hospital costs,” writes David Wolman in the Wall Street Journal. By combining the operating theater with a catheterization lab and an endoscopy suite, the hospital minimizes the risks and eliminates the costs of shuttling patients around various rooms. The technology includes:

• A Da Vinci surgical robot
• Voice-activated cameras “for peering into the circulatory system” Four
  high-definition monitors
• A ceiling-mounted fluoroscopy machine for angiography
• An adjustable, dual-purpose operating/imaging table

Operating controls for lights and all the equipment are “integrated” (which we assume means grouped at a command console), giving the surgeon direct control over “every aspect of the operating room and its interface with the hospital and the physician’s office,” a physician told Wolman.

The anticipated benefits include shorter procedure times, improved ergonomics, and a reduction in theater staff. In addition, the open-plan model not only facilitates multiple types of surgery but also helps eliminate rebuilds to accommodate future technologies. Investment can be concentrated in technology rather than in space.

Reference: Wolman, David (2004). “The Future of Surgery.” Wall Street Journal (reprint of an article from Technology Review), June 25.