HealthTechnology You might expect the mortality curve (the death rate) to be a straight diagonal line that is lower at the left and rises to the right. The older you get, the greater the chance that you will die. That idea of the mortality curve isn’t exactly accurate. Rather the curve is rather like a flatish U- shape. American death rates in infancy are relatively high, they decline after the first year of life during the late teen years perhaps due to risky behavior beginning in the teens. At that point, a combination of maturity and technology seems to create an improvement. Modern Medicine offers us longevity and health. We have defeated most infections, tuberculosis, polio, dysentery, malaria and even some kinds of cancer. At some point, the decay of the body makes itself evident and death rates begin to increase. http://www.disastercenter.com/cdc/Leading%20Cause%20of%20Death%201999-2005.html Science now offers us the probability of longevity but with chronic illness or mental incapacity. Unresolved scientific issues promise a long life ending in… Obesity, diabetes, heart disease, and Alzheimer's We will also face new medical challenges in increasing numbers. HIV, SARS, Bird Flu, H1N1 are mutations of less deadly viruses MRSA is a evolved infection immune to antibiotics Autism may be a genetic disorder, an reaction to the post-modern environment or both. With these happy thoughts let’s begin our examination of Healthcare Technology. http://www.cdc.gov/ Some sources for this lecture provided by… http://ocw.mit.edu/OcwWeb/Science--Technology--and-Society
Health Care and Technology offer some conventional developments that may be obvious to us. Other developments supporting Health Care seem decidedly un-medical. For example, The Center for Disease Control (CDC) uses Google searches counting key words that are flu symptoms to identify the localities suffering flu outbreaks or epidemics. The Gates Foundation is supporting the distribution of “Laser Curtains” that kill malaria-bearing insects before they can infect populations in developing countries. Four “curtains” starting on the perimeter of a property at intervals of about 65 feet, then becoming increasingly narrow until they defend the person’s bed, cost as little as 100 each and reduce the odds of infection to 1:100,000. “Zap! “The Economist,Technology Quarterly, June 6, 2009, 10.
Are medical expenses subject to supply and demand constraints? Do people forego medical treatment as prices increase? Rudi Volti says: Medical expenses "...are not usually weighed against cost...." (111) But haven’t we heard and seen evidence that the elderly may reduce prescription dosages or eliminate medications because of the cost? Are they subject to supply and demand? When are they not?" In 1960, one-half of medical costs were directly borne by patients...." by the 1990s, 46.7% is borne by the government; insurance covers 32.6% of total expense. Bryan Jennett, a British MD, says medical procedures should not be provided when treatment is... -unnecessary- too advanced -unsafe- complications outweigh benefits -unkind- the quality of life expected doesn't warrant the suffering -unwise- consumes resources more beneficial elsewhere
Like every other aspect of life, economics play a critical role in the availability of health care. In 1996, a concentrated publicity campaign resulted in the focus of attention on kidney disease and the availability of dialysis particularly to those receiving services through Medicare. In that first year after Congress approved funding, $12.7B/ was spent on dialysis. The result of the reallocation of services resulted in 1% of Medicare patients consuming 5% of payouts (114) In the first decade after the new millennium, there was a new Medicare issue. The debate was whether Viagra should be provided to incarcerated criminals and previously convicted sex offenders: Societies make decisions about how to spend resources. This is not a new problem. As early as 1983, one liver transplant and post-op care cost $34K. That was the equivalent of the funding for 29,000 clinic visits. Which should we buy? Rudi Volti says that "heroic efforts" to save an infant= $100K(117). What services do we not provide to save that infant? Our culture places a value on human life like none in the history of the world. As the result we expend… 30% of all Medicare payments support the last year of patients’ lives: about 12% for the last thirty days. Some of the expenditures our society makes in the health field, however, may be unproductive. 47% of all tests have no effect on the quality of patient care (118) Fetal heart monitors do not increase survival but do increase the number of cesarean sections. The AMA estimates that $15B is spent annually on unnecessary tests. These tests may be provided for legal rather than for medical reasons. Unbridled humanism may not be the best answer to health care. The UK offered maternity services free to any woman entering a hospital ready to deliver. The expectant mother didn’t need an insurance card or even identification. The UK no longer offers this service as it did prior to 2004. It seems that babies were being delivered by the thousands that upon discharge from the hospital were returning to their homes across the English Channel. Like every other issue we face, there are societal issues related to every technological issue.
Ancient Medicine Hippocrates (Fourth Century BC) and Galen (Second Century AD) developed, expanded and espoused a theory of four bodily humors that determined and if properly managed could ensure sound health. These Humors were… Yellow Bile Black Bile Phlegm Blood Each corresponds to a season Yellow Bile- Summer Black Bile- Autumn Phlegm- Winter Blood- Spring Em-ped-o-cles relates the humors to the four elements (earth, air, fire, water) Aristotle uses the image of wine to expose the nature of black bile. He says… Black bile like grapes contain pneuma which provokes hypochondriac diseases like melancholia.Like wine black bile is prone to ferment and produce alternating depression and anger. So each humor was related to an element, an emotional state, and a physical condition. Yellow Bile- fire- choleric- hot/dry Black Bile- earth- melancholic- cold/dry Phlegm- water- phlegmatic- cold/moist Blood- air- sanguine- hot/moist Hippocratic physician would prescribe diet and activity designed to "void the body of the imbalanced humor.” Later leeches and blood-letting. According to Gary Lindquester’s History of Human Diseases, if it was a fever-- a hot, dry disease-- the culprit was yellow bile. The doctor would try to increase its opposite, phlegm, by prescribing cold baths. If the opposite situation prevailed (as in a cold), where there were obvious symptoms of excess phlegm production, the regimen would be to bundle up in bed and drink wine. If this didn’t work the next course would be drugs, often Hellebore, a poison to induce vomiting. Ancient Greek medicine was based primarily on observation. They did have experience with treating open wounds, so they had some knowledge of the body’s interior. They also had contact during the Hellenistic period with Egyptians who practiced the removal of organs as part of the embalming process. After the 3rd Century some vivisection was performed in Alexandria on executed criminals. A understanding of man’s body was presumed from a knowledge of animals. They also used observation, philosophy and function to draw conclusions about the body.This may seem primitive but is not very different than the way psychologists treat the psyche today.
Internal Medicine in the pre-modern world June 6, 1822: Alexis St. Martin shot in the left upper abdomen. Duck shot discharged from about a yard away resulted in a wound which was the size of a man’s palm. The wound damaged the lung, two ribs and stomach. Dr. Wm. Beaumont bandaged the wound to prevent food from spilling from the stomach. The wound created a permanently open gastric fistula. It was large enough for Beaumont to insert his entire forefinger into the stomach cavity. On August 1, 1825 Beaumont begins to observe human digestion. He ties 1/4 ounce pieces of meat with a piece of silk line and dangles the "high seasoned a la mode beef," raw salt lean beef, raw salted fat pork, raw lean fresh beef, boiled corned beef, stale bread and raw cabbage into the wound. Beaumont pulls the string out three hours later to observe the rate of digestion of the various foods. On August 17 Beaumont has St Martin fast for 17 hours. He observes that the temperature of the stomach is 100 degrees. He removes gastric juice from St. Martin and observes of the "digestion" of corned boiled beef in a test tube. The stomach digested the beef in two hours; the test tube took ten hours. Chicken digested slower than beef.In August, St. Martin moved away. Who could blame him? In 1829, St. Martin returned to work for the Beaumonts. Some limited observations were done on the temperature of the stomach. It wasn’t until 1831 that Beaumont began to compare the effects of food: placed in water; placed in gastric juice; or in St Martin’s stomach. Beaumont also discovered that vegetables digest slower than meat and that milk coagulates before the digestive process. Not surprisingly, Beaumont was able to observe that anger hinders digestion. In 1832 Beaumont set out to locate St. Martin to conduct new experiments. He inserted various foods into the wound (once inserting twelve raw oysters). He learned that exercise helped the production of digestive juices. He failed, however, to experiment the effect of saliva on digestion. One of the limitations on Beaumont’s work was that chemical analysis was not available until the mid-nineteenth century. Alexis St. Martin lived for thirty years with the open wound. When he was in his eighties, his lawyer, Judge Baby of Montreal said that he "was very much addicted to drink." His family hid his body in an unmarked grave after his death to prevent autopsy or further experimentation.
Today there are tools for diagnosis that give the health practitioner access to the internal workings of the patient’s body without exploratory surgery or Beaumont-like cruel experimentation. CT Scan (Computed Tomography) allows for non-invasive diagnosis. CT uses cross sections using specialized X-rays and computer enhancement. MRI (Magnetic Resonance Imaging): Uses Magnetism and Radio-waves. This technology separates and identifies soft tissues.` In Radioisotopic Scanning, radioactive particles are attached to an injected, inhaled or ingested substance. This is often used with infants who may not remain immobile long enough for reliable readings from other scans. Urinary Bladder Scan (aka Radio-nul-clide voiding cystogram) tracks reflux to the kidney which signals infection. Ultrasound or Sonography uses high-frequency echoes to create safe (if imperfect) pre-natal images, etc. X-Ray, discovered by Wm Roentgen in 1895 is useful in creating images of bones and lung disorders such as pneumonia. Barium may be added to create an image of soft tissue structures. An example of this would be the "upper GI" series. My-e-logram: is an x-ray of spinal fluid made visible through the injection of a dye. This indicates cartilage and joint abnormalities. Fluoroscopy records images that show movement, This can indicate the processing of the GI or respiratory tracts or the bladder. Intravenous pyelogram (IVP): Uses a dye which outlines the urinary system including the kidneys, uterus and the bladder.
In an article titled “HEALTH CARE IT” BY SUSANNAH PATTON Dr. Scott Halpern of the University of Pennsylvania is quoted in his frustration over pop up onscreen alerts about medications. "I honestly haven’t paid attention to a pop-up alert in years….I just click right through them as quickly as possible and I think most doctors do the same thing," he says. To help resolve the issue, Medicare offers discounts to doctors interested in installing automated systems These resulted in the development of computerized drug-order systems at hospitals across the country. These are Computerized Physician Order-Entry or CPOE systems. But only four percent of U.S. hospitals are using the systems according to Klas Enterprises . S tudies at Brigham and Women’s Hospital, where informatics leaders developed their own system in the 1990s, revealed that CPOE cut medication errors by 80 percent. It is believed that Nationwide adoption of CPOE could save $44 billion a year in reduced costs from radiology, laboratory and medication errors, according to a study by the Center for Information Technology Leadership. But these systems are expensive and difficult to implement. CPOE can actually increase medical errors if poorly implemented. This occurs when the system does not fit in smoothly with a hospital’s particular "work flow." Until the turn of the 21st century, only a few major hospitals had attempted to design and implement CPOE systems. In November 1999, the Institute of Medicine published a report with some disturbing figures. Avoidable medical mistakes kill anywhere from 44,000 to 98,000 people a year ,m ore than breast cancer, highway accidents or AIDS. The report also said that more than 7,000 deaths are caused by medication errors. How can an effective CPOE be implemented then? Involve doctors and nurses from the start in designing the system. Encourage doctors to join in the effort by designating champions among the medical staff. Partner with your vendor to make sure it will make changes to the system in response to suggestions or complaints from medical staff. Train staff extensively and continue to provide help, preferably from fellow clinicians, once they are using the system. Monitor the systems closely after they are up and running. Be ready to fine-tune the system and make changes for years to come. It’s not easy. In January 2003, doctors at Cedars-Sinai Medical Center in Los Angeles, unhappy with entering orders into the CPOE, staged a rebellion that scrapped the CPOE from a $32 million projec. The system had been in use for only three months. UPenn published a study in the Journal of the American Medical Association (JAMA) documenting that their CPOE system, an early model from Eclipsys, could actually cause 22 types of medication errors. The study surveyed staff using the CPOE and observed medical and IT staff to see how they used the system. One problem was that the system screens made it difficult to ensure that treatment was ordered for the right patient. During this decade, the U.S. Medicare system has encouraged uniform online record keeping. Personal privacy issues still impede progress. Asif Ahmad, CIO of Duke University Medical Center and Health System chaired the CPOE task force with that hospital’s chief medical officer, and within his IT department. There were six physicians, thirty nurses and four pharmacists reporting to Ahmad. Duke’s system allowed doctors to define the workflow. When admitting a cardiac patient, for example, the system indicates an aspirin should be administered as a standardized treatment. Duke’s implemented 590 patient beds and 259 "order sets." Ahmad said, "The idea was to get all the cardiologists in one room and tell them they can’t leave until we agree on a set of directions on how to manage patients. Sometimes there are personal preferences but we have to agree to make the system work." Elsewhere At St. Jude, 40 percent of admissions are now done using the system that includes CPOE. They used the Medtech system to implement the system. Now St. Jude’s has nine levels of warnings for drug interaction. If every level of warning is implemented a time-consuming series of pop-ups will be displayed. Doctors decided to activate only the two highest levels of warnings to avoid making serious errors. (The Right Dose of Technology Helps the Medicine Go Down)
Hippocrates primitive model includes a high mortality rate throughout "youth. "Treatment was almost never preventative and usually ineffective. Treatment was personal, communal and local. The tools of treatment were individually owned. Treatment was based on theoretical, external observation. The pre-modern model personified by Beaumont included a mortality rate that is U-shaped but shows an increasing death rate throughout the average lifespan. Treatment preventatives begin to emerge. Treatment was a combination of personal and communal. Treatment Centers might be convalescent but were primarily places of birth and death. Treatment Centers tended to "belong" to specific communities (like religions) Treatment was based on limited internal observation, usually of moribund (or dead) organs. Modern treatment adds a protracted tail to the U-shaped mortality rate. Long life is complicated by mental incompetence and long physical disabilities. Preventative treatment receives considerable attention. Treatment Centers except for the aged are short-term facilities. Treatment becomes increasingly impersonal. Systems leverage less expertise to provide treatments of increasing complexity (the emergence of the Physician’s Assistants, for example) Treatment Centers become corporate entities. Internal observation dominates diagnoses. Although pre-modern rather than modern diagnosis has been characterized by invasive observation through surgery or injury, NMR spectronomers, bring modernity into invasive diagnosis. This device is used to perform biopsies. With a tissue sample no larger than a pinhead, these devices can analyze for malignancy within minutes. (Hamzelou, Jessica. “Smart Knives and Boosted Biopsies,” New Scientist, 5 February 2011, 6-7. Print.)
Single gene hereditary afflictions are being corrected through gene replacement. These problems include : sickle cell anemia; cystic fibrosis; severe combined immuno-deficiency (SCID) [currently treatable- but with sometimes tragic consequences- Jesse Gelsinger (the boy in the bubble) died from multiple organ failure in 1999 after receiving an early gene replacement]. Leber Congenital Amaurosis (LCA) [a condition resulting in blindness now promising cures through recent studies]. These represent the beginnings of the benefits of the study of the Human Genome. It will be decades however, before we can easily predict the effects of the relationships among traits that are effected by more than one gene. (Source used: Kaiser, Jocelyn. &quot;Gene Therapy in a New Light.&quot; Smithsonian, January 2009, 55-61.) Sangamo BioSciences has cured an AIDS sufferer by cutting into the patient's DNA and replacing the gene called CCR5 which is a receptor for HIV. This is a high-risk intervention and as of the time of the report had not been repeated. (&quot;Sangamo's Bet against AIDS: Gene Therapy,&quot; Bloomberg Businessweek. 14-20 Feb 2011, 18-20. Print.) There remain concerns over privacy (and how insurance coverage might be affected by knowledge about individual genetic tendencies) and about the safety of the testing itself. When UC Berkeley announced that it would conduct voluntary collection of student data in June of 2010, public watchdog groups howled. The tests include data “… related to the ability to break down lactose, metabolize alcohol and absorb folates.” Even some scientists remain cautious about our ability to wisely use data about the Human Genome. (Colliver, Victoria. “ Ethics of UC Berkeley's Gene Testing Questioned,” <The Chronicle.> 21 May 2010.)
The National Conference of Commissioners on Uniform State Laws in 1980 formulated the Uniform Determination of Death Act (UDDA). It states that: &quot;An individual who has sustained either1.(1) irreversible cessation of circulatory and respiratory functions, or1.(2) irreversible cessation of all functions of the entire brain, including the brain stem is dead. &quot;Legal Definition of Death&quot; by Kirsti A. Dyer MD, MS, FT for About.com Updated: August 24, 2006About.com Health's Disease and Condition content is reviewed by the Medical Review Board
