LECTURE The Impact of Technology on Clinical and IT Systems Introduction One of the factors driving change in the health care delivery system is the rapidly evolving technology that emerges from research and development. Emerging technologies create rapid and profound change in the delivery system and may have drastic financial impacts. However, adapting new technologies without a clear understanding of what they can do for and to the system is never a good idea. They must be evaluated for their abilities to enhance the quality of care, along with their capacity to drive new revenue in a procedure-based delivery system. Finally, the cost of new technology is highly correlated with how new it is, and whether it is a stand-alone product with no competition. All of these factors combine to make it essential to do careful business and clinical analyses prior to committing to even the most appealing new technology. In this module, we will examine two types of new technology: clinical applications and the electronic medical record (EMR). Clinical Technology In the realm of clinical technology, there are numerous subgroups. In selected subgroups, we will explore examples of new technology that is in the research and development pipeline. Cardiovascular The underlying theme of technology in cardiovascular care is the shift from significantly invasive approaches, such as open cardiac bypass surgery requiring a split sterna surgical approach and the use of a heart lung machine to maintain the patient during surgery, toward minimally invasive or noninvasive techniques. Ultra-wide band radar devices allow the measurement of cardiac output, heart rate, heart rhythm, and patterns of blood flow without any invasion of the body. The device is roughly the size of a deck of cards and can be worn in a shirt pocket without leads or monitor pads. The use of this type of radar-based approach allows noninvasive monitoring without pain or limitation of movement by patients. Another cardiovascular application is the use of bio-absorbable, drug-eluting stents to open coronary arteries. The old technology required a surgical intervention that involved removing an artery from another part of the body and suturing it to the blocked coronary artery to provide a bridge for blood to flow past the blockage. This generally required hours in the operating room, with a patient on a heart bypass machine, and several days to a week in the intensive care unit after surgery. This has been largely replaced by placing stents or coils in the coronary arteries to hold them open. This is done in the cardiac catheterization lab under sedation or light anesthesia and is accomplished by threading a catheter through the arm or leg vein up to the heart and into the artery. However, historically these types of stents could block up again. The newest technology involves placing a bio-absorbable stent that eventually melts into the arterial wall, along with the drug-eluting aspect, which preven ...

1. LECTURE
The Impact of Technology on Clinical and IT Systems
Introduction
One of the factors driving change in the health care delivery
system is the rapidly evolving technology that emerges from
research and development. Emerging technologies create rapid
and profound change in the delivery system and may have
drastic financial impacts. However, adapting new technologies
without a clear understanding of what they can do for and to the
system is never a good idea. They must be evaluated for their
abilities to enhance the quality of care, along with their
capacity to drive new revenue in a procedure-based delivery
system. Finally, the cost of new technology is highly correlated
with how new it is, and whether it is a stand-alone product with
no competition. All of these factors combine to make it
essential to do careful business and clinical analyses prior to
committing to even the most appealing new technology.
In this module, we will examine two types of new technology:
clinical applications and the electronic medical record (EMR).
Clinical Technology
In the realm of clinical technology, there are numerous
subgroups. In selected subgroups, we will explore examples of
new technology that is in the research and development
pipeline.
Cardiovascular
The underlying theme of technology in cardiovascular care is
the shift from significantly invasive approaches, such as open
cardiac bypass surgery requiring a split sterna surgical approach
and the use of a heart lung machine to maintain the patient
during surgery, toward minimally invasive or noninvasive
techniques. Ultra-wide band radar devices allow the
measurement of cardiac output, heart rate, heart rhythm, and
patterns of blood flow without any invasion of the body. The

2. device is roughly the size of a deck of cards and can be worn in
a shirt pocket without leads or monitor pads. The use of this
type of radar-based approach allows noninvasive monitoring
without pain or limitation of movement by patients.
Another cardiovascular application is the use of bio-absorbable,
drug-eluting stents to open coronary arteries. The old
technology required a surgical intervention that involved
removing an artery from another part of the body and suturing it
to the blocked coronary artery to provide a bridge for blood to
flow past the blockage. This generally required hours in the
operating room, with a patient on a heart bypass machine, and
several days to a week in the intensive care unit after surgery.
This has been largely replaced by placing stents or coils in the
coronary arteries to hold them open. This is done in the cardiac
catheterization lab under sedation or light anesthesia and is
accomplished by threading a catheter through the arm or leg
vein up to the heart and into the artery. However, historically
these types of stents could block up again. The newest
technology involves placing a bio-absorbable stent that
eventually melts into the arterial wall, along with the drug-
eluting aspect, which prevents clot formation. While this is a
significant improvement from the patient's perspective, it also
comes with a steep premium in cost, at least initially. Cardiac
services have traditionally been among the most lucrative
services for hospitals and physicians. However, the shift of
services from inpatient to outpatient and the marked reductions
expected in cardiac surgical volume result in a noticeable
decline in patient admission days and overall cardiac revenue
for the average hospital. Cardiac surgeons across the country
are indicating decreases in volume of 20% to 30% in their
patient load.
A brand new emerging technology is autologous cell therapy, in
which a patient's own heart muscle cells are cultured from their
own adult stem cells and then placed back into the patient's
heart muscle. This process is in clinical trials at present, and if
it works as expected, patients will have strengthened heart

3. muscle without the fears of tissue rejection from organ
transplants. It will also reduce the need for electromechanical
pumps or a full heart transplant. This technology could
potentially revolutionize cardiac health care.
Oncologic
With the growing rate of cancer diagnoses, oncologic care is an
area rife with new technology. One new area with great promise
is the use of radioactive trace markers to measure the effects of
chemotherapy or radiation on tumor growth. Fluorothymidine is
being studied as an imaging probe that measures tumor cell
proliferation and response to therapies. The ability to do an
early assessment of tumor growth and development should
provide better outcomes for patients with cancer and reduced
expenses from ineffective therapies.
Another new technology overcomes the problem of the blood-
brain barrier, which prevents chemotherapeutic agents from
penetrating the brain. The new technology, acoustic-enhanced
drug delivery, uses focused ultrasound to reverse the blocking
effects of the blood-brain barrier by agitating the brain tissue to
enhance its permeability. This also improves the tumor's uptake
of the drug, with a quicker and more effective response to the
chemotherapy.
Gastrointestinal (GI)
Digestive disorders have been diagnosed for years through
endoscopy. However, this process requires sedation of the
patient. Video capsule technology appeared in 2001, but its
diagnostic capability was limited, since the capsule's movement
was not controllable. The newest technology is a robotic
capsule that allows the physician to control the movement and
orientation of the capsule for better visualization of the GI
tract. Once the capsule is positioned properly, it can perform a
robotic biopsy or administer a treatment to a specific area with
a noninvasive approach.
Diagnostic Imaging
There are numerous technologies that are emerging in the field
of diagnostic imaging. Over the last five years, computed

4. tomography (CT) scans have become three dimensional and
capable of imaging thinner slices, giving much greater visual
resolution. However, increases in CT imaging have prompted
rising concerns about radiation exposure. Magnetic resonance
imaging (MRI), which creates images through a magnetic field,
is a safer option when radiation exposure is a concern. MRIs
can also visualize soft tissue in a way that CT scans cannot. A
new technology based on the MRI platform is MRI-guided
radiation therapy for tumors. In this approach, the MRI imaging
system is combined with three gamma ray sources, which
function together as a large robot. The patient is positioned
between two magnets, and the gamma ray sources rotate around
the patient. The higher imaging resolution and real-time
visualization of the tumor's shape and location can allow careful
coordination of the three beams, protecting healthy tissue for
more effective therapy.
These are all examples of clinical technology that are currently
being tested and developed. The issues of whether, how, and
when to implement new technology depend upon where one
wishes to be on the new technology adoption curve. Those who
invest early in the process, the "early adopters," may be able to
carve out a market and attract new physicians and patients to
the new technology and its early promise. The downside is that
the new product is generally very costly, especially if it is one
of a kind. Early adoption also may not provide enough time in
operation to clearly understand the pros and cons of the new
technology. The second phase of adoption, defined as the "early
majority," involves the emergence of competing vendors that
have developed their own versions of the technology. This
facilitates wider utilization and more competitive pricing.
Differences in the new technology also emerge, offering more
options for use. However, an early adopter may have already
seized market share, making it harder to attract new business.
The third phase, the "late majority," adopt the technology
before it becomes obsolete but after it has been thoroughly
tested in the market and has become the standard of care. At

5. this point, there are little distinguishing characteristics between
vendors, so that price and standardization become the
determining factors.
The assessment and evaluation of a new technology always
requires a strategic review, a financial analysis, and a carefully
done and accurate business plan.
First, how does the new technology fit into the
organization's strategic plan? Will it enhance the achievement
of specified goals? What physicians will be stakeholders and
users of the new technology? How will it fit with other
technology and competing demands for capital resources?
Second, what does the financial analysis show? What
increase in volume is anticipated? What is the potential payor
mix? What types of reimbursement are available? Will it add
costs for patients on a diagnosis-related group reimbursement
plan? What is the contribution margin once the initial capital
expenditure is covered, and what is the time frame for a return
on investment?
Third, what does the business plan reveal? Will it
attract new physicians and more patients, and from where? Will
it enhance elective procedure volume? What is the competitive
advantage it brings, or what possible loss of business would it
prevent? What market share of the affected patient population is
anticipated?
A word of caution: beware of vendors that offer to provide a
business and financial analysis to "relieve you of the workload."
It is generally not wise to rely on vendor-provided analyses
without strong validation of their assumptions from your own
internal resources. The wise administrator always does his or
her own analysis and review, looking at the new technology
with a critical and analytical eye and resisting the temptation to
acquire it just because it is new.
The EMR
The Healthcare Insurance Portability and Accountability Act of
1996 mandates that hospitals and health care entities move to an
EMR by 2015. While many hospitals have components of an

6. EMR, not many have the full package implemented and in place,
which includes the clinical documentation and the computerized
physician order entry modules. There are a large number of
vendors competing for the business, and the selection of an
EMR product is very difficult.
When preparing for the move to an EMR, there are several steps
to take:
1. Develop clear criteria for success. What does your
organization expect the EMR to accomplish for you? How will
you know if that is achieved once you implement it? How much
of the health care continuum will be included in your EMR
(physician offices, hospital entities, outpatient services, etc.)?
Many organizations may develop an EMR with the belief that it
will save staff time and result in fewer positions and staff costs.
In fact, the opposite has been shown to be true. Most EMR
implementations take more time than paper and pencil
approaches for the data entry. The value of an EMR may well be
in its ability to translate data into workable information via
reports. If you want to know the number of foley catheters that
are in patients for more than two days, a good EMR can
generate a report for you. Be sure that your criteria for success
are achievable, measurable, and make strategic sense for your
organization. Representatives of all stakeholder groups should
be involved in developing these criteria.
2. Use due diligence in selecting your product and vendor.
This is a hotly competitive market among vendors of various
EMR software products. The vendors will promise a great deal
in order to make the final cut and selection. It is essential that
you thoroughly evaluate the abilities of each product as it fits
your strategic goals, your criteria for success, operations in
each affected department, functionality, reporting capability,
ease of use, and robustness of the product. A smart way to
proceed is to sit through the vendor presentations, take careful
notes, and then go talk to hospitals that have used that vendor's
product. You need to understand how the product will be used
and whether all the components and departments that will use it

7. are integrated (built into the original software platform) or
interfaced (requires the build of a software bridge between
computer systems). An EMR that does not have an integral
surgical suite package would be at a significant disadvantage in
the competitive world, for example.
3. Learn from other hospitals that use the software platform
you are considering. You cannot go to too many hospitals to see
an EMR in action. It is a mistake to go to only one or two and
think that you have seen it all. Multiple visits will show
multiple different ways to use the system and the problems that
come with it. If you visit, talk to the users in the departments
about their feelings regarding the system, how easy it is to use,
how it changed their work flow and operations, and what issues
they see with it. These visits can help you avoid a very
expensive mistake. Having said that, keep in mind that there is
no perfect system and that these systems are extremely complex.
It is unrealistic to believe the vendor when they tell you that it
will be a smooth and organized implementation with no
problems, because there are always problems. The vendor's
commitment to help and support during and after the
implementation is critical to success.
4. Above all, do not leave any stakeholder group out of the
selection and design, especially physicians. Many physicians
look with skepticism on the advent of an EMR, and some have
likely had less than great experiences with it at other hospitals
or in their own practices. It is absolutely imperative that
physicians and other key stakeholders, such as staff, are deeply
involved in the selection, design, implementation, and
monitoring of the EMR system and associated processes. Failure
to do this step almost always guarantees a less than optimal
result and generally results in a complete failure.
5. Budget appropriately. The wise health care executive will
realize up front that the selection, design, and implementation
of an EMR will cost millions of dollars. The software costs
alone can run that much, and then one must plan for the
hardware costs, data storage expenses, and data entry

8. systems/computers. In addition, the planning and design teams
can take months to a year to complete all the implementation
planning, and the staff costs for participation can run into high
six figure amounts. It is always a good idea to ask the hospitals
where you are observing their usage to tell you what their total
EMR costs were, at least in ballpark figures.
The EMR requires a huge amount of resource commitment in
planning, selection, due diligence, implementation, and ongoing
monitoring. This is one of the decisions and change processes
that must go correctly, since so much is at stake.
Conclusion
New technology has had, and will continue to have, lasting
impacts on the health care delivery system and its individual
providers and components. Clinical technology continues to
pour out of the research and development pipeline, and new
drugs, new procedures, and new therapies will be a part of the
health care landscape for decades to come. It is new, exciting,
and very expensive. Careful analysis and evaluation is an
essential part of selecting what is useful and appropriate for a
health care entity and avoiding the high cost flash in the pan
that does not meet initial expectations.
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1-Unsatisfactory 0.00% 2-Less Satisfactory
65.00% 3-Satisfactory75.00% 4-Good 85.00% 5-Excellent
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9. Content 70%
40.0 %
Compare and contrast the competing visions among
stakeholders, identifying the areas where they conflict and
discussing how those conflicts could be seen in the delivery
system.
Does not demonstrate understanding of the competing visions
for health care delivery systems , including the issues and
implications. Does not demonstrate critical thinking and
analysis of the material.
Demonstrates only minimal understanding of the competing
visions for health care delivery systems, including the issues
and implications. Demonstrates only minimal abilities for
critical thinking and analysis.
Demonstrates knowledge of the competing visions for health
care delivery systems, including the issues and implications, but
has some slight misunderstanding of the implications. Provides
a basic idea of critical thinking and analysis. Include examples

10. or descriptions.
Demonstrates above-average knowledge of the competing
visions for health care delivery systems, including the issues
and implications (in your own words). Develops an acceptable
analysis of the conflicts. Utilizes some examples.
Demonstrates thorough knowledge of the competing visions for
health care delivery systems, including the issues and
implications. Clearly develops a strong analysis of the conflicts
and implications. Introduces appropriate examples.
30.0 %Use references and examples to support main points.
Does not provide supporting examples.
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and no references.
Supports main points with examples and explanations, but
includes few references to support claims and ideas.
Supports main points with references, explanations, and
examples. Analysis and description are direct, competent, and
appropriate of the criteria.
Supports main points with references, examples, and full
explanations of how they apply. Thoughtfully analyzes,
evaluates, and describes major points of the criteria.
20.0 %Organization and Effectiveness
7.0 %Assignment Development and Purpose
Paper lacks any discernible overall purpose or organizing claim.
Thesis and/or main claim are insufficiently developed and/or
vague; purpose is not clear.
Thesis and/or main claim are apparent and appropriate to
purpose.
Thesis and/or main claim are clear and forecast the development
of the paper. It is descriptive and reflective of the arguments
and appropriate to the purpose.
Thesis and/or main claim are comprehensive. The essence of the
paper is contained within the thesis. Thesis statement makes the

11. purpose of the paper clear.
8.0 %Argument Logic and Construction
Statement of purpose is not justified by the conclusion. The
conclusion does not support the claim made. Argument is
incoherent and uses noncredible sources.
Sufficient justification of claims is lacking. Argument lacks
consistent unity. There are obvious flaws in the logic. Some
sources have questionable credibility.
Argument is orderly, but may have a few inconsistencies. The
argument presents minimal justification of claims. Argument
logically, but not thoroughly, supports the purpose. Sources
used are credible. Introduction and conclusion bracket the
thesis.
Argument shows logical progression. Techniques of
argumentation are evident. There is a smooth progression of
claims from introduction to conclusion. Most sources are
authoritative.
Clear and convincing argument presents a persuasive claim in a
distinctive and compelling manner. All sources are
authoritative.
5.0 %Mechanics of Writing (includes spelling, punctuation,
grammar, language use)
Surface errors are pervasive enough that they impede
communication of meaning. Inappropriate word choice and/or
sentence construction are used.
Frequent and repetitive mechanical errors distract the reader.
Inconsistencies in language choice (register), sentence
structure, and/or word choice are present.
Some mechanical errors or typos are present, but are not overly
distracting to the reader. Correct sentence structure and
audience-appropriate language are used.
Prose is largely free of mechanical errors, although a few may
be present. A variety of sentence structures and effective
figures of speech are used.

12. Writer is clearly in command of standard, written, academic
English.
10.0 %Format
5.0 %Paper Format (Use of appropriate style for the major and
assignment)
Template is not used appropriately, or documentation format is
rarely followed correctly.
Appropriate template is used, but some elements are missing or
mistaken. A lack of control with formatting is apparent.
Appropriate template is used. Formatting is correct, although
some minor errors may be present.
Appropriate template is fully used. There are virtually no errors
in formatting style.
All format elements are correct.
5.0 %Research Citations (In-text citations for paraphrasing and
direct quotes, and reference page listing and formatting, as
appropriate to assignment and style)
No reference page is included. No citations are used.
Reference page is present. Citations are inconsistently used.
Reference page is included and lists sources used in the paper.
Sources are appropriately documented, although some errors
may be present
Reference page is present and fully inclusive of all cited
sources. Documentation is appropriate and citation style is
usually correct.
In-text citations and a reference page are complete and correct.
The documentation of cited sources is free of error.
Total Weightage 100%
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