Implementing New Technology: Balancing Needs vs. Wants for Success

New technology’s impact on hospitals across the country is increasing, mostly in terms of facility design requirements, physician satisfaction, and community image and reputation. Though exciting, the adoption of new technology can be somewhat of a challenge. These decisions can make the difference between your cardiovascular service line or catheterization lab being considered ‘cutting edge’ or in some cases, ‘cutting floor.’ Decisions, Decisions Indeed, choices about what technology or new equipment to consider, if and when to purchase, and how to implement are significant ones. Many important questions surface when getting started with this daunting process: • Are requests for new technology and equipment standardized? • How are such requests prioritized? • What capital budget constraints exist? • Who will own the implementation of the new technology and equipment, and any change in process that accompanies acquisition? • How do we ensure appropriate reimbursement? • What is the expected return on investment and how can we track it? • What are the IT implications for image and data capture? These are just a few questions…the list can be endless! There are ways to streamline this process and increase the chance of successful planning and implementation. Having a structured cardiovascular service line gives an organization a “leg up” throughout the capital planning and product evaluation process. The service line model provides the opportunity for the creation of a specialized committee. This committee’s sole mission is to evaluate, implement, and ensure the profitability of the newly-adopted technology or equipment. A Cardiovascular (CV) Product Evaluation Committee is spearheaded by a single physician, perhaps the medical director, or even a departmental manager. The leader could be high- or low-ranking, as long as the committee is made a priority and has the proper authority to make necessary decisions. Product Evaluation Committees can include multiple key players such as departmental managers, clinicians, and even finance, purchasing, and IT representatives who are involved in contract negotiations for any “carve outs” associated with new technology. Including those responsible for Chargemaster development can be helpful as well. Corazon has worked with programs where the Product Evaluation Committee has dedicated an FTE to serve in the analyst’s role and assist the committee in their endeavors. Job duties can include: • Researching and recommending new technologies in the industry; • Analyzing proposals and requests from both a quality and business perspective; • Education of key staff and physicians regarding newly adopted technology; • Facilitating the introduction of new technology within the organization; • Fiscal responsibility for vendor pricing and/or consignment strategies. Human resources aren’t usually the main hurdle. Financially, the price tags for new cardiovascular technologies are among the highest in the industry. Facilities might delay technology evaluation processes due to the dollars that can be involved. In fact, the biggest struggle comes from a capital resource perspective: “How do we find equilibrium between the cardiologists’ and staffs’ demands, and what we can afford?” Corazon promotes an innovative model where one lump sum of capital dollars is allocated from finance for the entire cardiovascular service line. This lump sum can have a relative relationship to the revenue generated by the program and/or to the importance of the program, as it relates to the bottom line of the hospital. The committee then determines what amount of money gets allocated to each department or cost center based on overall cardiovascular program and patient priorities. Technologies to Consider You may be asking yourself, “What is the latest technology out there?” At community hospitals, we see the movement towards technology integration. For example, a huge influx of providers with outdated imaging systems are moving towards digital flat panel technology, which provide much better imaging quality. Also, there are those who are incorporating intravascular ultrasound (IVUS) units as a component of the catheterization lab table and imaging system. At both small and large providers, key technology advances currently revolve around invasively treating cardiovascular disease. As clinical equipment becomes more refined, it is less invasive in nature, minimizing trauma to the patient and decreasing the cost of care. The gold standard for the diagnosis of coronary artery disease (CAD) has been invasive cardiac catheterization, now being challenged by CT angiography, especially with new developments such as dual-source CT. The newer technology acquires data more rapidly, allowing the accurate scanning of CV patients typically more prone to higher heart rates and arrhythmias which traditionally obscure images obtained by the slower, older CT models. A potential competitor to CT angiography in the near future is magnetic resonance imaging (MRI), since MRI studies not only evaluate cardiac structure, but also cardiac function. Larger tertiary and academic medical centers are currently assessing cardiac images produced by MRI. At larger institutions, we see the investment in hybrid suites and the movement of certain procedures, such as transapical aortic valve replacement, to these specialized rooms. Often, catheterization lab staff supports these rooms even if they are located within the OR suite. There are also organizations looking at new technology like the Sapien transcatheter heart valve device (Edwards Lifesciences, Irvine, CA), which allows for a transfemoral or transaortic approach to valve implantation, a procedure done in a hybrid suite. Aortic stenosis, in which elderly patients cannot withstand the trauma of major open heart surgery, is often treated with valve replacement. These high-risk patients are benefiting from new technology. The procedure involves a multi-disciplinary team, including a surgeon, an interventional cardiologist and an anesthesiologist. The addition of hybrid suites challenges all involved — physicians and clinical staff — to behave and interact in new ways. Also supporting less invasive care is image-guidance technology. More and more, as small incisions are used and instruments are manipulated inside the patient (often with robotic assistance), image guidance is required to understand where the instrument is in relation to the patient’s anatomy. Multiple specialties are still in their infancy in terms of exploring the uses and potential value of image guidance technology. Electrophysiology guidance technology enables operators to reach difficult areas in order to map and ablate using remote navigation, with the goal of decreasing radiation from fluoroscopy/imaging, and increasing accuracy through 3-dimensional visualization of patient anatomy and arrhythmia pathways. Although the systems employ different approaches, the physician uses a computer-controlled console while in the control room – removed from the catheterization lab. • The Stereotaxis system (Stereotaxis, Inc., St. Louis, MO) uses large magnets to allow the physician to remotely direct the catheter to different positions for atrial and ventricular ablations, and biventricular pacing lead placement. Essentially the catheters are gently pulled into the correct position by the magnetic force. • Instead of a magnetic field, the EnSite System (St. Jude Medical, St. Paul, MN) and Sensei Robotic Catheter System (Hansen Medical, Mountain View, CA) uses a robotic sheath and pulling wires to enable the physician to navigate the catheter accurately to the intended spot for atrial ablations. The company is exploring ways to use the system to drive wires so that it can be employed for interventional procedures, including bi-ventricular pacing lead placement. Although its clinical application is more limited than Stereotaxis, the Hansen system does not require specialized room construction, is mobile and can be used with multiple procedure rooms. The price differential is significant as well. The peripheral vascular field is also adopting Stereotaxis technology for assistance when navigating across chronic total occlusions and reducing the risk for vessel perforation. This approach has been proven safer than using angiography to steer guidewires with only 2-dimensional visualization. • Endovascular aortic repairs in hybrid rooms are being performed using the next generation of interventional imaging, in the form of a multi-axis C-arm that employs robotic technology. This new equipment extends imaging capabilities through virtually unrestricted C-arm positioning, resulting in advanced cross-sectional imaging. Real-time diagnosis of an endoleak is now possible as 3D imaging techniques, including cross-sectional imaging through Siemens’ Syngo DynaCT (Malvern, PA), are supported by this system. • Within cardiovascular surgery, traditional surgical approaches with large incisions are now being replaced with catheter-based, robotically-supported techniques for multiple procedures. The da Vinci robotic system (Intuitive Surgical, Inc., Sunnyvale, CA) combines superior 3D visualization with enhanced dexterity, precision, and control of laparoscopic instruments placed through small incisions. The system increases surgical precision, as traditional human hand-eye coordination allows surgeons to operate in an 8mm space, whereas with robotics, surgeons can work within the width of a hair. Another trend that Corazon has noted is an increase in the number of partnerships between tertiary and community hospitals regarding information technology advancements and telemedicine support. Telemedicine programs focused on the diagnosis and treatment of the stroke patient, for example, can assist in improving quality by bringing state-of-the-art expertise to underserved areas via virtual means. This approach can be a valuable method to increase availability and access to advanced care, but with a relatively minor investment in capital dollars and physician manpower. Within an organization, the decision to implement new technologies is never easy. This is particularly true with technologies directed at cardiovascular diagnoses and treatment, which often come with the highest price tags. A new technology or equipment acquisition will likely travel the rocky terrain of managing conflicting priorities, multiple personalities, and restricted capital; however, allocating the time and resources into setting up a structure, as well as providing education around that structure, is critical. Continued investment into the cardiovascular service line will be essential to providing state-of-the-art care and remaining competitive. Investment timing and sequencing must follow the vision for the cardiovascular program and a solid strategic plan. Just because an organization ‘builds it’ or ‘buys it’ doesn’t mean that new business will come. Every new purchase or investment must have a solid plan detailing essential action steps, accountable parties, and completion dates. The infrastructure offered by committees, a rigorous business evaluation process, and the quantification of clinical benefit will assist hospitals in charting their way through the technology jungle. The result: a clear path for program growth and success. Nicole McKenna is a consultant and Ross Swanson is a vice president at Corazon, offering consulting, recruitment, and interim management for the heart, vascular, and stroke specialties. Visit www.corazoninc.com for more information. To reach Nicole or Ross, call 412-364-8200, or email nmckenna@corazoninc.com or rswanson@corazoninc.com.

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