ECRI Institute charts the top 10 technologies 2009 and beyond

1. Electronic medical records: What should you be doing now?

Hospital chief information officers and administrators must figure out which of the myriad IT projects they need to accomplish to prepare for electronic medical records (EMRs) implementation or to continue along the adoption path if they’ve already begun. Doctors and hospitals not going electronic by 2015 will be subject to penalties, according to the terms of the federal stimulus package. Planning for EMR implementation might include projects such as establishing a fully closed-loop medication administration record, implementing a system-wide clinical data repository, and using clinical decision support systems that are based on evidence-based medicine, to name just a few.

Planning for staff buy-in and training to use such systems is also critical to implementation. The pressure is on to move toward EMRs with the U.S. Centers for Medicare and Medicaid Services policy to not reimburse for their designated and expanding list of "never events" and with the U.S. Agency for Healthcare Research and Quality’s designations of Patient Safety Organizations. Every hospital and healthcare facility’s ability and requirements to manage vast amounts of information is only increasing.

2. Ultrahigh-field-strength MRI and premium performance CT: Do you really need them? Now?

The magnetic resonance imaging (MRI) market has been moving toward use of more ultrahigh-field-strength (UFS) and open high-field-strength (HFS) systems. UFS is defined as a system with a 3.0 Tesla (T) or stronger magnet. Such systems provide higher signal-to-noise ratio (i.e., more signal, less noise) than lower-field-strength (i.e., 1.5 T) systems, enabling clinicians to obtain faster imaging times and higher quality images. Few studies have been done, however, on how 3T MRI changes patient management and outcomes.

Considering that most MRI magnets last 10 to 12 years and that it is likely that today’s high-end scanners will predominate in the next 5 to 8 years, hospitals considering acquiring MRI systems in 2009 will have a difficult choice to make. Should they go with the very high-cost UFS or open HFS systems or the lower-priced and lower-performing 1.5 T systems that may be outdated well before reaching the end of their expected life cycle? Although quicker procedure times and larger numbers of clinical applications available with new systems can increase revenue and while certain service-related costs are lower (i.e., for cryogen cooling), hospitals’ net costs for these systems will significantly exceed those of the standard 1.5 T systems. (Editor’s Note: Please see the full white paper for commentary on premium CT.)

3. Physician preference items: Do your docs know the costs?

The trend of rising costs for physician preference items (PPI) — implantable items that come in many brands from which a physician can choose — such as cardiac stents, pacemakers, orthopedic implants, and orthobiologics, shows no signs of slowing.

Why? Several factors are contributing to this trend. One factor is skillful marketing and continued innovation in areas such as gender-specific and custom-tailored or "smart implants" for joint replacements, osteobiologics in spine surgery, and more advanced pacemakers and implantable cardio-defibrillators for cardiac rhythm management. Another major contributing factor has been pricing opacity. Manufacturers of PPIs have more aggressively interpreted and enforced confidentiality agreements embedded in their hospital contracts to prohibit hospitals from sharing pricing information with consultants and third-parties, as well as surgeons and patients. The resulting lack of transparency of pricing often leaves a hospital holding the bag for the high cost of implants, but all too often in the dark about what it should pay for the devices.

As hospital administrators navigate an environment of decreasing reimbursement, they need to be ever vigilant to manage the shrinking profitability of key service lines such as cardiology and orthopedics, which traditionally have been financial winners.

4. Robotic-assisted systems for surgery and endovascular catheterization: How many should you have?

Advancements in medical robotics have risen steadily for surgical and endovascular interventions. The da Vinci surgical robot represents the best-known application of robotics in the operating room (OR), where surgeons trained in its use now routinely perform robot-assisted prostatectomy, mitral valve replacement, hysterectomy, coronary artery bypass, and other procedures. New surgical applications are emerging, and the pressure to acquire a robot has increased with the new generation of surgical residents in training, requirements of residency programs to offer robotic surgery training on a da Vinci system, and requirements at some medical schools that applicants take hand/eye coordination testing to assess their ability to use robotic systems. Hospitals should also be mindful that many of the applications for robot-assisted surgery have outpaced supporting clinical evidence for improved patient outcomes, cost-effectiveness, and commensurate reimbursement.

Constrained access to capital may dampen wider diffusion in the near term, however, given the $1 million to $3 million cost of these systems, annual maintenance contracts upwards of $100,000 per system, and the 5- to 6-year life cycle of the equipment.

5. Radiation oncology: Will proton centers fulfill their promise?

Proton therapy has been around for decades but has garnered much attention in the past 2 to 3 years with the number of high-end facilities in the United States expected to quadruple between 2009 and 2012. Now a commercially available "low cost" (i.e., $20 million) single-room proton therapy system is on the horizon, and hospitals concerned about being able to offer the "most advanced" radiation technology may be considering whether a proton system is appropriate. Concurrently, significant technical advances have been made in traditional linear accelerator radiation technology (e.g., CyberKnife) and radiation oncology applications (e.g., image-guided applications, and accelerated partial and whole breast irradiation technologies). These traditional technologies are less than one-fifth to one-thirtieth the cost of proton therapy. All these technologies offer the same promise: the ability to precisely deliver a higher radiation dose to the target tissue while lessening damage to collateral healthy tissue—tissue that surrounds or is on the radiation beam’s pathway to the target.

Proton therapy systems, however, have extremely high upfront capital and implementation costs as well as high operating costs. The reimbursement climate is limited to a few specific clinical applications, and it is uncertain for other applications because evidence to support improved clinical outcomes over conventional radiation modalities is not available and no randomized controlled trials making the appropriate comparisons are planned. Yet the cost of proton therapy is 2 to 3 times higher per patient than other methods of external beam radiation therapy, such as 3-D conformal radiation therapy.

6. Radio-frequency identification technology: What problems can it really solve?

Radio-frequency identification (RFID) technology has garnered a lot of attention in healthcare recently as a technology that can improve patient safety, efficiency of processes, and save money. The promise of RFID is also appealing as a way to monitor real-time whereabouts of critical staff, to mobilize rapid response teams, or to improve staff efficiency by monitoring patient locations to avoid wasting clinician time when patient transport from one clinical area of the hospital to another is delayed. RFID also promises to improve inventory management of medical devices and equipment within facilities.

However, the benefits of RFID sometimes come at very significant costs, and hospitals wishing to purchase RFID technologies in uncertain economic times should carefully examine their potential for a return on investment (ROI). While RFID vendors will promise rapid ROIs, the returns often are difficult to track concretely, or they may be intangible, making it hard to ascribe a value.

7. Alarm integration technologies: How best to monitor all those alarms?

Alarm integration systems are intended to provide a technology solution to enhance alarm notification and coverage. Such a system can be as simple as interfacing a ventilator to a physiologic monitoring system to provide alarm notification at a central station display. More recently, focus has shifted to complex alarm integration systems that incorporate many alarms (e.g., physiologic monitors, ventilators, infusion devices, medical telemetry) to notify a clinician’s wireless device (e.g., cell phone, pager).

8. Hybrid O.R.’s: How many of your ORs should have imaging capability?

A hybrid (OR)/catheterization laboratory is an interventional suite where a patient can undergo both a surgical procedure, such as open-heart surgery, and an endovascular procedure, such as angioplasty that requires fluoroscopic imaging. Thus, a hybrid interventional OR suite permits percutaneous coronary interventions (PCIs) to be performed immediately before, during, or after coronary artery bypass grafting (CABG) surgery without requiring the patient to be moved between two sterile rooms. This type of one-stage or simultaneous hybrid PCI/CABG procedure is being tested to treat high-risk patients with multi-vessel coronary artery disease (CAD) who need both stents and CABG. In these patients, the hybrid procedures potentially carry a lower mortality risk than conventional CABG surgery alone for multi-vessel disease. By contrast, the hybrid procedures typically involve placing one bypass graft to a major artery and stent implantation for the rest of the affected arteries. Another potential benefit of the use of hybrid interventional suites is the ability to perform a coronary angiogram at the end of routine CABG surgery. This angiogram helps to ensure that arterial bypass grafts are in place and that proper circulation has been restored.

As endovascular procedures become more time-consuming, fixed imaging systems rather than mobile C-arms are generally preferred by surgeons due to greater flexibility in anatomic coverage. Now, with next-generation fixed C-arm systems, many hospital administrators have to choose how to best utilize scarce OR resources. Hybrid ORs require larger space and typically have to be dedicated to only those procedures requiring that equipment. Besides having greater C-arm positioning flexibility, the new C-arm systems enhance diagnostic and therapeutic capabilities by enabling the acquisition of cross-sectional images showing soft tissue information as well as hard object information, which may aid in angiography-assisted tumor treatments and surgical planning.

9. Therapeutic hypothermia after heart attack, stroke, spinal cord injury: dawn of a new era in emergency medicine?

A new era of resuscitation medicine is dawning. The term applies to new protocols and technologies for rapidly cooling patients’ core temperatures after acute life-threatening cardiovascular and neurologic events to save lives and neurologic function. Known as therapeutic hypothermia (TH), rapid cooling using a special intravenously administered slurry has been shown in early clinical studies to contain and prevent damage to the heart and brain. Interest is also keen regarding rapid patient cooling for spinal cord injury.

The implications are large. For example, only 40 percent of the 166,000 patients having out-of-hospital cardiac arrests annually in the United States survive to be admitted to the hospital. Of those, the survival rate to discharge from the hospital is only 6 percent to 20 percent. The overall survival rate after out-of-hospital cardiac arrest is only about 5 percent.

Several dozen U.S. hospitals have a TH protocol in place for patients who have suffered cardiac arrest, but most do not despite the publication of several clinical guidelines recommending TH (32°C to 34°C for 12 to 24 hours) as a standard of care for out-of-hospital cardiac arrest in patients who have an initial rhythm of ventricular fibrillation.

10. Rapid tests for deadly infections: Where do they fit in infection control protocols?

With Medicare and third-party payers refusing to pay for healthcare-acquired infections (HAIs), hospitals and other healthcare facilities need to look at their infection control protocols and figure out where rapid tests (i.e., tests that give results in 2 hours rather than the 48 hours required for cultures) fit in their infection-control picture. C. difficile has become an even more pressing concern, if that’s possible, than super MRSA infections. The prevention protocols for these infections are necessarily different because of the different ways these bugs are transmitted.